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1.
DRAFT
CONFIDENTIAL
U‘
Report No. 15753-IN
India
A Comparative Review of Health Sector Reform in
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Four States:
—j An Operational Perspective
September 24, 1996
Population and Human Resources Division
South Asia Country Department II
(Bhutan, India, Nepal)
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Document of the World Bank
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INDIA
COMPARATIVE REVIEW OF HEALTH SECTOR REFORM IN FOUR STATES:
AN OPERATIONAL PERSPECTIVE
Table of Contents
Page No.
Executive Summary
Table on Main Findings and Recommendations
.3
CHAPTER ONE:
A.
B.
C.
D.
3
... v-xiv
xv-xviii
INTRODUCTION
Background..................................
Purpose and Scope of the Study..
Terms of Reference for the Study
Structure of the Report
1
....... 1
2
3
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CHAPTER TWO:
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A.
B.
THE UNFINISHED AGENDA IN THE HEALTH SECTOR
Sectoral Background
Looking to the Future: Challenges and Opportunities at the State Level
....5
....5
CHAPTER THREE: BACKGROUND TO HEALTH POLICY AND PLANNING
DEMOGRAPHIC FEATURES. EPIDEMIOLOGY AND BURDEN OF
DISEASE IN THE FOUR STATES
A.
B.
C.
D.
E.
Introduction
Demographic Features of the States
The Health Transition................................................
Epidemiology and the Evolving Burden of Disease in the Four States
Recommendations
.9
10
11
12
17
This report has been prepared by Tawhid Nawaz (Team Leader and Sen.or Economis.' with ma.or
(Calcutta), and S. Basu, the Foundation for Research and Development for Underprivileged Groups
r
The nerr
Jha. The report is endorsed by Richard Skolnik, Chief, Population and Human Resources Division and HrinV v™
Director, South Asia Country Depanment II (Bhutan. India and Nepal).
^in’
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CHAPTER FOUR:
A.
B.
C.
D.
E.
F.
G.
Introduction
............................................................................
Client Perceptions of the Role of the Private Sector
Scope of the Private Sector in Health Care Delivery
Expenditures in the Private Sector: Emphasis on Out-of-Pocket Spending
Quality of Services
Consumer Protection Act
Recommendations
CHAPTER FIVE:
A.
B.
C.
D.
E.
F.
G.
A.
B.
C.
D.
E.
32
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36
37
38
39
42
PUBLIC SECTOR HEALTH EXPENDITURE IN THE FOUR STATES
Introduction
State Finances
Trends in Expenditure in Health and Family Welfare
Per Capita Expenditures on Health
Effects of Fiscal Adjustment on Health Budgets
Share of Budgetary Resources Devoted to Health
Composition of Health Budgets
.
Future Trends in Public Sector Health Financing
Recommendations
.
CHAPTER SEVEN:
18
19
20
25
28
30
30
CENTER-STATE FINANCING ISSUES IN THE HEALTH SECTOR
Introduction
Center, State and Local Government Responsibilities in Health Financing
Inter-State Equity Issues
Government Health Expenditures: All States
Patterns of Health Expenditure Across States
Mechanisms of Adjustment Effects on Center-State Transfers
Recommendations
.
CHAPTER SIX:
A.
B.
C.
D.
E.
F.
G.
H.
I.
THE PRIVATE SECTOR IN HEALTH CARE AT THE STATE LEVEL
43
43
46
46
47
48
48
53
54
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A SUPPLEMENTARY HEALTH FINANCING MECHANISM:
USER CHARGES
Introduction
User Charges: Operational Issues.
User Charges: Existing Practices ..
Potential Revenues from User Charges: Examples from Karnataka and Andhra
Pradesh
Recommendations
._
56
56
58
59
63
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CHAPTER EIGHT:
A.
B.
C.
D.
E.
F.
Introduction
Burden of Disease and Cost-Effectiveness Study.........................
Cost-Effectiveness Analysis...............................................
Andhra Pradesh Burden of Disease and Cost-Effectiveness Study
Results
Recommendations.............................................
CHAPTER NINE:
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A.
B.
C.
D.
E.
F.
THE COST EFFECTIVENESS OF HEALTH INTERMINTIONS
.... 65
.... 65
.... 66
.... 66
.... 70
.... 71
SPECIAL ISSUES IN MANAGEMENT ADMINISTRATION TN THE
HEALTH SECTOR: DECENTRALIZE^ GOVERNANCE UNDER THF
PANCHAYATI RAJ SYSTEM
Introduction
Rationale for Decentralization of Administration
Three Models of Decentralization
Key Linkage between State Health Administration and PRIs : District Level
Organizational Structure of Health Administration
Role of PRIs in Health Delivery: Two Examples
Recommendations
Bibliography
.... 73
.... 74
76
78
80
82
85
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ANNEXES
1.
2.
3.
4.
Decentralized Administration in the Health Sector
Cost Effectiveness of Services at First Referral Vs. Ternary Level Hospital Care
Streamlining and Rationalizing Clinical and Diagnostic Service Norms
User Charges: Existing Practices in the Four States
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TABLES
3.1
3.2
3.3
3.4
3.5
4.1
4.2
4.3
Health Status and Epidemiology in India and the Four States
iq
DALYs Estimated to be Lost During the Year 1992
............................ <4
DALYs Lost per 1,000 Population
15
DALYs Lost per 1,000 Population by Major Cause Groups in Rural & Urban Areas 15
Total DALYs Lost per 1,000 Population and by Major Cause Groups
[g
Distribution of Private and Voluntary Hosp.tals by Type of Ownership in Karnataka' 21
Distribution of Private and Voluntary Hospitals by Range of Services Offered in
Karnataka
... 23
Cost of Treatment for an Illness Episode in Nellore District (AP)
... 25
- IV-
TABLES (continued)
4.4
4.5
5.1
5.2
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
7.1
7.2
7.3
7.4
7.5
7.6
8.1
8.2
8.3
9.1
9.2
Comparison of the Cost of Treatment in Government and Private Hospitals
25
National Health Spending: An Estimated ‘‘Source and Uses” Matrix
25
Center and State Shares in Different Components of the Government Health Budget 34
Trends in Public Revenue Expenditures on Health 1988-1992
Gross Fiscal Deficit as Proponion of State Domestic Product - Project States 1990/91 1993/94
Revenue Deficit as Proponion of State Domestic Product - Project States 1980/81 1993/94
Expenditure on Health and Family Welfare as % of SDP
45
Per Capita Expenditures on Health and Family Welfare
. . 47
Real Growth Rates in Health Expenditure - Project States 1980/81-1993/94
48
Share of Health and Family Welfare Sector in Total State Revenue Budget
. . 48
West Bengal: Composition of the Health Budget
49
West Bengal: Composition of Spending in Hospitals and Dispensaries 1992/93 —
1994/95
51
Karnataka. Distribution of Health Care Revenue Expenditures by Level of Care... 51
Punjab: Distribution of Health Revenue Expenditures by Level of Care 1990/91 —
1994/95
52
Cost Recovery in Medical and Public Health Services
56
Project Revenue from Paying Beds and Wards................................................
59
Projected Revenue from Major and Minor Surgery
60
Annual Collections from Paying Beds
61
Projected Revenues from Surgical Procedures (Paying Ward Patients Only) ........ 62
Revenue Collection from Paying Beds
62
Cost for DALYs Gained by Intervention
68
Detailed Cost for DALYs Gained - Vaccine Preventable Disease
70
Detailed Cost for DALYs Lost -- Vaccine Preventable Disease
70
Karnataka - Share of Allocations to PRI to the Total Health Budget
81
Decentralization Matrix: Scope for Change in Grassroots Administration in the
Health Sector
83
FIGURES & BOXES
5.1
5.2
6.1
9.1
9.2
9.3
The Structure of Government Health Financing
Channels through which Structural Adjustment Affects Health Spending**
Financial Situation of the State and Implications for the Sector: The Example of
Andhra Pradesh
The Maharashtra-Gujarat Model
The West Bengal Model
The Karnataka-Andhra Model
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45
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EXECUTIVE SUMMARY
A. Sectoral Background
1.
During the past two decades, the Government of India (GOI) has developed a health care
system which finances and manages basic health care infrastructure. Government-provided services
are the dominant source of preventive care, such as immunization, ante-natal care, infectious disease
control and hospital-based care, and account for about 20% of overall health spending. Tile private
sector, on the other hand, plays a dominant role in the provision of ambulatory health services, and
accounts for about 80% of overall health expenditures. Nationwide health care utilization rates show
that services provided by the private health sector is highest for primary health, and is financed
almost entirely from out-of-pocket sources. This is in sharp contrast to the situation in industrialized
countries, where hospitalization, secondary and tertiary health care services account for the largest
share of health expenditure, little of which is financed directly by iiouseholds. The reliance on such a
high proportion of funds from out-of-pocket sources in India places a disproportionate burden on the
poor. Private health services are inaccessible to large sections of the population and do not cover
many of the diseases which are most common to the poorest and most vulnerable sections of society.
As a result, substantial gaps remain in the effective delivery and quality of health care services
provided to the population.
2.
National Health Policy. India's health policy is based on the assumption that primary' health
care is a basic right to which people should not be denied access due to inability to pay or for other
socio-economic reasons. Based on the principle that equitable allocation means equal access to health
facilities on a per capita basis, nationwide population-size based norms determine the establishment of
health facilities throughout the country’. The National Health Policy (NHP. 1983) expanded this
approach by specifying quantitative targets for health and fertility reductions and setting a timetable up
to the year 2000 for meeting them. The NHP strongly emphasizes the reduction of preventable
mortality and morbidity affecting mothers and young children. This is an appropriate policy given
India’s burden of disease and epidemiological profile. However, investment allocations only
partially reflect the priorities highlighted in the Government’s policy. Public sector spending on
health is only about 1.3% of Gross Domestic Product (GDP), which is lower than in comparable
Asian countries and not sufficient to provide an adequate and necessary package of health services.
3‘
°le °
The R
Role
off thc
the Center and the State
Statess in the Health Sector. The provision of health care is
a responsibility shared by the state, central, and local government, although it is effectively a state
responsibility in terms of delivery. The responsibility for health stands at three levels. First, health is
primarily
a state responsibility and about three-quarters of public spending on health is accounted for
1
by the states. Second, the center is responsible for health in Union Territories without legislature.
o---------- Thc
...j
center iis also
1 responsible for developing and monitoring national
.
standards and regulations; providing
the link between the state governments and international and bilateral agencies; and sponsoring
numerous schemes through provision of finance and other inputs for implementation by state
governments. Third, both the center and the states have joint responsibility for programs listed under
the concurrent list.
list Goals and strategies for thc
the public sector in health care are established in a
consultative process involving these different participants through the Central Council of Health and
Family Welfare. While each state can formulate its own health policy, in practice state governments
* vihave to Junction within the parameters of the national health policy laid down by the Union
Government. There is. however, sufficient scope for the states to administer health schemes in
conformity with local conditions. As a result, any major initiative in financing and policy reform to
increase efficiency and improve effectiveness of health programs needs to be targeted at the state
level.
B. Scope and Purpose of the Report
4.
Scope. This report accordingly focuses on the state level in the financing, provision and
implementation of health care services. It is a follow-up to the earlier sector report: “India Policy and
Finance Strategies for Strengthening Primary Health Care Services”, Report No. 13042-IN, May
1995. This report elaborates what states can do to strengthen institutional capacity and implement a
program of health reform in selected areas in order to develop an effective and sustainable health
system which will carry India forward to the next century. It draws upon analyses on the changing^
epidemiology and burden of disease, rationalization of service norms at the various tiers of the health
care system, public/private partnerships in the provision and financing of health care, center-state
health financing issues, adequacy of finance and finance strategies, the cost-effectiveness of health
interventions and institutional and management issues related to decentralized initiatives at the state f
level. It also draws upon previous analyses of shifts in technical paradigm, incentives for the M
workforce and some aspects of the management of health care in the public sector, but does not
explicitly address them in the context of this repon. These analyses help to define a publiclyprovided and financed health care system, providing an adequate and necessary package of services
that would be affordable for the vast majority of India’s population.
5.
Purpose. The report provides a comparative review of the experience of the four states of
Andhra Pradesh, Karnataka. Punjab and West Bengal, which are being assisted by the World Bank
in the strengthening of their health systems. The review will lielp to develop action plans in several
key areas of health reform for other states that want to improve the performance of their health care
services, such as improved health status of the population, greater access and equity, improved
efficiency in the allocation of resources, and greater effectiveness of existing programs and
consumer satisfaction. The agenda proposed in this report is incremental and modest, but is critical
for setting the stage for India and its states to address improvements in health care services without
substantially escalating costs.
6.
Dissemination. The report continues the on-going dialogue on state level health sector
development issues between the Bank, GOI and state Governments which was initiated four years
ago. The report has also benefited from collaboration and substantial discussion with WHO, ODA
and KfW. It is intended to widely disseminate the report within India and among the donor
community, especially those agencies that have been actively involved in discussions on the
development of the health sector. The report will help to continue the series of workshop and
seminars that the Bank has been jointly conducting with the Union Ministry of Health and Family
Welfare (MOHFW) and will be used as an instrument to invigorate the public debate on health
sector development and reform issues in India. As such, the report and related dialogue will provide,
over the next three to five years, a clear assessment of state Isvel health sector strengthening and
reform that wiy be needed to be undertaken to promote an effeciive, efficient and sustainable health
system.
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C. Challenges and Opportunities at the State Level
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States in India are making progress in pursuing more efficient approaches to addressing
health care delivery. Nevertheless, states need to develop the essential components of a health care
system that will provide a basic package of services to address the major health problems and the
health transition currently underway. The development of a package of services would take into
account state level variations in disease pattern, public expenditure considerations, the extent to
which the private sector is providing some of these services, the extent to which poverty alleviation
is part of the government’s strategy in the health sector, the cost-effectiveness of health
interventions, and programs that have large positive externalities. The major challenges faced by the
states in delivering a package of health care services are summarized below:
8.
Key Aspects of the Health Care Strategy. Three main issues with regard to the existing
health care strategy at the state level need to be addressed. First, the government’s health care
strategy, which is anchored on population-size based norms, results in systemic inefficiencies. This
strategy does not address the varied epidemiological profile at the community level. At present, in
the four states included in this review, communicable diseases account for about 53%, noncommumcabie diseases about 30%, and accidents and injuries about 17% of the burden of disease on
average. Epidemiological indicators in all states show that, not only is there a health transition
underway with an increasing incidence of non-communicable diseases and injuries and accidents,
but the disease pattern varies from community to community, and between rural and urban areas
within states. Studies and data also show that the changing nature of the burden of disease at the
block, district, state and regional levels necessitate a change in health care planning, including the
provision of infrastructure and support services.
9.
Second, the technical efficiency of key programs is seriously limited, as service functions are
duplicated, and technical paradigms have become out-of-date. The mechanism for delivering public
health services faces serious problems, including overlapping functions and duplication among the
various tiers of the health care system; the lower tier institutions such as Primary Health Centers
(PHCs) are undepitijized due to a multitude of reasons, including lack of support from first referral
institutions and inadequate incentives for the referral mechanism function. Service norms are not
streamlined or1 rationalized, and yardsticks^ defining the sanctioned staff at facilities of various sizes
do^ot_fi£current needs based on patient load and sendcT norms. Tec^hm^aT^digiiT^ manv'
national and other programs are outdated. Some changes are taking^piace in programs such as
leprosy elimination, where paradigms are being updated by shifting to a multi-drug therapy
approach; similar innovations are needed in other programs. Unless these factors affecting technical
efficiency are simultaneously improved, additional resources would continue to be inefficiently
used.
7
10.
Third, incentives for the^worj^force are insufficient, and in-service training is limited.
Overall, there is no shortage of doctors in the country but there Is alhortageinremote ancTrural
areas. There is a shortage of nurses nationwide. There are few incentives to encourage doctors in the
public sector to remain in their rural posts. Problems related to the quality and availability of staff
impede the technical efficiency of health programs and productivity is low. Training facilities are
limited and there is little in-service training, and professional staff are not up-to-date in clinical and
- viiimanagement skills. A recent study
<
' by
‘ the All India Institute of Medical Sciences (AIIMS) confirms
that the quality of basic medical education has deteriorated, althoueh this i
is a topic which is beyond
the scope of this report.
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not cIp Publ|c-Pr'va‘c^Partnership. The role of the private sector in the overall health strateev is
role thJ y eflned' althou8h about 80% °f health expenditures occur in the private sector Thelhal
the pnvate sector plays in the provision of selected aspects of health services such as
m u atory care, and the opportunities which remain for greater private sector involvement in other
Xe rHeTinHd ,ly
-ain challenges with Xt0 pubL
P
oles include, enhancing the scope and importance of the private health sector voKi
improving the quality of services; encouraging private sector involvement in nrev r-’
promotive aspects of health care rather th!n Vely on ind'idua! ~ve care fmX tl
appropriate mix between provision versus financing of health care by the public sector ni !
pa ners ip between the public, private, and voluntary sectors; and imorovinp thp
’ r
arrangement for regulating health care.
exist,n8
12.
Complexity
of Budgeting
and
Accounting
Resource Allocation and Efficiency in C
Structures.
The
existing
fisml
a
”
sharp nf tntai
_!
1 a rising fiscal deficit, increasing interest
snare of total revenues, and an incrpacinn
outstanding as a
faced by the states affects health
■. total state revenue budgets has declined since the early
-rm
in the
the bud
budget
has been
been
exacerbated,
rather
than revered
nJ □ rr“
•. ,l “. T
L 1 sector’s share
h
,n
et has
real per eapiu
XX"n
ail XTp'
S
,'SP8‘,e
The decline in health
sector’s share occurred ‘despite
rise in the
to 1991, indicating that total government
SJTSh'ak!'“P'ndi,“r's ----- upS-'-enic-entlyUto
particularly rural and community hospitals. Much of tte resoureeXe aSTbs’orbed'by"^ '"'m
am
“■
is
'“■‘‘“.funded am/the pmgmms
J
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....... ,
J-’.fr'a '"Kk
gill
ilSi
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Zrr ",-yMrT 5®!
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- ixmechanism within the government to review user charges: weak administrative mechanism for
collection of user fees; difficulty in targeting the poor for exemption from user fees: and constraints
to greater retention of funds generated through user charges at the point of collection. In the longrun, issues such as private insurance and managed health care will need to addressed as in
industrialized countries.
15.
Analytical Capacity for Health Care Planning. Despite significant progress in recent years
in the availability and use of information on health financing at the national or state levels, the
capacity to undertake analytical work for health planning and policy analysis remains limited within
the central and state governments. Some recent analytical work, such as the work undertaken by the
Administrative Staff College of India on the burden of disease and cost-effectiveness of health
interventions have been very useful in this regard.
16.
Health Care Management and Administration. The health care management system at the
state level is inefficient. Some of the problems include: weak overall management and
administration in the implementation of health programs; overlapping functions of the different tiers
of the health care system and lack of coordination and integration between them; and the lack of
involvement of community level organizations in revenue collection, planning and budgeting.
17.
The state governments also need to build the capacity arid the management framework for
health care administration in the decentralized panchayati system. The existing decentralized
administration for health care suffers from inadequate coordination between different tiers of the
panchayat structure, between the panchayat structure and technical depanments, and between state
level coordinating agencies. Furthermore, the panchayat structure's limited responsibilities do not
allow for effective health care planning and implementation, particularly with regard to resource
allocation and revenue collection, planning, policy making and supervision. The inter,tier and inter
agency coordination of decentralized administrative structures needs to be improved, and the
responsibilities of panchayat structures need to be enhanced to support health functions.
D. Recommendations
18.
In response to the challenges faced in the health sector at the state level in India, it would be
important for state governments to undertake a series of measures to strengthen their health systems
and initiate a process of reform. The report makes the following specific recommendations:
I, Reorienting the Health Care Strategy
19.
SJiifting_jgtlwBjir^^qf^iseas£^dNeeji Based Approach. To enhance the effectiveness
and efficiency of health care programs, there is a need to shift the health care strategy from the
papulation-size based approach to an approach jhat_would,address the health care needs of the states
Lased-Qn the-epidemiolQgLcaLpxoflle at xhe community level. The health care strategy at the state
level should involve loca[administration in the planning and implementation process to reflect the
needs at the community level. StateTsHould develop the essential components of a health care
system that will provide a basic package of services to address the major health problems and the
health transition currently underway. The package of services would consist of: communicable I
disease prevention; limited clinical services; essential and emergency obstetric and pediatric care /
/
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Wit in easy access to people living in rural areas: capacity for prevention and health promotion
programs to cope with non-communicable diseases to be developed progressivelv; injuries
especially prevention; and limited treatment of non-communicable diseases which are very cost2 i^r'tI SJCh 3S Cataract 0Perati°ns and some medical treatment of heart attack, stroke and pain
re let. I he states should also play a more important role in other issues relating to health policy1
making at the national level as well.
P
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Rationalizing Service Norms and Updating Technical Paradigms. Service norms at
ifferent level health facilities need to be rationalized and streamlined on the basis of demand and
patient load to address the problems of duplication of functions and lack of efficiency Analysis
shows that substantial cost savings would be gained if an effective referral system was developed
un
be Pir°Vided 31 thC '°Wer 'eVe'S °f the hea'th Care S*Stem before Patients are pushed
up to a higher tier. Incent.ves need to be provided to make the referral mechanism between the
dl«erent tiers of the health system more effective. Once the service norms have been defined
yardsticks defining the sanctioned staff at health facilities of different size, infrastructure
requirement, equipment, drugs and medicine and supporting services will logically follow New
packages
n"d
adOP'ed “ Ur'nS'h"' ""
of programs and
Zeat,ng In<ce",,ves f°r Staff and Providing Training. Incentives need to be enhanced to
address the issue of shonage of critical medical personnel, particularly doctors, in remote and ™ral
areas. Such mcent.ves could include monetary as well as non-monetary benefits such as suitable
accommodanon, preferent.al school admissions for children of doctors living in remote areas
manlT
7
" Stipulated lenSth of stay- and lining opportunities in clinical and
management skills. A large pool of staff need retraining, and the public health functions of various
P"s°"nel categor'es need
be strengthened. States need to consider alternative means of engaging
ey technical staff on contractual arrangements. Lessons could be learned from the experience of
implem^
that are succ«sfully utilizing staff through contractual arrangements in the
implementation of some nat.onal disease control and other programs.
II, Coordinating and Integrating the Roles of the P hi’
Einancing of Health Care' Services^ at the State l evel
h p •
300 rnvalc ^cctQrs in Inc Provision and
Salih
EEnabling
{nablin8 Envi
ronntem for
Environment
for the
the Private
Private Sector.
Sector. The overall strategy for the
health sector should take into account the existing levels of private finance and provision of services
at the state level. State governments should play an active role in creating an enabling environment
for greater pnvate sector partic.parton m the health sector and fostering public-private partnership
There are several oprtons for the government to ensure that the private health sector continues to
play a v.tal role m the health sector and expand the scope of its activities.
23.
Increasing Private Participation. To make more efficient use of total resources available in
the health
------ state governments need to evaluate alternatives related to provision versus
....i rsector,
financing
.
- of health care’ services.
---------- State governments should promote the further expansion of the
private sector in areas where H has a comparative advantage such as tertiary level health care, super
speciality and support semces. Private sector participation in preventive and promotive care services
could also be promoted by providing incentives and developing schemes to finance, train and
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integrate private providers in case-findings, diagnostics, and treatment tor prioritv health problems
that are of public health significance.
24.
Increasing Opportunities for Contracting Out. There are no legal barriers inhibiting the use
of contractual services for support functions, and the Contract Labor Regulation and Abolition Act
(1970), which prohibits certain institutions from contracting out perennial services, exempts
hospitals and health care facilities. Private contractual services are often more efficient and effective
than directly hired labor. In view of the difficulties of employing government staff, such as slow
recruitment procedures and poor attendance, contracting-out certain services, especially support
services, is an attractive alternative. The state governments should, wherever economically
attractive, contract out support services such as laundry, kitchen, landscaping, dietary services,
samtation, security and mainstream "diagnostic and clinical services. In addition Fo economic
considerations, state governments shouid~aTsoTa1c?’into account the quality of services, as well as
administrative viability. Administrative procedures and guidelines and adequate accountability
functions will also need to be in place to facilitate the contracting-out of services.
25.
Strengthening Linkages between Government and Non-Governmental Organizations
(NGO). Government is the major provider of preventive and promotive health care services, but its
coverage is very low. There should be a concerted effort by the states to involve NGOs in this area
and provide them opportunities to work with PRIs. Support for NGOs should be increased in such
areas as social marketing of essential drugs and contraceptives, and behavior changing health
education activities. The government should actively seek the cooperation of NGOs in disseminating
public health messages by involving them in information, education and communication (IEC)
activities. NGO participation could be promoted in the delivery' of primary health care and first
referral services in remote and rural areas where outreach is limited. Contracting-out the delivery- of
primary health care in remote areas to the NGO sector, whidh has a comparative advantage in
improving access to such health services for some disadvantaged’ groups, could also be promoted.
26.
Expanding Capacity for Monitoring and Regulation. The governments capacity to register,
certify, regulate and monitor private health care provision, especially the qualifications of doctors
and other medical personnel and the quality of their services, needs to be strengthened and
implemented. State governments should enact legislation and issue guidelines to register nursing
homes, private clinics/hospitals and ensure minimum standards of care. Some of -these functions
could be undertaken collaboratively by the central and state governments, while others could be
undertaken by a professional body such as the Indian Medical Association in accordance with allIndia standards.
Ill. Strengthening State Financing Arrangemcuts
27.
Reviewing Fiscal Structures and Developing Budgeting and Fiscal Tools, in order to
simplify the complex budgeting and accounting arrangements, the state governments should, through
their Ministries of Health and Family Welfare and Finance: (i) review the fiscal structures and
procedures in the health and family welfare sectors including the roles of the central, state and local
government in financing the provision of basic inputs: (ii) develop program budeetinc tools at the
state and central levels to monitor and evaluate expenditure for important schemes; and (iii) develop
fiscal tools to enable greater experimentation with resource allocation, alternative financing
mechanisms, and provision versus financing of health care services.
- xii-
-8
Providing Supplementary Financing. The mechanism for the transfer of central resources
health resources assurance fund. Priority could be given to those states which are most in need and
are taking credible steps to improve their overall finances.
IYi Enhancing and Prioritizing State Expenditures on Health
29
Improving Overall State Financing. To address the overall deterioration in state finances
state governments need to take credible steps such as: increase tax revenue as a share of state
domestic product; increase the buoyancy of tax and non-tax revenue; and reduce overall public
expend.tures on subs.d.es, salaries, and poorly targeted welfare programs. By improvingP their
overall financ.al s.tuation, the states would be better equipped to address resource needs^n the health
LOl.
•
Increasing Allocation to Health within the Overall Budget. State governments on averaee
fu^d r'h PT
t m°re reS0Urces t0 the Present contribution of USS2-3 on an annual basis to
d their basic package of health care services. This amount may be difficult to provide in the
Sta!n‘f?cts"“’“on
by ““ s“es At •
.he health XT™:"sZ,°n
bUd6C' “
shoXa^„ it:
,he Sl,a" °f
-0™- .e
31.
Re-evaluating Priorities with.n the Health Budget. The state governments need to
reevaluate the priorities within the health sector budge!, especially with regard to resources between
emohaT 'Th"^
leVe'S
Pr'mary 3rd secondary levels of health care need more
h ThlS c°U d bC effeCted throuSh reduct'on in allocation to medical education including
(ESISHhat'are nm
S0C‘al T"™'6 T*16™5
35 the EmPloyees Sta* Insurance Schem!
wMc^nroviX th R P-r0Pr,aJ y
t0 the P00^ The share of P^ary and secondary levels
the overall C |C
packase of Publlc health and ’:linical services, should be increased within
the overall envelope of state government resources fo.- the health sector. Over the next 3-5 years
to the
would need to allocate 75% of incremental resources allocated to the health sector
to the primary and secondary levels.
Increasing Allocations for Non-Salary Recurrent Costs. The state governments also need to
re-evaluate theIr priorities w.th regard to non-salary recurrent inputs such as drugs, essential supplies
oftTheakhTd . 8etSh
m'nOr Var‘atiOn be'’VeCn the StatCS’ it aPPears that about 75%
state ph
H bUdg 1S absorbed
staff salaries and waves. Within these overall constraints the
“ 7°V“S ,n the next 2-3 years need to allocate adequate resources for drugs essential
budget o'nhe"1™?^^6^861^'" aCdCOrdanC; With est3blished "orms- I" addition, ihe health
, _y: , ... ..
.......... :
:
.. •. r
r
- xiii-
Yx Implementing Cost-Recovery Mechanisms
s
t
1
■1
33.
Developing an Institutional Framework for Periodic Review of User Charges. The states
need to set up an institutional framework to review the structure of user fees and pricing policy
periodically, and recommend revisions. The Strategic Planning Cells established in the health sector
in the four states studied provide a viable institutional arrangement for this purpose.
34.
Strengthening Collection Mechanisms and Targeting Vulnerable Groups for Exemptions.
Analysis shows that substantial increases in revenue can be gained by concurrently strengthening the
mechanism for collecting user charges and periodically revising such .arges. State governments
need to increase cost recovery in the health sector from an average of about 3% to about 15-20% in
the next 3-5 years. In addition, adequate targeting mechanisms to identify the poor should be
implemented both in rural and urban areas. Due to the administrative costs involved, it is preferable
to strengthen the existing system for targeting the poor rather than create a new mechanism.
35.
Retaining Revenues at the Point of Collection. Hospitals and health facilities should be
allowed to retain 100% of the revenues collected, or, alternatively, district health committees or
health systems corporations (e.g. as in AP and Punjab) could be empowered on their behalf to retain
such revenues and redistribute them among hospitals within the district according to both need and
level of collection.
36.
Utilizing Revenue for Non-Salary Recurrent Expenses.[Revenue collected should be used
for non-saiary recurrent expenditure items such as drugs, essential supplies and record keeping; a
nominal fee could be charged for out-patients, as is currently being done in West Bengal; and
charges could be concentrated on diagnostic and other services, as well as on voluntary services such
as private rooms or wards and on medical services with a relatively low cost-effectiveness.
Increased charges should be introduced in a phased manner and matched with higher quality of
service.
7
VI. Improving the Analytical Basis for Decisjon-Makin?
37.
Using Cost-Effectiveness Analysis and other Issues to Fine-Tune
~
Policy Planning. The
cost-effectiveness of health intervention is an important analytical tool to aid and fine-tune' policy
and better decision-making in the health sector, in terms of resource allocation for priority diseases,
development of a basic package of services, rationalization of services by levels of health care
institutions, and for establishing a basis for the charging of user fees. Cost effectiveness analysis
should not, however, be viewed as the only tool for decision-making. As stated in the WDR (1993)
the most justified public measures combine a rationale for public action with a cost-effective
intervention. There are several factors which need to be considered jointly in developing resource
allocation policies. These include: the presence of other interventions that might affect costs; the
possibility of eliminating a disease as a public health problem, such as leprosy; those diseases that
have large initial costs but permanent benefits; those interventions that have positive externalities
beyond health such as family planning and girls’ education; and those interventions that have high
poverty reduction benefits.
- XIV-MX-
38.
Developing Institutional Capacity for Health Sector Planning. States should strengthen
their planning capacity in the health sector to (i) undenake analyses of their burden of disease
regionally, at the community level: (ii) review the cost-effectiveness of key health interventions; and
(m) carry out other important analytical work, such as manpower planning needed to facilitate and
improve policy-making. Developing local institutional capacity to undertake such analyses should
remain an important priority.
VII. Strengthening Public Sector Management of Health Care in the Decentralized Administrative
Structure
39.
Strengthening Overall Management Authority. Management arrangements at the state level
and below need to be strengthened to ensure that health programs are implemented effectively
States need to strengthen the .mplementation and supervision capacity of the implementing agency.
ndhra Pradesh and Punjab have established autonomous implementing agencies at the secondary
level to improve management and administration, and provide financial and workforce related
autonomy. Although, this is not the only approach to improving the implementation and supervision
and
°f
'‘T65’
‘SSUe ofmanaSement authority with regard to finance, personnel matters
d effective implementation needs to be addressed. It is possible for the states' Department of
ealth and Family Welfare (DOHFW) to perform these functions, but they need to be given greater
authority and flexibility with regard to finance, supervision and workforce related issues8
4(f
Enhancing the Responsibilities of PRIs. Decentralized governance and local level
pan.c.pation can contribute importantly to improving the health care system, through better monitoring
X
hTt
^ct.onmg of the health system at the local level, and by assisting in developing
plans which take care of local perceptions and needs. In order for the PRIs to be more effective, more
Pennine
r 6
'b6™ 'n
°f budget allocation- resource use, revenue raising
p nnmg, policy making, supervision, maintenance and training. The notion of decentralised
governance would be more meaningful only when the PRIs' responsibilities are enhanced
H^hh t.rheS°UrCe| be‘0T more su^tantial. A process of consultation between the Department of
to be w k d
7 r
PRJs,needs t0 be initiated on these ^Pects and structures and systems need
to be worked out to facilitate implementation.
tie .n
Coo/dina‘ion between Administrative Agencies. Important features emerging from
? JZ, agencies needs t0 be strengthened by developing a viable mechanism which would facilitate
the effectiveness and efficiency of program implementation.
D. Need for Further Analysis
I
V'eW h,fS covered a number of major issues with regard to health sector reform at the
d d^
St‘1*rCma,n SeVeral health sector issucs at the state level where further analysis is
needed. These include incentives for workforce, alternative financing options such as health
1
u
I b.
•'
■"-■''■"■■■-
-
■
■
r
J - '
1
f
■’1
-•1
Table on Main Findings and Recommendations
sase
and
ai.^
u
Issues
Actions
Kcv Aspects of the Health
Reorient the Health Care Strategy
Care Strategy:
'e
y
yy
d
n
s
f
• Three main issues with regard to •
the existing health care strategy
at the state level need to be ad
dressed: (i) inefficiencies of the
population-size based approach;
(ii) shortcomings in the technical
efficiency of key programs with
regard to duplication of functions
and outdated technical para
digms; and (iii) insufficient in
•
centives for the workforce.
r
•
Addressing the Epidemiological Needs at the Community Level:
The government needs to shift its health care strategy from the
population-size based approach to an approach that would address
the health care needs of the states based on the epidemiological
profiles at the community level. The content of such a package is
outlined in the report and may vary across states based on their bur
den of disease. The states should also play a more important role in
matters of what constitutes a basic package as well as other issues
relating to health policy making at the national level.
Rationalizing Service Norms and Updating 'Technical Paradigms:
Service norms should be streamlined and rationalized: yardsticks
defining the sanctioned staff at hospitals of different sizes need to
be tailored to fit current needs based on patient load and service
norms; new paradigms to strengthen the effectiveness and effi
ciency of programs and packages of service delivery should be
created; and incentives need to be provided to make the referral
mechanism between the different tiers of the health system more ef
fective.
Enhancing Incentives for Staff and Providing In-Service Training:
Incentives for staff should be enhanced in order to address the
shortage of critical medical personnel, particularly doctors, in re
mote and rural areas. States also need to consider hiring key technical staff on a contractual basis.
Public-Private Partnership:
Guordinatc and Integrate the Roles of the Public and Private Sectors in
Considering Provision versus Financing of Health Care Services at the
State Level:
• The health care strategy at the
state level does not fully take
into account the existing level of
private and NGO sector provi
sion of health care services.
•
Increasing Private Participation: To make more efficient use of
total resources available in the health sector, state governments
need to evaluate alternatives related to provision versus financing
of health care services. This would imply further expansion of the
private sector in areas in which it has a comparative advantage,
such as tertiary level health care, super-specialty and support serv
ices. Private sector participation in preventive and promotive care
services could also be promoted by providing incentives and devel
oping schemes to finance, train, and integrate private providers in
case-findings, diagnostics, and treatment for priority health prob
lems that are of public health significance.
•
Increasing Opportunities for Contracting Out. Where feasible, the
state governments should contract out support services and diag
nostic and clinical services. The decision to contract-out should
take into account economic considerations without affecting the
quality of services, as well as administrative viability. Administrative procedures and guidelines, and adequate accountability tunc-
-XVI-
Issues
Actions
l,ons Wl11 also need 10 be in place to facilitate contracting-out.------Strengthening Linkages between Government and NGO Sectors
State governments should actively seek the cooperation of NGOs in
disseminating public health messages, by involving them in infor
mation. education and communications activities. Where feasible
they should also involve NGOs in increasing access to primary
health care and first referral services in remote and rural areas.
• The states capacity to register,
certify, regulate, and monitor
private health care provision is
weak.
•
Complexity of Budgeting and Accounting Structures:
Sircngthgn State Financing Arrangements:
• The existing financing arrange
ments and administrative struc
tures for financing health care is
complex and hinders effective
management.
Center-state health care fi
nancing mechanisms do not
adequately address inter-state
equity issues. States which
need funds the most are often
least able to provide resources
for health cdfe programs.
I
Expanding the Capacity to Monitor and Regulate: The states’ ca
pacity to register, certify, regulate, and monitor private health care
provision needs to be strengthened and implemented by enacting
legislation and issuing guidelines for ensuring minimum standard!
of care. Some of these functions could be undenaken by the gov
ernment. while others could be undertaken by a professional body
such as the Indian Medical Association in accordance with AllIndia standards.
welfare sectors with regard to the roles of the center, state and loca^
government in the financing of basic inputs; (ji) develop approprie budgeting tools to monitor and evaluate expenditures for impor
tant schemes; and (m) develop fiscal tools to enable greater^x.penmentation with resource allocation and alternative financing
mechanisms.
®
•
Providing Supplementary Financing: To achieve greater equity in
me ?TC'mS °f he1alth Care between the st««. ‘he central govern
ment should consider supplementary financing through, for exam
ple, a health resources assurance fund, giving prioritv to those states
which are most in need and are taking credible steps to improve
tneir overall finances.
H
Level of Resources and Effi Enhance and Prioritize State Expenditures on Healthciency in the Health Sector:
• Health sector financing issues
need to be reviewed in the context
of deteriorating overall fiscal
situation in many states. This is
indicated by a rising fiscal deficit,
increasing interest payments as a
share of total revenues and an in
creasing share of debt outstanding
as a share of State Domestic Prod
uct ( SDP).
• State health and family welfare
expenditures are: (i) well below
.
are o state domestic product; increasing the buoyancy of tax and
non-tax revenue; and reducing overall public expenditures on sub
sidies, salaries and poorly targeted welfare programs. Bv improving
their overall financial situation, the states would be better equipped
to address specific sectoral resource needs.
Increasing Allocations to Health within the Overall Budget: State
governments, on average, need to provide 50% more resources to
I
...4
'■
•
1
-XVII-
Issues
Actions
the international norms consid
ered adequate for low income
countries to meet public health
priorities as defined by the WDR
(1993), and (ii) below the levels
required to achieve the service
norms set by GOI.
i
r: |
n
k I
•, I
I
• Public expenditures in the health
of declining resources to the sector in most states
•
sector are skewed in favor of ter
tiary level facilities and medical
education relative to secondary
level hospitals, particularly rural
and community hospitals.
Re-evaluating Priorities within the Health Budget
ch
r
primary and secondary-level health care whirf
hareS °f
package of public health and clinical services need m be'
within the overall envelope of
'
d 1 be ,ncreascd
health sector. Over the next 3
need to allocate 75°/ nf
Y
rCS0UrCCS for thc
State Sovemments would
health sector to the pnmarv
• State level health expenditures
on drugs, essential supplies, and
operations
and
maintenance
services are low; the allocation of
funds to the PRIs for health care
are inadequate to carry out
maintenance activities.
dance wnh established norms.
t0 lhe
Supplemental fund? f
n“
SSI
ptXtsplnTiWit^ 0Ut 'heir ma'n,enanCe
!
I
i
I
Alternative Method*
Care Financing-
of Health
• There is no appropriate institu
tional framework for reviewing
user charges; the level of cost re
covery is minimal due to the low
structure of fees and inadequate
collection mechanisms; targeting
mechanisms for exempting the
poor from user charges are diffi
cult to implement; and there is no
adequate mechanism to ensure
that funds collected would be
used at the point of collection.
Implement Cost-RecPYcry Mechanism*
‘
^WOrk/or lhe Penodtc Revlew Qf
•
Strengthen.ng Collection Meehan,sms and Target,ng Vulnerable
SZ’^’Tk”'” ' s’a" E°vt“ "“d
covery
15-20%inin the
.he health
nw.^ sector
T™ from an
15-20% in the next 3-5 years. This c:
strengthening collection mechanisms
viewing and periodically revising i
--------- j to target the
«h„gt!
„..d to g.
°f abwl 3% 10 abou'
"p"“
di.™.™.™ . ”"■ •"'"■“"r
S3S===EE
_
.todd b. .nnn^n d^^Jgl“
-XV111-
Issues
Actions
------wel1 as on voluntary services such as private rooms or wards'
Analytical Capacity
Care Planning'
for Health
Improve the Analytical Basis for Decisj,
sion-Making:
• The states and the center have *
limited capacity to undenake
analytical work for health care
planning. Yet, analyses such as
the Burden of Disease and CostEffectiveness analyses under
taken in Andhra Pradesh have
proven to be very useful in
helping the state with its health
•
care planning.
C“Z'£#eC"Ve"Wi Analys‘s 10 Fine-Ti>ne Policy Planning
The burden of disease and cost-effectiveness analyses of health in
terventions should be viewed as analytical tools to fine-tune policy
and achieve bener decision-making in the health sector with respect
to resource allocation for priority diseases, development of a bLic
package of services, rationalization of services by levels of health
care institutions, and for establishing a basis for the charging of user
Other Factors Which Should Also be Considered in Decis.onTr
pre(Se".ce of other '"‘erventions that might affect costs
the possibihty of eliminating a disease as a public health problem"
those diseases where interventions have large initial costs but per-
bevond heahh'5' dT lnterven,ions lhat have Positive externalities
beyond health, and those interventions that have high poverty re
duction benefits should also be considered.
Oeve/opmg
Capacity for Health Sector Planning
States should strengthen their planning capacity in the health sector
the com
^i y? °f‘heir burden of disuse regionally and at
the community level; revlew the cost-effectiveness of key health
interventions; and cany out other imponant analytical work such as
manpower planning needed to facilitate and improve policy-
Health__ Care Management
Administration•
•
and
Sircngthen Public Sector Manat’em.£iil of Health Care in the DecentIized Administrative Structure-
Management of health care at
the top is diffused, as the De
partment of Health of the state
governments often lack the
authority on matters related to
finance, flow of funds and per
sonnel matters.
Strengthening Overall Management Authority: The issue of man
agement functions with regard to finance, flow of funds, personnel
The PRJs’ limited responsibili
ties and problems in coordina
tion are adversely affecting the
planning process at the lower
levels of the Panchayati Raj
bodies.
, autonomy ■" these key areas. The management structure
pmche' ZST
•
D0H™ ~ I— ■?-
Enhancing the Responsibilities of PRJs: In order for the PRIs to be
more effective, more power should be given to them in the areas of
ge allocation, resource use, and revenue raising, planning policy-makmg, supervision, maintenance, and training. A process of
consultation between the DOHFW at the state level and PRI needs
W be initiated on these aspects, and structures and systems need to
orked out to facilitate implementation.
Increasing Coordination between Administrative Agencies’ Link
ages between the three tiers of the PRI need to be improved in order
o enhance implementation of health care programs. The coordinalon between the PRIs and the technical departments and state-level
----- coordinating agencies also needs to be improved.
1
t
t
Chapter 1
Introduction
I
I
A. Background
1.1
The Government of India (GOI) and the World Bank have been engaged in a
dialogue on health sector development policy since 1992. The focus of that dialogue has
been on helping India address the most burdensome diseases in a cost-effective manner,
while moving toward the establishment of health systems at the state level that are efficient
and effective. A more sustainable health system at the state level will reduce the financial
demands on the state in the future and address poverty issues in a key sector of the economy.
The focus on health reform and financing at the state level is consistent with the recent
Country Assistance Strategy (CAS)1, which reiterates the Bank’s strategy to make health
systems more effective and sustainable in India. The first part of the stratecy in the health
sector is to reduce the most significant diseases through the suppon of priority proerams. The
second is to strengthen the performance of the health system of the states by providing more
efficient and effective health care, especially for the poorer .segments of society who have
limited access to basic health care services. This sector work is in line with the emphasis on
private sector initiatives and the importance of focusing’on state level issues such as reform
of sectoral expenditures and decentralized administration.
B. Purpose and Scope of the Study
1.2
The report analyzes health care strategy and reform in the four states" of Andhra
Pradesh (AP), Karnataka, Punjab and West Bengal that provide valuable lessons for other
states. It provides a comparative review of the experience of these four states and assists in
developing action plans in several key areas of health reform for other states that want to
improve the performance of health care services. Such performance indicators include
improved health status of the population, greater access and equity, improved efficiency in
the allocation of resources, and greater effectiveness of existing programs and consumer
satisfaction. The review continues the on-going dialogue bn state leve? health development
issues between the Bank, GOI and state Governments which was initiated four years ago.
The report has also benefited from collaboration and substantial discussion with WHO, ODA
and KfW. The report and related dialogue will, over the next three to five years, provide a
clear assessment of state level health sector strengthening and reform that would be needed
to be undertaken to promote an effective, efficient and sustainable health system. The agenda
proposed in this report is incremental and modest, but is critical for setting the stage for India
and its states to come to grips with what will be required to improve health care services,
without substantially escalating costs.
1.3
This study elaborates what states can do to implement a program of institutional
strengthening and health reform in selected areas, drawing on analyses of the
.... changing
epidemiology and burden of disease, public/private partnerships in the provision °and
1 India. Country Assistance Strategy-Progress Report. Report No IDA/R96-I54/1. September 5. 1996
financing ol health care, center-stale health financing issues, adequacy of finance and
finance strategies and institutional and management issues related to decentralized initiatives
at the state level. It does not. however, analyze financing issues such as health insurance or
community financing, efficiency and effectiveness analyses of technical paradigm shifts
related to specific health interventions, incentives for the workforce or all aspects of
management and administrative arrangements, some of which have been covered in other
reports or need to be further addressed.
1-4
Linkage with Previous Sector Work on Health Financing, This sector work builds
upon an earlier study “India: Policy and Finance Strategies for Strengthening Primary Health
Care Services”, Report No. 13042-IN, May 1995. While the earlier study focused primarily
on health care at the level of the central government, this sector work extends the discussion
on the center-state relationship and focuses on health care reform issues at the state level.
Subsequent to the earlier sector work, further studies, workshops and seminars on health
reform at the state level were undertaken during the preparation of two state health systems
projects and this sector work. The information garnereq through this further work on the
health sector provides some of the information and databr.se for the report. A review was
undertaken on public expenditures on health in the four states of Andhra Pradesh, Karnataka.
Punjab and West Bengal: a burden of disease and cost effectiveness study was undertaken in
Andhra Pradesh; a burden of disease study was undertaken in Karnataka, Punjab and West
Bengal; and a study analyzing the decentralized p .nchayat adminii -ation system to assess
their new capacities to manage and supervise heaith programs was undertaken. Extensive
discussions were held with central and state level policy makers in the health sector through
workshops and seminars. The bibliography provides a listing of reports used as background
material for this study. The detailed terms of reference far the study are discussed below.
C. Terms of Reference for the Study
1.5
An Initiating Memorandum (IM) was issued on July 19, 1995, with the following
objectives: (a) review the evolving burden of disease an; cost-effectiveness of interventions
at the state level; (b) analyze the role of the private sector in health service delivery, clarify
the roles of the public and private sectors in the Financing and provision of health services,
and explore the opportunities for enhancing the scope and importance of the private sector at
the state level; (c) analyze state level health expenditure data in the four states; (d) estimate
the cost-effectiveness of contracting out selective services to the private sector; (e) analyze
different scenarios of user-charges implemented at state le/el institutions; (f) investigate the
practical implications of decentralizing administrative authority on health related issues to
the panchayat level of administration; and (g) analyze selected aspects of the beneficiary
assessments to identify the most needy populations, assist in targeting such populations and
estimate the costs of delivering adequate and necessary health care to such populations.
1-6
Dissemination. The background work for the report has been conducted in a
collaborative fashion with the Union Ministry of Health and Family Welfare (MOHFW) and
several state Governments. Three important seminars, held in Jaipur (February 1995),
Shimla (June 1995) and Pune (October 1995) have contributed extensively to sharpening the
issues to reflect the priorities and to operationalizing the recommendations. Collaborative
work has also been conducted with local institutions, who have provided inputs to this report.
-3-
These include the Administrative Staff College of India (ASCI), the Delhi Institute of
Economic Growth. Operations Research Group (ORG). and the Foundation for Research and
Development of Underprivileged Groups, in addition to those who contributed to the
previous health sector report. It is intended to widely disseminate the report within India and
among the donor community, especially those who have been actively involved in
discussions on the development of the health sector in India. This report will help to continue
the series of workshop and seminars that the Bank has been jointly conducting with the
Union Ministry of Health and Family Welfare (MOHFW). The report will be used as an
instrument to invigorate the public debate on health sector development and reform issues in
India.
D. Structure of the Report
1.7
The chapters in this report are organized as follows:
1.8
Chapter 2 provides a discussion of the unfinished agenda in the health sector at the
state level in India and the challenges and opportunities that are presented. The key issues
highlighted are: health carb strategy, epidemiology and burden of disease: public/private
rotes in the provision and financing of health care: allocative efficiency of health care
resources: supplementary mechanisms for augmenting health care financing through user
charges; cost-effectiveness of key health interventions: and health care management and
administrative issues related to decentralized administration.
1.9
Chapter 3 provides a comparative overview of the health sector in the four states
including the sectoral background and demographic features in Andhra Pradesh, Karnataka,
Punjab and West Bengal: the evolving burden of disease and epidemiology; and the major
challenges arising from the epidemiological polarization in India.
1.10
Chapter 4 summarizes the role of the private sector in the delivery of health care
services at the state level, covering the availability and cost of private health services; access
to private health services: provision vs. financing of health services by the public and private
sector: and public/private/voluntary sector partnerships in providing health services.
1.11
Chapter 5 discusses center-state financing issues: central, stav and local government
responsibilities in health finances; inter-state equity issues; government health expenditures
in all states: patterns of health expenditures across states; and mechanisms of adjustment
effects on center-state resource transfers.
1.12
Chapter 6 analyzes public sector health expenditures in the four states included in
this review; trends in state level public expenditures on health and family welfare; per capita
expenditures on health; the effects of fiscal adjustment on health budgets; the share of
budgetary resources devoted to health: the composition of health budgets; and future trends
in public sector health financing.
1.13
Chapter 7 analyzes supplementary financing mechanisms related to user charges;
existing practices relating to user fees in the four states; and the potential for raising revenues
from user fees at the state level.
- 4 -
114
Chapter 8 discusses the cost-effectiveness of health interventions, using the Andhra
Pradesh Burden of Disease and Cost Effectiveness of Interventions study as a basis for
drawing lessons for other slates.
115
Chapter 9 discusses the opponunities tc improve implementation of health care
delivery- by decentralizing management and administration to the panchayati raj institutions
(PRJs) at the state level; key linkages between the state health administration and PRIs; and
the role of PRJs in health care deliver}'.
- 5 -
Chapter 2
The L nfinished agenda in the Health Sector
A. Sectoral Background
2.1
During the past two decades the government has developed a health care system
which finances and manages a basic health care infrastructure. Government-provided
services are the dominant source of preventive care, such as immunization, ante-natal care,
infectious disease control, as well as hospital-based care, and account for about 20% of
overall health spending. Tfie private sector, on the other hand, provides ambulatory care
services for acute illnesses or illnesses not requiring hospitalization, and accounts for about
80% of overall health expenditures. Nationwide health care utilization rates show that the
services provided by the private health care is highest for primary health care, such as visits
to general practitioners, and is financed almost entirely from out-of-pocket sources. This is in
sharp contrast to the situation in industrialized countries, where hospitalization, seconcjhry
and tertiary health care services account for the largest share of spending, little of which is
financed directly by households The reliance on such a high proportion of funds from outot-pocket sources in India places a disproportionate burden on the poor. Private health
services are inaccessible to large sections of the population and do not cover many of the
diseases which are most common to the poorest and most vulnerable sections of society. As
a result, substantial gaps remain in the effective delivery of health cqre services provided to
the population.
2.2
The Government's long-term strategy, as enunciated in the National Health Policy
(1983), gives high priority to the control of fertility, infectious diseases of public health
importance and preventable causes of maternal and childhood mortality and morbidity. This
is an appropriate policy given India's burden of disease. However, investment allocations
only partially reflect the priorities highlighted in the Government’s policy. Public spending
on health is about 1.3% of GDP which is lower than in comparable Asian countries. The
bulk of public spending on health, about three-quarters, is accounted for by the states, which
are primarily responsible for implementing health programs. As a result, a major area of
financing and policy reform to increase efficiency and improve effectiveness of health
programs needs to be targeted at the state level.
B. Looking to the Future: Challenges and Opportunities at the State Level
2.3
States in India are making progress in pursuing more efficient approaches to
addressing health care delivery. Nevertheless, the states need to develop the essential
components of a basic package of health services to address the health transition underway
and the major health problems which will face them in the coming years. At present, in the
four states included in this review, communicable diseases account for about 53%, noncommunicable diseases about 30%, and accidents and injuries about 17% of the burden of
disease on average. There are, however, variations by states, with states more advanced in
the health transition having a higher proportion of non-communicable diseases and injuries
and accidents.
- 6 -
A basic health care package should take into account these state level variations in
2.4
epidemiology and burden of disease. The package of services would consist ot.
communicable disease prevention: limited clinical services: essential and emergency
obstetric and pediatric care within easy access to people living in rural areas; capacity for
prevention and health promotion programs to cope with non-communicable diseases to be
developed progressively; injuries, especially prevention; and limited treatment of noncommunicable diseases which «are cost-effective, such as cataract operations and some
medical treatment of heart attack, stroke and pain relief. Within this framework, the
development of the package of services would take into account public expenditure
considerations, the extent to which the private sector is providing some of these services, the
extent to which poverty alleviation is part of the government s strategy in the health sector,
the cost-effectiveness of health interventions, and programs that create large externalities.
The package of services needs to be developed through a consultative and collaborative
process, involving leading health practitioners and policy makers from the different levels of
the health system, private and NGO sectors for social input, and the Finance Department of
the state government to assess the financial ability of the state to provide the recommended
package of services.
2.5
In order for the states to provide a basic package of services, which would be
targeted to the needy sections of society, state governments would need to undertake a series
of measures to reorient their health care system by strengthening institutional capacity and
initiating a process of policy reform . These are discussed below.
Key Aspects of the Health Care Strategy: Three main issues with regard to the
2.6
government’s health sector strategy include:
(0
The need to shift the government’s health care strategy from one that is anchored on
population-size based approach to an approach that addresses the health care needs of
the state based on the epidemiological profile and the burden of disease at the
community level. The government’s current health care strategy is based on a
network of primary health care centers that are more or less uniformly interspersed
across the country on the basis of a given population. This approach is neither an
efficient nor an effective way to address health care needs of different sections of the
population because of the variation in the epidemiological profile across
communities, block, districts, states and regions in the country. There is a need to
revisit the health care strategy, fine-tune it based on epidemiological data available at
the grassroots level, and involve the local administration increasingly in the planning
and implementation process. The panchayat administration provides an excellent
basis for greater community level participation in the planning process for health
care services, but the structures and systems linking the panchayat administration
with health administration will need to be more clearly defined;
(ii)
The need to improve technical efficiency of key programs which are seriously
limited, rationalize service norms at various health facilities, improve staffing norms
to better address need, and patient load, improve effectiveness of the referral
mechanism and update some of the technical paradigms.
For example, the
mechanism for delivering public health services faces serious problems, including
overlapping functions among the various tiers of the health care system. Services
provided at different tiers of the system are often duplicated and there is no clear
delineation of services at each type of facility - the lower tier institutions such as
primary health centers (PHCs) are underutilized due to a multitude of reasons,
including a lack of support from first referral institutions. The same applies for
national disease control programs. A few positive trends are noted. The leprosy
control program, for example, has shifted to a multi-drug therapy approach from the
ineffective Dapsone monotherapy that was used in the past; other inadequacies in
coverage, insufficient disability and ulcer care, inadequate detection of female
patients, low public awareness and associated social stigma are also being addressed.
Similar paradigm shifts are needed for TB. cataract blindness, malaria and other
national programs that are implemented at the state level.
(iii)
The need to provide better incentives for the workforce and address training needs.
Problems related to the availability and quality of staff impede the technical
efficiency of health programs and affect productivity. Overall, there is no shortage of
doctors in the country but there is a shonage in remote and rural areas. There is also
a shonage of nurses nationwide. Incentives need to be provided to medical
professionals to encourage them to remain in their rural posts, thereby decreasing
absenteeism. Training facilities and in-service training are limited, and professional
staff are not up-to-date in clinical and management skills. A better understanding of
the shortage of critical medical personnel and manpower needs are required.
2-7
tu
blic-Private Partnership in the Deliv
ery of Health Care Services- Despite
Public-Private
Delivery
accounting for 80% of overall health expenditures, the role of the private sector in the overall
health care strategy is not clearly defined. The vital role the private sector plays in the
provision of selected aspects of health services, such as ambulatory care, and the
opportunities which remain for greater private sector involvement in other areas have not
been fully recognized in policy making. The main challenges with regard to strengthening
the public-private partnership in the delivery of health care services include: enhancing the
scope and importance of the private health sector, while improving the quality of services;
encouraging private sector involvement in preventive and promotive aspects of health care
rather than solely on individual curative care; finding the appropriate mix between provision
versus financing of health care by the public sector; promoting partnership between the
public, private, and voluntary sectors; and improving the existing arrangement for regulating
and monitoring private health care.
28
Resource Allocation and Efficiency in the Health Sector: The overall fiscal situation
in many states has deteriorated sharply, with arising fiscal deficit, increasing interest
payments as a share of total revenue, and an increasing share of debt outstanding as a share
of state domestic product. The overall financial situation faced by the states has affected
health sector allocations. The public sector currently provides about USS2-3 per capita for
health.. The amount recommended by the World Development Report (1993) to provide a
basic package of public health and clinical services for low income developing countries is
about US$12 per capita annually. In the context of the Indian sutes, this may be a high
estimate. Nevertheless, a sizable increase over present allocation will be required to finance a
- 8 -
broadly defined package of services. Moreover, within the health sector at the state level,
resource allocation is skewed in favor of tertiary relative to primary and secondary services,
and- this imbalance needs to be corrected.2 In addition, since much of the resources are
absorbed by salary costs, the recurrent budget is chronically underfunded. Recognizing that
overall state finances pose a serious problem, the state governments’ objective of funding a
basic package of health service will require more resources for health care, especially for
primary and secondary' health care services.
2.9
Alternative Methods of Health Care Financing: Since cost recovery mechanisms in
the.health sector are not well developed in India, revenue collection remains low. Some of
the problems faced in this area include, inter alia: lack of an appropriate mechanism to
review user charges: weak administrative mechanism for the collection of user fees;
difficulty in targeting the poor for exemption from user fees, and constraints to greater
retention of funds generated through user charges at the point of collection. The resource
constraints faced in the health sector will require development of alternative methods of
health care financing, such as cost recovery, insurance and participatory schemes to
supplement budgetary allocations.
2.10
Health Care Management and Administration: The health care management system
at the state level is inefficient. Some of the problems that need to be addressed include:
weak overall management and health planning capacity; overlapping functions of the
different tiers of the health care system and lack of coordination and integration between
them; uncertainties associated with the decentralization of authority to the panchayat system
on the administrative operations of health care provision and financing; and the lack of
involvement of community level organization in revenue collection, planning and budgeting.
Health care management at the state will need to be strengthened by addressing these issues.
2.11
The key issues in the unfinished agenda are inter-linked. The dynamics between the
health care strategy, public-private roles, efficiency of resources in the public sector, alternative
financing mechanisms and management issues will continue to affect the quality, provision and
performance of the health care system. The improvements in the health sector will be
measured by the improved health status of the population, greater access and equity, improved
efficiency in the allocation of resources, and greater effectiveness of existing programs and
consumer satisfaction.
2
The terms first referral and secondary level hospitals are used synonymously in this report. They denote
commumty/rurai hospitals that have a bed strength of about 30-50 beds; area/taluka hospitals that have about 75100 beds; sub-divisional/State General hospitals that have about 100-350 beds; and district hospitals that have
about 300-550 beds The level of services offered increase from community to area to sub-divisional to districts
hospitals.
- 9 -
ClLU’TER 3
Backgroi nd to Health Policy and Planning:
Demographic Features and the Burden oe Disease in the Four States
A. Introduction
3.1
The challenge faced in the health sector of each state varies to some extent
depending on the burden of disease, existing public health programs, past pattern of
investment in the health sector, the involvement of the private sector and the level of
poverty. While resource allocation, institutional weaknesses and management issues are
themes common to the health care system in all states, the demographic characteristics,
epidemiological features and the burden of disease determine the nature of the health
problems faced by each state. This chapter provides a brief outline of the basic demographic
features, the epidemiological profile and the comparative burden of disease in the four states
included in this review. The findings of the Andhra Pradesh Burden of Disease and the BOD
estimates for Karnataka. Punjab and West Bengal are presented to illustrate the main
differences between the states. These differences show the varying pace of the health
transition across states.- the differences are especially marked between rural and urban
areas.
3.2
The states of AP, Karnataka. Punjab and West Bengal are included in this analysis
because of the richness of the data that was generated during the preparation of the state
level health systems projects and through subsequent analysis of the BOD in these states.
They provide an opportunity to study states that are at different levels of health and overall
development, and have diverse geographical, cultural and socio-economic features. West
Bengal, for example, is a state with large pockets of poverty and an underdeveloped private
sector in health care provision; Karnataka and AP are states with a per capita income which
are about the national average, but with large regional variations; and Punjab is a state with a
high per capita income, which requires a somewhat different emphasis in the type of health
package proposed. Together, they represent sufficient diversity among states in India to
draw lessons that are applicable at the state level generally.
3.3
These 1UU1
four biaies
states also represent oinerent
different stages in the health transition - ranging
from a high incidence of communicable disease, with relatively lower levels of noncommunicable disease and injuries to a situation of high levels of non-communicable
disease, with relatively lower incidence of communicable disease and injuries. The poorer
and more populated states, such as West Bengal, still face a large incidence of
communicable diseases. More prosperous states, such as Punjab, are further along in the
health transition and are seeing a sharply increasing incidence of non-communicable
diseases, especially in urban areas. There are states that are poorer than West Bengal and
less advanced in the health transition process (such as Orissa) and others that are further
along in the health transition (such as Kerala or Maharashtra), but the four states included in
this review generally represent the main spectrum of health care issues faced by the Indian
states.
1
- 10 -
B. Demographic Features of the States
I able 3.1: Health Status and Epidemiology in India and the Four States
India
Population (millions in 1995)
Crude Birth Rate
Crude Death Rate
Infant Mortality Rate
919
28.7
10.1
78.5
Expectation of Life at Birth
a) Male
b) Female
Percentage of Currently Married
Women 13-49 Using any
Contraceptive Method
Annual Growth Rate of
Population
Pregnant Mothers Receiving
Ante-natal Care
Deliveries by Trained Birth
Attendants
Immunization Status —
Percent Coverage
a) T T. (for preg. mothers)
| b) D.P.T. (infants)
| c)- Polio (infants)
[| d) B C G, (infants) __________
Andhra
Pradesh
66.5
24.2
Karnataka
47.9
25.9
8.5
Punjab
20.3
West
Bengal
72.4
25.5
7.3
75.3
9.1
70.4
65.4
25.0
8.2
53.7
60.6
59.1
62.1
66.6
62.0
40.6
47.0
49.1
58.7
57.4
2.1
1.9
2.1
2.2
78.1
84.0
85.1
80.0
69.8
78.1
51.7
70.0
70.0
91.3
70.7
73.6
53.4
71.4
73.4
62.2
73.9
81.7
77.4
Figures, unless otherwise noted, are from National Health Survey, 1991.
66.1
68.0
80.0
51.9
56.0
63.1
•
Andhra Pradesh: The population of Andhra Pradesh was about 72 million in 1995 and
a population density of 242 people per square kilometer, which was lower than the all
India average of 270. The percentage of Scheduled Castes (SCs) and Scheduled Tribes
(STs) is slightly lower than the all India average, while the sex ratio of 972 females per
1,000 males is higher than the Indian average of 927. The state has become more
urbanized, with 27 percent of the population living in urban areas in 1991.
•
With a crude birth rate of 24.2 per 1,000. a crude death rate of 9.1 per 1,000 and an infant
mortality rate of 70 per 1.000 live births, Andhra Pradesh’s demographic indicators are
similar to the all India average. The state's total fertility rate of 3.0 children per woman
is lower than the all India rate of 3.6 children per woman. The annual exponential
growth rate of the population (1981-91) at 2.17 is slightly higher than the all-India
average of 2.14.
•
Karnataka: The population of Karnataka was about 48 million in 1995, with urban areas
accounting for about 31 percent of the population. SCs and STs constitute about 16.4
and 4 percent of the state’s population respectively. With 40 percent of its population
living below the poverty line compared with about 33 percent for India as a whole, the
state has a comparatively large percentage of people living in poverty.
11 -
With a crude birth rale of 25.5 per 1.000. death rale of 8 per 1.000. and infant mortality
rate of 67 per 1.000 live births, health indicators are comparable to the average for Indian
slates. However, neonatal and post neonatal mortality and still birth rates have increased
over the past two decades and are high. In the last decade, the number of patients
admitted to government hospitals has increased by 60 percent, putting significant
pressure on hospital facilities.
•
Punjab: With a population of 22 million in 1995 and an annual population growth rate
of about 2.1 percent. Punjab is one of India’s more affluent states. Its population density
of 403 per square kilometer in 1991 is high compared to the Indian average of 273, as is
the percentage of the population living in urban areas (29.6 percent as compared to 23.9
percent for India). Punjab's 1991 per capita income at $554 ranked it first among Indian
states in terms of income. Yet 12 percent of the state's population is living below the
poverty line. Also, as in other states, there is substantial regional variation in per capita
income, with the northwest corner of the state having 40 percent of its population below
the poverty line.
•
Punjab's crude birth rate of 27.1 births per 1,000 is lower than the all India average, as is
the crude death rate of 8.2 deaths per 1.000 and the infant mortality rate of 55 per
thousand live births. While social indicators have improved on many fronts, the female
male sex ratio at 882 females per thousand males, is still a matter of grave concern.
•
West Bengal: With a population of about 72 million. West Bengal is the fourth most
populated Indian state. Around 40 percent of the population is below 15 years of age,
and only 27.5 percent live in urban areas. The large rural population is mainly
agricultural, with a predominance of small and marginal farmers. It is estimated that
more than 30 percent of the rural population lives below the poverty line. STs constitute
5.6 percent of the population and 23.6 percent belong to SCs.
•
High population density and poverty are mirrored in the state’s morbidity profile. With
an infant morality rate of 58, a crude birth rate of 25.6, and a death rate of 7.3, there is
still much room for improvement.
C. The Health Transition
3.4
Key health indicators in India show that the health status of its population remains
low. Communicable diseases continue to be major health problems; maternal mortality is
high; acute respiratory and diarrheal diseases account for a large proportion of childhood
mortality; and preventable mortality and morbidity especially among the poor, exact a high
toll. Health indicators in India, when compared with other countries in the region that started
with a similar resource base several decades ago, show that India has not fared as well as
some of its neighbors. The gains in life expectancy over the past three decades, for example,
have been 23% in India compared to 60% in China and 28% in Indonesia (World
Development Report, 1993).
3.5
In addition, India is moving into an epidemiological transition. Communicable
diseases and maternal and perinatal causes currently account for a large number of deaths in
- 12 -
India (about 470 per 100.000 population, standardized for age. compared to only 1 17 in China
and 187 in the world as a whole?)’* At the same lime, the gains achieved in life expectancy
have resulted in proportional increases in mortality from chronic and degenerative diseases of
adulthood, such as heart ailments and cancers. These trends are likely to persist. As fertility
declines, the age structure of the Indian population will shift and the proportion of people above
the age of 60 years will increase. As a result, the burden of non-communicable diseases will
rise further. At the same time, the challenge of communicable diseases of the young, middleaged. arid poor will persist. The central and state governments, therefore, will need to deal
with both a high level of communicable diseases and a rising incidence of noncommunicable diseases and injuries and accidents.
This dual burden of communicable and non-communicable diseases is likely to result
3.6
in an "epidemiological polarization" in which one part of the Indian population will
successfully complete a demographic and epidemiological transition while another part remains
in the pretransition phase. Indeed, this situation is already present in India, especially in terms
of the differences between rural and urban areas, and accounts for much of the dilemma of its
publicly provided health care system. The demands of the rural and urban middle and upper
classes for accessible, technologically advanced, and free clinical services compete with the
still pressing need for coverage with basic disease control interventions in rural areas. As a
result, the conflict over public resources is likely to be exacerbated by the on-going
epidemiological and demographic changes and poses a major future challenge for primary
health care policy at the state level in India. Moreover, the competition fur scarce resources has
the potential to worsen the unequal quality of health care among the states, as the poorer states
are unable to provide the matching funds required to qualify for some federal monies.
D. Epidemiology and the Evolving Burden of Disease in the Four States
3.7
For a long time, mortality was the predominant indicator in assessing the health
status of populations (Lopez and Murray, 1996). The burden of disease has traditionally been
based on the number of deaths different diseases cause and has relied on mortality data. This
approach served the purposes of development planners for a long time, since cause specific
mortality used to correlate well with morbidity and disability, particularly in many infectious
and parasitic diseases. Over time, with the decline of mortality rates, morbidity measures
have come to assume greater importance in quantifying the burden of disease, and the
inadequacy of mortality as a measure of health status is increasingly recognized. For
example, there is now evidence that low child mortality levels can be maintained even in the
presence of sustained high levels of under-nutrition and morbidity. There has also been an
accompanying shift from assessing causative factors to assessing risk factors. While it is
possible to identify causative factors in the case of communicable diseases, the etiology of
non-communicable diseases is so complex that it is usually not possible to point to a single
dominant cause. Therefore, sets of risk factors become important.
3.8
This calls for indicators that can simultaneously combine the load of morbidity,
disability and risks with the level of mortality. Burden of disease estimates provide a
mechanism of aggregating and comparing the size of various health problems through a
3
World Development Repon. 1993; Table A.7
- 13single indicator, which is the Disability-Adjusted Life Years (DALY).4 The World Health
Organization together with the World Bank developed a methodology and presented
estimates of the full loss of health life due to different causes in terms of DALYs lost in the
1993 World Development Report, which has been updated by Murray and Lopez, 1996.
According to these estimates. India accounted for 288 million DALYs lost in the year 1990,
which is over 21 percent of the global burden of disease, even higher than its share of overall
mortality.
3.9
Methodology. The Andhra Pradesh BOD study and subsequent analyses in
Karnataka, Punjab and West Bengal form the basis of the discussion of BOD in this chapter.
These studies were commissioned by the Bank and undertaken by the Administrative Staff
College of India (ASCI), with the objective of (i) estimating the BOD caused by common
diseases including accidents and injuries; and (ii) comparing the disease burden in urban and
rural areas of the four states. The cost-effectiveness of selected health interventions using
DALYs as a measure of effectiveness was also undertaken, but only for AP and is discussed
in Chapter 8. The BOD part of the study analyzed the following data: (i) demographic
estimates, including age-specific mortality, preliminary disease lists, and survey of cause of
death; (ii) information gathered from expert opinion and field inquiry; and (iii) literature
review of existing epidemiological studies and available data.
3.10
The methodology of the AP BOD study was repeated in the other three states
included in this review. Estimates of disease burden for 1992 were used, since this is the
latest year for which Sample Registration System data on age and sex specific mortality rates
are available. Population projections for 1992 were made using the exponential method. In
the three stales, original data' was used for the urban areas, which was obtained from the
Medically Certified Causes of Death Register. In rural areas, sample cause of death was
used based on verbal autopsy. For disability, epidemiological information from the national
programs at the state level were used to get at the state-specific prevalence data. Incidence
data in each state was modified from the AP data on the basis of state-specific disease
patterns ( e.g. kala-azar exists in West Bengal, but not in AP) and on the basis of existing
empirical evidence in each stale. The incidence rates in each state were calculated based on
the prevalence rate, general mortality and remission data, using the standard “Dismod”
model.
3.11
Findings of the BOD Estimates. The data are summarized in Tables 3.2, 3.3, 3.4
and 3.5. It is broken down according to DALYs lost in rural and urban populations, in
absolute numbers, as well as DALYs lost per thousand population. Diseases are categorized
as follows; category I denotes communicable diseases, including TB, sexually transmitted
diseases, diarrheal disease, meningitis, hepatitis, malaria, tropical cluster, childhood cluster,
leprosy, trachoma, intestinal helminths, respiratory infections, maternal causes and perinatal
causes. Since nutritional deficiency disorders predominate in the pretransition phase, they
were also included in this group; category II denotes non-communicable diseases, including
malignant neoplasms, diabetes, neuropsychiatric disorders, sense organs, cardiovascular.
4
The WDR (1993) defines Disability-Adjusted Life Years (DALYs) gained as a unit used for measuring both the
global burden of disease and the effectiveness of health interventions, as indicated in (he reduction in the disease
burden. It is calculated as the present value of the future years of disability-free life that are lost as a result of
the premature death or cases of disability occurring in a particular year.
i-l ‘
respirator}', dicestive. genitourinary, and musculoskeletal disorders, as well as dental health:
category III denotes accidents and injuries.
Table 3.2: DALYs Estimated to be Lost During the Year 1992
State
Andhra Pradesh
Karnataka
Punjab
West Bengal
Rural
14.037.909
8,945.778
3,942.743
14,032.832
Area
Urban
3.619.609
2,616,910
1,268.929
3,274.114
All
17.657.518
11,562.687
5,193.672
17.306.947
3.12
A major finding of the BOD estimates in the four states is that the distribution of the
BOD between categories I, II and III is different from the distribution presented in the WDR
(1993), but similar to the updated version presented by Murray and Lopez (1996). The first
difference is with regard to the contribution of non-communicable disease (category II) to
the overall BOD. In AP, Karnataka. Punjab and West Bengal, the contribution of category II
amounted to about 30%, 28%, 29%. and 28% respectively. This compares to 41% estimated
in the WDR (1993), but more in line with the 29% estimated by Murray and Lopez (1996)
and for India overall. A small percentage of this difference could be explained by the
exclusion of nutritional deficiency disorders from category II in the BOD estimates for the
four stales and in the Murray and Lopez estimates (1996). The second difference is with
regard to the contribution of injuries and accidents (category III) to the overall BOD. In the
four states, the contribution of category' III to the total BOD ranges from between 15% and
19%, whereas the WDR (1993) estimate, for all of India, was about 9% and the Murray and
Lopez (1996) estimate is about 14.6%. The difference between the BOD estimate in the four
states and the WDR (1993) estimate with regard to the contribution of communicable disease
(category I) is not significant. If these results were to apply to all of India, they would imply
that the contribution of non-communicable diseases to the BOD, which has been growing
quite rapidly, has however been overestimated in the past: and that of injuries and trauma has
been underestimated.
3.13
As shown in Table 3.2, Andhra Pradesh had the highest total of DALYs lost in 1992,
at about 17.7 million, followed by West Bengal, at 17.3 million. Karnataka and Punjab
followed, with about 11.6 million and 5.2 million respectively. The DALYs lost are roughly
in proportion to their overall population. The total DALYs lost in rural areas accounted for
80 percent of the total number of DALYs lost in Andhra Pradesh and West Bengal, but was
slightly lower for Punjab at 76 percent and Karnataka at 77 percent. Data elsewhere also
indicates that the relative burden of disease seems to be higher among the residents of rural
areas.
3.14
The data also show that the DALYs lost per 1,000 population in rural areas of
Andhra Pradesh, Karnataka, and Punjab are similar at approximately 289, 288 and 272
DALYs lost per 1,000 respectively. The figure for West Bengal was lower at about 276
DALYs lost per 1,000, largely because of the lower DALYs lost per 1,000 in urban areas.
Punjab and AP are estimated to have a higher disease burden in urban areas relative to the
other states, at about 205 and 202 DALYs lost per 1,000, respectively, as against only about
171 and 184 DALYs lost per 1,000 in West Bengal and Karnataka. As shown in Table 3.3,
- 15 -
the greatest difference between urban and rural areas was found to be in the state of West
Bengal and Karnataka, with a difference of about 105 and 103 DALYs lost per 1.000
respectively, indicating relaiivel) poorer access to health care in the rural areas in these two
states.
Table 3.3: DALYs Lost per 1,000 Population
State
Rural
Urban
Total
Andhra Pradesh
Karnataka
Punjab
West Bengal
289
288
272
276
202
184
205
171
266
Urban-Rural
Differences
87
103
67
105
253
252
248
Table 3.4: DALYs Lost per 1000 Population by Major Cause Groups
in Rural and Urban Areas
DALYs lost per 1000
Rural
State
Andhra Pradesh
Karnataka_____
Punjab________
West Bengal
DALYs lost per 1000
Urban
I
11
III
I
II
160.0
81.5
72.2
72.5
68.6
47.2
97.7
86.5
93.8
71.0
74,3
66.7
71.8
71.1
168.0
153.2
164.4
43.6
45.9
44.4
3.15
III
30.5
30.3
39.7
28.7
Communicable diseases (category I in Table 3.4) still predominate in the rural areas
of all four states. The total DALYs lost per 1,000 in rural areas in this category in AP,
Karnataka. Punjab and West Bengal were about 160, 168, 153 and 164 respectively. The
total DALYs lost per 1,000 in category II and III combined in rural areas was much less at
about 129, 116, 1 19 and 113 respectively. Moreover, the magnitude of the disease burden
caused by communicable diseases closely corresponds to the total burden, following a trend
in all developing countries. This trend, however, was reversed in urban areas, where in all
states, the total of DALYs lost per 1,000 in category II and III was higher than that of
category I, indicating that the urban areas are in a more advanced state of demographic
transition. The predominance in Punjab of DALYs lost per 1,000 due to diseases in category
III, especially in urban areas, can partly be explained by the political disturbances in the state
during that period.
I,
* 16 •
Table 3.5: Total DALYs Lost per 1,000 Population anti by Major Cause Groups
State
A.P.
Karnataka
Punjab
West
Bengal
Thousands
66,508
45.781
20.628
69,692
DALYs lost per 1,000
DALYs lost
Population
in
I
9,528,102
6.529,396
2,793.402
9,684,410
11
111
5.288.635
3,227.299
1,491,451
4,829,643
2,840,781
1,805,992
908,818
2,791,562
I
143.26
142.62
135.41
138.96
11
79.52
70.49
72.30
72.30
III
42.71
39.45
44,06
40.06
3.16
DALYs Lost by Age Group, The overall distribution of DALYs lost per 1,000
population in different age groups indicate that the pattern is more or less similar in all the
states. The highest burden was estimated in the 0-4 years age group, while in the 5-14 years
age group the burden was least. In the 15-44 years age group the burden of disease was
relatively higher among females due to maternal disorders.
3.17
The distribution of the DALYs lost in each age group by major cause category
(categories I. II and III) indicate that amot g the 0-4 years age group, category I disorders
were dominant as expected. Punjab had a re latively lower burden due to category I disorders
amopg males in this age group. The differences between both sexes with regard to category
I diseases were more marked in Punjab (a difference of 85 DALY per 1,000 between male
and female children) as compared to the difference in other states, thereby indicating higher
vulnerability of female children in Punjab.
3.18
In the 5-14 years age group, the burden caused by category I diseases was close to
that of total burden caused by categories I! and III together. In fact, the burden caused by
category III in most states was responsible for a third of the burden among males. This is
quite plausible, considering the higher vulnerability of this age group to injuries and
accidents. The corresponding proportion in case of females was less than 25%, suggesting
that female children are less prone to injuries in this group.
3.19
In the 15-44 years age group, the epidemiological transition is quite evident in males.
The total of category II and category III disorders was nearly double that of group I.
However, in case of females the trend observed in the 5-14 years (category I burden being
equivalent to total of categories II and III) still continued, essentially due to higher burden
caused by maternal conditions. Thus, the analysis clearly indicates that there is an urgent
need to address maternal health problems on a priority basis. Surprisingly, Punjab had the
highest burden due to category I among females in this age group. This has implications
related to access for essential and emergency obstetric services.
3.20
In the 45-49 years age group, the epidemiological transition is quite evident as
degenerative disorders (category II) are dominant. However, in the case of women, the
burden caused by all the major cause categories was estimated to be relatively less compared
to males. This trend was especially marked in the case of degenerative disorders (difference
of 40-60 DALYs per 1,000).
- r3.21
In the 60+ age group the degenerative disorders are the dominant cause of burden of
disease in both sexes. Higher relative burden of category III disorders among females could
be partly explained on the basis of higher vulnerability to injuries due to osteoporotic
changes and hormonal imbalances.
3.22
Data on Hospital Visits. Another issue of interest related to the BOD is the number
of hospital visits, both inpatient and outpatient, and their distribution between the different
categories of diseases In Punjab, for example, the overwhelming number of patients
presenting themselves at health care institutions belong to the non-communicable disease
category (category II). Hospital level data indicates that category II cases account for about
76% of all outpatient hospital visits and about 86% of all inpatient visits in Punjab. In
Karnataka, comparable data indicates that category I and category II diseases contribute
almost ^equally to outpatient visits — about 36% and 38% respectively. With regard to
inpatient visits, however, there is a significant difference, with category I diseases
contributing only 27% of hospital visits as compared to 49% by category II diseases. This
could be used as one indication that the health transition is well underway in Punjab, with
category' II diseases clearly placing a heavy burden on the health care system, even though in
terms of DALYs lost, category II diseases in Punjab appear not to evince a pattern different
from the other states. Karnataka seems to be lower on the transition curve, with category I
diseases not too far behind-category II diseases, although category II diseases seem to be
gaining predominance, particularly for inpatient care.
E. Recommendations
•
The comparison of the demographic features in the four states and their evolving burden
•of disease highlights the continuing need to address those diseases which contribute the
most to the BOD, in a cost-effective manner. As seen in Table 3.5, communicable
disease (category I) still accounts for the majority of DALYs lost in all four states. The
focus of health care policy in the short run should, therefore, continue to address the
large burden of communicable diseases.
•
The emphasis on addressing communicable disease, however, should not overlook the
marked difference in demographic indicators and disease burden at the state level. As
seen in the case of Punjab, which has a highly urbanized population and a high incidence
of category I and category II diseases, the situation varies from state to state. The policy
should, therefore, be flexible in addressing the evolving burden of disease.
•
The data indicate that in the case of urban areas, the emphasis should be in moving
towards improving lifestyle and behavior patterns due to the predominance of category II
and III diseases. Since the cost of health care in such situations is quite high, the state
governments should seriously consider the option of cost sharing for such services, with
exemptions for the poor. This issue will be elaborated in later chapters.
- 18 -
Chapter 4
The Private Sector in Health Care at the State Level
A. Introduction
4.1
Total health spending in India accounted for about 6% of GDP (1991), which is
about Rs. 320 or about US$13 per capita in 1991 prices. While the level of spending per
capita on health is low in absolute terms, the health sector's contribution to national income
in Indiac is higher than in most developing countries at similar levels of per capita income.
Despite the historical and legal emphasis on the Government's role in the health sector in
India, expenditure data clearly indicates the dominance of non-government spending.
Private sector expenditure in India is estimated to be about 78% of total health spending.
This share of total private spending on health is comparable with Thailand, which has an
absolute per capita spending four times greater than that of India. Government health
spending in India, on the other hand, is in the middle of the range reported for lower income
Asian countries - it is higher than Indonesia and the Philippines; and lower than China and
Sri Lanka.5
4.2
A 1991 national household expenditure survey carried out by the National Council
for Applied Economic Research estimated that out-of-pocket spending on health accounts for
almost all of private health spending; private and corporate insurance contributed only about
3.3% of private spending on health. Per capita out-of-pocket spending in India was Rs. 240,
which is about 75% of total national health expenditure.6 Other estimates also point to the
conclusion that private out-of-pocket expenditure is the major contributor to financing health
care in India.
4.3
The role of the private sector in the overall health strategy is not clearly defined. The
vital role the private sector plays in the provision of selected aspects of health services, such
as ambulatory care, and the opportunities which remain for greater private sector
involvement in other areas have not been fully recognized in policymaking. The main
challenges with regard to public-private roles include: enhancing the scope and importance
of the private sector, while improving the quality of services; encouraging private sector
involvement in preventive and promotive aspects of health care rather than solely in
individual curative care; finding the appropriate mix between provision versus financing of
health care by the private sector; promoting partnerships between the public, private and
voluntary sectors; and improving the existing arrangement for regulating health care.
4.4
This chapter is based on the information provided by four separate studies of the role
played by the private sector in the provision of health care services in the states of
5
India: Policy and finance Strategics for Strengthening Primary' Health Care Services World Bank Report No.
13042-IN; 1995.
6
ibid. pg. 66.
- 19 -
Karnataka. Punjab. West Bengal (WB) and AP.7 It also draws upon the Gujarat Institute of
Development Research study, '’Utilization of and Expenditure on Health Care in India. 198687. A Study of Five Slates”, which was undertaken as pan of an earlier study on primary
health care financing. This chapter assesses the scope of the private sector in the states,
including the geographical and social spread of the sector and the types of services offered;
assesses the quality of services provided at private sector institutions relative to the public
sector, and compares the fee structure for different services at private vs. public institutions;
the possibilities for expanding the scope of private sector involvement, including the
voluntary sector; opportunities for contracting out: and analyzes the extent to which the state
health Secretariat/Directorate regulates, accredits and monitors private sector institutions,
with particular reference to the Consumer Protection Act.
B. Client Perceptions of the Role of the Private Sector
4.5 - The following findings are based on the private sector and beneficiary assessment
studies in the four states:
•
The main advantage of the private sector health facility is its easy accessibility. Not only
are private clinics better located in urban areas, there is also the facility of round-theclock availability of a specialist on the premises, unlike in the case of a government
hospital where doctors are available only for a fixed number of hours every day. In
addition, due to better maintenance and sanitation, and more courteous treatment by the
medical personnel, private hospitals are perceived to be providing better services than
government hospitals.
A majority of patients visiting private clinics belong to the middle and upper socio
economic classes, since the costs of private treatment are very high when compared to a
government hospital. In West Bengal, for example, it was found that, of out-patients
visiting a private practitioner, 58% spent about Rs. 100, 24% spent Rs. 100-300, and 7%
spent more than Rs. 300 on medicines in the three months preceding the interview. By
comparison, the figures for those visiting a government hospital are 28%. 12% and 5%
respectively. In other words, only about 10% of out-patients were spending less than Rs.
100 in the private sector, as against almost 55% of out-patients visiting government
hospitals.
•
Of those belonging to the low-income and tribal groups, a majority were of the opinion
that, although private hospitals offered modem equipment and convenient service, the
costs of treatment were prohibitive, and few of them could afford to consistently visit a
private practitioner. Moreover, it was felt that the private practitioners commitment to
low-cost preventive care was minimal, and that in the case of emergencies a government
hospital was much more likely to provide efficient service.
•
The private sector in health care delivery is unorganized, and is operated by a mix of
qualified and unqualified practitioners. In the four states studied, it is relatively better
7
The study in Karnataka was done by the Administrative Staff College of India; in Punjab, by the Foundation for
Research on Underprivileged Groups; in WB by the Operations Research Group; and in AP by G. Kumara
Swamy Reddy.
i
- 20 -
developed in Karnataka. Punjab and AP. particular!} around urban centers, than in West
Bengal. Services are provided mainly through small clinics and nursing homes. Most
private practitioners dispense allopathic medicine, although homeopathy and ayurved are
also widespread. Both preventive and curative services are provided, while emergency
and medico-legal cases are generally referred to government first referral hospitals.
C. Scope of the Private Sector in Health Care Delivery
46
Relative Size of the Private Sector. The private health sector is fairly large in all the
states, except in West Bengal, and is growing very fast, particularly in AP and Karnataka. At
the primary care level, the private sector is pervasive and heavily used despite the vast
network of primary health infrastructure developed by the government. At the secondary
and tertiary levels, the private sector presence is less dominant, but is increasing its share of
services in the tertiary sector. This is partly due to client perceptions of public health care
services being more positive at the secondary and tertiary levels than at the primary level. In
1992 a survey conducted by the Institute of Health Systems indicated that in AP the bed
strength in the private sector was larger than the public sector: the government accounted for
33,949 beds, while the private sector accounted for 42,192 beds, in 3,029 private health care
institutions. In Karnataka, the total bed capacity of registered private and voluntary
institutions was 40,900, in 1,709 private health care institutions as against a total of 31,840
beds in government hospitals. West Bengal is an example of a state where the contrary is
true: only 10% of the total bed strength is in the private sector, with a total of only 6,912
beds. As a result, in the states studied, apart from West Bengal, the distribution of medical
manpower is also skewed towards private institutions. In AP, for insUnce, of a total of
33,983 doctors registered with the Medical and Nursing Council, only 5,148 doctors
(excluding those in administrative positions) are employed in the government sector. Almost
50% of registered nurses and auxiliary nurse midwives (ANMs) are employed in the private
sector as well.
4.7
Due to various data problems, we may still have an incomplete picture of the size of the
private sector. In recent years, the corporate sector has invested heavily in large and highly
sophisticated facilities catering to the urban middle and upper class patients. Evidence suggests
that the number of nursing homes, even in rural towns, has rapidly expanded. There is rapid
and highly visible growth of for-profit hospitals in major urban centers. Private sector
investment in secondary level hospitals has not increased rapidly.
48
Ownership and Management. With regard to ownership and management, the
private sector facilities in the states studied can be classified as follows:
•
•
•
•
•
Clinics owned and managed by single practitioners.
Nursing homes/hospitals of varying sizes.
Large corporate hospitals.
Hospitals not-for-profit.
Chantable/religious institutions.
49
— .
.
The data indicates that in terms of bed strength, hospitals can be divided into those
with less than 30 beds; 50 beds; 100 beds; and more than 100 beds. More than three-fourths
I
- 21 of private institutions have less than 30 beds. These small facilities are usually owned by
single doctors or a family, and are generally attached to a medical shop. Very few hospitals
have more than 100 beds, and these are usually attached to private medical colleges.
Partnership firms constitute about 7% of private institutions, while charitable trusts and
religious missions constitute about 5%. The pattern of ownership of private institutions in
Karnataka, for example, is shown below:
Table 4.1: Distribution of Private and Voluntary Hospitals
by Type of Ownership in Karnataka
Ownership
Charitable Trust
Religious Mission
Registered Society
Limited Company
Partnership
Individual______
Total
Bed Strength
<10
10-29
30-39
50-99
8
3
6
I
17
575
610
20
10
10
5
18
2
6
13
4
I
5
7
31
61
717
829
”34
90
153
100 and
above
9
___ 8
19
5
" 12
56
Total
68
27
42
19
128
1425
1709
4.10
In addition, the private contracting of health services, especially support services, by
the government is becoming increasingly important since the state Governments can effect
substantial cost-savings through such a mechanism. The changes in technology and
manpower mix are affecting the services offered at specific government facilities.
1
Regional VarialiQnS- Neither the private institutions nor the hospital beds are evenly
distributed across the states. They tend to be concentrated in densely populated urban
centers. In AP, for instance, the bed-population ratio ranges from a low of 0.07 beds per
1,000 population in Mahbubnagar to a high of 1.41 in Krishna district. In WB, 21% of all
hospitals and 47% of all hospital beds are concentrated in the Calcutta Metropolitan Area. In
Karnataka, private sector institutions in three districts - Dakshina Kannada, Bangalore and
Belgaum - contributed more than 1 bed per 1,000, while the districts of Raichur, Bellary and
Chickamagalur had less than 0.5 beds per 1,000 contributed by the private sector. The
principal contributing factor to this disparity is the relative affluence of a region, making it
more profitable to establish and operate a private hospital. Other factors include higher
population density, the presence of educated clientele, and the existence of pressure groups.
There are also intra-regional disparities for many of the same reasons: rural vs. urban
population, and level of socio-economic development.
^•^2
SfirViccs Offered by the Private Sector. Government provided services are the major
source of inpatient care. In contrast, non-govemment providers — mainly for-profit, fee-forservice practitioners — provide the bulk of outpatient and ambulatory care, the curative
component of health care. Government providers are also the major source of preventive
care in rural areas, although coverage remains low overall for several dimensions of routine
preventive care for mothers and children. In urban areas, the coverage is higher, and there is
a larger private sector role. Diseases for which mass public health outreach programs exist,
such a§ FB control, malaria control, diarrheal disease control and safe motherhood/matemal
and child health (MCH) make up a large pan of the caseload for public hospitals. Most of
these public health programs have low coverage in terms of finding and treating patients on
an outpatient basis. Publicly funded outpatient treatment of TB reaches only half of those
reporting the disease, and coverage for other diseases is much lower. Private primary level
treatment is the dominant source of care for a number of such diseases which have been
targeted by public disease control programs in both rural and urban areas.
4.13
The studies in the four states indicate that the private health sector provides mainly
diagnostic and curative health services, leaving the entire field of preventive health services
to the government. For example, private nursing homes catering to delivery cases are very
extensive. A high percentage of curative services offered are comprised of ambulatory
services not requiring hospitalization. Intermediate patient care services, with short term
hospitalization, are also provided by private institutions. On the other hand, very few private
institutions offer intensive care. Most intensive and emergency care is provided by
government teaching hospitals.
4.14
Allopathy is the predominant system of medicine practiced, especially at the hospital
level. General medicine iss the most common service offered by private institutions.
Obstetrics and gynaecology comes next. The size of the hospital seems to have an influence
on the range of services offered: most smaller hospitals offer general medicine, with very
few surgical specialties. The number of surgical specialties seems to increase with size of
hospital.
. 5
The support services available to private sector institutions is uneven. Based on data
rom Karnataka, about 55% of private institutions had attached diagnostic laboratories, while
about 40% had x-ray plants. About 25% of the hospitals had ultrasound scanners, and 20%
had attached pharmacies. The private/ voluntary sector in the whole state had 33 CT
scanners, of which nearly half were located in the state capital. However, only 3% of the
private hospitals had a blood bank, and in many districts, there was no blood bank listed in
the private sector.
r
:L:
- 23 Table 4.2: Distribution of Private and Voluntary' Hospitals
by Range of Services Offered in Karnataka
Number of
hospitals____
Health Edu.
Immunization
Family
Planning
MCH_______
G. Medicine
Obstetrics
Gynaecology
Pediatrics
Cardiology
General
Surgery
Urology
Nephrology
|[ Orthopedics
[I Oncology
j Ophthalmology
Skin & VD
Dentistry
Psychiatry
Physiotherapy
Anesthesia
No.
610
%
100
No.
829
%
100
No.
153
%
100
No.
61
°/o
No.
100
IT
%
100
No.
1709
%
100
236
283
269
38.7
46.4
44.1
320
508
587
38.6
61.3
70.8
60
115
126
39.2
75.2
82.4
30
47
46
49.2
77.1
75.4
39
51
46
69,6
91.1
82.1
685
1004
1074
40.1
58.8
62.8
331
483
334
362
311
59
143
54.3
79.2
56.4
59.3
51.0
9.7
23.4
598
688
653
670
581
240
467
72.1
83.0
78.8
80.8
70.1
29.0
56.3
121
135
141
141
130
83
118
79.1
88.2
92.2
92.2
85.0
54.3
77.1
48
52
47
52
51
42
51
78.7
85.3
77.1
85.3
83.6
68.9
83.6
48
52
53
53
54
49
55
85.7
92.9
94,6
94.6
96.4
87.5
98.2
1146
1410
1238
1278
1127
473
834
67.1
82.5
72.4
74.8
65.9
27.7
48.8
23
18
88
16
88
80
70
19
18
15
124
3.8
3.0
14.4
2.6
14.4
13.1
11.5
3.1
3.0
2.5
20.3
131
64
316
42
185
276
185
51
101
65
15.8
7.7
38.1
5.1
22.3
33.3
22.3
6.2
12.2
7.84
50.8
61
26
109
26
74
95
74
36
58
43
115
39.9
17.0
71.2
17.0
48.4
62.1
48.4
23.5
37.9
28.1
75.2
29
16
43
21
35
41
35
20
22
21
49
47.5
36
27
49
29
45
47
45
34
40
41
54
64.3
48.2
87.5
51.8
80.4
83.9
80.4
60.7
71,4
73.2
96.4
280
151
605
134
409
539
409
100
239
185
763
16.4
8.8
35.4
7.8
23.9
31.5
23.9
9.3
13.0
10.8
44.7
■421
26.2
70,5
34.4
57.4
67.2
57.4
32.8
36.1
34.4
80.3
4Access- The private sector studies in the four states also indicate that the
access to services in the public and the private sectors in health varies widely between states.
The factors which determine the access to health services include socio-economic status, the
level of fees, availability of services and the nature of the illness.
•
■
Physical Access. Clearly, hospital services provided by the government are inadequate
in rural areas. Distance traveled to reach first referral hospitals seems to be an important
factor in determining utilization. Community hospitals in tribal areas are located very far
from tribal hamlets, with poor transportation and communication facilities, and often
with no convenient residential arrangements for the medical personnel. Non-availability
of staff, particularly doctors, is stated to be the most important reason for preferring
private medical care over government hospitals. Especially in emergency situations, the
easy accessibility and ready availability of quacks or underqualified doctors is a major
determining factor of community preference for their services. Another important issue
is the non-availability of necessary drugs and medicines at first referral hospitals,
particularly for curative care, which has been identified as a major constraint to patient
satisfaction. The community, however, seems to be willing to pay for the medicines
provided by the hospital staff. In addition, areas such as the Sunderban region of West
Bengal, for example, pose a special challenge since transport and communication
networks are inadequate, and riverine transport between the network of 54 islands is
- 24 -
unreliable. In the case of Karnataka, the nonhern districts of Bidar, Bijapur, Gulbarea
and Raichur have historically been neglected in terms of health sector development and
health indicators tend to be poor in these areas. There is a special need to strengthen
health care networks in these areas, and to encourage the development of the private and
NGO sectors to provide outreach services which the public health services are unable to
provide.
Social Access. Results from the qualitative survey conducted in the three states indicate
that tribals have a special set of social beliefs and practices which affect their health
seeking behavior. In addition, in tribal areas, the insensitivity of medical personnel
strongly influences the community’s confidence in them. According to hospital sources,
the proportion of hospital users belonging to SC/ST groups is commensurate with their
proponion in the general population. However, considering the poor socio-economic
condition of these groups, and their low nutritional level, the morbidity and mortality in
this population is greater and warrants a higher utilization of primary care and secondary
hospital services. An additional issue is the low utilization of health services by women
In Karnataka, for example, the National Sample Survey (NSS) indicates that the sex ratio
among hospitalized cases is 786 females per 1,000 males, whereas the sex ratio in the
population is 960 females per 1.000 males. There is therefore a need for special outreach
efforts to improve the access of these groups to health care services as well.
•
Economic Access. The data show that substantial costs - on fees, drugs, tests and
transpon - are being incurred by tribals and |poor populations possibly because they
postpone treatment until the problem has become: imore acute. In addition, due to the
relative inaccessibility of government health care services, populations in rural and
remote areas are approaching the private sector first for their health care needs.
<17
Eee Structure. The data on fees charged in samples taken in Karnataka and AP are
shown m Tables 4.3 and 4.4. It is evident that a wide variation in fee structure exists
Charges' are highly subsidized in hospitals run by charitable organizations and religious
missions. Some hospitals run by private medical colleges also offer subsidized services to
the poor. Fees are charged generally for registration; consultation; investigative procedurestreatment; inpatient procedures; and use of support facilities. Fees charged vary from
institution to institution, depending on the range of services provided; doctor’s qualifications
experience and expertise; type of disease; location of hospital; equipment and facilities; local
availab.hty of alternatives .(competition); availability of facilities like operation theater and
surgery; availability of consumables and disposables; and the reputation of the hospiul.
4.18
There is a wide difference in the cost of inpatient treatment between urban and rural
areas: for s.m.lar illnesses, though not fully controlled for case-mix, rural patients at private
institutions spent Rs. 225 per illness episode, while their urban counterparts spent Rs. 975
a most 4 times as much. Fable 4.4 gives the use of services and cost of treatment in private
and government hospitals. The data show that the cost per illness in private hospitals is
nearly three times that in government hospitals for inpatient services (Rs. 600 vs Rs 208)while for outpatient services, the cost per illness in private hospiuls is about double that in
government hospitals (Rs. 96 vs. Rs. 47). Chapter 7 presents a more detailed discussion of
user charges in the public sector.
- 25 Table 4.3: Cost of Treatment for an Illness Episode
in Nellore District (AP) in Rs.
Rural Areas
___ ^Jrban Areas
Individual
Private
Govt.
Private
Contributions
Inpatient
I
123 ___________ 225
12
975
Outpatient
T
____ 32
~71~______________
1
120
Source: A Review ot the Private Health Sector in Andhra Pradesh. G. Kumara Swamy Reddy; 1994.
Govt.
Table 4.4: Comparison of the Cost of Treatment in
Government and Private Hospitals
Type of Health Care Provider
Average Expenditure per illness (Rs.)
Inpatient
Outpatient
i Government Hospitals and PHCs
208
47
| Private Hospitals. Nursing Homes, Non600
96
II Profit Organizations
Source: A Review ot the Private Health Sector ,n Andhra Pradesh. G. Kumara Swamy Reddy; 1994
D. Expenditures in the Private Sect i
or: Emphasis on Out-of-Pocket Spending
4.19
exnendit
711"
“u65"
Sh0Wn in Table 4 5 shows that household out-of-pocket
oX m n' aCC°UntS u ' ab°Ut ?5% °f ‘Otal nati°nal health expenditures. Corporate and third
78°/oft
c°ntrlbu‘es an additional 3.3%. As a result, private health spending is about
remaining -“/o Privlu 8' d^31’
'0Cal 8°Veniment contributions account for the
70V of
~7
PC
8 aCC°UntS f°r 82% of Primary care- 92% of curative care
70/o of secondary/tertiary care and only 27% of preventive and promotive care In contrast’
state governments account for only 10% of all primary care spending, 6% of curative care 2”%
of secondary and ternary care, and 30% of preventive and promotive care
Table 4.5: National Health Spending: An Estimated “Source and Uses” Matrix
(in percent of total expenditures)
Uses
Primary Care
Curative
Preventive and
Promotive Health
Central
Government
4.3
Sources
State & Local
Government
5.6
Corporate/
3rd Party
0.8
Households
Total
48.0
58.7
0.4
3.0
0.8
45.6
49.7
4.0
2.7
2.4
9.0
Secondary/Tertiary
0.9
8.4
2.5
27.0
38.8
Inpatient Care
Non-service
0.9
1.6
N/A
N/A
2.5
Provision
TOTAL
|
6.1-------15.6
|
3,3
75
100
Derived from: India; Policy and Finance Stratrpii
1995.
* ^.ior Strengthening Primary Health Care Service Report n0 13042-IN;
I-
- 26 -
-Big Contribution of Out-of-F^ockei Spending on Out-Patient Services. In industrialized
countries, hospitalization accounts for the largest share of health expenditure and little of it is
financed directly by households. In India, the pattern is reversed. About two-thirds of
household out-of-pocket health spending in India is on ambulatory or outpatient services and
one-third on inpatient care. Thjs pattern is especially relevant to policy on primary health care,
since private practitioners dominate in the provision of outpatient services, much of which
substitutes for services which are supposed to be available through government providers as
part of public sector primary health care programs.
4.21
An estimated 65% and 60% of household health spending in rural and urban areas
respectively goes towards ambulatory illness treatment. Extrapolating from the national
estimate that 75% of total health spending is direct household spending, these figures imply
that household ambulatory care spending accounts for approximately one half of total national
health expenditures.
4.22
Unfortunately, there is little basis for estimating spending on primary' care from private
firms, or estimating household out-of-pocket spending on preventive and promotive services
Both are likely to be modest. Thus, approximating primary care expenditures with the available
evidence suggests that it accounts for about 60% of total national health expenditures and that
fouf-fifths of that expenditure is from household out-of-pocket sources.
4 23
Qui-of-pockct Health Spending and the Poor- Government primary care services do
not appear to be well targeted to the poor.8 Despite public subsidies for hospital care, out-ofpocket expenses for serious illnesses impact the poor disproportionately. In a serious illness
episode, families might pay fully for private ambulatory care, then go to a public hospital
where they might receive a free or highly subsidized day charge but still pay for other services
as well as for .terns not available at a public hospital. After discharge, they may again pay fully
for private follow-up treatment. The total costs of treatment are much higher due to the use of
private health services.
4.24
The burden of out-of-pocket spending falls disproportionately on the poor even for
pnmary illness care. On average, 5% of total household consumer expenditure in rural areas
was health expenditure, while 2.3% of total household expenditures in urban areas was health
expenditures. In almost all cases, the percentage of household spending on health was highest
m the lowest expenditure quintiles, reflecting the fact that the burden of out-of-pocket spending
was regressive and imposed a heavier burden on the poor. This trend was even stronger when
household spending on ambulatory illness care was examined separately. Ambulatory care
accounted for a larger portion of household health spending in the lower expenditure quintiles
in both rural and urban areas.
4.25
Approximately half of household out-of-pocket expenditure is payment to private
ambulatory care providers. The figures are fairly similar in both urban and rural areas, despite
8
9
India; Policy and Finance Strategies for Strengthening Primary Health Carr .Services- World Bank Report No.
13042-IN; 1995; pg. 76^
ibid. Tables 5.1 and 5.2.
*
27 .
the fact that one might expect higher percentages in cities accompanying the greater
concentrations of private providers likely to be found there. Most illness care contacts in all
expenditure quintiles are with non-govemment providers. These contacts generally involve
out-of-pocket payments about 1.5-2.0 times higher than when contacted with government
providers. These estimates suggest a consistent pattern that household health spending is
mainly for private ambulatory care providers and that the burden of this cost falls
disproportionately on the poorest households.
4-26
Elivare Expenditures on Inpatient Treatment. Overall inpatient care accounts for about
one-third of total out-of-pocket spending. About 70% of in-patient care expenditure is
attributable to household spending.
Household health expenditure data show that
hospitalization is a smaller pan of household health spending than ambulatory care. This
implies that poorer households may be much less likely to seek inpatient treatment, and when
they do, they are much more likely to use public facilities which require lower out-of-pocket
expenditures.
4.27
In fact, government facilities provide approximately 60% of all episodes of inpatient
treatment in India, and out-of-pocket costs are well below those in non-govemment facilities.
?iV7?o/e Srtate’levei out-of-Pocket costs for hospitalization in government facilities ranged from
1 i-74/o of the cost reported for hospitalized episodes in non-govemment facilities.
4.28 Contracting Out. Anne Mills (1995, 1996)'° provides a rationale for contracting and
summarizes the lessons from experience with contracting in six developing countries. The
study notes that non-clinical contracting was usually justified in terms of lower costs easier
implementation and greater flexibility in the use of labor; the justification for clinical
contracting was the unavailability of the service in the facility or area, a pragmatic response to
the inability to expand the service and financial restrictions on capital investments The study
shows that the extent of contracting is relatively limited. For example, in Bombay, clinical
contracting for hospital and primary care was done by agencies providing health services for
civil servants and the compulsory social insurance scheme, but not for health services for the
general public. Also, in the Bombay case, contracting for non-clinical services such as
cleaning, catering, pharmacy, laundry, maintenance, printing and security, was more common
which seems to be consistent with practice in other urban areas of India
4.29
Contracted out services are a small proportion of overall expenditures at the state level
in India, but there appears to be considerable scope for the expansion of contracting out
services, especially for non-clinicai services. There are no legal barriers inhibiting the use of
contractual services. The Contract Labor Regulation and Abolition Act (1970), which prohibits
certain institutions from contracting out perennial services, exempts hospitals and health care
facilities. In view of the difficulties of employing government staff, such as slow recruitment
procedures and poor attendance, contracting out certain services, especially support services, is
io
Mills Anne "Contractual Relationship between Government and the Commercial Private Sector in Developing
PubTc Inter^ S *
HCa'th rmVil1i:t5 in DcVglnniny
Mills, Anne. “Improving the Efficiency of Public Sector Health Services in Developing Countries: Bureaucratic
versus Market Approaches." Departmental Publication No 17; London School of Hygiene and Tropical Medicine;
1995.
- 28 -
an attractive alternative. However. Anne Mills (1996) points out that contracting out is not a
solution to weak public sector management and is more demanding on managers than direct
provision, requiring some new skills. The state governments should take into account lessons
learned from past experiences in contracting out. In particular, where economically attractive,
governments should consider contracting out support services such as laundry, kitchen,
landscaping, dieury services, sanitation, security and mainstream diagnostic and clinical
services. In addition to economic considerations, state governments should also take into
account the quality of services, as well as administrative ability such as management capacity
to supervise such contracts.
Administrative procedures and guidelines and adequate
accountability functions will also need to be in place to facilitate the contracting of services.
4-30
Ihe Role pf Health Insurance. Inpatient care is the predominant expenditure for
private sources of financing, such as private firms, which make payments directly for their
employees or pay for private insurance. There currently exists a government subsidized
insurance plan, the ESIS. providing benefits to a narrow group of government workers and
their dependents for sickness or employment injury covering about 27 million beneficiaries.
ESIS maintains a sizable network of hospitals (111) and dispensaries (1.400). In addition, the
CGHS provides medical care to central government employees and their dependents
covering 3.8 million beneficiaries. Estimates of the composition of ESIS and CGHS
expenditures were not available for this report. Overall, these insurance schemes do not cover
private citizens and are subsidized for government workers.
4.31
For rural and urban areas, insurance coverage is only about 3.3% for the country as a
whole. This is low compared to other Asian countries - in Indonesia, for example 9% of
the populatmn is covered by some type of insurance, mainly civil servants and the armed
forces
However, in India, the scope for private insurance remains limited at this time but
is likely to increase m the urban and industrial sectors with an increase in income levels
literacy and numeracy.
E. Quality of Services
a Although Prlvate health services are easily accessible, the quality of medical services
offered by the private sector is uneven. There is a need to monitor the clinical effectiveness
and quality of services offered at different private facilities; to strengthen the referral system
between private sector institutions and government first referral institutions to faciliute the
treatment of poor patients; and to ensure that staffing and technical norms used in the private
sector are within an acceptable range. In addition, the quality of medical practitioners varies
jC
4.33
Dau on the total number of "doctors" or "medical practitioners" are not available in
India. Government figures indicate a national average of one privately practicing physician for
every 3,500 people. These figures do not include
include the
the often-illegal
often-illegal private
private practices
practices of
of publicly
publicly
employed doctors, although these may not be as widespread as in other countries. Official data
provide information only on the
the qualified,
qualified, allopathic
allopathic practitioners
practitioners - the
the MBBS
MRR<; or MD
un
rtev!.|Anmlh',Bran 5OmnUlS7Y Htilllh ln5"rilnrf- Researeh Pr°jecI °n Strategies and Financing for Human
Development, Center for Development Studies, Thiruvanantapuram; 1995.
■
<1
•-
- 29 -
physician. "Registered" or "licensed" medical practitioners also exist with lower qualifications.
However, there are no numbers available and in most states registration or licensing has not
functioned for almost two decades.
4.34 Part of the reason why data on the number of doctors is unavailable is the long-standing
uncertainty about what constitutes a "doctor" or "practitioner" and the quantities and types of
practitioners available. Private providers include a wide array of qualified, less-than-qualified,
and unqualified practitioners. Most of them practice an eclectic medical care, combining
allopathic and one or several "traditional" forms of medical care. Most are unregistered,
unlicensed, and unregulated, although there are numerous gradations of legal practice which
vary from state to state.
4.35
There has been little change in the percent of physicians in full private physician
practice over time. For the other components of private practice, information is very limited. A
recent study of the "rural private practitioner" in Uttar Pradesh estimated that there may be as
many as 1.25 million practitioners in India, or one for every 600 people in rural areas (IMRB,
1993). While this is a very tentative estimate, it highlights a fact that is obvious to a careful
observer, i.e. there is widespread access to private, fee-for-service health care throughout India,
although the quality of that care is likely to be very low. It may be that such practitioners are
even more numerous in urban areas, serving the growing numbers of the urban poor.
4.36 The 1MRB used an innovative technique to identify private practitioners - asking
village respondents to name the "doctors" they knew, then interviewing all those mentioned.
The survey shows them to be young (under 40), male, and modestly educated. About half of the
practitioners had received some formal health care training, but in most cases this was
inadequate for a full qualification. They had on average more than 10 years of practical
experience, saw 11 patients a day, and more than 90% of them used clinical methods from
allopathy and at least one other system of medicine. The survey found these practitioners doing
fee-for-service" treatment, although they reported mainly charging for medicines plus a profit
margin and not for "consultations." They both prescribed and dispensed medicines.
4.37 Most studies of health care utilization and spending in India have not adequately
investigated the role of these private practitioners. The National Sample Survey results for
private care provision reported in tljis chapter are a typical example of this problem, coding
responses for "private doctor" without distinguishing between qualified and unqualified
practitioners. More careful micro studies have found that these "less than fully qualified"
practitioners account for the vast majority of treatment contacts and expenditures in both urban
and rural areas.
4U38 Qlhgr Types of Providers. While little is known about the typical private practitioner,
there may be ether sources of private medical care even less well documented. Drug sellers and
pharmacists commonly diagnose and prescribe as well as dispense drugs. It is unclear to what
extent they are included in the response "private doctor" on surveys. In some parts of India,
private diagnostic facilities such as radiology and laboratory testing are now appearing even in
small rural towns. It is not known to what extent these are also increasingly functioning as
private treatment facilities.
I
'r
-304-39
Monitoring and Regulation- As noted above, private fee-for-service providers are
easily accessible to the rural and urban population and are heavily used by the poor for
ambulatory care. However, many of these providers are unqualified, and they may cause
substantial harm as well as good. In a society where it is mandatory to have a license to run
a hotel, cinema theater or any commercial trade, it is strange that no permission or license is
required to set up a nursing home/private hospital or operate a medical laboratory. The same
is true for the monitoring and regulation of the drugs and pharmaceuticals industry'.
F. Consumer Protection Act
4.40
More recently, as a result of the consumer movement in India, the government
passed the Consumer Protection Act (CPA) in 1986. In order to make it more meaningful
and effective, the Act was amended to bring medical services under its purview. It was
clarified
by the National Consumer Redressal Commission (1992)
that
....
>
— services of any
description which involve payment should be given consideration under the Act, and the Act
should not be restricted in its interpretation only to services related to consumer transactions.
This has raised concerns in the medical community with regard to the sanctity of the doctor
patient relationship, the spread of defensive medicine, and the fear of doctors being held
responsible for problems caused by the lack of support services such as clean blood banks,
ambulance services and para-medical services.
4.41
The issue is complicated by the fact that there is no standardized medical audit
system which can provide patients and the legal community with information regarding
acceptable procedures for diagnosis and treatment. The need for documentation with regard
to standard medical care is urgent, not only for the benefit of the patient, but also for the
appropriate regulation and accountability of the medical profession. As a result of the CPA
the Indian Medical Association (IMA) has recommended that the MCI Act be appropriately
amended to ensure more complete accountability of doctors. While no doctor would be
proof against human error, the medical profession would henceforth operate under the
scrutiny and supervision of .the amended MCI Act. The IMA also recommended, in order
not to overburden the legal system, that only cases involving criminal dimensions be referred
to the courts. A separate tribunal would be constituted in the place of a civil court, receiving
the greatest priority and attention in disposing of cases expeditiously. In the state of
Karnataka, for example, there are about 25 such cases pending judgment in the court system.
G. Recommendations
* bating an Enabling Environment for the Private Sector. The overall strategy for the
health sector should take into account the existing levels of private finance and provision
of services at the state level. State governments should play an active role in creating an
enabhng environment for greater private sector participation in the health sector and
fostermg public-private partnership. There are several options for the government to
ensure that the pnvate health sector continues to play a vital role in the health sector and
expand the scope of its activities.
•
Increasing Private Participation. To make more efficient use of total resources available
in the health sector, state governments need to evaluate alternatives related to provision
versus financing of health care services. This would imply that state governments should
LfBRARY^X^
umr
now y
- 31 -
promote the further expansion of the private sector in areas where it has a commr-ir'
XSX
nrnv d
,'v"
-P-P.ei.li.y J! 3UPP»^XP™'"
,c,Patl0n ,n preventive and promolive care services could also be promoted hv
:^o"'„auv
,,h“
deliven. of p,?“„”h'" °“‘re“h » »-«
tr
Contranmg^. lhe
comparative advantage in' 'imorovinv
6 31X25 'O 'f
seclor’ which has a
disadvantaged groops.Tould aZ: pZote^ ’° “b h'2l,h
“ f» “™
■
r^^eblonnoriPP ,hd FrH.I-nlnn. The Govemmenfs capacity to
collaboratively by the central and stare
unctions could be undertaken
by . professional\edySas tte ndifn” mT i'a
C°uld b'
India standards.
'Cal Ass°ciatl°n in accordance with all-
- 32 -
Chapters
Center-State Financing Issues in the Health Sector
A. Introduction
5.1
Over the past two decades, state governments on average have directly provided
about 73% percent of the toul public resources for health, the central government about
25%, either directly or through grants for centrally sponsored schemes managed by the
sutes, and the rest is provided by urban municipal bodies. This chapter focuses on centersute responsibilities for health in the public sector. It includes a discussion of the
administrative set-up and budgetary processes in the health sector, inter-state equity issues in
the transfer of central funds to the health sector; the levels, trends and patterns of health
expenditures at the state level generally; and the mechanisms of adjustment effects on centerstate transfers.
B. Center, State and Local Government Responsibilities in Health Financing
5.2
The provision of health care is a responsibility shared by the state, central and local
governments. Although it is effectively a state responsibility in terms of delivery the
responsibility for health stands at three levels. First, health is primarily a state responsibility
Second, the center is responsible for health in Union Territories without legislature The
center is also responsible for developing and monitoring national standards and regulations
providing the hnk between' the state governments and international and bilateral agencies’
and sponsoring numerous schemes through the provision of finance and other inputs for
implementation throughout the state governments.
Third, both the center and the sutes
have joint responsibility for programs listed under the concurrent list. Goals and strategies
for the public sector in health care are established in a consultative process involving these
different participants through the Central Council of Health and Family Welfare. While each
state can formulate its own health policy, in practice state governments have to function
w.thm the parameters of the NHP. Within the overall ambit of national policies, there is
sufficient scope for the states to administer health schemes in conformity with local
conditions. The mechanism used by the central governments to fund health programs at the
state level has the potential to reduce disparities in resources among states, and even within
sutes. However, as currently organized, these mechanisms are not designed to overcome
inter-state inequities, and in some cases are exacerbating the problem.
53
Center-State Financing Rcsponsibilifirs. The interaction between the center and the
sute governments in the health sector occurs at two distinct levels. The first involves the
overall allocation of resources by the center’s Planning and Finance Commissions to sutes
which constrains or provides opportunities for states’ initiatives in new projects. The second
level involves the intra-sectoral
allocations of
of grants-in-aid
and other
other earmarked
earmarked funds
-sectoral allocations
grants-in-aid and
funds from
from
the center to the states.
5.4
The budgeting and accounting of government expenditures at the central and sute
levels are influenced by the planning process, which takes place within the framework of
- 33 central and state five -year plans. The plan budget refers to ; "
all expenditures, both capital and
recurrent, incurred on programs and schemes that have been initiated in the
. ...-■ current five-year
plan. Once the five
■-year period of any particular plan is over, the r----recurrent expenditure
associated with the icontinuation of that activity is generally transferred
to the
— • • • -’ non~p I a n
budget, except for the family
/ welfare program.
Figure 5.1: The Structure of Government Health Financing
U nion
G overnm ent
State
Governm ent
C enter-sme untied transfer! plan/non-pIan
Stete/secioral allocations
Plsn.'N on-P la n
Union MOHFW
F
--------- —_ Tied yraniti
C enirallv »pon»ored
i
ichemti
““
State
MOH
CGHS
J
Ticd grams io
local governm ents
Other central
MOHFW
functions
Central
T eaching
Hospitals
I
Plan
I
ESIS
M edical
Pnm ary Care
Facilities and
Program s
~T~
Non-Plin
I
Public
Health
Fam ily
Welfare
Local
Governments
M unicipal/Local
Hospitals and
Facilities
_______ I
Salaries
Other recurrent
inputs
Other Facilities
and Program s
Source: “IIndia.
“
Policy and Finance Strategics
for Strengthening Primary Health Care Services."
IN, May, 1995.
Report No. 13042-
5.5
Plan expenditure in the health
,
psector accounts for about one-third of total
government health spending.
the Family Welfare Program, which is financed almost
- 34 -
entirely out ol the central plan budget is excluded, the ratio of plan to total health spendine
drops to less than 20%. In other words, more than 80% of government health spending,
excluding family welfare, is made up of committed expenditure on maintaining existing level
of services, financed out of the non-plan budget. In fact, the degree of flexibility that central
and state governments have over their health budgets is even more limited than this 20%
ratio would indicate, since a part of plan spending is also of a committed nature. Between
the center and the states, the former enjoys relatively greater degree of flexibility; about 65%
of central health spending and 99% of family welfare spending is in the plan budget, while
86% of state health spending in the aggregate is in the non-plan budget.
5.6
In the case of centrally sponsored programs (other than the Family Welfare
Program), central financing ratios refer only to the plan component of expenditure. For
example, the centrally sponsored National Tuberculosis Control Program is implemented as
a 50% centrally funded program. This means that central grants finance half of plan
expenditures under this program, while state governments have to bear the full amount of
non-plan expenditures. This implies that central grants account for much less than 50% of
total government spending on tuberculosis control. The same is true of other national
programs where the states actually fund a greater share than the officially mandated ratio.
The average share of central financing of communicable disease control programs is less
than 25%. Thus, central leverage is limited in its power to assure adequate state funding of
the r.on-plan inputs. These include field staff, drugs and other operational expenditures.
3 7
^nicr-State Contributions- Central and state Governments finance very different
components of total expenditures. Table 5.1 breaks down the uses of funds in the 1991-92
budget by the center and state shares. States heavily finance primary health care facilities
hospitals, disease control programs and insurance. The center, on the other hand’
emphasizes family welfare, and, to a somewhat lesser extent, education and research.
Capital investment is shared equally by the center and the states. The central Department of
Health allocates over 45% of its budget to the central teaching hospitals and research
inst.tutions, about 15% towards the Central Government Health Scheme (CGHS) a medical
benefit scheme for its own employees, about 35% towards the disease control programs. The
Department of Family Welfare allocates about 85% of its budget towards family planning
and 5 /o towards maternal and child health and universal immunization.
Table 5.1: Center and State Shares in Different
Components of the Government Health Budget (1991-92)
Hospitals
”
Public Health
Primary Care (Disease Control)
Family Welfare
Insurance (CGHS, ESIS)
Medical Education & Other
Administration & Other
Capital Investment
■
Center s Share
%
3.1
0
99.7
22.6
18.2
41.7
II
49.7
Stales’ Share
%
96.9
100
0.3
77.4
81.8
58.3
89
50.3
I
5.8
The family planning and immunization programs are fully centrally financed, while
most of the disease control programs are partially financed by the center. The state
governments are required to allocate matching funds from their budgets and bear staff costs.
In either case, the concerned depanment of the central ministry is responsible for program
design and monitoring, while the corresponding state level depanment is responsible for
implementation. The entire expenditure on these national programs is recorded in the state
budgets, while the centrally financed component is also recorded in the central budget as a
grant to the states.
rState. Governments finance the bulk (97%) of curative hospital care, as well as a
significant share of expenditure involved in operating the primary health care infrastructure
in rural areas. Central grants partially finance the disease control programs and the centrallyfinanced “rural health” scheme under the public health head which provides some resources
for operating primary care facilities. The state governments bear all other costs of non
hospital rural services.
5.9
5.10
Central intervention in the health sector is both through the design and operation of
centrally-sponsored programs as well as through support for infrastructure development. A
major vehicle for the latter is the National Minimum Need Program (NMNP), a mechanism
that allows the center to influence and encourage states to spend on building up infrastructure
for rural health, water supply and nutrition. The NMNP is pan of each state government’s
own plan, but for each rupee that the state spends towards these minimum needs, it receives a
matching rupee from the center as a grant. In other words, disbursements under one of the
central national programs is tied to the states’ own efforts to fulfill minimum requirements of
rural health infrastructure.
511
LflCal Governments. Local bodies have no significant financial authority in India
except in large cities. In some states, however, local bodies have a significant responsibility
for managing services and implementing national or state government programs. The degree
and pattern of decentralization in state-local relations exhibits wide inter-state variation.
Transfer to local bodies, as a share of total state government budgets, for example, vary from
over 40% (Gujarat and Maharashtra) to 15% or less (Haryana and Madhya Pradesh). For the
14 major states, the average share of transfers to local bodies was 30% of total expenditure in
the second half of the eighties; the share of such transfers accounts for about 11% of state
health spending.
5.12
While the federal structure of government in India is based on a significant
devolution of taxing powers to the states, supplemented by a statutory right to their share in
major central taxes, local bodies have very limited taxing powers or statutory rights.
Decentralization has taken the form of delegation of implementing responsibility with
minimal or no devolution of financial powers. Thus, even in the case of Gujarat or
Maharashtra, where 40% of state government expenditures is transferred as grants to local
bodies, the local bodies have little or no access to any financial resources on their own; their
spending is totally dependent and determined by what is transferred from the state budget.
The only exception to this general rule are municipal corporations of cities and towns, which
raise their own resources on health and related services.
4
-36-
5.13
Of the total amount transferred as grants by the states to local bodies, over 95%
consist of specific purpose grants to support social service facilities run by local bodies, such
a grants to support salaries of Panchyat school teachers, and grants to support salaries of
paramedical staff in rural health centers. Less than 5% consists of general purpose grants
over which the local authority has flexibility of use. Such grants have remained more or less
constant in nominal terms in all states, over the past four and half decades.
5.14
In sum, the existing fiscal and administrative set-up in the health sector is complex
and hinders effective financing and accountability for decentralized management of health
facilities. The center-state financial transfer mechanisms along with the plan and non-plan
breakdown of the budget and the two separate structures for the Health and Family Welfare
Departments is ineffective in providing essential inputs, correcting inequities between sutes
strengthening decentralized management and monitoring program performance The central
and state governments should consider: (i) a substantial review of the fiscal structures and
procedures in the health and family welfare sectors including the roles of central, state and
local government financing in the provision of basic inputs; (ii) the development of program
budgeting tools at the central and state levels to monitor and evaluate expenditure for
important schemes: (iii) the development of fiscal tools to enable greater experimentation
with resource allocation, alternative financing mechanisms and with regard to choices
between providing versus financing of health care services.
C. Inter-State Equity Issues
■
The mechanisms used by the central government to fund health programs at the state
level have the potential to reduce disparities in resources among states, and even within
states. .As currently organized, however, these mechanisms are not designed to overcome
inter-sute
-■ inequities. Interstate disparities are manifest in the following ways in the health
sector:
5.16
F.rst,
First, a few of the centrally-funded communicable disease programs, including the
largest Nat.onal Malana Eradication Program are inequitable, since they are funded on a SO
SO matching basis by state and central budgets. Some poorer states are unable to raise
sufficient matching funds to make optimum use of the program. Even 50-50 matching
schemes often require more than a 50% contribution by the states, since overhead and some
other recurrent costs borne by the states are excluded from the estimate of total program cost
Poorer sutes are least able to attract but most in the need of suppler.-ntary central allocation
to these programs.
5 s7
Second, since schemes revert to non-plan schemes after five years, states are wary of
part.cipating m projects initiated by the central government under plan budgets
(PHCs) under one plan period can become a liability during the following period when all
operating costs must be found within the non-plan allocation, and the center completes its
assisunce. The mtegration of Indian Systems of Medicine doctors into PHCs, underuken by
the central government m many sutes in an earlier plan period, must now be supported by
the states, which find themselves with additional personnel costs. Again, the better-off sutes
- 37 -
are betier able to take advantage of plan projects than the poorer states, though their need for
such projects may be smaller.
5.18
These factors point to the conclusion that central transfer of resources for the health
sector has not been commensurate with the needs of poorer states where socio-economic and
health indicators remain depressed. Moreover, because of the differential impact of
stabihzation policies on state resources for the health sector, some poorer states have
suttered disproportionately from imbalances and cutbacks introduced into the system at the
state level. There is, therefore, a growing need to provide increased supplementary central
funding to the poorest states where alternative sources of revenue are limited for the health
sector. Supplementary financing could be provided to those states most in need which are
taking credible steps to improve their overall finances.
D. Government Health Expenditures: All States
5.19
In India, governments account for about 20% of total expenditures on health services,
e me to include medical, public health and family welfare services. About 75% is funded
by individuals directly from out of-pocket sources; indirect funding through health insurance
SC ernes is limited (about 3.3%). It is important to stress that, apart from some services
provided at teaching hospitals, the public sector caters largely to the poorest segment of
Indian society Th.s is imponant for assessing the adequacy of government expenditure in
providing health serv.ces, the pattern of allocations and the desirability and feasibility of
'"Rasing cost recovery for services. A second factor of some importance in analyzing
publ'c y financed health expenditures is that the population’s health is directly affected by
several government programs outside of the departments of health. These include domestic
water supply, sanitation, nutrition and housing in addition to those welfare programs which
healthv an.d'nd,rect|y'ncreiase the Purchasing power of the poor and their ability to adopt a
y an hygienic lifestyle. Most of the discussion in this chapter uses a narrow definition
of government hea th expenditure
that spent by the departments of health
Other
expenditures are included only selectively.
5.20
Overall
expend.tures are a small share of total government expenditures and
Overall, health expenditures
the trend over the past two decades has been downward. Whereas the share was 3.8 percent
ring the period 1974-78, it had fallen to 3.4 percent between 1986-90, with mos^of the
reduction occurring during the later years (Tulasidhar 1996). However, publicly financed
health expendKures broadly maintained their share of national resources at around 1 percent
the Deriod'nThe8failiern?henthXPenrltUreS haVe h**" increasin8 at a faster rate than GDP over
U sha e of CDP J"
of g^^ment expenditure on health and the maintenance of
its share of GDP does not .mply that real resources did not increase. Over the period
cnbed, per capita health expenditures increased by over 60 percent. Relative toother
go emment activiUes, however, health services were neglected. For instance the share of
the shire oTgDP allo^
t0 eduCat‘On increased from 9.4 to 11.6 percent and
the share of GDP allocated to education increased from 2.4 to 3.6 percent.
521
The fall in the share of health expenditures in total government expenditures has
recently intensified: from 3.1% in 1991/92 to 2.6% in 1994/95 (budget estimates) (Duceal
andraj, Vadair 1995). Since the central government’s share has been largely maintained (at
- 38 -
under 0.50 percent of its total expenditure), the reduction is due solely to falling expenditure
shares in the stales. The reduced share resulted in a lower level of real expenditure equal to
about 4 percent less by 1992/93 compared to 1990/91. This was compensated for in the
following two years. Real expenditures per capita in 1992/93 remained below the levels of
1990/91.
5.22
Not all categories of health activity have been subject to the same trends. Between
the periods 1974-78 and 1986-90, the share of the mainly curative medical services
decreased from 65 to 62 percent, and that of public health from 21 to 19 percent while the
family welfare share increased from 14 to almost 19 percent. These changes in shares
reflected differences in real percentage increases over the period of 49, 42 and 102 percent
for medical services, public health and family welfare, respectively. In contrast, during the
first two years of adjustment when real expenditures on health fell by 4 percent, both medical
services and family welfare shared the major brunt, while the public health allocation
remained virtually constant.
E. Patterns of Health Expenditure Across States
5.23
Public sector health budgets at the state level, which include all non-hospital primary
health care as well as hospitals up to the district level, are financed out of three distinct
budget sources: (a) the state's non-plan budget that finances the recurrent cost of
mamtaming the infrastructure and level of services established through previous plans; (b)
the state plan budget that finances schemes initiated by the state during the current five-year
plan, as well as the state’s component of financing centrally sponsored programs; and (c) the
central plan grants that finance the central component of national programs. Total spending
in health and family welfare at the state level is financed out of these three different budget
sources roughly in the ratio of 68:14:18 (1990/91). The corresponding ratio in the case of
drinking water supply is estimated at 28:56:16.
5A4 j ThC comPosltlon of the health bud8« of state governments by these different sources
of funds is significant from the standpoint of protecting public health spending in the context
of general fiscal contraction. The degree of financial constraint can be very different on
these three different budget sources. Typically, the non-plan budget of each state is
constrained by the overall revenue position of that state, supplemented by the sututory
central transfers recommended by the Finance Commission. The state plan budget is
constrained by the non-plan gap of the state and the untied central assistance to state plans
whose level is determined by the Planning Commission. Finally, the constraints on tied
central plan grants are determined by the budget of the concerned central ministry. In the
former two cases, inter-sute differences in the degree of financial constraint can be
considerable, whereas the constraint is uniform in the case of the budget services financed
out of central plan grants.
5.25
P
‘ . aggregate resources available tc states and the commitment to provide
Both‘ the
health services differ between states. In 1994/95 in the* 16 major states, the average share of
state government revenue devoted to health was f5.8 percent. The range was between 4.7 and
7.4 percent (apart from Haryana where the share' was much lower). In 11 of these 16 states
the share was lower than in 1991/92. The shares in 1994/95 compare to an average in
- 39-
Sanin^es m th^e^ZS^^h
SE ~
over lour nme periods back w lOTOTd
services and fam , weZe .be esub,
’’'h '’T 'Xp'nd""rcs acrass
f°'"" 'nd'v'd^l Rories of medical
F. Mechanisms of Adjustment Effects on Center-State Transfers
5.26
Several recent studies have attempted to document the effects of the nd’
ble 5.2. Trends in Public Revenue Expenditures on Health 1988-1992
Constant Prices (1989/90 = 100)
,
AII States
Poor
Middle Income
Rich
1988/89
93
87
94
98
1989/90
100
100
100
100
1992/93 h.d bUr XxZdiwS
!X“ “i,ure was
”d “
1990/91
106
98
115
107
TT '">W'V'r-
1991/92
102
93
108
107
1992/93
102
93
I 13
103
°f s““ -
varied by states according to income group The
h '
^d
'988/89 t0 1992/93
services and disease control maintained them ’ rich States reduced expenditure in medical
welfare. The middle incom™^J
m 'n S
d hea'th
increased ^em in family
maintained those for family Welfare and
exPe"dltures m medical services,
expenditures in public health The nOo
and
increased
categories of service. Aero alHutes e ?
eXpenditure in each
the four
maintained while those for all XZ/ . eXpcnd,tu_res on Publ* health activities were
welfare expenditures dTst^
SinCC a larSe sh-e of family
receipt of central government' mms the /eXpenditures ar' dependent on
health authorities is thaZith XT
h1655*8" rCgardin8 the decisio^ of state
rce constraints, the attempt was made to defend public
1
- 40 -
health expenditures at the expense of medical services.
5.29
A separate study of the impact of adjustment by Gupta (1995) on public expenditures
uses data to 1993/94 but includes water supply, sanitation, housing and urban development
together with health expenditures. In that year, the growth in state ‘social’ expenditures was
below the overall growth in state expenditures across all states and for the low income group
was equal to only half the growth rate across all states. Further, in this low income group of
states alone, the growth was below the rate of inflation. The study also notes that over the
past two decades, government financing of health services across India has demonstrated a
downward trend in relation to both total government expenditures and GDP. Within this
trend there have been variations between individual states. Overall, the variations in
expenditures across states has been narrowed in relative terms though the absolute
differences in per capita expenditures remain very wide.
5.30
The process of adjustment can affect the output of government health spending by
affecting: (a) the quantum of financial resources available with health ministries and
depanments: and (b) the unit costs of providing health care. Fiscal contraction by the central
government is translated into tightening of budget constraints at the state level through different
mechanisms, corresponding to the three different sources of financing health expenditures at
the state level, namely by the non-plan budget of the start, the state’s own plan budget and the
budget of centrally sponsored programs. Figure 5.2 shows the different channels through
which impact of adjustment is conveyed to the state level.
Figure 5.2: Channels Through Which Structural Adjustment
Affects on Health Spending
EMogenout reduciioni in
cenier t revenue
CENTER’S EXPENDITURE
M OH FW
Planning
Com m iis io n
C u ta in
central
tchtme i
I
Finance
Com m ission
C ula in
untied
plan grama
Cuts m u ntied
n o n -p lan grama
STATE EXPEND ITURE
1
Sector-apecific
a d ju a tm < n ti at
atate level
PLAN
M pjcrocconom ic
vffe eta
on input pricea
~
non Ian
E xogtnoui
reduction a
in ataic revenue
State H eallh B edget
HEALTH SERVICE PROGRAMS
Source: “India
1995.
Policy and Finance Strategics for Strengthening Primary Health Care Services."
Report No. 13042-IN. May,
- 41 -
5.31
There are two kinds of pressure on the financial resources of stale governments,
namely: exogenous macroeconomics factors and contraction of central transfers to states. A
deceleration or decline in domestic industrial output, for example, may lead to a reduction in
tax revenues collected by both the center through excise duties and personal income taxes, and
through sales taxes, since a statutorily fixed proportion of central excise duties and personal
income taxes are shared with the states. Reductions in either of these types of tax revenue
squeeze the revenue of both the center and state Governments.
5.32
In addition to revenue effects, the center can; (a) reduce the quantum of untied plan
grants to states and/or (b) reduce the quantum of tied plan grants transferred under one or more
centrally-sponsored programs. Reductions in allocations to centrally-sponsored health sector
programs are the most obvious form of squeezing the health sector and have received attention
in Bank-GOI dialogue. However, the other channels of pressure, though less visible, are likely
to be more significant as the funds involved are much larger in magnitude.
5.33
Central transfers to the non-plan budget of states, consisting of tax sharing and gap
filling grants, are statutorily determined by a quasi-judicial body called the Finance
Commission; such transfers are therefore not al the discretion of the central government and
hence not vulnerable to contractionary pressures by the center. On the other hand, central plan
transfers to states, both tied and untied, are largely at the discretion of the center and hence
more vulnerable to central policy.
5.34
Untied transfers from center to states, called “central assistance to state plan”, consist
of 30% grants and 70% loans in the case of the 14 major states, and of 90% grants and 10%
loans in the case of the special category states, which are mainly hilly and predominantly tribal
states plus the state of Jammu & Kashmir. The center is free to decide the quantum of
assistance to each of the special category states, whereas the assistance to the 14 major states is
distributed among them on the basis of an objective formula called the modified Gadgil
formula. However, even in the case of the latter, only the inter-state distribution is formula
driven; the total quantum of such assistance is at the discretion of the central Ministry of
Finance.
5.35
States also have some discretion in how they use untied funds. For example, a
reduction in central assistance to state plan may result in different levels of reduction to health
spending in different states. Similarly, states exercise some discretion in their non-plan
spending, and so can favor or disfavor the recurrent cost needs of the health sector.
5.36 v In addition to the factors outlined above, there are also other macroeconomic pressures
that operate, such as (i) reduction in small savings by households and (ii) the devaluation of the
Rupee. A fixed proportions of collections from national savings schemes, operated by post
offices and linked with tax incentives, are on-lent by the center to the states as a loan under the
non-plan account; any decline in such collections would thus reduce the quantity of central
loans available to the states. A major devaluation of the currency, by affecting the cost of
imported inputs, especially drugs and pharmaceuticals, could affect the unit cost of health care
financed by the government; even if financial allocations are maintained, the real value of such
allocations could decline due to an abnormal rise in the unit costs.
- 42 -
G. Recommendations
5.37
The following recommendations are suggested to improve the existing complex
structure of fiscal and administrative set-up in the health sector and the inter-state inequities
in the transfer of funds from the center to the states, as well as to better prepare the states to
address financing issues in the course of designing future strategy:
•
The state governments should consider, through their Ministries of Health and Family
Welfare and Finance, a substantial review of the fiscal structures and procedures in the
health and family welfare sectors including the roles of the central, state and local
government financing in the provision of basic inputs. Some of this is occurring at the
state level in the four states where Bank-financed health systems projects are under
implementation by undenaking more systematic planning of state and local level health
sector related activities. For example, through planning cells in the DOHFW. This is
also applicable to MOHFW.
The state governments should develop program budgeting to monitor and evaluate
expenditure for imponant schemes;
•
The state governments should develop fiscal tools to enable greater experimentation with
resource allocation, alternative financing mechanisms and with regard to choices
between providing versus financing of health care services.
A mechanism for
coordination between the Departments of Health and Finance would be essential to work
out the opportunities for such activities.
•
fo alleviate the health care needs of poorer states, where socio-economic and health
indicators remain depressed, supplementary financing could be provided with a priority
to states most in need which are taking credible steps to improve their overall finances.
For'example, a health resources assurance fund at the center could be established
to
mitigate some of the interstate inequities in allocation of central funds to the states.
•
Greater sharing of responsibilities and coordination between the center and the states in
the health and family welfare sectors is needed, especially with regard to sectoral
planning, health strategy and policy reform. Involving the states more intensively and
collaboratively will help to solidify their commitment to the overall development policy
oo health and family welfare. The modalities need to be discussed and worked out
oetween the center and the states.
- 43 -
Chapter 6
Public Sector Health Expenditures in the Four States
A. Introduction
6.1
This Chapter provides an analysis that is complementary to the center-state financing
issues in the health sector that were examined in Chapter 5. It focuses on health expenditures
at the state level, which currently account for about 73% of public expenditures on health care
in India. Illustrative case studies of trends and patterns of health expenditures in four states are
presented to provide a comparative perspective of health expenditure patterns generally at the
state level. A review of selected aspects of state level public finance in the states of Karnataka,
Punjab. West Bengal and Andhra Pradesh is initially presented to provide some background
against which to view the main concern of this section - state government expenditures on the
provision of health services. As part of the exercise, total health expenditures in the
respective states have been disaggregated and re-classified by level of service.
6.2
This chapter reviews public financing of health care from the perspectives of the
state governments. Public expenditure analysis provides several opportunities for examining
priorities, evaluating government intentions, policies and implementation, particularly in
times of economic austerity when resource choices are unavoidable. Sectoral expenditures
over time measured against total expenditures or national income, provide a basis for
evaluating the importance of the sector and changes in its importance in terms of pre
empting resources. Expenditures across states and disaggregations of expenditures by
categories of activities also provide information with which policy-makers can re-think their
own priorities. Efficiency aspects and effectiveness of public programs play an important
role in such decisions of policy-makers. However, equity aspects in the provision of health
services must also play an important role in a country like India where nearly a third of the
population live below the poverty line. Eighty percent of health expenditures in India are
borne directly by individuals; equity aspects should therefore remain important because
government services in general are utilized by the poorest sections of the population.
B. State Finances
6.3
Trends in the level and composition of public expenditures on health and family
welfare need to be seen against the backdrop of the overall developments in state government
finances - both prior to the economic and fiscal crises of 1991/92 and during the period of
adjustment and including specific policies enacted by particular states outside of the context of
adjustment. Through the 1980s, overall state government revenues grew at a slower rate than
expenditures leading to the emergence of revenue deficits and the growth and changing
composition of fiscal deficits. In the more recent period, state finances have been influenced
both by the nature of macroeconomic adjustment, which affects overall tax revenues, and by
fiscal adjustment by the Central government which has affected the size of the Central
government's transfers to states, particularly the grant component.
- 44 -
6.4
The combined gross fiscal deficit (GFD) of the states was equal to 3.0 percent of GDP
in 1986/87 and to 3.2 percent in 1993/94. Calculations of individual state deficits as a
proponion of their own State Domestic Product (SDP) suggest that for the eleven most
populated states the average increased slightly, from 4.2 to 4.3 percent between 1990/91 and
1994/95. Differences between states, however, are quite substantial. Table 6.1 presents the
data for Andhra Pradesh. Karnataka, Punjab and West Bengal from 1990/91 to 1993/94. Apart
from Andhra Pradesh, in each state the deficit has fallen as a share of state income. It remains
the highest in Punjab.
Table 6.1: Gross Fiscal Deficit as Proportion of State Domestic Product
Project States 1990/91 - 1993/94
1990/91
-5.2
-8.5
-6.0
Karnataka
1992/93
-4.7
-6.3
-3.4
-4.2
1991/92
1993/94
-3.7
Punjab________
-6.5
n/a
-4.2
West Bengal
•3.8
Andhra
Pradesh
-3.3
_____________________
-3.3_
-4.0
Note Measurement ot state domestic product may differ slightly between stales. This may at feet comparisons
between states but not trends within states. No estimate of SDP for Punjab in 1993/94 is available.
6.5
The gross fiscal deficit largely reflects the combined balances in the revenue and
capital accounts. Between 1980/81 and 1986/87 a deficit on the aggregate states’ revenue
account occurred in only one year. Since then, deficits have occurred in each year.
Although trends in the revenue deficit are unfavorable for all states combined, the
position of individual states again is far from uniform. Karnataka has had relatively small
revenue deficits in recent years and a small surplus in 1993/94 (Table 6.2). As a
percentage of net SDP, the revenue deficit/surplus was -0.6% in 1991/92 and +0.6% in
1993/94. In Andhra Pradesh, the deficit remained equal to 0.5 percent over this period,
though it increased to 1.4 percent in 1994/95. Punjab has had more substantial revenue
deficits, both in absolute terms and as a share of SDP. In 1991/92 and 1992/93, they were
equal to ^2.4% and -2.2% of SDP respectively. The revenue deficits of West Bengal have
also increased since 1989/90 though not yet to the extent as in Punjab.
Table 6.2: Revenue Deficit as Proportion of State Domestic Product
Project States 1980/81 - 1993/94
1980/81
1985/86
1989/90
1990/91
1991/92
1992/93
1.0
-0.8
-0.8
-0.4
-0.7
-0.6
Punjab
+0.4
+0.1
-1.5
-3.3
-2.4
-2.2
n/a.
W. Bengal
-0.3
+0.5
-1.8
-3.2
-1.8
-1.6
—
-0.9
-0.5
-0.3
-0.3
-0.5
Karnataka
Andhra
Pradesh
1993/94 |
|
Note
SDP figures taken from Slate Directorates of Economics and Statistics; Karnataka SDP figures from 1990/91 onwards
supplied by Govt, of Karnataka
Source Reserve Bank of India Bulletin (various issues).
- 45 -
Box 6.1: Financial Situation of the State and Implications for the Health Sector:
The Example of Andhra Pradesh
Andhra Pradesh (AP) has been under considerable financial stress since the mid-1980s due to the
declining tax revenue as a share of its gross state domestic product (GSDP), the extremely low buoyancy of
tax and non-tax revenue, rising public expenditures especially on subsidies, salaries, poorly targeted
welfare programs, and sharply falling longer term investments in infrastructure and social sectors, and non
wage O&M. The increase of the fiscal deficit to a level between 3 to 4 percent of GSDP, an average GSDP
growth rate of 4.3% over the past 15 years, outstanding debt as a share of GSDP of 24%, and interest
payments of 12% as a share of total revenue highlight the deteriorating financit I situation. While the fiscal
situation and its rate of deterioration
have been somewhat1 worse in Andhra Pradesh than the average of 14
------------ -----------------------major states, the lessons are applicable to other states as well.
AP has also not been able to generate the amount of revenues needed to meet its budgetary
requirements. It’s tax revenue has been declining since the 1986/87 when the proliferation of rates and tax
concessions made administration difficult and inefficient. The introduction of full liquor prohibition in
1995 aggravated the revenue situation and contributed to the decline in tax revenue from 9.5% of its GSDP
in 1986/87 to 6.8% in 1995/96. The very low buoyancy of both tax and non-tax revenue is a critical
weakness of the state’s revenue system and one which has not been adequately addressed by the tax reform
measures of the past two years.
The problem of the deteriorating fiscal situation and low level of revenue generation is
compounded by Andhra Pradesh’s expenditure priorities. There has been a proliferation of welfare
programs; an increasing salary bill which has grown at an annual rate of 5.7% in real terms over the past 10
years and a rise in the shares of subsidies. The cost of these has been smaller allocations for investment in
Bthe social sectors and non-wage O&M. This has led to the share of health and family welfare in the total
| state revenue budget to decline since the early 1990s.
I
Andhra Pradesh must take credible steps to improve its overall finances through reprioritizine I
expenditures and enhancing revenues. This will help to better address health sector needs as well Within
the health sector, the state needs to address the issue of public expenditures which are skewed in favor of
tertiary, facilities and low expenditures on drugs, essential supplies and O&M. The state must also enhance
and ^nontize expenditures on health through increasing health allocations within the overall budget
allocating 75/. of incremental resources in the health sector to the primary and secondary levels over the
next 3-5 years, and increasing allocations for non-salary recurrent costs over the next 2-3 years The
I government has initiated a move to this end through policy initiative in the ongoing Andhra Pradesh First
Referral Health Systems Project- This project is helping improve efficiency in the allocation of health
resources through policy and institutional development and performance of health care through improved
quahty, coverage and effectiveness of health programs. Better sectoral resource allocation and enhanced
cost recovery with exemptions for the poor will help improve provision of basic health care services and
ensure improved health care services in the long run.
6.6
As a consequence of increased revenue deficits in general, the nature of the fiscal
deficit, and hence the borrowing requirement, has changed. Whereas, previously, borrowing
had been required only for covering deficits in the capital account, by 1994/95 over a quarter
of the borrowing was to cover deficits in the revenue account. This indicator is particularly
revealing of the financial health of state governments, since it represents the pre-emption of
borrowed funds for meeting current expenditures. In Punjab, the revenue deficit contributed
over 50% of the GFD in 1992/93 and was budgeted to be about 34% in 1994/95 In West
Bengal, the revenue deficit was 43% of GFD in 1992/93 and was scheduled to rise to over
- 46 -
62% in 1994/95. A substantial increase also occurred in Andhra Pradesh where the share
increased from 17 to 32 percent. In Karnataka, the revenue deficit was 12 percent of the
GFD in 1992/93 but made no contribution to the fiscal deficit in the following two years.
6.7
Budget deficits have led to increased loans and indebtedness. At the same time,
interest rates have increased. As a result, interest and capital repayments are high and
growing. As a percent of total state revenue in 1985/86 and 1993/94 they doubled in many
states and trebled in some. Across 11 major states in 1994-95, interest payments averaged
18.0 percent of revenues - in Kamauka 14.7, Andhra Pradesh 14.8, West Bengal 19.1 and
Punjab 22.4 percent. Interest payments are increasing at an unsustainable rate and are
resulting in a falling share of development expenditures, including those in the health sector.
C. Trends in Expenditure in Health and Family Welfare.
6.8
In all four states, government health and family welfare expenditures are well below
iooirel cons,dered adequate t0 meet public health priorities (World Development Report
1993); and below the levels required to achieve the service norms set by the Government of
India (India: Policy and Finance Strategies for Strengthening Primary Health Care Services)
Punjab spends less than 0.9% of state SDP. Andhra Pradesh and West Bengal 1 1 percent
I'3 PerCCnt (Table 53)- ,n addition’ comPared t0 the early and mid
1980s the shares have dechned in three of the four states. The decline has been especially
i no/ ,n
Where health exPenditures fel1 from around
of SDP in 1980/81 to
1.0/o m 1992/93; and is estimated to be around 1.16% in 1993/94. In Punjab and Andhra
1980" m
of'sDP) Kan’““k‘',h' Star' “
" "" S“n"
“ in ,h'
v Table 63: Expenditures on Health and Family Welfare as % of SDP
80/81
85/86
89/90
90/91
91/92
92/93
93/94
R.E.
94/95
B.E.
Karnataka
1.26
1.33
1.25
1.18
1.11
1.29
1.29
1.40
Punjab
1.09
1.00
1.04
0.99
0.91
0.88
n/a.
n/a.
1.28
1.17
1.35
1.07
1.03
1.16
n/a.
1.19
1.05
1.00
1.07
1.13
°-96
W. Bengal
Andhra Pradesh
Note: SDP figures taken from State Directorates of Economics
and Statistics; Karnataka SDP figures from
1990/91 onwards supplied by Government of Karnataka.
D. Per Capita Expenditures on Health
69
Measures of aggregate resources devoted to public sector health programs do not
f
ftC
°f 7* exPenditure Psr capi* (Tab.e 6.4). Despite !he relatively
been rh h hP f
t0 hea‘th " Punjab’ real Per caPita expenditures have
1980/8 i S R i S StatCS a"d haVC bCe" maintained at roughly the same level since
o
t (bctween Rs- 30-35 per year at 1980/81 j rices). Per capita expenditures which were
Karnataka - between Rs 20-25 per yea at constant prices during the 1980's have
J
- 47 -
risen since 1991-92 to around Rs. 30. West Bengal displays the most disturbing trend. The
fall in real expenditures per capita has become pronounced in recent years, from Rs. 25 per
year in 1980/81 and Rs. 26 in 1990/91 to Rs. 22 per year in 1993/94. the decline has been
most serious for non-salary recurrent expenditures.
Table 6.4: Per Capita Expenditures on Health and Family Welfare
(in 1980/81 Rupees)
80/81
85/86
89/80
90/91
91/92
'2/93
93/94
R.E.
94/95
B.E.
Karnataka
19.00
22.12
26.00
24.12
25.01
27.83
30.20
33.31
Punjab
29.13
31.95
38.06
36.18
34.12
33.60
33.30
31.16
W. Bengal
24.63
21.50
22.36
26.07
21.37
20.99
21.97
20.95
6. 0
Despite these differences between the four states, the per capita expenditures in each
is low In 1993/94. per capita expenditure at current prices was Rs. 100 in Punjab. Rs 90 in
Karnataka, Rs. 72 in West Bengal and Rs. 65 in Andhra Pradesh (or between USS 2-3 per
caP'tay rhe expenditures are well below those required to fund the health provision norms
set by GOI which, in total, would require a 50 percent increase in budgetary allocations over
the current level.
E. Effects of Fiscal Adjustment on Health Budgets
6.11
Spending
Spending on health
health and family welfare
welfare grew
gre at around 12-13% per annum in nominal
terms m the four states between 1980/81 and 1990/91. At constant prices, annual growth
Andhra d 'tTn
Ofu2'8°/O t0 4'4°/0’ ExPenditures 8rew most rapidly in Karnataka and
Andhra Pradesh, followed by Punjab and West Bengal (Table 6.5).
6.12 The consequences of the economic and financial difficulties at the start of the 1990s
and the result.ng adjustment measures have differed across the three states. In West Bengal
and Punjab, expenditures fell in real terms in the first year of adjustment. While there has
been a part.al recovery m Punjab, the level of expenditures previously attained in West
Bengal have yet to be regamed. Expenditures fell by 16% in real term; in 1991/92. Although
9938/r94
rateII,n^7aseduin subsequent years, the absolute level of real expenditures in
1993/94 was st.ll below that of 1990/91. In Andhra Pradesh real expenditures in 1993/94
were around 4 percent higher in 1991/92. In Punjab, the nominal growth rate in 1991/92 was
positive, but real expenditures fell by almost 4%. Real growth in subsequent years was vety
small so that again the level in 1993/94 was (slightly) below that in 1990/91. Karnataka has
been the most successful in sustaining high real growth rates resulting in much higher real
expenditures in 1993/94 when compared to those attained in 1990/91.
6J3
It would appear, therefore, that the effects of the fiscal crisis and the consequent
adjustment measures on the overall budgetary position were handled in such a way in
Karnataka that the health sector was not unduly affected. Conversely in Punjab and West
Bengal there were declines in real expenditures. Given the relatively low level of
expenditures on health particularly in West Bengal, these trends are of concern. Special
- 48 -
mechanisms will be required to protect and raise the level of real expenditures on health in
t ese two states. While in Andhra Pradesh, real expenditures were initially maintained the
state s decisions to both increase the rice subsidy and reduce income from liquor taxes have
led to a fall in health expenditures as a share of state GDP from 1.13 percent in 1993/94 to
0.88 percent in 1995/96 (budget estimates).
F. Share of Budgetary Resources Devoted to Health
6.14
Health and Family Welfare budgets in the four states generally absorbed less than
10% of the total state revenue budgets throughout the 1980’5 (Table 5.6). In each state the
share has declined over time suggesting that during the period of adjustment past trends have
been exacerbated, rather than reversed. This decline in shares occurred despite the rise in real
per capita expenditures in all states up to 1990/91, indicating that total state government
expenditures rose even faster than health expenditures. Since 1990, the budget share has
increased in Karnataka (from 6.1 to 6.4%), but fallen further in West Bengal (from 8 4 to
7.2%), Punjab (from 6.6 to 5.3%) and Andhra Pradesh (from 5.9 to 5.4 percent).
Table 6.5: Real Growth Rates in Health Expenditures
Project States 1980/81 -1993/94 (annual in %)
1980/81-90/91
1991/92
1992/93
1993/94 R E.
Karnataka
_______ 4.4 1
_______ 5.7
______ 13.4
10.6
Punjab
4.3
-3.8
0.5
1.1
W. Bengal
2.8
-16.2
0.4
7.0
Andhra Pradesh
4.4
3.2
2.9
Table 6.6: Share of Health and Family Welfare Sector
in Total State Revenue Budget (%)
Karnataka
Punjab______
W, Bengal
Andhra Pradesh
80/81
85/86
89/80
90/91
91/92
7,87
9.00
12.05
6.53
7.19
8.90
5.95
6.51
7.76
6.12
6.60
5.96
6.44
4.32
8.01
8.44
5.87
6.40
5.78
7.55
5.60
6.42
8.79
7.32
92/93
93/94
R.E.
6.43
5.31
7.15
5.38
G. Composition of the Health Budgets
b.lS
The allocation of spending between primary, secondary and tertiary level facilities
and services is not readily available in state bidget documents. The approximate shares can
be obtained only by reclassifying individual line items. This exercise has been undertaken in
varying degrees for each state.
6.16
West Bengal. The total health budget in V.
’
West
Bengal for the years 1989/90 to
1994/95 has been re-classified under five heads: (i) primary health
i care (ii) rural hospitals
and dispensaries (iii) urban health care facilit es (iv) items of general expenditure and (v)
medical education (Table 6.7). Primary. care c >mprises expenditure on public health, family
welfare, rural health services (allopathic and non-allopathic) and urban non-allopathic
- 4Q -
services. Expenditure on Employee's
f
State Insurance has been placed under urban health
care facilities since the scheme covers workers in the organized sector of industry, which is
mainly located in urban areas.
Table 6.7: West Bengal — Composition of the Health Budget
(as % of total)
I. Primary care
MNP
|| Subsidiary centers
| Other
| Rural health service.
| (non-allopathic)________
Urban health service.
(non-allopath i c)
School health scheme
Public Health
Family Welfare ~~
I II. Rural Hospitals &
I Dispensaries
III. Urban facilities
Urban hospitals &
Dispensaries
Employees' State Insurance
Iv. General
—
Direction & Admn.
Medical store depots
Other exp.
~~~~
V. Medical Education and
Training
Total (Rs. crores)
89/90
39.66
6.40
1.73
3.01
1.42
90/91
38.19
91/92
4030
92/93
38.55
93/94
40.53
94/95
"3934
1.03
1.02
0.008
0.009
0.006
0.009
0.004
0.009
0.004
0.006
0.007
0.007
0.008
0.009
13.02
13.38
i 1.33
1.90
12.25
13.0
10.92
2.2
12.48
14.59
11.15
2.13
12.28
3.90
13.77
12.36
9,32
2.42
11.40
2.24
40.00
32.49
40.12
33.38
43.16
35.40
43.16
36.67
42.52
34.20
43.50
34.96
7.5
3.15
6.4
0.006
6.12
6.74
12.23
3.58
5.43
3.03
7.01
7.75
8.15
3.75
4.03
6.98
8.62
3.85
4.51
8.32
7.46
3.25
3.86
8.54
7.48
3.32
3.81
6.47
7.44
7.34
7.52
322.77
445.2
386.96
426.55
502.11
539.46
12.42
12.93
1.73
1034
0.009
13.09
Source : Govt, of West Bengal, Budget Documents.
urban (secondary and tertiary) facilities increased from 40.0% to 43.5%, much of it going to
from 6%"'7.5X'i«rl"re f°r ""diCa'
,nd 'raini”8
6.18
By contrast, rural hospitals and dispensaries have received the lowest share of
expenditures and this has been reduced almost by half since 1989/90, from 3 9% in 1989/90
to 2 % m 1994/95. Recent sector work has demonstrated that there is considerable underfundmg nationally of this segment of the health services in relation to both needs and
prescribed norms (India: Policy and Finance Strategies for Strengthening Primary Health
Care Services). Moreover, it appears that these services have been under the greatest
pressure in recent years.
b
- 50 -
6.19
[he share of general expenditures has also decreased, from 10% to 7 5% This is
almost entirely due to the reduction in the share for medical stores and depots, which
declined from 6 4% to 3.8%. thus, in addition to rural hospitals, expenditure on drugs and
other consumable has also borne the brunt of expenditure contraction during the period of
6.20
In order to determine the broad allocation of resources across different categories of
inputs and different levels of hospital services, the composition ofnon-plan expenditures on
hosp.ta s and d.spensaries in West Bengal during the last three years was examined. Urban
hospitals were divided into two categories, tertiary and secondary. Hospitals in metropolitan
centers and specialty hospitals were designated as ltertiary, while all district urban hospitals
were designated as secondary. The results are presented in Table 6.8. The level
of
expenditure on urban secondary' and tertiary hospitals is broadly similar. Expenditure
on
rural secondary hospitals is only pne ninth of that on urban secondary hospitals.
6.21
In urban tertiary hospitals, salaries and
wages account for about two-thirds of
revenue expenditure. Although there was a slight
‘
reduction in 1993/94 (to about 60%), the
budgeted share rose to 65% in 1994/95. Expenditure on i
’ '
materials and supplies (including
drugs) comprise around 9-10% of the total, although again there was a slight dip in 1993/94’
Machinery and equipment absorbed over 5 % of the total in 1992/93 and 4 7% in 1993/94
Expenditure on d.et rose from less than 6% to 9%. Expenditure on maintenance has been
neghg'ble. but th.s understates the overall maintenance expenditure on buildings which is
4% respectiveV''"
""a'
*'d 'O
hospiuls - about 10% and 3-
S J
hC ,expenditure
eXper\ditUrf pattern
Pattern is broadly
broad|y similar
similar iin urban secondary hospitals, with about
The
5/o go.ng towards salaries. Apparently, expenditure on materials and supplies fell quite
dramatically
1992/93 (to less than 5%), rising to around 9% in subsequent years
Expenditure
about
7% It°nwmdCd
andkequiPme1nt is 2%- while expenditure on diet has increased to
n i , h
k u ! ?PPear that
Urban secondary hospitals, the share of salaries was
protected w.th the budget cuts of 1992/93 which was borne by drugs and consumables.
^^jQrwiileTh"'13?' hOSPriU11S’
01 material3 and suppl.es fell to 1% of the total
cL
r ’
Sa‘ar,eS W3S 75%- In the Allowing two years, however the
hare of salaries and wages was brought down drastically to less than 60%- salary
The'sh
C aCtta y fCl1 ‘n a|bS°IUte tCrmS’ Pr°bably indicatin8 ^at vacancies were not filled
The share spent on materials and supplies rose to over 12%. However, since the absolute
e*Pendl‘ures on rural hospitals hardly increased in this period, and real expenditures fell the
se in the share does not indicate any significant improvement in availability of drugs’and
e“3
8
11 d°eS 'ndiCate 3n attempt t0 reStOre the levels °f ending attained
- 51 -
Table 6.8: West Bengal - Composition of Spending in Hospitals and Dispensaries
1992/3 - 1994/5
Urban Ternary
93-94
94-95
66.1
60.1
65.0
92^93
Salaries and
Wages
Materials &
Supplies
Machinery and
Equipment
Motor Vehicles
Diet charges
Maintenance
Aid to non-govt.
hospitals
Office Exp. &.
Oth.
Total (Rs.
crores)
Urban Secondary
92-93
93-94
94-95
74.9
74.5
74.1
Rural Secondary
93-94
94-95
75.3
58.3
59.8
92-93
10.2
8.7
9.3
4.6
9.5
8.9
1.0
12.7
11.9
5.2
4.2
4.7
1.2
1.7
2.0
2.8
4.2
4.5
0.2
5.9
8.0
f 7.1
0.1
8.0
1.0
0.4
15.8
0.4
15.0
0.06
3.0
0.9
6.7
0.02
0.9
7.9
0.06
0.3
6.6
0.02
0.3
0.03
0.3
3.2
0.02
0.9
2.7
9.7
9.1
9.9
14.9
6.5
7.1
11.9
8.5
8.5
74.49
87.58
8830
76.82
83.85
91.82
8.43
9.48
10.06
Note: Total refers to Non-Plan spending only. 1993/94 expenditures are revised estimates and 1994/95 expenditures
are budget estimates.
Source: West Bengal, Budget Documents.
6.24
Karnataka- Budget allocations in Karnataka r
were disaggregated and re-classified into
functional activities: primary health, family welfare,
. secondary and tertiary health, medical
trainin8’ and ^ministration. The percentage distributions from 1990/91
to
1994/95 are described in Table 6.9.
Table 6.9: Karnataka - Distribution of Health Care Revenue Expenditures
by Level of Care 1990/91-94/95
Function
Administration
Medical Education
Secondary &. Teniary
Public Health
Family Welfare
T990/91
2.6
9.1
34.3
38.3
15.7
1991/92
2.9
9.8
34.8
34.3
18.2
1992/93
2.2
10.5
32.5
38.4
16.4
1993/94
2.2
8.7
35.9
37.2
16.1
1994/95
2.1
10.1
33.0
37.7
17.1
6 25
Throughout the period, primary health care and family welfare have absorbed around
53 percent of the total health budget. Secondary and tertiary care combined have absorbed
between 33 and 36 percent and medical education and training, around 10 percent. The most
notable change in shares has been for family welfare. For this activity, nominal expenditures
mcreased by 23 percent a year compared to the lowest growth rate of 16 percent for secondary
and ternary care and 18 percent for primary health care. It is of interest to note that family
welfare is a 100% centrally sponsored scheme.
pH' (So
05073 ■''it,
■
*
i
•4
6.26
Complicating the disaggregation of allocations in Karnataka is the substantial degree of
this"t 95’ ^e,Share f°r?hese facillties aPPears t0 have falle" from 23 percent to 5 percent If
this is typical, the rural hospitals in Karnataka have been under severe and increasing pressure
similar to the apparent case in West Bengal.
®
6.27
2^. Health expenditures for Punjab were re-classified under primary secondary
SSncVh^i TraTtOrieS and
S-XCOc-
expe^itures between'these Sei SVsXSsS^n TaHe
breakdown, an average of 61 percent of expenditures are allocated to primary care
percent
occumed The^ T6"'
'he
h0WeVer’ SOme chanees hav«
occurred. The shares for pnmary and ternary health care have fallen by 5 and 1.5 percentaee
points respectively while the share for secondary care has increased by 6.5 percentage points.
Table 6.10: Punjab - Distribution of Health Revenue Expenditures bv Level of Care
1990/91 - 1994/95
Function
1990/92
1991/92
1992/93
1993/94
1994/95
Primary
63.5
60.9
65.9
56.9
58.4
Secondary
23.0
26.5
21,8
31,8
29,6
Teniary
13.5
12.6
12.3
11.3
12.0
6.28 The data prepared for Punjab also allow for some analysis of items of expenditure
percem of'o '
ltemS
,n ,994’ salari« absorbed 77. 70 and 67
percent of pnmary, secondary and tertiary care expenditures. Materials supplies and
,0' 25 “d 18
- "O
health s^t
h h' Makhapatra and Berman <1995) and Mahapat.a (1996) have analyzed
health service expenditures between 1980 and 1993. A number of conclusions emerge First
the share devoted to public health increased from 48 to 57 percent while the share for
^condary level hosp.tals were very slightly above those for tertiary hospitals in 1980 by
0„,y four countries spcnl, lh„ 40
- 53 H. Future Trends in Public Sector Health Financing.
■ 11
The level of government resources made available for health services depends to a
arge extent on the overall public finance situation facing each state. This issue of the overall
developments in state government finances was discussed in Section B on state finances.
ith that as background and subsequent discussion on trends in expenditure on health, the
share of resources to the health sector and the composition of the health budget, a brief
discussion on the state level risk and sustainability of public health finance follow.
6.31
Kamaiaka: Is there any reason to expect that the high growth rates of health
expenditures over the past fifteen years will be maintained despite the deterioration in the
states overall financial position? The revenue account in 1993/94 was in surplus. The gross
fiscal deficit is equivalent to 17 percent of revenues - one of the smallest among the major
iqoo/o ntereSt PaymentS °n deb‘ accounted for 11-6 Percent of total revenue expenditures in
1992/93 nsmg to 12.7 percent in 1994/95. Public debt was equal to 26.3 percent of state
domestic product in 1990/91 and to 27.0 percent in 1994/95. The indicators of public
inances in Karnataka show some slight deterioration over the past few years as a result of
increased borrowing for capital expenditures but overall demonstrate a picture of reasonable
6 32
Ejumab; How feasible is the assumption of overall revenue growth in the state beine
equa to the level of the 1980s? The deficit on the revenue account was estimated at 13 5
percent of revenue receipts in 1994/95 and to 23 and 24 percent in the two previous years
The gross fiscal deficit has been equal to 40-45 percent of revenue receipts over the past
three years - the hlghest for any state. Interest payments on the state government's debt as a
share of total state revenue rose from 12.5 percent in 1985/86 to 37.2 percent in 1994/95 JLT
k 8 k5' 2 K°n8 thC elCVen m°St highly P°Pulated states- Revenue growth from
state taxes has been buoyant m recent years and well above that for all states combined
r °.
' addltl0"al effons will be required both to increase revenue receipts further and to
tUrCS ,f 8r0Wth ln S0C'al Sector real expenditures is to revive. The relative
wealth of the state suggests that increased revenues should be possible to generate.
6.33
Bengal: Real growth rates in health expenditure through the 1980s averatted
.8 percent a year. In 1991/92 real expenditures fell by 14 percent. Since then they have
risen by an average of 2.9% a year. The deficit on the revenue account was equal to 19
?ncrreent I rT reCCiptS
*994/95’thC higheSt rati0 across the >5 -ajor states TOs h
ncreased from 14 percent m 1991/92. The gross fiscal deficit is currently (1994/95) equal to
to ^I'of re°vereVenUe
'T31
°n the SUte g°vernme"t's debts were equal
to 19.1 of revenue expenditures m March 1995. This is slightly above the average across the
major states (18.0 percent). Outstanding debt is equivalent to 22.6% of sure domestic
product which is slightly below the average. Efforts are underway to improve state public
shared’
05031 def‘C't
'S anticiPated t0 be below
previous year’s and as a
share of revenue rece.pts is planned to fail to 27%. Further effons to increase revenues and
to alter the structure of expenditure obviously will be necessary to reverse the relativelv
- 54 -
6-34 Andhra Pradesh' The financial situation of the state has deteriorated considerably
during the past 15 months, largely because of a drop in revenue receipts and new government
subsidies on nee. Ini 994/95 the revenue deficit was 1.2% of the state domestic product the
g oss iscal deficit was at 4% of the state's domestic product; and total outstanding debt
stood at about 24% of the state'domestic product. The interest payment on the debt was
We” bXTXX'1"’
“'’endi,“reS- "W"
lower .han
6-35 What emerges as a lesson for other states is a mixed picture among the states for
terns 'y5 ana yS'S *'as undertaken- Karnataka appeared better-off than the other states in
terms of its overall financial situation, but by no means in a situation h
complacency. Given the outstanding debt situation of each state, the interest payment oTtha^
will1 be d'ff 51,11 hlgh expectcd fiscal deflcit in coming years, it appears quite clearly that it
hJi th d ffiCUi
the StatCS
general t0 substantially increase their contribution to the
(1"6) ana'ySiS °f health Sector expenditures, which includes
penditures beyond those included by the Department of Health, provides a more positive
P ture than the one presented above for health services alone. Nevertheless the increase in
resources to the health sector would have to resuit from a diversion of reXces from some
other sector. Such a change will have: to have strong political support and will on the part of
each state government.
I. Recommendations
recommendations may be considered by most states
S general
would be better eqmpped'to addre"XalZurce"Zds. SItUat‘°n’
ihT"'d ,O ‘CrUm ,h'
■»"» “■ by .be ^e™o’f
nnanclahy worse ofTsu^
governments should maintain the share of health sector allocations in the overall budget
to redress the share of declining resources to the sector in most states.
8
- 55 -
•
The state governments need to reevaluate the priorities within the health sector budcet.
especially with regard to resources for the primary, secondary and tertiary levels.
Secondary level hospitals, particularly rural and community hospitals have received a
-low share of resources by comparison to teniary hospitals’ The share of primary and
secondary level health care, which provide the basic package of public health and
clinical services, needs to be increased within the overall envelop of state government
resources for the health sector. Over the next 3-5 years, state governments would need to
allocate 75 percent of incremental resources allocated to the health sector to the primary
and secondary levels of care. This would imply a lower level of allocations for medical
education and the existing social insurance schemes which are poorly targeted.
•
The state governments also need to re-evaluate their priorities with regard to non-salary
recurrent inputs such as drugs, essential supplies and maintenance budgets With some
mmor variation between states and the level of health care services, it appears that 75
percent of the health budget is absorbed by staff salaries and wages. Within the next 2-3
years, state governments need to allocate adequate funds for drugs, essential supplies and
maintenance budgets in accordance with established norms.
•
The health budgets of the panchayats also need to be enhanced, in order to allow them to
carry out their maintenance function and newly provided responsibilities.
- 56 -
CH/V PT ER 7
A Supplementary Health Financing Mechanism: User Charges
A. Introduction
7.1
This chapter focuses on key aspects of supplementing state government budget
allocations for financing health care services. It reviews user charges as a means of providing
a supplement to enhancing budget allocations for the health sector, especially with respect to
operating or recurrent expenditures. It does not, however, cover other financing options,
such as health insurance or community financing, which were considered beyond the scope
of the present study at the IM stage. The important questions on user charges raised in this
chapter relate to mobilization of supplemental funds and their allocation within the health
sector. These issues have taken on increasing significance due to the financial constraints
faced by the states and the competition for budgetary resources from other sectors. The
rationale for user charges arises from the difficulty in obtaining sufficient resources from the
state budget and the need to provide additional funds to supplement the budget as well as to
provide the correct incentives to address health care needs at lower level facilities.
B. User Charges: Operational Issues
7.2
A general observation is that the level of cost recovery in medical and public health
services is very low in India. Table 6.1 below shows the percentage of cost recovery in the
medical and public health budget in the 15 major states of India.
Table 7.1: Cost Recovery in Medical and Public Health Services (Non-ESIS)
(in percent)
State
15 Major States
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana______
Karnataka_____
Kerala______
Madhya Pradesh
Maharashtra
Orissa
Punjab_________
Rajasthan
Tamil Nadu_____
Uttar Pradesh
West Bengal
7980^8?
1975-6
6.4
2.9
3.9
17,0
3.7
6.4
11.0
3.8
4.9
12.9
2.6
15.6
4.0
40
5.3
2.2
4.1
3.4
3.5
8.5
5.0
3.9
3.2
4.1
2.4
3.5
3.0
5.6
3.9
9.5
1.9
2.1
Source: Tulasidhar, 1992, p.85
I
I
1984-85
3.04
3.8
3.3
1.9
7.7
2.7
3.7
6.4
1.7
4.3
4.3
2.5
3.2
1.3
2.1
1988-89
1.6
0.8
1.6
2.6
“i.5
6.6
1.6
2.4
1.7
1.1
5.4
0.8
1.6
0.5
-0.8
Average
3.8
2.7
2.2
7.2
3.3
4.9
5.9
3.3
4.0
5.0
2.8
7,7
2.8
4.6
2,3
1.4
- 57 -
7.3
Of the 1 5 major states, the a\erage levei of cost recoven' for the period 1975-89 was
the highest in Punjab at 7.7%. and was as low as 1.4% in West Bengal. In Karnataka it was
5.9% arid in AP it was 2.7%. The average for India was about 3.8%. international experience
in developing countries with somewhat higher per capita income than India, and where
performance of the public health sector has been better, shows that revenue collected from
user charges accounts for about 15-20% of the health budget. The low level of cost recovery
implies that the state Governments will continue to depend for most of their resources from
the government budget. A large portion of Government funds, in turn, are directed to salaries
(75-80%) and little money is left to spend on investment ard non-salary recurrent
expenditures. As a result, health facilities face operational deficiencies, including underfunding of drugs, supplies, other consumables; shortages of diagnostic facilities and
laboratory equipment: and general deterioration of the physical infrastructure. These factors
have all added to the state Governments’ inability to deliver health services of adequate
quality. In this scenario, user charges are viewed as supplemental funds mainly for funding
operational activities or non-salary recurrent costs. They are. however, not viewed as funds
that would substitute or replace the state government’s contribution to the health sector
through the budget.
7.4
The low' level of user charges in government facilities do not fully reflect the actual
cost per illness episode. Beneficiary assessment studies in the states show that considerable
costs are incurred by patients and their families per illness episode, such as for
transportation, medicines, clinical tests, under the table expenses, social diets and rituals.
Out-of-pocket expenditure, even among the poor and tribal populations, is an indication of
the willingness to pay in times of acute illness. However, more detailed analysis is needed to
obtain more precise estimates of the actual expenditures incurred by households, beyond the
official fees charged.
7.5
The low level of income generated through cost recovery is due to the low structure
of fees, the narrow range of services for which fees are charged and the inadequate
mechanism for enforcing the collection of fees. These are discussed below.
7-6
Low
aw structure
Structure of
Qf fees. The fees charged to out-patients and in-patients at various
health care institutions are highly subsidized and do not reflect demand or user welfare. The
cost of services provided and the demand for such services indicate that the structure of fees
are significantly below the market rate or the fee structure in the private sector. As such, fees
are not used as a pricing mechanism to improve allocative efficiency by reducing the use of
hospital services, removing excess demand or providing appropriate incentives to providers
and patients. Beneficiary analyses in the four states show that at the low level of the fee
structure, the demand elasticity of services is not very responsive to changes in user fees.
Patients using the public health care system incur significant transport costs and are quite
often willing to increase their out-of-pocket spending. However, despite the willingness to
spend more out-of-pocket funds, there are equity considerations and ability of patients and
their families to pay for such services. The increase in the structure of fees can adversely
affect access of health care services to the poorer sections of society, who are most frequent
users of public hospital services.
I
- 58 Narrow rangy ot■services for which fees arc chiirycd. The Government's policy is not
to charge lor services provided at the primary level. This includes those services provided at
mnCnnAerS' P"™17 health
and community health care centers serving up to
100.000 people. Fees are charged for services at the level of the community hospital and
above, including other secondary and tertiary hospitals. However, the range of services for
which fees are charged are limited and many diagnostic and treatment services are not
charged at all.
7.8
Inadequate mcchantsms for collecting user fees. Although government orders are in
place m most states specifying the level and range of eligible charges, it is observed that
mechanisms to ensure that such charges are collected are weak. As a result, there are plenty
of leakages constraining the collection of funds. The weakness are both at the institution
evel of the hospital as well as the level of the Department of Health. At the hospital level
the ^‘em of account keepmg is outdated and the finance and audit wings of the Departmem
of Health are poorly staffed to carry out this function. Analysis shows that the strengthening
of the fee collect.on system could potentially contribute more to revenue than an
enhancement of the fee structure in the short term. Moreover, all states are committed to
exempting the poor from most of the fees for hospital -services. However, adequate
mechanisms are not in place to target the poor appropriately and there
are leakages on both
sides: those who should be eligible to receive free services are
having to pay, while those
who are not eligible to receive services benefit from the existing syst- n. This is partly due to
the administrative complexity of identifying and targeting the poor.
Y
. ^£lenlipn and use of rcvcmif. collected af IhcJnstitutional level Administrative and
mancial responsibilities at the hospital or institutional level are diluted. The funds that are
co ected at the hospital level go to the Finance Department of the state Government where
hey become pan of the general revenue. They are not retained by the institution collectine
Finance" d'’
generated b> them Provided to these institutions by th!
mance Department in proponion to the level of revenue collected. As such there are no
incentives for these institutions to collect such fees. In recent months, however the state
ovemments of the four states have taken initiative to retain the funds collected at the
institutional level or at the level of the district health committees, to be reallocated by the
istnet committees withm the district on the basis of need and level oT-evenue collection.
p9
C. User Charges: Existing Practices
Current Government practice in India is to provide free services un tn a cn. r
d servi“ l'v" i" P“wi' «
institulons. This Implies lha. user fees am not
nur f
h“ 'h
incl“dinS fwentive and promwive care services
nor for people whose income level is below the poverty line. As a result the im t r
adopting user charges in hospitals for those sections of the population above the pove^line
£lS “eaoXm
ade^ resources for the
eaith sector from the general public revenue of the states. User charges are exoected m
provide additional revenue for under-funded public programs
patients’ ability to pay and be targeted specifically for direct’ health clr^utiliwion
Implementation of these general guidelines is expected to improve access to health care
services and strengthen the quality and efficiency cf services provided.
7.10
- 59 -
7.11
’
irrii o»-»z-j ^re unlikelv t
K '
ii
'
on user fees do not go
far enough
sector
Th and
/
unlikely to substantially increase supplemental revenue for the health
nro d I State5Jovernment's policies need to take account of the quality of services to be
provded, a ^gntficant enhancement in service quality would provide a strong rationale for
cha30^0^' 6 eVel °f charges and broadening the services for which user fees can be
arged. More importantly, each state has to create a suitable environment through adeauate
admmistranve arrangements and analytical work that would provide a framework for a
continuous rev.ew of user fees. The involvement of the Bank has been cata " Tseting u
hea hTs^
Of!USerS Char8e P°licieS and Practices in
four states whet a
the
y ? prOject’s ,n p,ace’ Opportunities for enhancing the level of these charges and
estabiXd
ChargeS C3n be ‘eVied need t0 be reviewed within the newly
such a? r
niStraJ1Ve mechanism- The existing policies and practices on user charges
such as outpatient and mpatient charges, criteria for exemption for the poor and revenue
administration, in the four states are described in Annex 4.
D. Potential Revenues From User Charges: Examples from Karnataka and AP
chXs ' reVfUe'b^ nbeXgefnZedrthrough 'tht implemenSdon ’7 ttTpesXs'er
Karnataka
7.13
Paying beds and wards. , Currently, the total bed strength is 14 848
.ha. one
““ — * “
ha,.
category and two thirds under the latter and
'"Cl °f 85 P're'"h •«» ------- ..ii"revenue
X°d Z“ ‘r°“"d 'he
Table 7.2: Project Revenue from Paying Beds and Wards
Current.
Future:
■*
362 bed
TOSS beds
x"
?
310 days
310 days
310 days
X
X
X
Total
Increase
____________ 6 ■ Rs 0 7 m,
— __________
Rs. 50- RS 5 6m
— ________ Rs. 20- Rs. 6 7 m.
Rs. 12.3 m
Rs. II.6m
! I
- 60 -
7.14
Charges for Diagnostic Services and Surgery.
A proposal is currently beine
considered by the Government to charge a registration fee (Rs. 5) for each in-service case"
The most recent estimate, for 1992. is of 900.000 cases a year. The fee (if applied with no
exemptions) would raise Rs. 4.5 million. The charges being discussed for diagnostic services
and surgery in Karnataka tend to vary according to whether the patient is in a special ward or
the general ward. It is proposed that one set of charges would apply to all those in paying
beds while those in general wards (but with an income of over Rs. 11,850 a year) would pay
half that rate. Obviously, in setting charges for patients in special wards, care will need to be
taken to ensure that the combined higher quality of room and services can justify the
additional charge. Otherwise, patients will either opt for the general wards or for private
sector treatment and the paying beds will be underutilized. Currently, while there is a
schedule of charges, last revised in 1988, few are collected owing to the lack of institutional
incentive previously described. The charges in Karnataka, similar to those being proposed in
West Bengal, suggest a level of Rs. 45 for minor surgery and Rs. 100 for major surgery.
f°r some forms °f diagnosis are higher but apart from scans etc. few are above Rs.
7J5
Those inpatients below the defined poverty line and therefore to be exempted from
charges are estimated at 30 percent of the total number on inpatient cases - 270,000 patient
cases. Of the remaining 600.000 or so cases, six percent or 36,000 will be in paying beds.
The remaining 564.000 would be in general wards. Assuming that one-quaner of patients
require major surgery and the rest require minor surgery, the annual revenue from the
charges would be:
Table 7.3: Projected Revenue from Major and Minor Surg
______Patients
36.000 in paybeds
564.000 in general
Major Surgery
9,000 x Rs. 100+
141.000 x Rs. 50+
Minor Surgery
27.000 x Rs. 45=
423.000 x Rs. 23=
Total
surgery: s total of Rs. 34.5 million.
7.17
ery
Revenue
Rs. 1.3 m.______
Rs. 17.0 m. wards
Rs. 18.3 m.
B
and
Outpatient charges. A recommendation to charge a registration fee (covering a year
conTd
d h8 rratlOn
!S filled UP) °f RS- 2 f°r 0U‘Patients without exemptions is being
considered by Government. In 1992, roughly 10 million cases were registered Revenue
would be about Rs. 20 million.
revenue
SSSE-SSSS
Ks. 82 million a year.
-61 -
ivlle' “our 9eXm onbe
R°3U“ 5» m
2002 or over 29 XTpf'lllX'b
J"“Xes " Tfe Zin'VZ. dd'r ""I
mtght be compared to the average private expenditures of an episode of hosokaSon
rural private hospital in 1986/87 of Rs 733 fNSSCn
Th^
osP,tal|zation m a
opportunity to review and enhance charges for minor and major surgeXhfie ma^nr36'6
that appropriate mechanisms for protecting the poor are in place.
8
8
7.20 These calculations are mainly illustrative However the ectimo,^
user charges are a. .he low end ot .he po.en.ial ™ge a” to nclod X exhZ'h
=~
xxx.“xphX::±'ses more
■»
Andhra Pradesh
7.21
7Paying beds and wards. The plan is to allocate 20% of all beds at district and area
hospitals
,OikK
comprises cobicles FrXral wards "iX "JJ'
C
revenues calculated below are based on th P
• s0™? privacy t0 Patler|ts. Projected
classified as Category A 45 percent as
aSSUpPt,°" ^at 35 Percent
Paying beds are
opting for paying wards would have to pay bld charge" - those^r"1
Ca‘e80ry C' Patients
would also have to pay for treatment cosVfor surged? and! d'gnoS.
B Cate8°rieS
oX
occupancy is expected to be about Rs 17 7 miir
to be about Rs. 19.6 million
rrTeT; ur r™*™
annual collection assuming 70%
aSSUmin8 8°% OCCIW, it is expected
Table 7.4; Annual Collection:is from Pay ng Beds
Category A
Category B
Category. C
Total Revenue
Bed Charge
(Rupees/day)
50
30
5
Number of beds "
735
945
420
2.100
70% oc< upancy
_
(Rs. rjill.)
________ 9,3''
80% occupancy (Rs.
_____ mill.)
“
10J3
___ 7^*"
0.5*
_
i7.r~
~
8.28
0.61
I
iw
'
- 62 -
/.-J
I able 7.? presents projected revenues generated bv sureerv for patients in
paying
wards. Fhe total revenue generated by surgery charges, under the above assumptions is
expected to be Rs. I 1.8 million for 70% occupancy and Rs. 13.4 million for 80% occupancy
Surgery charges have been assumed to be Rs. 700 for major surgeries and Rs 200 for minor
surgenes (data prov.ded by APVVP) and are inclusive of expenditures on suturing materiS
anesthetics
and
dtraso drugs hand OT
°T charges
'b3'6’65 and
Patholo8y
Drugs, disposables, X-rays
separateK
inC'Uded in this Packa8e and are expected to be charged
3P 'V 'eStS
Table 7.5: Projected Revenues from TSurgical Procedures
(Paying Ward Patients Only)
Category A
Category B
Total
Occupancy
Inpatients
70%
80%
70%
80%
70%
80%
18,780
21.460
24.145
27,590
42,925
49.050
Major
Surgeries
4,695
5.365
6.035
6.897
10,730
12.262
Revenue
(Rs. m)
3.29
3.76
4 22
4.83
7.51
8.59
—— — i
Notes
Minor
surgeries
9,390
10.730
12,070
13,795
21,460
24,525
Revenue
(Rs. m)
1.90
2.1
2.41
2.76
4.31
4.86
occupancy rate to get total number of bed. — ...» current average).
reSPeCliVC,y
50% respectively of
years show that currently about
can be safely assumed that the
7 24
Additional revenue will be generated bv charging for X ravs nit™ c
consumables. Since data are not available on the 8 8
* ' ’ ultra'sono8raPhy, and
consumables, a rough estimate of prospective revenues can'bemadTb these.services a"d
of Rs. 200 per inpatient A sum of r/r so
ir r
6
d by assuming a Oat rate
for 80% occ%anPv
“d R’-
Table 7.6: Revenue Collection from Paying Esds
(Rs. million)
Bed Charges
80% Occupancy
70% Occupancy
19.6
17.2
’»dL
Surgical
procedures
13.4
11.8
Drugs and
consumables
9,8
8.6
Total
42.8
34.5
pa>""8 bcd
attendants and extra amenities such
betweenls^.gmillion'a^
collect.ons, net revenues generated will be
- 65 -
7.26
Outpatient charges. The number of new outpatient visits is currently about 10
million. Improvements in quality which are envisaged in the project and the normal growth
in population would probably result in an annual turnover of about 12.5 million new
outpatients. Data on the number of outpatients by gender, age, and type of case are not
available. However, an estimate of the gross revenues can be made under different
assumptions. Assuming an outpatient charge of Rs. 2 and that 30% of outpatients fall in the
non-exempted categories, the gross revenues collection is Rs. 7.5 million. On the other
hand, !f only 50% of the outpatients are exempted, Rs. 12.5 million can be collected
annually.
.
Additional services. APVVP proposes to set up special outpatient clinics and offer
lagnostic services for the private sector. The market for the latter is estimated to be large.
The decision to offer these services would have to follow a more precise estimate of demand
Preliminary estimates indicate that about as much as Rs. 10 million can be raised through the
sale of these services.
7.28
Potential revenue from hospital charges in /
AP. The few simple measures outlined
above can raise revenues to the order to Rs. 65 million, representing about 24% of the annual
non-salary recurrent costs when the present phase of upgradation is completed. The
assumption used in the above calculations are fairly cautious. Dif rent pricing rules for
instance a larger differential between Category A and Category B -.i.arges, can lead to the
generation of additional revenues and also create possibilities for a greater degree of crosssubsidization. The s.mple simulations indicate the possible levels of revenue collections A
deta.ls analysis would involve the effects of prices on efficiency, equity and revenue
generation and their effects on the optimal level of user charges.
E. Recommendations
7.29
The existing system of user fees in each state is based on a combination of partial
fee-for-service voluntary payments and targeting of the poor for exemption. The level of
user fees and the range of sendees for which fees could be collected are politically sensitive
issues and the state governments need to sensitize the public to the need to increase user fees
in order to improve quality of services at the secondary level and aHve. There is, however
w.lhngness-to-pay for quahty services and considerable opportunity exists at the state level’
to enhance revenue collecuon through user fees, especially to finance some of the non-salary
^cun-ent cost expenditures such as drugs and supplies at the facility level. Full cost recovery
at pubhc health care facilities is neither feasible nor desirable. It is appropriate to recover a
part of the costs of inpatient hospital services from those patients who can afford to pay
wh.le protectmg the poorest sections of society. As such, the setting of user charges should’
consider abdity-to-pay criteria; view user fees as a signal for allocative efficiency; rcfiect the
quality of services provided; and take into account externalities.
. 0
Analyses in the four states show that increased revenue can be achieved through
strengthening institutional mechanisms for revenue collection and preventing leakages,
putting in place adequate targeting mechanisms, and revising the structure of fees
^?„l:Ca ly’ USer feeS Wil1 be easier t0 imP*err-ent Politically once improvements in quality
of services
-Z. -.ZZ^ are provided and adequate targeting measures to protect the poor are put in place.
- 64 -
Therefore, col lection mechanisms need to be strengthened concurrently with the revision of
charges. Lach of the four states -- Andhra Pradesh. Karnataka. Punjab and West Bengal —
has adopted a system of user charges at secondary level hospitals that subsidize the cost to
the patients. This implies that patients pay only pan of the costs of health care services.
However, they will now pay more often than they have in the past, and revenue collected
will be substantially higher. These slates are also improving the mechanisms for revenue
collection by strengthening the finance and audit wings of the implementing agencies,
appointing finance personnel at the hospital level and implementing a more effective
targeting mechanism. These present important lessons for other states to consider.
7.31
The following actions on policies and practices regarding the implementation of user
charges at the state level are recommended:
The states need to set up an institutional framework for periodically reviewing the
structure of user fees and pricing policy. This could be one of the functions of the
Strategic Planning Cell, established in the health sector in the four states studied.
•
Collection mechanisms need to be strengthened. State governments need to increase cost
recovery from an average of about 3 percent to about 15-20 percent in the next 3-5 years
fhis can be achieved by concurrently strengthening collection mechanisms at the facility
level and by periodically reviewing and revising user charges.
•
Adequate targeting mechanisms to identify the poor need to be implemented. It is
preferable to strengthen the existing system for targeting the poor rather than create a
new mechanism because of the administrative costs involved. The existing JRY system
identifying families below the poverty level, with minor adjustments appears to be the
most effic.ent way to implement a targeting policy. However, there can be variation as in
West Bengal.
Revenue collected should be used for non-salary recurrent expenditure items such as
drugs, essential supphes.and record keeping; charge all outpatients a nominal fee (Punjab
vand West Bengal); concentrate charges on voluntary services such as private rooms or
wards and on medical services with a relatively low cost-eff-.- iveness such as those
diseases under group H with appropriate targeting for exemption in urban areas.
•
In the absence of quality improvements, new or increased charges could lead to reduced
•demand for hosp.tal services with an overall reduction in revenues. Increased charges
should, therefore, be introduced in a phased manner and matched to higher quality levels
of services. Some would be appropriate immediately; others would need to await
improvement in services and infrastructure.
•
Hospitals should be allowed to retain
i
100 percent of the revenue collected, or district
committees and
state
level
health
L
L
s>'stems corporations (e.g., as in AP and Punjab) on
their behalf should be empowered to retain such revenues and redistribute them amone
hospitals within the district according to both need and level of collection
- 65 -
Chapter 8
The Cost Effectiveness of Health Interventions
A. Introduction
8.1
This chapter extends the discussion on the allocation of resources for the health
sector and the financing of health care at the state level by highlighting the cost
effectiveness of some key health interventions and the implication this would have on
policy-making. Understanding the cost effectiveness of alternative interventions, the relative
burden of disease and health risk factors is critical for improving the allocation of resources
and the planning of financial systems. Health policy analysts in India are increasingly aware
of the inadequacies and the inertia of the existing system, the potential for improvements and
the increasing costs of health care in an environment that is rapidly changing the manpower
and technology used to provide health services. The challenge is to seek improvements by a
more medically and economically rational approach to health service provision. As a result,
there is a need to estimate the burden of disease and study the cost effectiveness of
alternative health intervention strategies. Cost effectiveness of alternative strategies and
formal economic analyses of health care programs are relatively new approaches facilitating
policy-making in India. It is being increasingly recognized that economic analyses of health
care issues and interventions can substantially contribute to improving health policy. As a
complement to this analysis. Annex 2 provides a detailed analysis of unit cost at different
levels of the health system, and shows how an intervention at a lower level facility can result
in substantial cost savings.
B. Burden of Disease and Cost-Effectiveness Study
wnn /oo?rngutheuGI°bal Burden °f DiSeaSC (GBD) analysis unde^ken as part of the
WDR ( 993), which measured the combined losses from premature death and loss of
healthy hfe resulting from disability, National Burden of Disease analyses were undertaken
m Mexico, Columb.a, South Africa and India. While in other cou: ies these studies have
been at the nat.onal level, m India, considering the vast population and reported diversity in
disease pattern, the analysis was undertaken at the state level. Andhra Pradesh was chosen as
the state where such an analysis would be undenaken to support the preparation of the first
ealth systems project in India. The Andhra Pradesh Burden of Disease and Cost
Effectiveness of Health Interventions study was undertaken by the Administrative Staff
College of India (ASCI) in conjunction with the Harvard Center for Population and
eve opment Studies, with support from the Bank. Detailed results and description of the
methodology are available in the ASCI study which was undertaken as part of our state level
health sector work in India. The BOD part of the study was repeated separately for the states
of Karnataka, West Bengal and Punjab by ASCI. Some of the main findings with respect to
interstate comparison of the BOD studies are summarized in Chapter 3. This Chapter focuses
on the cost effectiveness part of the analysis.
-.I-
- 66 C. Cost Effectiveness Analysis
Applications of economic analysis to resource allocations in the health sector must
make the choice of whether to value outcomes in terms of economic benefits or in terms of
some proximal measures of effectiveness. In the health sector since outcomes can be
measured in deaths or disability averted, the challenge is to come up with a measure that will
allow comparisons to be made across the sector. The cost effectiveness approach by
focusing on choosing between mutually exclusive health interventions, provides such a
measure. The choice of interventions is a necessary condition for designing a delivery system
and influencing government policy towards effective delivery. In India, as in other
developing countries, much of the choice of intervention has not been based on rigorous
analysis. The key elements of a health care delivery system, including the planning of
human and physical infrastructure, logistics for drugs and supplies, appropriate management
structures and financial instruments, depend in important ways on the composition of the mix
of intervention. As a result, these are factored into the cost-effectiveness analysis reported in
this chapter. The cost-effectiveness methodology, however, does not allow intersectoral
comparisons which are possible when cost-benefit analysis is used. However, cost-benefit
type analysis,, is not suitable for health interventions due to the difficulty in quantifvimz
benefits and other data limitations.
8.4
The basic assumption of cost effectiveness analysis is that the health outcomes can
be measured quantitatively allowing intrasectoral comparisons. Though several measures of
effectiveness of health interventions such as deaths averted, years of potential life lost
quality adjusted life years lost, risks trade-offs and quantitv of life trade-offs have been used
by different researchers, the inherent difficulties in measurement of effectiveness still
remain. Certain diseases may cause more disability, while other diseases may result in higher
mortality. Recent efforts by Christopher Murray et. al. (1992) to develop a comprehensive
indicator of BOD resulted in the genesis of the BOD approach. DALYs, defined earlier, are
used as the specific cost effectiveness measures for the BOD analysis. DALYs combine
duration of life lost due to premature mortality and duration of unhealthy life lived with
disability; and express this as a single
‘
’index,
*
‘ ‘
which
can be used as a measure of
effectiveness. This provides an unique opportunity not only to compare the effectiveness of
different interventions for the same disease but also between intei ventions for different
diseases.
D. Andhra Pradesh Burden of Disease and Cost Effectiveness Study
8.5
The Andhra Pradesh Burden of Disease and Cost Effectiveness of Health
Interventions study used the BOD approach to estimate the burden caused for 96 diseases
including injuries and accidents. It undertook cost effectiveness analysis using cost per
DALYs gained as a measure of effectiveness of interventions. Cost effectiveness of about
preventive, curative and promotive health interventions has been estimated. The
specific situation and examples are exclusive to Andhra Pradesh, but with appropriate
modifications, the analysis could be extended to other sutes in India. It presents an example
of how health policy can be shaped and influenced as a result of the in-depth analysis that
was undertaken, especially with respect to the choice of interventions.
- 67 -
8.6
Using the GBD approach and fine tuning the data to the specific situation in Andhra
Pradesh, an innovative approach was used in the analysis in Andhra Pradesh to address some
of the data problems.12 The methodology involved: (i) analysis of input costs by fixed,
variable and infrastructure categories: (ii) accounting for some non-tradable goods costs in
non-monetary terms of a “full-time equivalent’’; (iii) measurement of technical efficiency of
different services by actual numbers or persons covered under the intervention and by units
of time segregated by active and passive durations; (iv) use of data source depending on the
type of intervention evaluated by program experience, rapid assessment and expert opinion;
(v) extensive use of expert opinion in the disciplines of epidemiology, internal medicine,
health economics and health policy to develop an exhaustive list of 200 interventions after
reviewing the current state of clinical, epidemiological and technological information; and
(vi) developing a typical course of event framework for undertaking detailed cost estimation
of an intervention using the concept of entire population covered by an intervention rather
than a specific group. An important assumption in the calculations is an evaluation of the
effectiveness of the existing program with regard to the efficacy of the treatment. More
detailed analysis in Tables 8.2 and 8.3 also consider the inefficiencies of the public
programs.
8.7
Table 8.1 below gives a list of 70 interventions for which cost per DALY gained by
intervention were estimated in the Andhra Pradesh study. The first column lists the disease
for which the estimates were made. Sometimes, several interventions for a specific disease
were estimated, which are shown in the second column. The third column gives the
estimated total cost, which includes fixed, variable and infrastructure costs. It is calculated
as thp product of average cost per person covered by intervention and the population at risk,
he^fourth column on efficacy is the probability that a particular intervention will provide a
100% protection rate, i.e„ it is a fraction denoting the protective value of a particular
treatment. For example, if it is a vaccine, the number denotes the protective value of the
vaccine; if it is a treatment or therapy, it denotes the therapeutic efficacy by taking into
account the expected outcome.13 The fifth column denotes DALYs lost in the absence of the
specific intervention listed. It takes into account the epidemioiopical situation, general
mortality and prevalence, incidence and remission of the specific disease. The sixth column
denotes DALYs gained because of the specific intervention and is a product of DALYs lost
and efficacy. The last column denotes the cost per DALY gained - the lower it is, the more
cost-effective is the intervention.
Details on the methodology are discussed in the ASCI studv ‘ Andhra Pradesh
Effectiveness of Health Intervention, (1996)”
•urdcn of Disease and Cost-
The efficacy of a prevention or treatment can vary because of a number of factors. For example, the efficacy of
iron tablets is low in India because of the low absorption of iron which results from local dietary habits.
- 68 -
Table 8.1: Cost for DALY’s Gained by Intervention (in Rupees)
S. Disease
No.
I. Abdominal
Surgery
2.
3. Asthma
4
5. Anaemia
6
7.
8.
ARJ
9.
10.
11.
12. Cancer Stomach
Cataract
F
15.
16
17. Cervix
Cancer
18. COPD
19
20 CVA
21.
22.
23. BAD
24. Diabetes
25.
26
27. Diarrhea
28.
29
30
Diphtheria
31
Epilepsy
32.
33 Eclampsia
Fiariasis
35
36 Hepatitis A
H
Intervention
l otal Cost
Efficacy
1.709.991.975
0.95
DAL^s
Lost
NA
Emergency Abdominal Surgery
1.023.668.665
inhaler Therapy
342.389.567
OP Treatment tor Asthma_______
157.794.926
Treatment tor Mild. Moderate and
NA
Severe Anaemia
Treatment tor Mild, Moderate and
287,777.984
Severe Anaemia in Pregnancv
Iron and Folic Acid
NA
Supplementation for Pre-School
Children
Treatment tor ARJ in Rural Areas
280.971.371
Treatment for ARJ in Urban Areas
144.779.759
Treatment for ARI at Secondary
396.530.742
Level (Rural 1__________________
Treatment tor ARI at Secondary
196.600.529
Level (Urban)_________
Hospitalization &. Treatment tor
73.359.030
Stomach Cancer
Camp Surgery with IOL
312.321.647
Camp Surgery with Spectacles
186.110.331
Hospitalization with IOL
~
188,259,579
Hospitalization with Spectacles
63.940.930
Active Screening and Treatment lor 1.162,553.859
Cervix Cancer
090
0 75
0.25
NA
NA
135737
135737
NA
NA
101803
33934
NA
NA
3363
4650
NA
032
97980
31354
9178
NA
NA
NA
NA
0.30
0.30
0.37
1363428
400927
1363428
409028
120278
504468
687
1204
786
0.37
400927
148343
1325
0.05
59861
2993
24510
0.95
0 85
0 95
0.80
127164
127164
127164
127164
84364
120806
108089
120806
108089
67491
2585
1722
1558
592
17225
1,342.749
0.05
155604
7780
173
14.793.009
254,502.953
435.390.018
0 05
04
0.75
155604
622440
622440
7780
248976
466830
1901
1022
933
103,716.746
173.998.034
153.850.449
0.70
0.50
0.75
622440
17122
118907
435708
8561
89180
238
20324
1725
113.234.272
0.65
118907
77290
1465
1.795.849
1,507.673,805
0.25
0.80
118907
273820
29727
219056
60
6883
1,761,793.173
0.60
934168
560501
3143
1.548.905.068
3.879.569
0 65
0 50
1207987
8503
785192
4252
1973
912
34.580.172
0 28
152529
42708
810
9.303.466
2.080.713
2.185.467
424.805.781
42.737.967
0 70
0 15
0.70
0 50
0 60
152529
4623
39766
39766
152601
106770
693
27836
19883
91561
87
3002
__ 79
21365
467
(%)
Elective Abdominal Surgery
Hospitalization and Treatment tor
COPD_____________________
Domicilary freatment tor COPD
Hospitalization tor CVA
Antihypertensive & Antiplatelct to
Prevent CVA
________
Rehabilitation tor CVA
Treatment for Depression
Active Screening at Outreach.
Diagnosis and Treatment at PHC
Hospitalized Treatment lor Severe
Diabetes______
Treatment tor Diabetic Foot
Hospitalization &. Treatment lor
Diarrhea (above 4 years)
Hospitalization &. Treatment tor
Diarrhea (less than 4 vears)
ORT
---------Hospitalization &. Treatment tor
Diphtheria
Hospitalization & Treatment lor
Epilepsy________
OP Treatment lor Epiiepsv
Treatment tor Eclampsia
DEC for Fiariasis
DEC Prophylactics tor F i an as i s
Hospitalization and Treatment tor
Hepatitis A
TTsT
DAL\s
Gained
NA
Cost/DALYs
Gained
NA
-69-
Table 8.1 (continued)
S. | Disease
No.|
37
Intervention
Total Cost
LHicacy
(%)
0.40
DALYs
Lost
796479
DALYs
Gained
318592
Cost/DALYs
Gained
1887
040
0.25
0.60
0.30
796479
796479
796479
150564
318592
199120
477887
45169
53
1250
2534
926
0.30
150564
45169
697
0 80
39510
31608
6431
0.30
49654
14896
5989
005
0 60
49654
41182
856
24709
4498
3702
0 60
86281
51769
596
0.60
49354C
296124
54
0.70
0.50
4498
207971
348714
103986
939
21
0.30
207971
62391
701
0.60
1778021
1066813
2257
0.30
374260
112278
19777
0.60
0.60
374260
374260
224556
224556
8501
9638
0.75
94457
70843
27397
0.50
94457
47229
25164
0.50
I695C
84752
202
0 70
0.80
0.70
169503
169503
169503
I 18652
135602
118652
6489
40500
1043
0.75
1370483
1027862
698
0.80
1370483
1096386
607
0.40
1370483
548193
974
473,080.358
0.50
1370483
685242
690
61.632.355
0.05
2377060
11853
5220
“ 619.293,214
72,994.191
0.30
0.30
24501
2450 f
7350
7350
84254
9931
107,135.209
NA
0.74
NA
505394
NA
372318
NA
288
NA
IHD
Hospitalization and Treatment
601.089.068
for Acute Ml with streptokinase
38
Acute Ml - ICCU
~~
16.760.450
39
Aspirin Treatment lor Ml
248.872.783
40
CABG for IHD
1.211,173.633
41
Intestinal
Mass Chemotherapy for Intestinal
41.832,527
Helminths
Helminths________
42
Screening <k Treatment tor
31.485.512
Intestinal Helminths
43 Leprosy
Active Screening &. Treatment tor
203.268.470
Leprosy__________
44 Malaria
Active Screening & Treatment tor
89.220.273
Malaria_________
45 Mania
Hospitalization & Treatment
J.851.091
46 Maternal
Attended Low Risk Deliveries in
91 463.888
Rural Areas_______
47
Attended Low Risk Deliveries in
30.865.306
Urban Areas
48
Referral Care tor High Risk
15.860.636
Pregnancies
‘ *'
Measles
Hospitalization A Treatment
235.288.715
50 Meningitis Hospitalization & Treatment
2,141.905
(above 5 years)
51
Hospitalization A Ircatment (less
43,751.202
than 5 years)
52 Perinatal
Neonatal Care
' 2.407,775.889
Conditions
53 PEM
Hospitalization &. Treatment of
2.220.502.549
PEM___________________
54
_ Screening and Treatment tor PEM 1.909.016.877
55
Supplementary Feeding for
2,164.297.528
_ Pregnant Women and children
56 Peptic dice Medical Treatment tor Peptic
L940.9ll.468
Ulcer
57
Hospitalization of GI bleeding
1,188.450.407
cases tor peptic ulcer
58 RHD
Passive Screening & Treatment tor
17.078.818
RHP
_
59
Primary Prophylaxis tor RHP
769.966.059
60
Secondary Prophylaxis for RHP
5.491.938.001
61
Surgical Valve Replacement for
123.697.508
RHP
62 TB
Active Screening. SCC for sputum
717.781.428
♦ Ves and LCC for suptum - Ves
63
Active Screening, SCC for Sputum
666.034.817
■♦■Ves & -Ves
64
Passive Screening, SCC for
534.190.297
Sputum ♦Ves & LCC for sputum -
IL
Ves______________
65
66
67
68
69
70
letanus
Trachoma
U1P
Vitamm-A
Passive Screening. SCC for
Sputum ♦Ves & -Ves
Hospitalization de Treatment lor
Tetanus
Mass Treatment for Trachoma
Screening &. Treatment tor
Trachoma
Universal Immunization Program
Vitamm-A Prophylaxis for
Preschool Children
- 70 -
8 2 and 8 3 alS° 'Show lhe detailed costs i'«r DALYs eained for vaccine
nr. .
Table 8.2: Detailed Cost for DALY’s Gained - Vaccine Preventable Disease
Disease
Pertusis
Diphtheria
T’olio
Measles____
Tetanus
Childhood TB
Observed
Coverage
Vaccine
Efficacy
Program
Effectiveness
0.66
0.66
0.66
0.54
0.66
0.50
0.95
0.80
0.69
0.95
0.75
0.33
0.63
0.74
0.53
0.37
0.63
0.55
At Risk
0.67
0.37
0.47
0.63
0.37
0.45
Estimated
DALY’s
Gained (Rs.)
118,387
8,503
96,821
358, 030
237,065
58,906
877,712
Table 8.3: Detailed Cost for DALY’s Lost - Vaccine Preventable Disease
Disease
Pertusis
Diphthena
Polio
Measles
Tetanus
Childhood TB
Observed
Coverage
Vaccine
Efficacy
Program
Effectiveness
0.90
0.90
0.90
0.90
0.90
0.90
0.50
0.95
0.80
0.68
0.95
0.75
0.45
0.86
0.72
0.62
0.86
0.68
At Risk
0.55
0.13
0.28
0.38
0.14
0.32
Estimated
DALY’s Lost
(Rs.)
97 J 83
2,987
57,680
215,955
89,701
41,888
505,394
8.9
The net DALY’s gained are 372.318 (877,712-505,394). The cost per DALY gained
for implementing th<ie Universal Immumzation Program (DIP) is therefore equal to about Rs.
288.
E.
Results
8.10
As expected, the cost per DALY gained estimates vary considerably in rance
dX f"6
7C,dence' Prevalence, remission of the specific disease, the probability of
etc It Provides
CHStS aSS°C,ated Wlth treatin8 the disease, the efficacy of the program
etc. It provides an indicative cost per intervention for DALYs gained, which could form a
basis for senmg user fees or for making a deliberate choice regarding the subsidization of a
specific mtervention. The results shown in Table 8.1 - 8.3 are summarized below
The cost/DAL¥ gained in general is lower for interventions related to most
acC“sC
k iS f°r non-communicable diseases or for injuries and
The cost/DALY gained is lower for early diagnosis and prevention, than it is for
u
- 71 -
treatment of a more advanced stage of the disease.
The cost/DALY gained is higher for hospital treatment than for ambulatory care; for
example, treatment of diarrhea when hospitalization is involved is two to three times
more cosily than outpatient treatment per DALY gained.
-The cost/DALY gained for the universal immunization program at about US$8
confirms the high cost effectiveness of this intervention. The high degree of cost
effectiveness of UIP in India is due to the under-nourishment of children which
increases the probability of dying with the intervention.
The cost/DALY gained for treating infants (0-5 years) is generally higher for many
interventions than it is for treating children above 5 years, especially for diseases
such as diarrhea. .In some cases, these differences in cost/DALY gained are very
. - substantial because of the intensive care that below 5 year children need in the earlv
years.
7
The cost/DALY gained is considerably lower for specific interventions in urban
areas compared to rural areas. I his is largely because of factors relating to poor
access to health care services in rural areas.
K
tAnC./nrA i vUre eTrgXS reeardins the intcrventions for diseases which have very low
th
TheSe 'nClUde dlseases such as treatment of diarrheal conditions
through ORf. eclampsta. referral care for high risk pregnancies, UIP. treatment of
epilepsy, some conditions of ARJ etc.
Some treatment of non-communicable diseases are cost-effective, such as cataract
operations and some treatment of heart attack and stroke.
and8eothral’fhe
Sh°Uld nOt necessari|y dictate public spending
nd other factors should be considered, interventions that are low in cost/DALY
gained provide hlgh returns and may be included in a basic package of services if
they contnbute heavily to the overall disease burden. However X other
mterventions wh.ch have hlgher cost/DALY gained need al., to be included in the
basic package of services because they address the diseases Lced by children those
bu d!nlnfT
remote areas as well as represent a significant part of the overall
those that 'Tk
th°Ugh’ exPenditures
diseases should be guided by
XalyX““0’ larg' Shar' of ,h‘ di”“'
F.
Recommendations
The cost-effectiveness of health intervention is an important analytical tool to aid and
Xca^onP“orCy,
l’ctter dec,slon-m“king in the health sector, in terms of resource
al ocat on for pr.onty diseases, development of a basic package of services
bTs^foHheTh ^"f" r"6'5 °f
ins,itutions’ ™d for establishing a’
oasis tor the charging of user fees.
6
As "tated in the WDR (1993). the most justified public measures combine a rationale
shouldbnot “h " W,tk 3 C0St'effect,ve 'ntervention. Cos! effectiveness analysis
Should not, however, be Viewed as the only decision making tool for government
f
u
policy. There are several factors which need to be considered jointly in developing
resource allocation policies in the health sector. Low cost/DALY gained should not
be the only criterion for allocating resources because of efficiency as noted above.
Other factors that ought to be consider are: the presence of other interventions that
might affect costs; the possibility of eliminating a disease as a public health problem,
such as leprosy; those diseases that have large initial costs but permanent benefits;
those interventions that have positive externalities beyond health such as family
planning and girls' education; and those interventions that have high poverty
reduction benefits (i.e.. public expenditure and sustainability analysis).
A basic health care package should take into account these state level variations in
epidemiology and burden of disease, public expenditure considerations, the extent to
which the private sector is providing some of these services, the extent to which
poverty alleviation is pan of the government's strategy in the health sector, the cost
effectiveness of health interventions, and programs that create large externalities.
The package of services needs to be developed through a consultative and
collaborative process, involving leading health practitioners and policy makers from
the different levels of the health system, private and NGO sectors for social input,
and the Finance Depanment of the state government to assess the financial ability of
the state to provide the recommended package of services.
Based on the above, the package of services would consist of: communicable disease
prevention; limited clinical services; essential and emergency obstetric and pediatric
care within easy access to people living in rural areas; capacity for prevention and
health promotion programs to cope with non-communicable diseases to be developed
progressively; injuries, especially prevention; and limited treatment of noncommunicable diseases which are cost-effective, such as cataract operations and
some medical treatment of heart attack, stroke and pain relief.
The Burden of Disease and Cost-Effectiveness of Health Interventions study
undertaken in Andhra Pradesh has been a useful analytical exercise to fine-tune
policy-making. The BOD pan of the analysis in Karnataka, ’Aest Bengal and Punjab
'•has allowed cross-state comparisons. It is the kind of exercise that ought to be
repeated in several other Indian states, to take account of the regional variations and
the differential health transition that is taking place in the Indian states.
Developing local institutional capacity to undertake such an exercise has been key.
The development of the institutional capacity in ASCI to undertake such analysis has
been an important capacity building exercise.
- 73 -
Chapter 9
Special Issues in Management administration in the Health Sector:
Decentralized Governance under the Panchayati Raj System14
A. Introduction
9.1
In addition to a basic package of services, adequate resources and appropriate technical
paradigms, strengthening overall management arrangements is a critical input towards the
effective implementation of health programs. Concomitant with the change in disease pattern
m India, noted in Chapter 3, is an increase in the diversity of the client populations, since the
health transition is occurring at different rates in different regions of the country. Depending
on environmental conditions, urbanization, and cultural and behavioral practices of different
populations, the burden of disease is likely to vary from one community to the next, with
poorer people in remote and rural areas bearing the heaviest burden." The evolution of
decentralized administration in India in this context is an appropriate mechanism that can
potentially address the main health problems arising from the epidemiological transition.
The effectiveness of decentralized administration would be considerably enhanced if
financial and administrative authority were to be devolved to the grassroots level.
'~
Three aspects of health management in the public sector need state level attention- the
implementation and supervision capacities of state level implementing agencies; the increased
emphasis on decentralization in the overall management of the health sector and the enhanced
responsibilities of Panchayati Raj Institutions (PRIs); and increased coordination between
different tiers of PRIs, technical departments and state level agencies. The first issue of
management and administration in the health sector has been addressed in other reports. Apart
from alerting the reader to the. operational relevance of this topic within the health sector at the
statg level in India, this report will not address the overall management issue. It will however
address the two latter issues noted above.
9.3
This chapter focuses on the implications of the decentralization process on the health
sector, and provides an outline of the broad structure of health administration at the state level
with particular focus on health administration at the district and lower levels. In this context,
sPec‘fic mention is made of the power and functions of decentralized administration vis-a-vis
the health department. This is followed by a brief outlining of the experiences of some of the
states studied in terms of the working relationship of the line departments with those of the
PRIs at various levels of the administrative structure. The analysis is largely based on literature
rev.ew and interviews with a cross-section of people associated with line departments and
PRIs.
14
This chapter is based on a background study conducted by Dr. D Gupta. Intitule of Economic Growth.
University of Delhi.
Heaver, Richard. Managing Primary Health Caret implications of the Health Transition- World Bank
Discussion Papers. No. 276; 1995.
u
. 74 .
9-4
In the discussion ol decentralized governance, it is also important to note the
significance of strengthening overall implementation and supervision capacities in the health
sector, first, states need to strengthen the implementation and supervision capacity of the
implementing agency. Andhra Pradesh and Punjab have established autonomous implementing
agencies at the secondary level to improve management and administration capacity and
provide financial and workforce related autonomy. However, this is not the only approach to
improving the implementation and supervision capacity of the states, the issue of management
authority with regard to finance, personnel matters and effective implementation needs to be
addressed. It is possible for the states' DOHFW to perform these functions, but they need to be
given greater authority and flexibility with regard to finance, supervision and workforce related
issues. Second, the planning process for the health sector also needs to be strengthened and
better coordinated with the implementation and monitoring functions. For example, the four
states of AP, Karnataka, Punjab and West Bengal have set up strategic planning cells to address
planning issues in the health sector and provide management with policy options, undertake
relevant research, organize relevant seminars, and monitor the overall development of the
health sector. Streamlined service norms developed in each state throughout the different tiers
of the health system will facilitate administrative functions and result in substantial
improvements in management arrangements.
B. Rationale for Decentralization of Administration
9.5
The rationale for decentralization of administration is discussed below:
One answer to the difficulty of appropriate targeting of policies and programs, which
has important implications for the design and management of health service delivery in
the future, is decentralization. Many governments, including GOI, have tried to devolve
health planning, budgeting and spending authority to provincial and lower levels in
order to increase program responsiveness to local needs.'" People from disadvantaged
communities such as the Scheduled Caste and Scheduled Tribes (SC/ST), and women,
have a forum to be heard, to speak out, and to act.
•
Examples abound of local involvement improving both the efficiency and effectiveness of
programs. One example is of the construction of a small bridge in Purulia. West Bengal,
where involvement of the local population decreased the construction costs and time.17
Similarly, a study of local self-government in West Bengal shows that Panchayats have
helped, among other things, in efficient and cost effective implementation of several
programs of rural development including the construction of local health centers.
Decentralization offers an opportunity for communities to impose greater transparency and
accountability to development administration. An example of community involvement
16
17
ibid., pg. 10.
According to the documentation, the official estimates were that it would cost Rs. 21 lakhs and would lake 2 years
to construct. The project was handed over to the local population with the condition that would be constructed
withoucany outside technical or other help. The local population agreed, and not only did they construct it in one
year but it had cost only Rs. 6 lakhs.
- 75 -
(Dreze & Sen) concerns (he provision of health care in Kerala. The involvement of local
institutions has resulted in better attendance of health functionaries in rural hospitals as
well as their involvement in the constructton of health centers has been beneficial In a
study on Karnataka (Rtchard Crook and James Manor) it was noted that the creation of
ected councils (at local levels) have helped in reducing absenteeism and in enhancing
employees work rate when they were on job. although they felt that these achievement!
sometimes tend to be exaggerated. The moral pressure from councils at both district and
mandal levels have been more important than formal disciplinary action Clearly all
evidence points towards a posmve role which local level institutions can play in effective
planning and implementation of programs.
as
?a7r7high^reXftlXr’and'res^ing in'l
Undoubtedly, the PRIS ha've gtven'! Zsuo the eZe^X^'of bc^Se"^^^ P^'
new seats of power to be f.Hed by the competitive meLamsm Xoc^Zai^11!
i ion. a arge number of women have been elected into the PRJs Elected women
representanves have been drawn from a wide cross-section of
f
d
administrators who had previously worked with NGOs and women'!
programs are now elected PRJ representatives.
empowerment
9.6
In India, the notion of local involvement was institutionalized with the estahlkhme . r
Development Council at the top. Panchayats were established in oil
the Village Panchavats included village
d
r ? J (ZP>/Dlstrict
state to state, broadly the functions entrusted to
ZPs were made responsible for primary education and the functions Hating o Zl ' T’
primary health care, medical relief, women and child welfare
r
industries,
grounds and other community lands and properties and provision of’fnpu s'
production. The extent and tempo of the involvement of th PRI
k
,Or|agr,Cultural
implementation of development projects was also subject to wide v^X^Sm^^sute
and even within the states.
CoLtitu^on (^rdTme^dment) Au, ^Tetoe on “7 iw" Z
73rd Amendment, there has been a proliferation of activity on the pan of^th
Governments with regard to modifying their existing Panchavad Rai Z
one, a™„6
sz."pt
eomple.e iegi,!,,!™
,hings. lhc pr^
“T.X"' "'"i
o[
,£*“•of pr°Brams °f —
f«r
i
J*"’*'
“ <’>
bodies by conducing elee.ions. while ensuring .h„ 30% of ’’“tay-’■ memta,“ P"'‘ha>'“
an (c, take appropnaie sreps „
pmers and function,, as well a, neeessa^'reZureei
- 76 -
so as to enable the PRIs to perform their assigned functions."
9.8
In order to analyze the issues with regard to the Indian <experiment with local selfgovernment the experiences of four major states of Punjab. Karnataka. Andhra Pradesh
--------- 1 and
West Bengal are relied upon. The varied social, political and economic environment in these
states provtdes an unique opportunity for preparing a typology of the problems and solutions in
oitterent politico-economic environment. For instance. West Bengal has a strong Panchavat
system with an active party cadre at the grass root level. It is also the state which has been
politically stable for a long time. Karnataka, on the other hand, has essentially two major
parties in the state both of which are more or less evenly balanced. It also has a long history
and experience of having a decentralized system of administration since 1973. Andhra Pradesh
has a non-commumst Government. While Andhra Pradesh and West Bengal have both stable
and efhoent political system, they have different political ideologies. Punjab, on the other
hand is at the moment the most prosperous state in the country, with some experience of
rancnayati raj.
C. Three Models of Decentralization
9.9
The legal framework establishing PRIs has been interpreted and implemented
mS'l " f PR?
T
StateS'
9J- 9 2 and 9 3 Provide details o<'>l’ree dominant
models of PRI m the country, from which useful lessons could be drawn bv other states A
±
Ind a
TT ',1e ,hr" ™d'ls “ pr<,vid'd in A""“ 1 A
,he
r
r W°U!d nOt really be aPPropriate in the federal political svstem prevailing in
India. In the first model presented, the Maharashtra-Gujarat model the district or Zp8 is
accepted as the main umt for devolution of powers. The administrative bureaucracy at the
istnct level (the IAS) is kept out of the panchayat structure altogether. The District Rural
collaborate to inIhi t
i ri
i
but the ZP and the DRDA
oanchn
t0.lmP‘ement rural development programs at the district level through the
annro
samitl and 8ram Panchayats. In the West Bengal model, all levels of PRI have been
throuTS
and m°St devel°Pment programs have been channeled
through them. Another .mportant feature of this model is that the DRDA is headed by the
o '’ZTT
AS 3 reSUlt’thC DRDA iS 3n administrat>ve arm for the implementation
of the development programs of the ZP ( the reverse of the previous model). All centrally
the d'm pr0.eramSf a"d Programs financed by international agencies are also implemented by
n n d,fi!re".tierS Off PRJsthird mode1'lhg Karnataka - AP model is characterized by a
proper devolution of powers and functions at each tier of the PRI, with a prime place given to
adm n I
|SUb'd'S‘nCt) leVel Panchaya'- 't has been strengthened both financially and
programs ' 'V
aSSUmCd
P'anning and impic™ntation of development
18
HTderabadHW^^ ^' lnSlllU"t,n^ ln lniln
19
Apprnml. National Institute of Rural Development.
Panchayai Rai Instnutions m India: An Appraisal National Institute of Rural Development. Hyderabad; 1995.
Figure 9.1: The Maharashtra - Gujarat Model
/.ilia Panshad l/.l’) - Dislrm Level
Consisb ol 40 - 60 Councilors directlv elected bv the people
Administrative leadership rests with (. EO who is appointed bv the state
Is divided into subject committees Standing Committee. Imancc Committee. Agricultural and Animal Husbandry
Commitice. Works (. ommntee. Health ( onnnittee. and Education Committee.
Has full executive authority with respect to development functions which were earlier discharged by die stale
government and has some revenue collection responsibilities
it
Panchayat Samiti - Block Level
Functions as a link between the ZP and the Village Panchayats
Consisb of elected, nominated, and coopted members
( hairperson is elected from among ns members
Has a Block Development Officer who is sent on deputation by the slate government. This person is also the Executive
oincer of the Samiti
rhe Sam,tts have been given lunct.ons ,n the spheres of san,tat,on. rural health and commun,canons, educat,on and
culture, soc.al education, agriculture and annual husbandry, small industries, cooperanon. and commumty development
l he Samms are respons.ble lor pnmary education, n.nnmg of dispensaries, mamtenance of certain roads and d,e
Community Development Programs
_______
+T
Gram Panchayal - Village Level
Consists of 7 to 15 directly elected members (include. 2 women and SC/ST)
11,6 SafT,“Ch 'S i‘SSiS‘ed " his
'S e'eClCd frOm a"’0"*51
ar‘mal husband,y'educat,on- saniuii°n'
Figure 9.2: The West Bengal Model
ZJIIa Parishad - District Level
t^eaJhXVl01' rS'd,;n^ “t0" PanChaVa' Sami,'S Wi,h'n
members of the ZP
Chairperson and president is elected by members from amongst themselves
e«XX7 15 ll’e CE° °f
ZP An°,hCr
Ofr‘“r °f
‘
to be directly elected
D,s,ntl a*"1 lw‘>
' LeglSlatUre and lhe -"entbers of the Parliament within the districts are also
C-‘ S— -es as addiltona.
Panchayat Samiti - Block Level
’
.
k
As J^th
Chanper’ons1of,he
Pancha^
the Block, percons elected from each Gram Panchayat
On populatlon- and the ‘"emberc of the Stale legislature from the Block area.
ST> - ~—»«“
~“hsc-
-U,
_______
—
i'l
-------- --------------------- -------
Gram Panchayat - For a small group of villages
’
Consisb of: 5 • 25 members directly elected by die people.
pie chairpercon ,s elected by the Gram Panchayat members from amongst themselves
As with the Samiu, the state government, on the recommendation of lhe Gram Panchayat. has die power to nominate m
make up the number of SCs and STs and women members in the Panchayat to a minimum of two ea7h
- 78 -
Figure 9.3: The Karnataka - Andhra Model
/'Hla Panshad - District Level
Its members are all direct!) elected
(l functions as die head ol the district development and welfare admm.strauon. I
‘
administers schemes and programs
^ansierred to it or evolved by n. mamtams cadres lor manmng die ZP and Mandal Ilstaff
—-R’nnulates die district plan, and
irames and approves its budget and that of the Mandals.
nReservations
."c.
are provided lor women and vulnerable sections of the society.
Block Panchayat Samiti - Block Level
rhis IS a nominated bods which consists of all the chairpersons of the Mandal in lhe Block, all the memh,r ,.i' .h
It is enunsled"witf '’'d^ '1"d
Manda“ Block
mC"’bcrS ol tile Zi,,a ,’ans,l“d representing any part ol die block.
rcvlew'"* «'
u.tra-Mandal coordmat.on hmeuons
C
vis-d-vis die
Mandal Panchayat - Group of \ illages
’
Each Mandal covers a group of villages with a population of about 10.000 on average
One seat represents 400 people out of its population
25% ol the membership is reserved for women and 18% for the more > '
vulnerable members ol socicts
.X“o:eXC*MC llJnC,,°nS- POWere- “d resPons'bllil'«
‘“velopment and ueBam
.
------- ------- j programs and has a
- -------------------------------------- Gram Sabha - Village Level
Cons.su of all ehg.ble vote (l c. all village member, above (he age of 18 vean)
Is required by law to meet no less than twice a year
-"“w
p,™„f
D. Key Linkage between State Health Administration
and PRIs: District Level
Organizational Structure of Health Administration
9.10
The dtstnet level is lhe most crucial in lhe chain of command of the public health
M taTe'vel meyeff ‘I"
'"“‘""S °n
'»
»!>'"'»" of h««llh centers are made
larorlv ri
<
,mP emental,on °f various health policies and programs, therefore
rgely depends upon the supervision and control exercised by the district offleers over the
wiTX?d
lH Cen‘e? ln 1,16 diStriCt- R iS alS° at lhis leVel that conation and liaison
with other departments and agencies of the Government takes place under the overall
supems.on of either the □■strict Collector (DC) or ZP President. This is particularly necessary
dcpanmcmYcoVdmX
-9- inter.
1
In dismeu. in various siales. lhe District Health Officer or Chief Medical Officer is in
usuX°undcI'rn<hen?hmCd'C“;a”d|',“'‘h
family’planning pr„gn,f
S“r8'“S- Wh'le
f’miiy Wdf“"' T!» dis"'"
famil>' "'dfare "flk“
9.12
In Andhra Pradesh, the District 1Medical
* ** ' Officer
’
(DMO) is responsible for
implementing all national and state health programs. The DMO is
-------- .J not concerned with the
- 79 -
management of ihe district hospitals and is assisted by one additional district medical and
health officer exclusively in charge of family welfare programs and two deputy district medical
and health officers. Separate district program officers are also appointed for such programs as
the National Malaria Eradication Program.
9.13
In Karnataka, the district health and family welfare officers are responsible for
supervision, guidance and prompt and effective implementation of various national and state
health programs in their respective districts and all Primary Health Units (PHUs) and PHCs are
under their control. At the district level all hospitals in the secondary level (i.e., district, subdistnct and CHCs) report to the district surgeon. The district health and family welfare officers
are assisted by the district leprosy officers, district malaria officers, district TB officers, medical
officers of district health laboratories, medical officers (FW & MCH) and regional assistant
chemical examiners in the implementation of various health programs. Further, in Karnataka, at
the sub-divisional level, the Assistant District Health & Family Welfare Officers are
responsible for the supervision and provision of guidance to the medical officers of the PHUs
and the field staff for prompt and effective implementation of various national and state health
programs including family welfare and MCH schemes through the network of various types of
health and medical institutions other than major and specialized hospitals within their
respective jurisdiction.
9.14
In West Bengal, the Chief Medical Officer (CMO) of health is the district level head
and ts asststed by Deputy and Assistant CMOs. The secondary level hospitals are all headed by
superintendents from the medical cadre. For proper management of the hospitals and health
centers, committees have been formed with representatives from all levels of the Panchavat
System and the administration.
y
At the district level and below, the Revenue Department and the Zilla Parishads play a
r°^ln
Provision of medical and health services to the citizens in several ways As
lhe Cfuef Coordmator at the district level, the DC or the Chief Executive Officer of the Zilla
Panshad acts as the link between the Health Department and all other public agencies As the
Development Commissioner of the district, it is also the responsibility of the DC to ensure the
elfare of the rural masses. The DC also exercises considerable influence in the location of the
primary health centers in the district. The Revenue Department plays an important role in
he pmg the acqu.smon of land for PHCs. The Revenue Department is also concerned with the
collection and transmission of viral statistics to the health department. They report the outbreak
of the epidemics. Similarly, in case of famine relief works and at the t: - e of fairs and festivals
Th RnrZenDt:pan?enl °r the Z'lla Par'Shad eXt=nd their co°Perat>on die Health Department.’
Ihe DC/CEO can also exercise authority in respect of public health as for example ordering
mass inoculations and destruction of infected food or drugs.
9.16
9.17 r
Mech• anisms for Strengthening Links between State Administration and PRIs A
mechanism that
—t would bring the PRIs and health officials together at the district level and
- SO -
Systems Developm^rProjec^T'o^^
h3''.11 P^™- In the State Health
Committees have been creaLd in ea^Z i^Ih
" Com™e^istrict Steering
level medical officers as members (among others) The, J"1'™ of the ZP and the district
responsible for planning and implementing several of the cn
^Ommittees w°uld be
referral and medical waste management- manaeine and
mPonents ot
project, such as
equipment maintenance, collection of user fees and^nrov'
many activities such as
and evaluation of all activities at the district level Thed" T""1?165'
monitoring
coordinate them activities in order to accomplish these goals.
'
OffiCia'S W0U,d
Karnataka. The DOHFW ^Kamaukl intoldsT^
iCOnsiderably strengthened,
as in
populations in rural areas throueh a n
d r ,mProve the access to health
care of SC/ST
implemented at the PHC level and
^H"3' CheCk-UPS' The program would be
ANMs under his/her jurisdiction, xyould cond^Sl/PHC'
assistance offoe
order to facilitate this process the Government h h
h
PS accordlng
a timetable. In
■he CEO. ZP.
'? ’? "P “
but also the newly designated taluk level medical offi
overseeing the work of the PHC doctors. Tn^is
y d'Strict ,evel med'cal officers,
b"
ommitment of the PRls would be brought to bear on n
®
lnvolve™nt and
level.
tnt to bear on programs implemented at the village
E. Role of PRJs in Health Delivery: Two Examples
919
WESJL BENGAL- The West Ron
t
government is
leve?0^8 °f thC hea'th dePan™nt and involve^PRIs^
h
deCenlrali2e
levels. The state Government disburses 50% of its d
I
hea lh care de,ivery at various
allocates 50% of their funds to Gram Panchavats GP)
‘0 ZPs’ Which in turn
hetr own development project.' The remaining 50% of th^f'd anChayat Samities (PS) for
where two or more ZPs and PSs are respective^
t ?
Spen‘ by the state a"d
implemenutton are effected from the bottom.
' 'nV°
ThUS the Plannin8 and its
9 20
T
three-tier Panchay^and't^oiher^y^XreuSD Cl 3dniinist™tions' name|y- the elected
and the block development officers iRDOd Cretariat/D'borate, the district magistrate (DM)
of .he Z^’
T,,^ panchayaP
pubhe healU,. Since .he Go.emmen. of We'?BeZ? r
“"“™d
administration in a non-bureaucratic manner it h ISCOmmined t0 a Policy of running the
consultative and advisory - to help the adm’’
b*18 '^'tuted a number of committees to
''^Oepan.nen.s.i.^
.he sa.e .„ CHC bo.rd, Fo,
I
“ “PKttd “ resul1 in
tener performance wi.hTmaher rewmceT h
toon mnHnr fmrmoc should i» „SiBM
,ac Eaya^'
b
■'■ftminierrHien md
C cinciency of program implementation
-81 -
through administrative decentralization but has a much deeper goal concerned with the transfer
of function of governance from state level to the district and lower levels. In Karnataka, PRIs
are seen as units of government enjoying a great deal of autonomy but at the same time
ensuring greater accountability through the proximity of elected representatives in these bodies
so because of the intimate knowledge of local resources, these institutions are in a better
position to create realistic development plans. In addition, an important externality is the
possibility of a more effictent administration through clear supervision and accessibility of the
local bureaucracy to the elected bodies.
of the state government to make PRIs truly function as a viable unit of the government through
9 |npmvi’d
P°TS arnd/UnCt'OnS With cornrnensurate support of financial resources. Table
not d th d k50"1!/?!.3 °f the extent Of decentralization in rural health administration It will be
noted that about 4/5th of the health budget meant for the rural areas is now controlled bj the
Table 91: Karnataka- Share of Allocations
Rs. crores
to PRI to the Total Health Budget
Plan
Non-Plan
Total
40.69
174.93
215.62
ii) Provision for urban
health services &
medical education:
10.86
95.45
106.31
iii) Total provision for rural
health services:
29.83
79.48
109.31
iv). Of which transfer to ZP:
20.71
65.63
86.34
(69.4%)
82.6%
79.0%
i)
Total revenue budget for
medical and public
health:
ASSESS
- 82 workers; and (iii) improvement in the supplies of drugs and medicines.1
9.25
Despite the positive role of -the PRls in Karnataka, there is ample evidence of
transitional difficulties in rural health management owing to the nature of organization within
the PR bodies.
i)
As mentioned earlier there are instances of friction between the state government and
ZPs over issues such as personnel management including recruitment, transfer and
overall disciplinary control. These frictions impact negatively on the functioning of
health department.
ii)
Implementation of health program has suffered due to gaps in proper understanding
between the officials and the elected representatives.
iii)
Another major negative impact of Panchayat is that in some areas the ZPs have been
excessively concerned with petty details and issues with transfers and postings making
administration highly bureaucratic. This causes delays in the process of health
improvement either by postponing implementation of health development plans and
schemes or by delaying the training of health personnel.
iv)
The Panchayat representatives (ZP, MP) are influenced by caste, clan and religious
affiliations. These parochial affinities have a negative impact on development schemes
including health development schemes.
9.26 *The real aim of the establishment of Panchayat has been to
to take
lake power
power to
to people
people and
and
not to establish an elite rule in local areas parallel to the one in the stale. Hence the role of the
Panchayat has to be a positive one, with a positive impact on the implementation of health
programs. For the moment, all what one can say is that the role of PRJs in the health sector has
generally been positive as far as Karnataka is concerned, but there is a lot more potential of
these PRJs in the health sector provided a serious attempt is made to identify and isolate factors
obstructing the smooth functioning of the health department within the context of
decentralization.
F. Recommendations
•
Strengthening Overall Management Authority. Management arrangements at the state
level and below need to be strengthened to ensure that health programs arc implemented
effectively. States need to strengthen the implementation and supervision capacity of the
implementing agency.
Andhra Pradesh and Punjab have established autonomous
implementing agencies at the secondary level to improve mar.dgement and administration
capacity and provide financial and workforce related autonomy. Although, this is not the
only approach to improving the implementation and supervision capacity of the states, the
issue of management authority with regard to finance, personnel matters and effective
implementation needs to be addressed. It is possible for the states’ Department of Health and
Family Welfare (DOHFW) to perform these functions, but they need to be given greater
authority and flexibility with regard to finance, supervision and workforce related issues.
Decentralized governance and local level participation can contribute importantly to improving
- 83 -
the health care system, through better monitoring and supervision of the functioning of the
health system at the local level, and by assisting in developing plans which take care of local
perceptions and local needs. There are many viable models for decentralized governance
operating in India, in different states. Notwithstanding this, some general recommendations for
strengthening the effectiveness of the PRls in the health sector follow:
Table 9.2; Decentralization Matrix - Scope for Change in Grassroots Administration
in the Health Sector
Areas and Scope
of Decentralization
Legislation
—=
Revenue raising
Policy rpaking
Regulation/Supervision
Planning
Resource allocation
Management - Personnel
Budget allocation
Supplies/Equipment
Property maintenance
Intersectoral collaboration
Interagency collaboration
Training
•
Current Scenario
Limited in most states/ dependent on
state grants ______
Very little at the moment
Varies from one state to another - at
present weak to average
Process has been set in motion particularly in choice of location and
construction of SC/PHCs
in some states, this is being done as
part of the district planning exercise
Except recruitment, transfers outside
districts, and punishment, PRls are
exercising control over line dept,
personnel
Most PRls doing it
Limited operations
Hardly any funds - thus limited
operations
At present very limited
Reasonably good
'
”
No sustained effort
Proposed Scenario
Should be able to raise resources
Scope should be expanded
Tremendous scope
Should be given greater scope in some
selected areas
Should have more freedom
For effective implementation, vast
powers to PRls are needed for
personnel related matters
More needs to be done
□reater involvement/freedom to order
(local procurement is more cost
effective)
More funds - greater scope - PRJs to
put more effort
Much greater need for best results
Greater scope
Highly desirable
“
Enhancing the Responsibilities of PRls. In order for the PRls to be more effective more
power should be gwen to them in the areas of budget allocation, resource use, revenue
dee^r’ r a"nin8’ P° ICy rnakln8- supervision, maintenance and training. The notion of
en ra ise governance would be more meaningful only when the PRls' responsibilities
are enhanced and their access to resources becomes more substantial
A process of
consultat.on between the Department of Health at the state level and PRls needs to be
initiated on these aspects and structures and systems need to be worked out to facilitate
implementation.
Increasing
Coordination between Administrative Agencies. Important features
°f the PanChayat
Act5 Of difTerent s^s include: (i) X
between the three tii
tiers of the PRI need to be improved in order to enhance implemenX
- 84 -
of health care programs. An i
<>' the Panchavat
Xai Acts ofdiffere,™ states is thauiot' all'^e SuS’have0'11 'h
More^XXE^
inlW '^ages
between the three t-sofPanchavats.
ti
at a consensus on‘ ‘the•• working of PR1S at differcn( |evPe|'
Pj "'eS Wl" have to arrive
government with the
various tiers of PRI?_>■
c rL‘faiionship of state
(,,) co-°rd|nation between PRk A t
technical departments needs m h
K and the
health programs at the needs to be improved in order to iin-nnts. ..
grassroots level; and (iii) coordimf k " 16 lmP,ementation of
agencies needs ‘o be strengthened bv developing
AbetVVetn PWs and state level
facilitate the efTectweness and efficiency of program imn/' 0 meChanism wh|ch would
have been r~
entrusted with a number of development and o
Panchayats
°f PRJs with difTere;
coordination mechanism. ThTa^ect Valso ^mn™'
3 pr0Per ^"vLtle
^-s.tei„.erac,,onandcooperPo; “XZZ™“K.for
9 27
T
^non:n^th:a:c^:r
o7hXng the
*
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Annex 1
Page 1 of 29
deceni ralized adminlsi ka iion in ihe IIealtii Sector
A. Decentralization in India: Recent Developments
In order to better understand the impact of decentralization on the health sector it is
useful t° briefly review the development of PRIs as entities integral to the implementation of
development programs in India. The village communities in India have been in existence
for a long t.me They were called >nchayats”- a council of five persons in a village Though
c^|a^n°my °
PanChayatS
owing to the establisliment of local
itro^h oTZ aT5’ reVhen^ and P°11Ce organization, increase in communications and the
growth of mdividualism, the Constitution of India recognized the need to revive these
ins itutions /Vticle 40 of the Constitution therefore states that "the State shall take steps to
rgamze village panchayats and endow them with such powers and authority as may be
necessary to enable them to function as units of self government".
V
2
The fate of PRIs was uncertain, with declining financial and political support at the
en ral and state levels, until 1977, when the Government of India rearmed its com Jmern
to he notion of local self-government. An awareness of the need for reforms in Panchayati Rai
y tin was created at that time In addition, attempts in Karnataka and Andhra Pradesh tJ
create new PRIs pointed to the need lor the revival" of the PRIs all oveX cou'ry
highlighted the need to transfer power to democratic bodies at the local level
The
R Se' "T \C0,nmi'tee ,0 PrePare a concept Paper on the revitalization
g other things, the Committee recommended that local self-government should
be constitutionally recognized, protected and preserved by the inclusion of a^ewXenn t!
Constitution It also recommended a constitutional provision to ensure regular free and fur
Of PR^’Tmon
r.„ Ok- i-iUs and ............... .
,.sk „„ ..... .
,o 1)|e
jj
that
Ho are
Const ! 7
tarC i°W UP aCti°" 11 iS SiBnlflCant 10 nOte that' while Anide 243 G of the
Constitution visualizes the panchayats as institutions of self-government, it subjects the extern
the 73rdUAOn I
funCtl0,IS 10 lhc dcciS10"
state Legislature With revard to
the 73 d Amendment, the state Panchayat Acts have been amended within the prescribed time
ame through a piocess of consensus Many states are in the process of amending their Acts
also constituting various committees as required under the Act to carry out vanous tasks
Olution of powers and assignment of functions are also under way A new challenge has
challenge has
y'
r"'""""' of thePRh
”d "entrusted to them
flective implementation
programs
PKls - Meed
Page 2 of 29
B- Three Models of Decentralization
differently in d.ierent'VX
'rl[erpreted and implemented
dominant models of PR] in the country f n ° ! ‘n8 SeCtlOn Provides details of three
could be utilized by other states. It must bXm in
J
which
country as a whole would not reahv L
m
3 C°mmon model for the
P'-eva.hng in India In the first model presented^ M 1^ 5’ederal po,itical ^tem
district, or ZP, is accepted as the mam uni fn
’
the
bureaucracy at the district level (the IAS) is kept oXfth"
administrative
The D.stnct Rural Development Aeencv BRna?
f
P^chayat structure altogether
ZP and the DRDA collaborate to implemXuralde"
pendent or8amzation, but the
evel through the panchayat samiti and X
development programs at the district
'-els of PR, have been'appropnate y tXTcX"
^taaXmndd. all
programs have been channeled tU tS Ann h P°
'
m°St devel°Pment
that the DRDA.is headed by the Cha X
,mportan' Mature of this model is
admmis.m.lve a™ for „le iXenZ
d ' f
DRDA - »
reverse of the previous model) All centrallv sXX™"' pr°Srams of the ZP ( the
y international agencies are also implemented bv th^ ProSrarns and Programs financed
model,
th^^ajaka^AfCmodel
°f PRJs T,'e third
model, thgJCarnataka
.- AP model j.is chXeX h
^cuons
at
eachZZZFZZZF
with
a
m
J
Y
*
deVo1
^
°f powers and
—j at each tier of the PRJ
level panchavat
k -1 r L.
. VI 1 a prime place given to the taluk (or sub district)
panchayat Itft has
been
assumed the lead in the j '
appointment of a senior officer
improved its effectiveness I
Government officials the power
• c.- to scrutinize resolutions passed by the PrS ■
5the ~
i - yiAEA
SHTRA_^ GUJARAT MODFI
r
m ,
mauguratton. of Mahl^^t, on
unmemately after the
3USS«tJ»“'for "Z„e9 r’ I"'
G0V'r™'"> ° “ZaraZ
up a Committee to suggest ways for the mor
h Government of Maharashtra set
State Following the; enactment
°f PRIs in
enael? , of
of the
,he Panchava't
' the
Panchayat. Raj ln Maharashtra was nauZted ' m
2,"a Par‘Shad Act
'he three-tier Panchavat s7S ,naUgUrated
May 1, 1962.
'
1962 f
Followins
a si*
off
r
- —menJatiXX DemorXC Pa-haya,s A«. 1961, which
office m Gujarat on April 1. 1963
Democratic Decentralization Committee, took
»Zii::T%rs 0 ",e Democriuic d—“-d
ZP as th t Maharashtra Ac‘ provided for a three-ti
P ’ aS. he kcy level of decentralization The 7P-h tier system with the top tier, namely the
Councilors directly elected by the )eoi
- a nnmmum of 40 and maximum of 60
representatives of co-operat.ve societies .
There 'S also a provision for cooptinu
addiuon to members from the SCs Ihe’srt
_^2!lJZ2^LCO'1VC',,C,,Ce °f itS day->o-day'•' "°'kinS
Hyderabad, itz
zr « divided imo several
Na„ona| Instituie of RuraJ Development
------------- ----------- ---------------------------------------------- ---------- --------
Annex 1
Page 3 of 29
An?™i S’T’T65 rnamely> Stand'nfi Commlttee’ Flnance Committee, Agricultural and
Animal Husbandry Committee, Works Committee, Health Committee Social Welfare
Committee and Educate Committee, The ZP elects a president, Vice-president 7nd the
hairperson of the Subject Committees from amongst its members.
«*
7
The ZP has been entrusted with full executive authority with respect to
Disu c^vel TheZp5 h^^l
discharged
the State Government at the
istrict level The ZPs have also been entrusted with some responsibilities in the sphere of
venue collections. The District Collector has been kept outside the ZP and Another
officer equal to the rank of the Collector has been assigned to heaJ the ZP so
eve opmental activities may receive adequate attention. It is argued that the Collector is
ready overburdened and overworked and cannot be saddled with further work The
bodyeSthOenGo
C°^ttee'. namely that by keePing the Collector outside the local
y, he Government will have in him an independent officer who can also evaluate
■mpartially the functioning of the local body and can keep the Gov rnZt i ^orm d on
an« wh-ch .s of sufficient importance, was agreed to^nd the CoZtor
mvest^d
local Todies '
S
enj°yed in regard
the then existing
Generally1?^" CEoT leadershlp of the 2P rests
the Chief Executive Officer (CEO)
appointed bv th^T T8' t0
°f the Ind'an Administrative Service and is
;n ,1
y
e ^Oveniment The
The CEO
CEO exercises
exercises al!
all the
rhe po
powers specificallv vesrerl
" f»rP"”n ‘r a“'ndS lhe n,“""SS of
ZP “"1
«« CoLnrees T e CEO d
call for any ,„fo,malJ0n, re,urns sla,emen|
office, of “e
-P mOThe,s. rhe’cEO »o^
working und'er the" PaTchayat'samT 7*^?™“*°" Or rePort from any officer or servant
movable property in the block oT nv w'
‘S a,S° given Powers
Aspect any
block undertaken by the ZP or ffie P
d|Vel°Pment 5chemes
Progress in the
:ee,™es ofthe Samhi and coo.ro.s rhe
P-ea^CXXSSSlp^sX a£
■......... —.................. =.
)
Annex 1
i'age 4 of 29
given functions i^the^sphere^of saXioT"67 I“h ^h'68fantS' The Samitis have been
and Culture, social education, agricultural aid'a
operation, and community development Thev haT'h
f0r Pnmary education, of running dispensaries^^m
C°rT,munications- education
USbandry’ s™11 industries, coentruSted with responsibilities
out the Community Development Promm Th
'and revenue powers and function a d e^
F
°f Car^inS
entrUSted with certain
of re,ief work and other measures during
natural calamities like scarcity and floods
Panchayat. Each Gram Panchayat has^a i i
T
StrUC‘1S at the village level, called Gram
Generally™™™™!)0
30(1 f maX'mum of 15 members, all
Gram Panchayat is required by law to have at leas7
representative- Each
of whom are directly elected
reserved for the SCs and STs on the basis of th
T WOmen n,embers and seats are
Panchayat elect a Chairperson (who is called S^m P°P“ at'°n Tbe members of the Gram
of functions entrusted to the Gram Panchavat cam°nS themselvcs- The list
agnculture, animal husbandry education
,
aWlde ran8e of activities relating to
potion of land revenue collections is' also e O’ Oh
S°Cia' Welfare' ™e
Sarpanch is made directly responsible for the FHcO
Panchayats. The
Panchayat. In his or her capacity as Samanch E
0
dUt'eS imp°Sed upon the
Gram Panchayat. The Sarpanch^eeps Ehe rec’n H
’O preSldes over the meetings of the
exercises supervision and control over the
t
h‘S °r her custody and
Panchayat. He or she is authori^To eraEservants of the
signature for monies received Th Sarn
h
Sewak („llage ,evel work “ Jo
"P’™J's
Vlllase
iSSUe recciPts ^der his
i" Ma »' her work by a Gram
26
The Dlsl„c, Collector has been alien
W °m criminal proceedings are instituted
villages), Panchayat Samiti (at the Block i §
Panehaya, had be,„.e„ ^ 25
'''' P*ncharat
P
in 'he
t0 SUSpend a Sarpanch against
pensal Panchayat Act, 1973 also
Pancha>'at (for a small group of
'•’a'’:
conamueneies were reserved for lire SCs and ST, H, "
yJh' PK>ple ThouSh
the recommendation of the Gram Panchavat had F W°men’ the State Government, on
number of SCs and STs and women merZ ’• J Pn°WerS t0 nominate 'o make up the
women members
in by th"?31 p
Chairperson of the Gram Panchayat
was elected
ICaS‘ The
was
among themselves
ed by the Gram Panchayat members from
Panchayats within the Block^such pe^ons^s mav
wuhin the block based on population and th
?
within the area of the Block As
the case ofTTp'
power to nominate two members each from SCs
Cha'rmen of tbe Gram
°m Cach Gram Panchayat
LeS,S'ature fa,linS
Annex 1
Page 5 of 29
their number in the Samiti does not come iup to two each. —
The President of the Samiti
was elected by the members of the Samiti from amongst themselves
]4
—
ZP conisisted of the Presidents of the Panchayat Samitis within the District and
two
members
nnnsin,.'
c to be directly' elected from each
----- block.
-----There was a provision for
nomination of up to two members from the SCs and STs and two women, as in the case of
Panchayats and Panchayat Samitis. The members of the State Legislature and the
Members of Parliament within the District were also members of the ZP. The President of
the ZP was elected by the members from amongst themselves
15. .k
tn
Left Fr°nt Government ln West Bengal, elected in 1977, decided to continue
e
ee-tier structure as against the two-tier system proposed by the Committee The
Hanchayat elections under the amended Act were conducted for the first time in June
rZ? °n.Pk?y ? uA nUmber °f ChanSeS Were brought about at the organizational level
most notably, (a) the merger of the community development department with the
Department of Panchayats, (b) making the District Mag.strate (who is the equivalent of
the Distnct Collector m other States) the Chief Executive Officer of the ZP and providing
another senior officer of the State Civil Services to work as additional executive officer
(c) statutorily associatmg all the District-level and Block-level officers of the different
Development Departments with the corresponding Standing Committees of the ZP and
Panchayat Samms respectively, (d) making the block Development officer as the
Smffi and^eHh
ChairPerson of ^e Panchayat
Pan/h
( \ n Cfe 00 3 nCW aCC°UntS and aud,t organization in the Department of
chayats and Community Development to
to assist
assist the
the new Panchayat! Raj leadership in
budgeting, accounting and audit work The political will to increase the prestige of PRIs
was reflected through various schemes of program devolution that followed. Most of the
eve opment Programs with necessary financial resources were assigned to the PRIs and
in as ear y as
-79 the Gram Panchayats were on an average handling Rs. 150 000 each
(approximately S15.000 then) and the ZPs Rs 45 million each (approximately M S mZn
16
the Panchayats build i
Gram Panchayats a matching grant equivalent to the total
.
- *
t to the total cess collected by them everv
year
In
addition,
the
Government
gave
away
of land
land revenue
collected" b“v tte0 D'r ,GOrr"m‘n' .SaVe a”ar ‘a certain percentage of
collected by the District administration
Panchayat Samitis.
------ 1 to
to the
the Panchayat
Samitis. It
I also agreed to
empower the Panchayat Samitis to
to control
haats (local
markets), bazaars
bazaars and
and ferry
control haats
(local markets),
services, and levy rates upon them,, to
to credit
the
entire
collections
of
road
cess
publm
credit the entire collections of road
works cess etc direct to the funds of the ZP concerned wtthout any deduction of
collection costs, and to merge the Darjeeling Improvement Fund and such other area
ActTm^ffie"? Whh thVUndS °f thC ZP COnCerned' Through an amendment to the
of 1973 the I anchayat Samitis and ZPs were empowered to borrow money from the
Annex 1
----- ---------------------------- -------- ------------- - ----------------- ---------- ---------- Page 6 of 29
State Government or with the previous sanction of the State Government, from the Banks
or other financial institutions on the basis of specific schemes.
THE KARNATAKA-ANDHRA MODEL
SaEfr^h
XS A r
°n 2nd AugUSt’ 1985> with the Gram
Sabha o the Vtllage Counctl as the baste tier of the system. The Gram Sabha comprised
of eligible voters under the Panchayati Raj system, i.e. all members above the age of 18
years of that village. There was a Gram Sabha for each of the villages in the State and it is
required by law to meet not less than twice in an year. It discusses and reviews all
ve opment problems/programs of the village, selects beneficiaries for all beneficiarvonented programs transferred to the PRIs; plans for local improvement including
minimum needs we fare and production oriented programs including cropping pattern for
season for the village, and constitutes land army consisting of all able-bodied persons
18 ,
The Mandal Panchayat was the first elected tier of the system. It was entrusted
th
ovic functions and powers and responsibility for development and welfare
programs with an mter-mandal orientation. The number of seats was one for every 400
population 25% of the membership was earmarked for women and 18% for the weaker
sections of the society. 7'he mandal covered
------- J a group of villages with a population of about
10,000 on an average.
19.
At the next higher level was the Block Panchayat Samiti which was a purely
,,nominated
, body„ comprising
,
d ex-officio all the chairpersons of the Mandal in the block all
Pa
'eSiS'“OrS re,’reS‘",i"S
P""
of'he ziSa
the isZ
members of the' legislat
Panshad represent,
representing
etc" This body was entnrsted with advisory
ng any part
pan of the block etc
y
reviewing and intra-mandal coordination functions vis-a-vis the Mand^s
of the Block.
hs
Z1Ha PariS^dwas the third directly elected tier of the Panchayat Raj system
hea^ofVt
P°WerS Were formulated
render it unambiguously the
n o ml
r development and welfare administration It administered schemes and
p ograms transferred to H or evolved by it; maintained cadres for manning the Zilla
andlls'o
? I3' k3?' f°rmulated the district Plan; framed and approved its budget
and also approved the budgets of the Mandal Reservations were provided for women and
the weaker sections as in the case of Mandals.
cu tor women and
L i yL SyStern also Provided for devolution of schemes to the PRIs In decidine
detailed devolution of schemes, the principle observed was that all the schemes wi^a
manda ^^^0^ W° d d
transfened t0 the Mandal> a" schemes with an intramandal, mtra-block or district onentauon were transferred to the Zilla Parishad schemes
remaining in the State sector being strictly those with a pronounced inter-district
u
Annex 1
Page 7 of 29
orientation and the externally assisted programs. The transfer of provisions/schemes to the
Zilla Parishads and Mandals from the State Plan, and non-plan budget was, perhaps, the
most massive sharing of the state budget by transfer to the PRJs The transfer of staff to
the complete control of the PRls had been the unique feature of the Karnataka system.
22.
Andhra Pradesh Model is also very similar to the Karnataka model except that the
size of the Mandal was kept comparatively bigger in Andhra Pradesh. On the average a
population of the mandal in Andhra Pradesh was kept at around 50,000 against 10,000 in
Karnataka It therefore, necessitated a three-tier system with an elected village pan’chayat
for a group of villages, at the lowest level.
C. Organizational Structure of Health Care Administration at the State Level
:>
This section provides a brief description of the organizational set up of health
administration at the state level The administrative set up at the district, Taluka/BIock and
village levels are also outlined This system applies to items such as public health and
sanitation, hospitals and dispensaries which are included in the state list, and items like
population control, medical education, adulteration of food stuffs, medical profession,
registration of births and deaths, and mental health which fall under the concurrent list. The
report, ‘India Policy and Finance Strategies for Strengthening Primary Health Care Services”,
provides a complimentary discussion of health administration in India at the Union level.
r24 u Qaanizational set up for Health at the State l^evel. The broad administrative structure
tor health in most states is more or less the same, with some minor variations. At the
headquarters in a state capital, there are two levels, the secretariat and the Directorate of health
services ^cretanat level Generally at the highest level, there is a department of health and
amily welfare located in the Secretariat which is headed by a Minister, generally of Cabinet
rank, as health is considered to be an important state subject. At the official level the
department is headed by a Secretary who usually belongs to the Indian Administrative Service
Assisting him are Additional Secretary/Joint Secretary (IAS), Deputy Secretaries, Under
Secretanes and other office functionaries. The department of health at the secretariat level is
concerned with the formulation of policies, besides dealing with all legislative matters including
the making of rules and regulations on matters of health and administration. The secretanat
also helps the health Minister in the discharge of his responsibilities to the legislature by
providing necessary information and assisting in answering questions raised by the legislators.
All important proposals or schemes relating to health are submitted by subordinate
agencies for approval and sanction of the Secretariat It also broadly supervises regulates and
a^1V,tleS °f the n6tffications
the iss“e of circular memoranda and Government
Orde* The Department, besides receiving periodic reports and returns, reviews the progress
01 wor t ough inspection and other ways. The Secretariat exercises considerable authority
oth in personnel and financial matters. In some states there are separate Secretanat
Departments for Health and Family Welfare (eg Tamil Nadu and Karnataka) while in others
u
-------------—
Annex 1
Page 8 of 29
(as in Andhra Pradesh) they have a Health, Medical and Family Welfare Department as these
subject are related
26
Directorate level. The directorates function as technical wings of the state
departments of health services. These directorates are responsible for implementing the health
policies of the state Governments by maintaining proper technical standards. The precise
administrative arrangement at the level of the directorate however varies slightly from state to
state. For instance in some states (eg. Tamil Nadu) there is more than one directorate
separating medical care and medical education from public health. Some states have even gone
further by creating separate directorates for the primaiy health centers. The underlying
rationale for moving away from one single directorate to more than one directorate is the
expansion of health services in the country in the last couple of decades.
27.
In Andhra Pradesh, for example, there were several instances of bifurcation and
integration of medical and health services unit 1978 when a single directorate emerged,
although with two directors, one each for Medical education and administrative and health and
family welfare. In Karnataka until 1978, the directorate was looking after both medical and
health and family welfare, but in order to improve the standards of medical education, two
directors in charge of medical education, and health and family welfare services were appointed
while retaining the system of single directorate. It is the Directorate of health and family
welfare services in the state that is responsible for providing health care services to the
community through implementation of various national and state health programs including
family welfare and MCH services in the state.
2s
In West Bengal, the Director of Health Services who is also the ex-officio Secretary
heads the Directorate and is the Chief Technical Adviser in the State Government on all
matters relating to medicine and public health. He is responsible for the organization and
director of all health activities. The teaching institutions are however under the purview of the
Director ofMedical Education. The Director of Health Services in the state is assisted by an
appropriate number of personnel as Additional Director, Joint/Deputy/Assistant Directors and
other officer and staff
29
EggonaJ Organization: The field organization functions at the district, and the
taluq/mandal/block levels. For administrative reasons the states are divided into a number of
zones or regions through which the directorates supervise and control the field operations. For
instance in Andhra Pradesh, there are six regional Directors for six zones. This came into
effect in 1978. Each regional director has the responsibility for the management of health and
medical programs in his jurisdiction. He also looks after the personnel and establishment
matters in his assigned area. In Karnataka also there is decentralization of supervisory
authority at the divisional level, with four divisional directors with Bangalore, Mysore,
Belgaum and Gulbarga to look after all health and family welfare activities in the respective
divisions. The large hospitals are excluded from their purview.
u
Annex 1
Page 9 of 29
30
It should be noted that, in practice, decentralization to the regional level is inadequate
in all the states In several respects sanction or approval of the Directorates has to be obtained
even for the decisions made by the Regional Directors It is also true that the regional officers
are reluctant even to exercise their limited authority. It appears to be more convenient for them
to pass on the papers to the Directorate rather than take a decision and accept responsibility for
D. Subdistrict, District and State Level Organization and Functions
31.
The following charts, based on the analysis of the states of Andhra Pradesh,
Karnataka, Punjab and West Bengal, provide information with regard to: (i) the
composition of PRJs at the village level, intermediate level and district level; (ii) the
functions of different levels of panchayats; (iii) the committees proposed, with their
composition and functions at different levels of panchayats; (iv) obligatory and
discretionary sources.of revenue, (v) control exercised by the state governments over
panchayats at different levels, (vi) composition of the state finance commission; and (vii)
District Planning Committees Also included are charts showing the organization of the
government administrative structure for health at the state and district levels in West
Bengal
u
Annex 1
Page 10 of 29
STATE-WISE POSITION OF PANCHAYA I I
RAJ: COMPOSITION
^PANCHA YA TA T THEVIL1AGF LEVEL
-------- rEL
State
Nomen
Minumum
Number
.Chairperson
clature
size for
of
of the
constituting a members Nomen
Mode
Pancha
Panchayat
to be
clature
of
-yat
area
elected
Election
Andhra
Pradesh
Gram
Pancha
yat
A revenue
village
irrespective of
its size
Karnata
ka
Gram
Panchaya t
Village(s)
with a
population
between 5 & 7
thousand
Punjab
Gram
Panchayat
A village
having a
population of
200 or more
Gram
Pancha
yat
A mauza or of
rnauzas
irrespective of
its size
West
Bengal
5-21
Sarpanch I Direct
One
Adhyakmember
sha
for every'
400
I
populatio i___
5-13 (A
Sarpanch
Gram
Sarpanch
Sabha to
be treated
a multi
member
single
Constituen-cy)
5-30
Pradhan
__
Indirect
Direct
Indirect
Rese na
tion for
backward
classes
No confidence
motion against
the
Chairperson
One-third
of the total
seats
Notice by not
less than half of
the total
members
Motion carried
by 2/3
members. No
motion within
first two years
and it can be
moved only
once against the
same person.
Notice by 1/3
members.
Motion carried
by 2/3
members.
About onethird of the
total scats
One scat of Notice by 2/3 of
member
Panchas.
where the
Motion carried
population
by majority of
of
voters of the
backward
Gram Sabha.
classes is
No notice
over 20%
within first two
in the
years.
Gram
Panchayat
area,______
No
Motion carried
reservation by majority of
total elected
members. No
notice within
one year after
its election.
Not more than
one resolution
within six
months
Annex 1
Page 11 of 29
SI A IE-WISE POSITION OF PANCHAYA II RAJ: COMPOSITION
If. PANCHA F/l TA T THE WLLAGE TEVET
Nomencla
Nomcncla
ture of the
State
Composition of the
-Cure of
Panchayat
Panchayat
the
Chairperson
Andhra
Mandal
Directly elected
President
Pradesh
Panshad
members Mps and
MLAs One person
belonging to
minorities to be
coopted. The
Sarpanches of all
Gram Panchayats
shall be permanent
invitees
Karnata
ka
Ta Iuka
Panchayat
Punjab
Panchayat
Samiti
West
Bengal
Panchayat
Samiti
Elected Members
(One for every'
10,000 population)
Mps, MLAs &
MLCs. One-fifth of
Adhyakshas of the
Gram Panchayats by
rotation._________
a) Directly elected
members 6-10 (one
for every 15
thousand population)
b) Representatives of
the Sarpanches to be
elected (Ratio of
a:b/40:60)
c) MLAs and MLCs
Directly elected
members (not
exceeding three from
each Gram)
All Pradhans of
gram Panchpyat
MPs and MLAs
Reservation
for Backward
classes
No confidence
motion against the
Chairperson
One-third of
the total
elected
members.
Notice by not less
than half of die
total members.
Motion carried
by 2/3 members.
No motion within
first two years
and it can be
moved only once
against the same
person. ________
Notice by 1/2 of
the elected
members. Motion
carried by a
majority of the
elected members.
Adhyaksha
About onethird of ±c
total scats
Chairman
Only one scat
in such
Panchayat
Samitis where
the population
of backward
classes is not
less than 20%.
Notice by onefifth members.
Motion carried by
2/3 elected
members.
Sabhapati
No reservation
Motion carried by
majority of total
elected members.
No notice within
one year after its
election. Not
more than one
resolution within
six months.
u
Annex 1
Page 12 of 29
STATE-WISE POSITION OF PANCHAYATI RAJ:
C PANCHA YA TA T THE VILLA GE LEVEL
State
Nomencla
Composition of the
ture of the
Panchayat
Panehayat
Andhra
Pradesh
Zilla
Panshad
Karnata
ka
Zilla
Panshad
Punjab
Zilla
Panshad
West
Bengal
Zilla
Panshad
Nomencla
ture of the
Chairperson
Directly elected
Chairman
members (one
member from each
Mandal Parishad)
Mps & MLAs. Two
coopted members
belonging to
minorities All
Presidents of
Mandal Parishads
shall be permanent
invitees._____
Elected Members (at Adhyaksha
the rate of one for
every' 40 thousands
people) Mps, MLAs
& MLCs.
All Adhyakshas of
laluka Panchayats,
Dirccdy elected (qo
Chairman
to 25) at the rate of
one for every 50
thousand population.
All chairmen of
Panchayat Samitis
Mps, MLAs &.
MLCs.
Directly elected
members (not
exceeding three from
each block).
All Sabhapatis of
Panchayat Samitis.
MPs and MLAs
Sabhadhipati
COMPOSITION
Reservation
for
backward
classes
One-third of
the total
elected
members.
No confidence
motion against the
Chairperson
Notice by half of
die total
members.
Motion carried by
2/3 members.
No motion within
first two years
and it can be
moved only once
against the same
person.
One-third of
the total
seats.
Notice by 1/3 of
the elected
members. Motion
carried by a
majority of the
elected members.
One scat
shall be
reserved in
Zilla
Parishad
where the
population of
backward
classes is not
less tfian
20%,
No
reservation
Notice by onefifth members
Motion carried by
2/3 elected
members.
Motion carried by
majority of total
elected members.
No notice within
one year after its
election. Not
more than one
resolution within
six months
0
Annex 1
Page 13 of 29
FUNCTIONS OF DIFFERENT LEVELS OF PANCIIAVATS IN WEST BENGAL - I
fl
Head
Gram Pa rich ay at
Obligatory
Functions
Gram Panchayat shall
provide
1. Sanitation,
conservancy, drainage
& prevention of public
nuisance
2
Prevention of
epidemics
3 Supply of safe drinking
water
4
Maintenance, repair,
construction and
protection of public
assets
5. Management of public
tanks, grazing grounds,
burning ghats and
public graveyards
6. Supply of any local
information to higher
authorities ,
7
Organising voluntary
labour and community
works.
8 Control and
administration of Gram
Panchayat fund.
9
Imposition, assessment
and collection of taxes,
rates and fees.
10. Maintenance and
control of Dafadars and
Chowkidars
11 The constitution &
administration of Nyay
Pane haya is.
Panchayat Sainiti
1.
Zilla Parishad
To undertake schemes or
1. Same for Zilla
adopt measures including
Parishad.
the giving financial
2. Same for Zilla
assistance relating to the
Parishad
development of agriculture,
3. Same for Zilla
livestock, cottage industries,
Parishad
co-operative movements,
4. Same for Zilla
rural credit, water supply
Parishad.
irrigation, public health and 5. Undertake
sanitation, establishment of
Schemes or adopt
hospitals, and dispensaries,
measures
communication, primary
(including giving
and adult education, welfare
financial
of students, social welfare
assistance) to the
and other subjects of
development of
general public utility.
industries and
2. To undertake execution of
secondary
any scheme, performance of
education
any act or management of
6. Same for Zilla
any institution or
Parishad.
organization entrusted by
Government.
3. Management of any work of
public utility.
4. To make grants in aid to
any school/institution of
public welfare institution.
V
Annex 1
Page 14 of 29
FUNCTIONS OF DIFFERENT LEVELS OF PANCHAYATS IN WEST BENGAL - II
Head
Other duties
Grain Panchayat
If State Government may
assign Gram Panchayat, shall
perform:
1. To undertake primary,
social, technical or
vocational education.
2. Management of rural
dispensaries health cares,
maternity and child
welfare centers.
3. Management of public
ferry
4
Management of irrigation
works.
5. Grow more food
campaign.
6. Care of infirm and
destitute.
7. Rehabilitation of displaced
persons.
8 Animal husbandry'.
9 Acting as a channel
through which
Government assistance
should reach the village.
10. Wasteland/fallow land
improvement.
11. Plantation
12. Assistance in
implementation of land
reform works.
13. Schemes entrusted by
Government.
14. Field publicity of
development
works/wclfare programmes
undertaken by the State
Government.
Panchayat Samiti
Zilla Parishad
1.
To make grants to
1. Coordination and
Zilla
integration of the
2. Parishad or Gram
development plans
3. Panchayats.
and schemes prepared
4. To adopt measures
by the Panchayat
for the relief of
Samiti.
distress.
2. Examination and
5. To contribute sums
sanction of the budget
towards the cost of
estimates of the
waler supply or anti
Panchayat Samitis.
epidemic measures
3. To contribute such
undertaken by a
sums as may be
municipality within
agreed upon towards
the Panchayat.
the cost of
6. Coordination and
maintenance of any
integration of the
institutions situated
development plans
outside the district
and schemes
which arc beneficial to
prepared by the
inhabitants of the
Gram Panchayats.
district.
7. Examination and
4. Establishment of
sanction of budget
scholarship or award
estimates of Gram
stipends for further
Panchayats.
more of technical or
other special forms of
education.
5. To make grants to
Panchayats Samitis
and gram Panchayats.
6. To advise State
Government on all
matters relating to
development work
among Panchayat
Samitis and Gram
Panchayats.
_________
Annex 1
Page 15 of 29
FUNCTIONS OF DIFFERENT LEVELS OF PANCHAYATS IN WEST BENGAL - III
Head
Discretionary'
Functions
Gram Panchayat
1
The maintenance of lighting of
public streets.
2. Plantation on public streets
and public places.
3. the sinking of wells and
excavation of ponds and tanks.
4. To introduce and promote
cooperatives.
5. Construction and regulation of
markets, melas, hats and
exhibition of local produces.
6. Allotment of places for
securing manures.
7. Sanitation work.
8. Managing the distribution of
State loans.
9. Promotion of cottage
industries.
10. Destruction of rabies and stray
dogs
11. disposal of unclaimed cattle,
corps and carcases.
12. Construction and maintenance
of Sarals, dharmasalas, rest
houses, etc.
13. Establishing of libraries and
recreation places.
14. Statistics.
15. Fire protection
16. Prevention of burglary and
dacoity.
17. Any other works of public
utility.
Panchayat
Samiti
1. A Panchayat
Samiti may
undertake or
execute any
schemes if it
extends to
more than one
Gram
Panchayat.
Zilla Parishad
1. Zilla
Parishad
may
undertake or
execute any
schemes if it
extends to
more than
one block.
u
Annex 1
Page 16 of 29
A. ^CHAYATS
T
AT VILLAGE LEVEL: <
COMMITTEE SYSTEM
State
I No. of
Name of the
Mode of
Major Functions
Remarks,
Committee
Members Election of
if any
incl.
the
Chairman Chairman
Andhra
Beneficiary committee
As may be
Execution of works
Pradesh
for the execution of
prescribed
of Panchayal
works of the Gram
Agricultu/e, Public
Panchayal and
Health, Water
functional committees
Supply, Sanitation,
for agriculture, public
Family Planning,
health, sanitation and
Education, etc.
communication in
every' Gram Sabha.
Karnata
I. Production
3-5
Adhyaksha Agriculture
One
ka
Committee
Production, Animal
representative
Husbandry, Rural,
from co
Industries, Poverty
operative
Alleviation
societies.
Programmes.
2
Social Justice
3-5
Upadhya1 Promoting major
At least one
Committee
ksha
interest of
member form
SCs/STs/BCs.
SC/ST and
2. Protesting them
one woman
from social
injustice.
3. Welfare of women
and children.
3. Amenities
3-5
Adhyaksha Education, Public
Committee
Health, Public
works.
__________
Punjab
I. Production
3-5
Sarpanch
Agriculture
A Representa
Committee
production, Animal
tive from
Husbandry', rural
cooperative
industries, Poverty
societies shall
Alleviation
be co-oped.
Programme.
(Farmer
II. Social Justice
3-5
Sarpanch
1. Promotion of
Clubs, Yuvak
Committee
major interests of
kendra &
SCs/STs/BCs.
Mahila
2. Protecting tliem
Mandals). At
from social
least one
injustice and
member
form
IH. Amenities
3-5
Sarpanch
exploitation.
SC/ST
Committee
3. Welfare of women One woman
and children.
Public Health,
Education, Public
Works
West
No mention in the Act
Bengal
Annex 1
Page 17 of 29
B. PX/VC/Z/l YA TS A T INTERMEDIA TE LEVEL: COMMITTEE S YSTEM
Name of the Committee
No. of
Major Function/
Remarks,
State
Members
Chairman
Functions
if any
incl.
Chairman ______
Andhra
A Mandal Panchayat may and if so required by the Government shall, join with other
Pradesh
local authority in constituting a joint committee for any joint purpose.
Karnata
ka
1.
General Standing
Committee
Not more
than six
2.
Finance Audit and
Planning Committee
Not more
than six
3.
Social Justice
Committee
Not more
than six
•
General Committee
Not more
than six
•
Finance Audit and
Planning Committee
Not more
than six
•
Social Justice
Committee
Not more
than six
Punjab
West
Bengal
1
Arth Sanstha,
7-9
Unnayan,
Parikalpana Sthayec
Samiti
2. Jan Swasthya
7-9
Stjayee Samiti
3. Pun Karya Sthayec
7-9
Samiti
4
Krishi Seeh O
7-9
Samataya Sthayec
Samiti
5 Shiksha Sthayec
7-9
Samiti
6
Khudra Silpa Tran
7-9
Jankalyan Sthayee
Samiti
7 Samanvay Samiti
7-9
Adhyaksha
1. Establishment
matters,
communications,
rural housing,
Adhyaksha
relief works, etc.
2. Finance,
Budgets, Account
UpadhyaSavings, etc.
ksha
3.Securing Social
Justice to weaker
Sections of the
society_____
Chairman
♦Establishment
•matters,
communication,
Rural Housing
Chairman
Water Supply, etc.
•Finance, Budgets,
Accounts, Small
Vicesavings, etc.
Chairman
•Securing Social
justice to weaker
sections
Sabhapati
Finance,
Establishment
Development and
Planning
Elected
Public Health
Elected
Public Works
Elected
Agriculture,
Irrigation and
cooperation
Education
Elected
Elected
Elected
Cottage Industries,
relief works and
social welfare
No member to
serve on more
than one
committee
No member
except chairman
shall serve on
more than one
committee
1. Out of all
members
a) 3-5 shall be
elected members
b) Sabhapati
shall be exofficio
member.
Three members
shall be from
officers of State
Govt, (not
having right to
vote)
2. No person
shall be allowed
to serve on more
than three
committees.
Annex 1
c.
rage 18 of 29
STRICT PANCHA YA T:
Name of the
Committee
State
Andhra
Pradesh
2.
Karnataka
4
1.
COMMIHEE SYSTEM
No. of
Members
Chairman
incl.
Chairman
I As may be I Viceprescribed
Chairman
Function (Other than
delegated functions)
Rema
rks,
if any
Standing
Agriculture, Animal
~~~
Committee for
Husbandry
,
Forestry,
Soil
Agriculture
Reclamation, Seri culture.
2. Standing
As may be
Chairman
Poverty
Alleviation
Committee for
prescribed
Programmes,
Area
Development
Development
3. Standing '
As may be
Chairman
Programmes, employment,
Committee for
prescribed
Housing
Cooperation,
Education and
Small Industries, etc.
Medical Services
Education, Social
4. Standing
As may be
Chairman
education,
Medical
Committee for
prescribed
services,
drainage,
Relief
Planning &
works.
Finance
Budget, Taxation,
5. Standing
As may be
Chairman
Finance,
Co-ordination of
Committee for
prescribed
works
relating
to other
Women Welfare
committees.
6. Standing
As may be
Chairman
Women and Child Welfare
Committee for
prescribed
Welfare
of SCs/STs BCs,
Social Welfare
Cultural activities.
7 Standing
As may be
Chairman
Communication, Water
Committee for
prescribed
Supply,
Power Irrigation.
works.
I.
General
_________
Not more
Adhyaksha
Establishment matters, No mem
Standing
than five
communications,
ber to
Committee
building rural housing, serve on
II. Finance Audit
Not more
relief works, etc.
and Planning
niore than
than five
Adhyaksha
Finance,
Budget,
Committee
one com
Accounts, Expenditure mittee
HI Social Justice
Not more
Upadhyaand Revenue,
Committee
than five
ksha
Planning, Evaluation,
IV. Education and
Not more
Elected
etc.
Health
than five
Securing Social Justice
Committee
to
weaker Sections of
V. Agriculture and
]
Not
more
Elected
the
society
Industries
t than five
Education activities,
Committee
development planning,
survey, literacy
programmes health
services, etc.
Agriculture production
animal husbandry,
cooperation, village
industries and
industrialization
Annex 1
Page 19 of 29
3. Punjab"
I.
General
Committee
Not more
than five
Chairman
Finance Audit
and Planning
Committee
III Social Justice
Committee
IV. Education and
Health
Committee
Not more
than five
Chairman
Not more
than five
Not more
than five
Chairman
II
4. W.
Bengal
Elected
V. Agriculture and
Industry
Committee
Not more
than five
Elected
Arth Sanstha,
Unnayan O
Parikalpana
(Finance,
Establishment,
Development
and Planning)
2. Jan Swathya
(Public Health)
3. Purt karya
(Public works)
4. Krishi Sech
Somabaya
(Agriculture,
Irrigation and
Co-operation)
5. Shiksha
(Education)
6. Khudra Silpa,
Tran Jankalyan
(Cottage
Industry, Relief
and Social
Welfare)
9-11
3-5 elected
5 members
nominated
and one exofficio
member
same as
above
same as
above
same as
above
Sabhapati
1
Finance, Budgeting,
Plan priorities,
evaluation review
programmes.
Securing interests of
weaker sections of the
society.
Promotion of
Education planning,
survey and evaluation,
literacy, health medical
and welfare.
Agriculture
production, animal
husbandry,
cooperation, village,
cottage industries and
industrial
development. _______
Finance, Establishment
Development and
Planning
Elected
Elected
Elected
No mem
ber shall
serve on
more than
two com
mit-tees
1.
Nominate
d (by state
Govt.)
member
have no
right to
vote.
Public Health
Public Works
Elected
Elected
same as
above
same as
above
Establishment matters,
communication,
building, relief works,
etc.
Agriculture, Irrigation
and Co-operation
Elected
Education
Cottage industry,
Relief and Social'
Welfare
2. Tenn of
a member
is 55
years.
3. The
Secretary
ofSilla
Parishad
shall be
ex-officio
Secretary
to all the
Slhayce
Samilis.
u
Annex 1
Page 20 of 29
STATE-WISE POSITION OF PANCHAYAT1 RAJ:
A. PANCHA YA TS A T VILLA GE LEVEI
State
Obligator)- Sources
Tax revenue
Andhra
Pradesh
1. House Tax
2. Tax on village
produce sold in
the village.
3. A duty on
transfer of
property.
4. Tax on
advertisement
5. Vehicle tax
6. Special lax on
houses for
providing
facilities.
'-■'I:
Karna
taka
• Tax on
buildings @
10% of annual
letting value.
• Tax on lands
(not subject to
agricultural
assessments) @
one Re per
annum for every
one hundred sq.
km. of area.
Non Tax revenue
RESOURCES
Discretionary Sources
Tax revenue
1. Payment by Market
I. Vehicle tax.
Committee
II. A tax on agriculture land
2. Payment made by
for a specific purpose
Mandal Panchayat and
III. A land cess at the rale of
Zilla Panchayat for share
two per cent.
in income derived from
IV. A duty in the form of
markets and ferries.
surcharge on the
3. Fees for temporary’
seigniorage fees on
occupation of village
materials other than
sites, roads and other
minerals.
public places.
V. Surcharge on tax leviable
4.Income from
on.
endowments and trusts.
a) education
5.The net assessments on
b) land.
service income.
6.Income form village
fisheries, woods, reeds.
V.Unclaimed deposits etc.
8. Income from lease of
Govt, property.
9. Grants from Mandal
Panchayat.
10.income from
investment of amount
taken from Panchayat
Fund.
11.One-tenth of the gross
income derived by
Government from fines
imposed by Magistrates
in the village._____
• Transfer of amount by
• Tax on entertainment other
Govt, on account of
than cinematography (shows
collection from local cess
@ Rs.25 per show)
levies on land revenue
• lax on vehicles other than
• Grant of one lakh RS.
motor vehicles.
(annually)
• Tax on Advt. and Hoarding
• Rent/Salcs proceeds
• Pilgrim fee for management
• Market fee on persons who
expose their sales .
• fee on registration of cattle
• Surcharge on lax (as may be
directed by Govt.)
Remarks
Nn.
TR.
A
fee
for
use
of
com
mu
ni ty
land.
Taxes are
yearly
•Water rate
•Fee on
buses,
taxies,
autostands
for
providing
facilities
•Fee on
grazing
cattle in
grazing
lands.
Annex 1
Page 21 of 29
STATE-WISE POSITION OF PANCHAYATI RAJ:
RESOURCES
A. PANCHA YA TS A T VILLA GE LE VFl
Punjab
• Tax on lands and
• Sale proceeds of
• Free on
buildings
produces, dust, dung
registration
• Tax on profession,
etc.
of vehicles
trades, callings and
• income from village
• Special lax
employment other than
fisheries
on adult
agriculture
• Income from
male
• Duty in the shape of an
common land
members
additional stamps duty
• Promotion of land
for
for all payments for
revenue (not less
community
admission to any
than 10% of revenue
work.
entertainment.
realized related
• Surcharge on stamp duly
panchayat area) by
(not exceeding 2 % ) by
State Government.
slate Govt, for Gram
Panchavats.
West
l .Tax on Land and
1. Income form
1. Fees on
Bengal
buildings (a) @ one
schools/hospitals/
registratio
percent of the value is
other institutions
n of
less than Rs. one
and works under
vehicles
thousand
control of
2. Fees on
2. Tax on professions,
Panchayat
complaints
trades callings (subject to 2. gifts and
and
a maximum of Rs. 250
contribution and
petitions
per annum
income from
in suits
3. A duty in the shape of
trusts and
and cases.
additional stamp duty for
endowments
transfer of property @ 2
%)•
4. A duty in the shape of
additional stamp duly for
all payments for
admission to any
entertainment @ ten per
cent
1
Fee on
sanitary
arrange
ments
Water
rate
Lightin
g rate
Conser
vancy
rate.
1.
2.
3.
4.
Fee for
sanitary'
arrange
ments
Water
rate
Ligh
ting rate
Conser
vancy'
rate
—It
Annex 1
Page 22 of 29
Si ATE-WISE POSITION OE PANCIIAYATI RAJ: RESOURCES
IE LEVEl
State
——
—--------- Obligatory Sources
Discretionary Sources J
Remarks
Tax
Non Tax Revenue
Tax Revenue
Non
Revenue
T. R.
Andhra
1 Share of the land revenue,
Proceeds from
l.Such
Pradesh
state taxes or fees.
taxes, surcharge or
contributions
2. Donation and contribution
fees which the
as the parishad
from Gram Panchayats or
parishad is
may levy from
from public
empowered to levy
Gram
3. Annual grant @Rs.5Z- per
under laws.
Panchayat
person (based on the last
2.
Any other
census) from Government.
income from
4. Grants to cover expenses
remunerations,
of establishment matters
enterprises and
by Govi.
Karna
the like.
• Grants to cover expenses of
Surcharge on stamp
taka
establishment matters by
duty
Government
• Rent
• Sales Proceeds
Punjab
Local
Rent/profits from
• Tolls on persons, vehicles
rate @
property managed
animals, etc. , for using
25 paise
by Samiti
road and bridge under
per Rs
Samitis
control
of land
•
foils
on
ferry
revenue
• Fee for registration of
vehicles other than those
registered under motor Act
1986
•Fee for licence for a market
• Fee for any other licence
West
J .Contribution and
1 Toll on persons, vehicles
Bengal
1. Water rate
grants from Govt,
and animals (for roads and
2. Lighting rate
including part of
bridges)
land revenue
2 Toll on account of ferry
2. Income from
3.Fee on registration of
schools, hospital.s
vehicles.
& other
institutions <&
work
3. Gifts and
contributions
4 Income form
trusts &
endowments
5 Fmes/Penaltics
Annex 1
Page 23 of 29
STATE-WISE POSITION OF PANCHAYATI RAJ: RESOURCES
C. DISTRICT PANCHA YA T
State
Obligatory Sources______
Tax
Non Tax Revenue
Revenue
Andhra
1 Income from endowments for trusts
Pradesh
administered by Parishad.
2. Income of Dist. board as Govt, may
allocate to it.
3. Donations and contribution form
Mandal Parishad or public.
4. Any income fonn remunerative
enterprises.
5. Annual Gran @Rs. 2/ per person
(based on last census data) from
Government.
Karna
taka
Punjab
With the
permission of
the State Govt,
on the
recommenda
tion of the
SFC, the Zilla
Parishad shall
levy any tax,
duty fee toll
which has not
been levied by
any Panchayat.
West
Bengal
Proceeds of
road cess
• Grants to cover expenses of
establishment matters, by Govt.
• Grants, assignments, loans,
contribution made by the Govt.
• Fmes/Penalties
• Interests, profits, gifts, etc. ________
• Contribution and grants by
Cenlral/State Govts, including the
part of Land revenue.
• Contribution and grant by Panchayat
Samiti
• All receipts on account of taxes, rate
tolls, etc.
• All receipts in respect of
schools/hospilals, building,
institutions, works etc.
• Gifts and contributions.
•
•
•
•
•
•
Contribution and grants by
Panchayat Samiti or other local
authority
Loans granted/raised
Income from management of schools
hospitals and other institutions or
work
Gifts, contribution
Income from trusts and endowments
Fines/Pe na 11 i c s.
Discretionary Sources
Tax Revenue
Non
Remarks
T. R.
1. Share of the
land cess, State
taxes or fees as
may be
prescribed.
2. Taxes or fees
which parishad
may levy under
any law.
Such
contribu
tion as the
Zilla
Parishad
may levy
from the
Mandal
Parishad
with the
previous
approval
of Govt.
All fees,
imposed,
if any
Road cess and
public work cess.
1. Tolls on persons
vehicles
2. Tolls in respect of
ferry
3 Fee for
registration of
vehicles
1. Water
rate
2. Fee for
sanitary
arrange
ments
3. Lighting
rale
Annex 1
Page 24 of 29
STATE-WISE POSITION OF PANCHAYATI RAJ -STATE CONTROL
A. ^NCHA
E"
YATAT THE VILLA GE LEVEL
State
Andhra
Pradesh
Karna
taka
Punjab
Control Over Chairperson
Power of
Suspension
District Collector
Control Over Panchayat
Power of
Removal
District Collector
Arrangement in
Case of
Dissolution
Commis-sioner
Power of
Inspection
Commissioner/Go
vemment _____
CEO
Director
Government
Director
Government
Government
Government
Inspector of
Panchayats
Government
Government
Government
Government
Government
CEO
Commissioner
Government
Government
Government
Director
Government
Government
Inspector of
Pancvhayat
Government
Government
Government
Government
Government
Director (at any
time) Dy.
Commissioner
/DDPO during
enquiry
West
Bengal
Power of
Suspention
Government
Power of
Dissolution
Government
CEO (with
confirmation of
Commissioner)
Cornmis-sioner
Government
A person/
persons
empowered by
Zilla Parishal of
Govt.
b. r
PANCHA YATATINTERMEDIA TE LEVE!
Andhra
Pradesh
Government
Karna
taka
Punjab
Government
West
Bengal
Government
A person/ persons
empowered by
Govt.___________
A person/ persons
appointed by ZP
or Govt.________
A person/persons
appointed by
Govt.
________
A
person/persons/au
thority appointed
by Govt.
C. DISTRICT PANCHA YA T
Andhra
Pradesh
Government
Government
Karna
taka
Government
Commissioner
Government
Govenunenl
Punjab
West
Bengal
Government
Government
Govenunenl
Inspector of
Panchayats
Jirector
Government
Govenunenl
Govenunenl
A person/persons
appointed by
Govt, from lime to
time
A person/persons
appointed by
Govt.
Annex 1
Page 25 of 29
DISTRICT PLANNING COMMITTEE (DPC)
State
Andhra
Pradesh
Whether the
Composition
provision of the
comm, (in the
Act) is made or
______ not_________
No mention in the Act
Karnataka
Provided
Punjab
Provided
West Bengal
Provided
Mps, MLAs, MLCs.
Adhyaksha, Zilla Parishad,
Mayor/President of the
Municipal Corporation/
Municipal council having
jurisdiciton over the H.Q.s
of the district Elected
members as prescribed
under the Amendment.
Details not mentioned in
the Act._____
Details not mentioned in
the Act.
Secretary
CEO
Chairperson
To be chosen as
prescribed
STATE FINANCE COMMISSION
State
Number of Members
Including Chairman
Chairman
Andhra Pradesh
five
Experience in public
Affairs
Karnataka n
three
As may be prescribed
Punjab
West Bengal
Qualifications
Prescribed for
Members
1. Special knowledge
of finance and
accounts in
government or
2. Wide experience in
financial matters/
administration or
3. Special knowledge
of economics_____
As may be prescribed
fo be constituted in accordance with the provisions
of Articles 2431 of the Constitution.
Not exceeding five
Selected from justice, economics, administrators
and social and political workers of eminence.
phincipai. SECRETARY
I
COMMISSIONER
fFamity Welfare)
SPECIAL SECRETARY
JOINT SECRETARY
[Family Welfare)
ASSISTANT SECRET ARY
[Famity Welfare)
f MA
r
JT. SECRETARY
(Planning. Budget A
Vigilance)
JT. SECRETARY
(General Administration :
Honicepathy)
OSD A DY. SECRETARY
(Planning & Budget)
Medical
I
Administration
MEET
Medical Education
Research & Training
PHP
Public Health
Programme
I
JT. SECRETARY
(MERT)
OSD A EX-OFFICIO
DY. SECRETARY
(Ayurveda & UNANI)
JT. SECRETARY
(MA)
OSD & EX-OFFICIO DY.
SECRETARY
I
OSD & DY. SECRETARY
(General Administration)
IHornoeopatliyl
I
I
JT. SECRETARY
(LAW)
I
JT. SECRETARY
JT. SECRETARY
fTDE A Project)
(Medical Sendees)
DY. SECRETARY
(PHP)
ASST. SECRETARY
IMERT)
DY. SECRETARY
(MA)
ASST. SECRETARY
(LAW)
ASST. SECRETARY
(Medical Sendees)
OSD A DY.
SECTETARY
(TDE & Project)
I
ns
w
era
CD
ASST. SECRETARY
>
o n
(PHP)
O 5
-h rr
ba
KO ►—
Annex 1
Page 27 of 29
1 *-?' !.
i2
11 [
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$
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-7L
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’■"H
20 i Ml
Jo
------- Is
9
2=
2d°dZ
DISTHICT LEVEL ORGANIZATION CHART
C. M. O. H.
ACMOH (Modi. Axhnn.)
- ACMOH (HI 6 IW)
district
I
I
DY. CMOH I
r
I
SUPDT.
DIST. HOSPT.
ADO.
D.L.O.
I
DY. CMOH II
DY CMOH iu/rv
— D.I.O.
molcu/mlcu/lc
SUB-DIVISION
ACHOH
(SUB-DIVN.)
SUPDT.
(SUB DIVN. HOSPT.
- D P II.N.O.
I
I
ACMOH
(SUB. DIVN.)
SUI'Dl
(STATE GENL. HOSPT I
ACMOH ere.
(SUB DIVN.)
BMOH/MOIC/CHC
— 2nd/3rd/4th M.O.
— MO New PHC
— (Coincides vdih Sector)
BLOCKS
r~
I
swo I
B.S.I.
M.l.
SI.
MPHS (M|
MPHA |M)
D.I.O. ’
D.P.H.N.O.
B. S.I.
S.W.O.
C. H.S.O.
Ml.
S.l.
I
i
coMpcrroR
I
swo II
C.H.5.O.
------- 1
BPHN
- CIIC / ID - CMC / ID - CIIC I ID - CIIC / ID - CIIC / ID -
• District Immunisation OfTlcer
- District Public Health Nurslnj; Officer
• Block Sanilac) Inspector
■ Social Welfare Officer
■ Community Health Services Officer
• Malaria lns(>ector
• Sanitary Inspector
PHN
MPHS (Fl
MPH (11
M.P.H.S.
M P II A
B P H N.
P H.N
C H C
T D
- Multipurpose Health Supervisor
- Multipurpose Health Assistant
- Block Public Health Nurse
» Public Health Nunse
= Community Health Grade
> Tr.lined Dai.
to
cro
o
bu >
00 5
O
e
- • ■.........................
- -i-'-•
Annex 1
Page 29 of 29
STRUCTURE OF THE PANCHAYATI RAJ SYSTEM IN WEST BENGAL
ZILLA PARJSHAB
Sabhapatis of Panchayat
Samities
PANCHAYATSAMITI
Members directly
elected by people
One Member for 2500
voters
_■
_J_
Members directly
elected by people
2 Members from
each block
Pradhans of Gram
Panchayats
GRAM PANCHAYAT
1 Member for 400
voters
PEOPLE
PEOPLE
PEOPLE
Annex 2
Page 1 of 28
Cost Effectiveness Analysis: Unit Cost Analysis at Different Tiers
of the Health Care System
1. This annex estimates the cost effectiveness of treating patients at a secondary hospital
compared to a tertiary hospital using different unit cost measures. These estimates are
achieved by comparing the overall unit costs related to specific inputs for in-patients and
out-patients at secondary versus tertiary hospitals and by giving cost and efficiency
comparisons of secondary versus tertiary level hospitals in terms of costs per case
equivalent. Section A estimates costs at a secondary versus a tertiary level hospital in
Andhra Pradesh, in terms of cost per case equivalent, which is arrived at by taking into
consideration the number of inpatient (IP) and outpatient (OP) services and recurrent
and capital costs. Section B provides a more detailed analysis and summarizes a time
motion study in which 1 PHC, 7 secondary hospitals, and 2 tertiary hospitals in AP were
compared in order to estimate unit health care costs in terms of bed day, OP, IP, Level I
and II tests and x-rays.
2. Analysis comparing cost-effectiveness between different types of hospitals is limited
in India, because of the non-availability of data and due to variations in the case-mix.
Moreover, even when data is available, it is difficult to compare certain services because
for example more
ious and complicated cases are admitted at tertiary hospiiaL, and the
length of stay and treatment costs tend to be higher at tertiary hospitals. Previous
analysis has showTi that between 25-40% of costs could be saved by treating patients at
secondary facilities rather than at tertiary hospitals. The data used in such analyses have
been more broad-based and have tended to overlook some of the problems noted here.
Moreover, such analyses did not compare similar services.
3. One of the rationales for focusing on providing services at the secondary level, from
an economic efficiency point of view, is that the unit costs of treatment can be reduced
considerably by providing health care services at lower level facilities where unit costs
for comparable services are lower. The analysis in this annex will approximate the
magnitude of cost savings if diagnosis and treatment of conditions that could be
addressed at secondary facilities are indeed taken care of at that level, rather than at the
tertiary level.
Section A
4. In this section, a preliminary' analysis is presented which estimates cost savings of
treating patients at a secondary' hospital compared to a tertiary hospital in Hyderabad.
Hospitals in Hyderabad were chosen because of the availability of accurate cost data and
the comparability of the services provided. The chosen hospitals were the Suraj Bhan
hospital, a secondary' facility, and the Sultan Bazaar Maternity hospital, a tertiary hospital
attache^ io
Both hospitals provide
to the Osmania Medical College in Hyderabad
Annex 2
Page 2 of 28
antenatal, intranatal and Family Planning Services in addition to gynecological care. The
case-mix al the two hospitals is more or less similar: a large percentage of the in-patient
facility is utilized by obstetric and family planning cases, which have constituted about
40% and 30% of in-patients, respectively during the past 2 years patients admitted for
gynecological problems and procedures comprised about 11% of the in-patients; and a
roughly equal proportion of in-patients had complicated obstetric care. One difference,
however, was the higher utilization of out-patient services at Suraj Bhan (first referral)
Hospital, with a much higher number of out-patients per in-patient (6 to 1) compared to
the Sultan Bazaar Maternity Hospital (1.2 to 1).
5. Estimation of Costs, The recurrent costs for the Sultan Bazaar Hospital were taken
from the budget books, and the recurrent costs of the Suraj Bhan Hospital were taken
from hospital records and grants received from the government. The recurring
expenditure, under different heads for three financial years for both the hospitals is
presented in Tables 1 and 2. Since both hospitals come under different administrative
systems, cost heads do not exactly match, and information on some heads is not being
routinely compiled by these institutions. However, at an aggregate level, both data sets
represent average recurring costs.
Table 1: Recurring Costs of Suraj Bhan Hospital (Rs.)
Head of Account
Pay & Allowances
Rent rates and
Taxes
Water and
Electricity
Cleanliness
Charges
Stationary, Imprest
&. other
Contingents
Maintenance
Electrical Goods
Drugs and
Medicine
Drugs &. Supplies
Provided from
Headquarters
Diagnostic and Lab
Material
Surgical
Instruments
Uniform
Diet
Total
|
1992-93
1993-94
1994-95
1,641,124
2,397,259
2,656,855
50,263
80,419
69,214
23,776
17,514
17,534
Y274
3,624
2,650
3,137
13,687
15,496
12,111
13,803
10,869
73,709
19,143
1,326
9,935
65,037
1,973
57,247
5,632
14,539
61,142
3,803
425,000
467,500
514.250
490,875
2,812
2,532
4,999
3,765
1,380
3,060
767
1,914
48,648
_______ 0
2,297,868
40,855
91,250
3.196.454
39,578
91,250
3,491,230
40,216
Average
1993-95
2,527,057
74,817
4—__
17,524
91,250
3,343,842
Annex 2
Page 3 of 28
nt. Table 2: Recurring Costs of Sultan Bazaar Hospital (Rs.)
Head of Account
1992-93
1993-94
1994-95
Pay &. Allowances
Service Postage
Water and
Electricity
Other Office
Expenses________
Rents and Taxes
Publications
Machinery and
Equipment_____
Motor Vehicles and
Other Expenses
Maintenance
Materials and
Supplies
Diet____________
Total
5,055,000
______0
0
5,862,000
0
0
7,110,000
3,000
597,000
Average
1993-95
6,486,000
1,500
298,500
33,000
0
90,000
45,000
70,000
15,000
172,000
29,000
50,000
1,546,000
112,000
15,000
150,000
70,500
32,500
848,000
0
157,000
0
78,500
_____ 0
1,450,000
581,000
1,397,000
9,000
1,400,000
295,000
1,398,500
______ 0
6,795,000
220,000
9,842,000
220,000
9,706,000
220,000
9,774,000
of Capital—Costs- Capital costs, however, were more difficult to
estimate, since both hospitals are located in old residential structures that were converted
several decades ago. In addition, the equipment is relatively old. Hence, it was not
possible to arrive at precise capital costs. An approach suggested by WHO for estimating
capital costs was used. This included a detailed listing of existing capital resources of
both hospitals, namely building (area), equipment (major, minor and surgical) and
furniture. The current costs of these capital resources were applied to the existing
facilities of both hospitals. For each capital facility the mean duration of utility was
arrived at by obtaining expert opinion. Examples from the Indian context were taken to
arrive at a capital facility with a mean duration of use and the annual capital cost
component.
Andrew Creese & David Parker; Cost Analysis in Primary Health Care: A Training Manual for
Program Managers; WHO. Geneva 1994.
Annex 2
Page 4 of 28
Table 3: Estimation of Annual Capital Costs (Rs.)
I Capital
Facility
I Description
Ii
,
IKE3BC
'IlT
XOBCMIW 1 ■CJ
Current Costs
Sultan
Bazaar
4,287,100
187,000
230,000
1,395,200
Equipment Major
Minor
Surgical
Furniture @ Rs.
8720/bed
Building
@ Rs. 400 per 15,290,000
Area
_2
Sq. Feet
Total Capital Costs per Annum
Suraj
Bhan
1,050,100
90,000
67,000
436,000
6,960,800
3
Mean
Duration
or Use in
Years
Estimated Capital
Costs
per Annum
1
10
Sultan
Bazaar
428,710
37,400'
230,000
139,520“
Suraj
Bhan
105,010
18,000
67,000
43,600
50
305,800
139,216
10
5
1,141,430 372,826
1
Sultan Bazaar Hospital: Total Building Area 38,225 Sq. Feet
2
Sultan Bhan Hospital: Total Building Area 17,402 Sq. Feet
J
■ £s.U.ni3tiQn of Unil Costs. Since the hospitals studied provide both in-patient and out
patient services, a comprehensive index which captures both types of services was
applied to arrive at a unit cost figure. The day equivalent method which equates the cost
of one in-patient day with four out-patient visits was used. Using the case equivalent
method, the unit cost for each hospital was calculated. The results are shown in Table 4.
2
3
Andrew Creese & David Parker; Cost Analysis in Primary Health Care: A Training Manual for
Program Managers; WHO, Geneva 1994.
Howard Barnum & Joseph Kutzin; Public Hospitals in Developing Countries, published for the World
Bank by The John Hopkins University Press.
Annex 2
Page 5 of 28
Table 4: Estimation of Unit Costs for 1993-95 (Rs.)
______ Description
Average IP
Average OP
Case Equivalents
Annual Recurrent Costs
Annual Capital Costs
Total Annual Cost
Cost per Case Equ iva 1 ent
Sultan Bazaar Hospital
52,516
62,150
68,054
9,774,000
1,141,430
10,915,430
160
Suraz Bhan HospitaI
12,199
_______ 79,962
________ 32,190
3,343,842
372,826
3,716,668
115
8. Since data on in-patients and out-patients were available only for two years (1993-94;
1994-95), the analysis applies only to this period. The results indicate that day unit cost
equivalent at the Suraj Bhan secondary hospital is about two-thirds that of the Sultan
Bazaar Maternity Hospital. The results are similar to other studies which found that
services at secondary facilities can be provided more cost effectively than at tertiary
hospitals if it is technically possible to provide these services at the secondary level. In
other words, there can be considerable cost savings if services that can be provided at
secondary level facilities are provided at those facilities rather than at tertiary hospitals.
The main reason for the savings from our study of at the two hospitals was largely due to
the greater unit costs of infrastructure and overheads at tertiary hospitals.
9. A review of several studies undertaken by Barnum et. al. also concluded that within a
country tertiary hospitals tend to have higher average costs than the less technically
complex district level hospitals. However, since they did not analyze unit costs for
similar types nf services provided, these results are merely indicative, and apply only for
two hospitals.
Nevertheless, they do illustrate the fact that streamlining and
rationalization of services can result in considerable cost savings.
Section B;_Tiine Motion Study - Costing at Different Levels of Health Facility
10.
Cost effectiveness can also be measured for specific interventions at the primary,
secondary, and tertiary levels. This section summarizes the results from the Andhra
Pradesh Burden of Disease and Cost Effectiveness Study.4 This study is a time-motion
study which used the BOD to estimate the burden caused by 96 diseases including
injuries and accidents. It provides a unique opportunity to undertake cost effectiveness
analysis using DALYs gained as a measure of effectiveness of interventions. While the
data, specific issues, and examples presented are specific to the situation in Andhra
Pradesh, with a few modifications the results are applicable to other Indian states. Level I
4
Administrative Staff College of India. 1996. “Andhra Pradesh Burden < Disease and CostEffectiveness of Health Interventions.” Report Volume II. Center for Social Services, Hyderabad.
Annex 2
Page 6 of 28
in this study refers to blood picture, urine exam, and sputures for TB. while Level II
refers to blood sugar, blood urea, electrolyte, and urine and blood culture and sensitivity.
Out Reach:
Health worker's Contact
A health worker (HW) on an average will visit 10 houses per day.
Salary/month =Rs. 2813
Salary/day
= 2813/26
= Rs. 108.
Cost/Contact = 108/10
= Rs. 10. 82
Sub center:
Health worker's contact:
On an average a HW will contact 20 patients per day.
Cost/Contact = 108/20
= Rs. 5.4
Cost of building for one contact = 1.37
Cost of furnishing for one contact = 1. 63
Total Cost/Contact = Rs. 8.4
Primary Health Center:
Bed Day:
11.
The cost per bed day at PHCs was determined by taking into account furnishing &
other equipment, 40% cost of staff room, 60% cost of OT, 40% salary of staff (excluding
MPHWs), 40% cost of Medical Officer Room, 40% cost of refrigerator, 50% cost of
building.
OP Contact:
12.
An ideal PHC on an average will have at least 50 OPs a day. The cost per OP
contact included the cost of OT (40%), examination room, visiting hall, 60% cost of staff
room, 60% salary of staff (medical officer, staff nurse, pharmacist, attendee), 60% cost of
medical officer room dispensing room, ante natal check-up room, verandah dressing and
injection room, 60% cost of refrigerator, 50% cost of building.
Level I Test:
Annex 2
Page 7 of 28
13.
The cost of lab equipment for 20 minutes was calculated. Salary for 20 minutes
time of lab technician and an additional cost of Rs. 5 for reagents was taken.
X-ray:
14.
20 minutes time of equipment, salary for 20 minutes time of radiographer, dark
room assistant and an additional cost of Rs. 30 for X-ray film was taken.
Vehicle:
15.
The distance from PHCs to secondary level hospitals was assumed to be around
120 km, the time taken to cover this distance to be 3 hours, and the cost of one hour’s
time of the vehicle therefore turned out to be Rs. 3.42.
Casual Labor:
16.
Here the driver's salary for 3 hours was taken.
Fuel:
To cover a distance of 120 km, 12 liters diesel will be needed.
The cost of 12 liters of diesel = Rs. 96
Operational costs
= Rs. 4
Total Cost
= Rs. 100
Cost/Km
= Rs. 100/120
Table 5:
Furnishing and other equipment
Lab Equipment
Minor OT
Examination Room
Visiting Hall
Labor Room
Staff Room
Manpower
Medical Officer Room
Dispensing Room
A.N.Check Up Room
Verandah
Building
Refrigerator
Vehicle
Costs at the PHC Level
Cost/day
”12.23
Cost/day/bed
104
Cost/hr
1.11
17.16
2.15
1.45
1.68
6.06
1.56
1,623.04
202.88
3.55
1.06
2.42
2.92
85.61
5.48
82.19
42.81
3.42
Annex 2
Table 6: Final Costs at the PHC Level
Unit Cost
Bed Day
OP Contact
Level I test
X-ray
__________ _______________________ (Rs.)
__________ _ ____________________ 73.18
-----------9-65
--------------------- --------------------------- 12.88
_______
48.45
Table 7: Final Costs at the PHC, Secondary, and Tertiary Levels
(Unit Cost: Rupees)
Bed Day
OP Contact
Level J test
Level II test
X-ray
Major OT
PHC
73.18
9.65
12.88
48.45
Secondary
69.52
2.45
11.95
24,86
55.45
55.67
Tertiary
52.7
14.24
27.21
38 28
75.66
125
Calculation of Manpower Component of Bed Day and OP Contact:
J 7.
•
*
■
■
This was done by:
Determining the staff involved in IP as well as OP care;
Obtaining the salary’ devoted towards the staff;
°?t ‘he perCentage of time devoted for IP and OP care-
3 XsElaeydXdena'adge of time ,owards’,p ““op care for finding
X“WardS 'P by n“mb" °f bedS “ ,he
Calculation of the Equipment component of IP Day and OP Contact:
JI
Annex 2
Page 9 of 28
Table 8: Cost of Different Equipment included in OP contact and in IP day
Bedded
Hospitals
Furnishing &
Hospital
Minor Equipment
Administrative
Hospital Plant
and Furnishing
Equipment
(generators etc.)
Refrigerator and A/C
I
Equipment
30 CH
IP
OP
IP
OP
IP
OP
IP
OP
IP
OP
30 CH
4,04
0.25
1.31
0.08
0.19
0.012
1.24
0.08
1.19
0.07
50 CH
2.42
0.15
0.78
0.05
0.12
0.007
0.75
0.05
0.71
0,04
100 AH
3.82
0.24
0.81
0.05
0.40
0.025
0.59
0.04
0.96
0.06
200 PH
4.54
0.28
0.85
0.05
0.52
0.032
0.42
0.03
0.76
0.05
250 PH
3.63
0.23
0.68
0.04
0.41
0.026
0.33
0.02
0.6
0.04
300 + PH
2,79
0.17
0.53
0.03
0.32
0.02
0.26
0.02
0.46
0.03
50 MCH
2.42
0.15
0.80
0.05
0.12
0.007
0.75
0.05
0.71
0.04
100 MCH
3.82
0.24
0.82
0.05
0.40
0.025
0.59
0.04
098
008
50 Pediatrics
2:42
0.15
0.80
0.05
0.12
0.007
0.75
0.05
0.71
0 04
Level II
test
X-ray
OT
7.25
18.98
38.98
0.24
0.48
3.88
7.49
19.46
42.86
7.25
18.98
38.98
0.24
0.48
3.88
7.49
19.46
42.86
9
18
38.98
0.69
1.39
21.24
9.69
19.39
60.22
Table 9: Costs at Different Sizes of Secondary Hospitals
Components included
Bed day
OP
Contact
Level 1
test
30 Bedded Community Hospitals
Man Power (excluding doctors)
47,52
Building Space
4,53
Minor Equipment & Furnishing
1.32
Hospital Plant_______ ____________
1.24
Refrigerator & AC_______________
1.19
1.38
0.07
Lab Equipment (Lab 1 & II. X-Ray)
Administrative Equipment
Total
_____ 0.2
60.04
1.7
50 Bedded Community Hospitals
Man Power (excluding doctors)
46.84
1.49
Furnishing and Hospital Equipment
2.42
0.15
Building Space
3.76
Minor Equipment & Furnishing
0.79
0.05
Hospital Plant__________________
1.24
0.07
Refrigerator & AC
0.71
0.04
0.11
0.01
55.87
1.81
Lab Equipment (Lab I &. II, X-Ray)
Administrative Equipment
Total
100 Bedded Area Hospitals
Man Power (excluding doctors)
Furnishing and Hospital Equipment
46.12
3.82
Building Space
5.42
Minor Equipment & Furnishing
0.82
0.05
Hospital Plant
0.59
0.05
Refrigerator & AC______________
0.96
006
Administrative Equipment
__ 0.4
0 02
Total
58.13
1.7
1.28
0.24
Lab Equipment (Lab I &. II. X-Ray)
10.52
10.52
Annex 2
Page 10 of 28
Table 9 (continued)
Components included
Bed day
Man Power (excluding doctors)
Furnishing and Hospital Equipment
Building Space
Minor Equipment & Furnishing
Hospital Plant
Refrigerator & AC
Lab Equipment (Lab I & II, X-Ray)
Administrative Equipment.
Total
Man Power (excluding doctors)
Furnishing and Hospital Equipment
Building Space
Minor Equipment &. Furnishing
Hospital Plant
Refrigerator & AC
Lab Equipment (Lab I & 11, X-Ray)
Administrative Equipment.
Total
Man Power (excluding doctors)
Furnishing and Hospital Equipment
Building Space
Minor Equipment & Furnishing
Hospital Plant
Refrigerator & AC
Lab Equipment (Lab 1 & II, X-Ray)
Administrative Equipment.
Total
4,53
4,79
0.85
0.42
0.76
X-ray
29.9
44.07
1.26
2.53
25
16.21
32.43
69,07
10.52
14.95
29.9
44.07
10.52
1.26
2.53
25
16.21 |
32.43
69.07
10.52
14.95
29.9
44.07
10.52
1.26
2.53
25
16.21
32.43
69.07
114
22.81
39.98
0.24
048
3 88
11.64
23.29
42.86 | __
16.06
32.11
38.98
OT
____
10.52
0.05
0.03
0.05
0.52
0.03
87,05
11.95
250 Bedded DH
74 88
12.56
3.63
0.23
4,36
0.68
0.04
0.33
0.02
0.6
Level II
test
0.28
0.04
0.41
0.03
84,89
12.92
300+ Bedded (325)
7094
7.7
2.79
0.17
3.91
0.53
0.03
0.26
0.02
0.46
0.3
0.32
79.21
0.02
7.97
50 Bedded MCH
59.04
2.29
Man Power (excluding doctors)
Furnishing and Hospital Equipment
I Building Space
2.42
10.52
0.15
4.29
Minor Equipment & Fumishing
Hospital Plant______
Refrigerator & AC
0.8
0.74
071
Lab Equipment (Lab I & ||, X-Ray)
Administrative Equipment
0 12
68.12 |
Total
Man Power (excluding doctors)
Furnishing and Hospital Equipment
Building Space
Minor Equipment & Furnishing
OP
Level I
Contact
test
200 Bedded District Hospitals
74.95
75.18
11.51
I
0.05
0 05
0.04
0.01
2.58
100 Bedded MCH
59.63
2.24
3.82
0.24
4 3
0 82
0 05
10.52
i
Annex 2
Page 11 of 28
Table 9 (continued)
Components included
Hospital Plant
Refrigerator & AC
Lab Equipment (Lab 1 & II, X-Ray)
Administrative Equipment.
Total
Bed day
0.59
0.98
OP
Contact
0.04
0.08
0.4
70.54
0.02
2.67
Level I
Level II
test
X-ray
0.9
1.39
21.24
16.96
33.5
60.22
9.65
19.3
38.98
0.69
1.39
3.88
10.34
20.69
42.86
test
OT
10.52
50 Bedded Pediatrics
Man Power (excluding doctors)
Furnishing and Hospital Equipment
Building Space_____
Minor Equipment & Furnishing
Hospital Plant____________
Refrigerator & AC________
54.44
2.42
3.68
0.79
0.75
0.71
0.05
0.05
0.18
Lab Equipment (Lab I & II. X-Ray)
Administrative Equipment.
Total
0.12
62.91
0.01
2.28
19.
1.85
0.15
Costs which are not included in IP day or OP contact are given below.
Table 10: Electro Medical Equipment:
(Specifically the Cost of Specialists Equipment; expressed in terms of hours)
Type of Hospital
Community
Area Hospital
District Hospital
1.15
2.63
Hospital
Cardiologist Equipment
ENT Equipment
Ophthalmic Equipment
Neonatal Equipment
AMC
GE
____________
General OT
049
0.97
0.23
0.49
0.66
0.75
1.43
0.46
4.39
0.022
2.31
8.12
29.771
1.11
Table 11: Pneumatic, Hydraulic and Sterilization Equipment
Cost Per Hour
Coni munity
Hospital
795
Area Hospital
District Hospital
8.58
13.44
Annex 2
Page 12 of 28
Table 12: Vehicle time (expressed in hours)
Types of Vehicle
Ambulance
Pick Up Jeep
Total
Community' Hospital
T99
_______ 3.42_______
7.42
Area Hospital
3?99
0
3.99
-I
District Hospital
T99
3.42
11.42
Table 13: Costs of Specialists’ Time (expressed in hours)
Specialist Category_________________________________________
Civil Surgeon Specialists (Medicine, Surgery, Obst.. &, Gyn. Pediatrics,
Anesthesia, Orthopedics, Ophthalmology, Cardiology, Pathology,
Radiolog\, etc.)_______________________________________ _
Civil Surgeon RMO__________________________________________
Deputy Civil Surgeon_____________________________ ___________
Deputy Dental Surgeon______________________________________ _
Civil Asst. Surgeon (Medicine, Surgery, Obst & Gyn., Pediatrics,
Anesthesia, Orthopedics, Ophthalmology, Cardiology, Pathology,
Radiology, ENT, and other category)___________________________
Cost per hour
34.54
34.54
31.49
31.49
28.97
Operational Cost
20.
These costs mostly include the recurrent expenditure of the hospital. The cost per
day could be easily derived from the Table 14 below. The same-table can be used for
secondary as well as tertiary level hospital.
Table 14: Recurrent Expenditure
Contingency account (for soaps
disinfectants etc.)
Diet (Patient/Food/Drinks)
Toilet maintenance and Supplies
Stationary
Electricity and Water Bills
Night duty meal allowance for MOs
Hospital POL and Servicing
Incinerator Fuel / Power
Library materials and Journals
Total
Telephone Bills
Telephone Bills for Consultants
Total
Total Cost
(in Millions)
0~7
19.9
1.8
4.6
4.6
0.2
4.4
0.7
0.58
38.59
0.9
1.1
2
Annex 2
Page 13 of 28
Table 15: Final Cost Estimates at Secondary level Hospitals
Bed Day
OP Contact
Level 1
Level II
X-ray
Major OT
Unit Cost
69.52
2.45
11.95
24.86
55.45
55.67
Tertiary Level Hospitals
21.
In order to arrive at different components of the infrastructure at a tertiary level
hospital a survey was conducted at Gandhi hospital (1012 bedded), Secunderabad. Based
on the information obtained from the survey the unit cost was derived for different
components. The data is given in the following tables. The components are: bed day, OP
contact, OT Hour, Level I test, Level 11 test etc. The costing procedure for the tertiary
level hospital is same as secondary level hospital with the exception that in the case of
tertiary level hospital the costs have been presented department wise.
A. Estimation of IP Day and OP Contact:
22.
The following points were considered for calculating the IP day and OP contact:
f.c»
•
•
•
•
Staff (excluding doctors) time was calculated in the same way as secondary level
hospital.
First, the total salary of the staff for a each department was found.
The* percentage of time spent per day for IP and OP care depending upon the
categories of staff was determined. For example some nurses are exclusively meant
for IP care where as others are for IP and OP. For those nurses whose time is used for
IP as well as OP we assumed that they spend 90% of their time for IP and 10% for
OP.
The result was then divided by the number of beds available in each department in
order to find out the cost per day per bed.
B. Other staff involved in patient care:
23.
Under this category, the staff included were security guards (100% IP), other
clerical and official staff who work for IP and OP (90% IP, 10% OP), drivers and
cleaners (90% IP, 10% OP), Dhobi, Mali and Electrician (90% IP, 10% OP), Cooks
(100% IP), Pharmacist and Refractionist (50% IP, 50% OP), Staff on power supply (90%
IP, 10% OP). The cost of the above staff for IP and OP care was calculated as follows:
Annex 2
Page 14 of 28
•
•
•
The cost of percentage of time devoted for IP and OP.
All categories of staff time were then added separately (by taking into account the
cost of percentage of time).
The total cost of time devoted for IP was divided by the total number of beds to
arrive at the cost per bed per day and time devoted per one OP contact by the total
number of OPs.
C. Estimation of Building Space:
24.
Taking cost per square feet as Rs. 300, Life expectancy as 20 years, and 400
square feet per bed, the cost of building space per bed per day was calculated as follows:
•
•
•
•
Cost per Square feet - Rs. 300/Given the life expectancy of 20 years the cost per square feet per year is Rs. 15
Cost per day per square feet is Rs. 0.041
Cost per day for 400 square feet is Rs. 16.44
D. Furnishing and Other Equipment:
25.
This includes cots, mattresses, bed sheets, saline stands and other accessories in
the ward which vary from department to department. The cost of ward furnitire was
calculated as follows:
•
•
•
•
The total cost of the equipment was found.
Assuming a life expectancy of 5 years, the total cost was divided by 5 in order to
arrive at the cost per year.
Cost per day = Cost Per Year / 365
Cost per IP day = Cost per day / Number of beds in respective departments.
E. Generator & Lifts, Other Electrical Equipment, and Minor Equipment and
Furnishing:
26.
All the equipment were considered for inpatients only.
F. Furnishing and other Equipment for OP:
27.
These equipments arc exclusively meant for OP Services.
The total cost of these equipment was obtained.
Taking their life expectancy to be 5 years, the cost per year was obtained by
dividing the total cost by 5.
Cost per day = cost per year / 365 days
Annex 2
Page 15 of 28
•
Cost per OP contact = Cost per day / (No of beds in the hospital X 4)
28.
In tertiary level hospital the Level II tests are done at different departments. They
are Biochemistry, Radio Diagnosis, Microbiology, Serology and Pathology.
For.
calculating the cost of Level II test the following components were considered.
1.
2.
3.
The cost of equipment time used for the test.
The cost of man power involved.
Any additional expenditure on x-ray films, different chemicals etc.
Table 16: Costs of Different Departments at Tertiary Level Hospitals
Salary' Component
Bed/Day
OP
Level I
Contact
Test
Radiology' Department (IP)
Level II
Test
Staff__________
Machinery Cost
Operational Cost
Total
X-Ray
3.5
43.16
30
76.66
Radiology Department (OP)
Staff__________
Machinery Cost
Operational Cost
Total
3.5
15.75
30
49.25
Biochemistry Department
Staff__________
Machinery Cost
Operational Cost
Total
26.31
1.42
10
37.73
Microbiology Department
Staff__________
Machinery Cost
Operational Cost
Total
18.67
49.57
10
78.24
Serology Department
Staff__________
Machinery Cost
Operational Cost
Total
13.14
“To
23.24
Clinical Pathology'
Staff_________
Machinery- Cost
13.14
9?08
Annex 2
Page 16 of 28
Table 16 (continued)
Salary Component
Bed/Day
OP
Contact
Operational Cost
Total
Level I
Test
5
27.22
Blood Bank
Staff_________
Machinery Cost
Operational Cost
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
equipment________
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block__________
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
8.01
1.28
5
14.29
24.39
Medicine
08
14.75
0.39
16.44
3.38
0.01
0.32
0.04
0.16
59.29
1.23
Acute Medical Care
94.21
2.08
14.75
16.44
0.39
2.21
0.01
0.32
0.04
0.16
Level II
Test
X-Ray
*
•
■
Annex 2
Page 17 of 28
Table 16 (continued)
Salary Component
Bed/Day
OP
Contact
2.63
Neurology
0^65"
Total
142.26
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
23.56
57.66
1.2
Cardiology'
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
35.37
OF
14.75
16.44
6.94
0.39
73.86
1.53
Dermatology'
Staff excluding
Doctor
Other Staff
Building Space
5.83
TTTT"
14.75
16.44
0.39
14.75
16.44
2.55
0.39
0.01
0.32
0.04
0.16
0.01
0.32
0.04
0.16
Level I
Test
Level II
Test
X-Ray
Annex 2
Page 18 of 28
Table 16 (continued)
Salary’ Component
Furnishing and other
equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
Bed/Day
OP
Contact
2.21
0.01
0.32
0.04
0.16
39.6
13.68
STD
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
131.26
3.65
14.75
16.44
2.79
0.39
0.01
0.32
0.04
0.16
165.6
4.2
60.18
GE
1.67
14.75
0.39
16.44
2.93
0.01
0.32
0.04
Level I
Test
Level II
Test
X-Ray
Annex 2
Page 19 of 28
Table 16 (continued)
Salary Component
Bed/Day
Furnishing and
Hospital Equipment.
OP Block
Total
OP
Contact
06
94.63
2.22
Pediatrics
14.84
oTT
14.75
16.44
2.1
0.39
Staff excluding
Doctor
Other Staff_______
Building Space
-Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
Staff excluding
Doctor
0.01
0.32
0.04
0.16
48.45
32.17
0.96
Surgical
09
14.75
0.39
16.44
2.32
0.01
0.32
0.04
0.16
66.05
1.44
Orthopedics
36.78
loT"
Level I
Test
Level II
Test
X-Ray
Annex 2
Page 20 of 28
Table 16 (continued)
Salary Component
Bed/Day
OP
Contact
Other Staff_______
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
14.75
039
Total
16.44
2.14
0.01
0.32
0.04
0.16
70.47
1.57
Urology'
Staff excluding
Doctor
60.05
L67
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
14.75
16.44
0.39
Total
93.28
2.19
59.05
ENT
1.64
0.39
Staff excluding
Doctor
2.67
0.01
0.32
0.04
0.16
Other Staff
14.75
Building Space
16.44
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
2.67
0.01
0.32
Level I
Test
Level II
Test
X-Ray
!
Annex 2
Page 21 of 28
Table 16 (continued)
Salary Component
Bed/Day
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
0.04
’T^l
93.28
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment______
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
OP
Contact
Level I
Test
0.16
2.19
Neuro Surgery
39.37
1.09
14.75
0.39
16.44
8.2
0.01
0.32
0.04
0.16
79.12
1.64
Cardiothoracic
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
34.74
0.97
14.75
0.39
Total
73.22
1.52
Pediatric Surgery’
16.44
6.92
0.01
0.32
0.04
0.16
Level II
Test
X-Ray
Annex 2
Page 22 of 28
Table 16 (continued)
Salary Component
Bed/Day
Staff excluding
Doctor___________
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
44.67
Staff excluding
Doctor
Other Staff
Building Space
I Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
14.75
16.44
2.54
OP
Contact
L24
0.39
0.01
0.32
0.04
0.16
78.76
268.75
14.75
16.44
1.64
1.79
Dental
14.93
0.39
0.01
0.32
0.04
0.16
301.94
15.48
Ophthalmology
134.37
3.73
14.75
16.44
2.56
0.01
0.39
Level I
Test
Level II
Test
X-Ray
Annex 2
Page 23 of 28
Table 16 (continued)
Salary Component
Bed/Day
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block________
Total
0.32
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
OP
Contact
0.04
0.16
168.49
4.28
_____ Traumatology
134.37
3.73
14.75
16.44
9.8
0.39
0.01
0.32
0.04
0.16
133.33
0.55
Plastic Surgery
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
55.77
7.55
14.75
16.44
2.24
0.39
0.01
0.32
0.04
0.16
Level I
Test
Level n
Test
X-Ray
Annex 2
Page 24 of 28
Table 16 (continued)
Salary’ Component
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block
Total
Staff excluding
Doctor
Other Staff
Building Space
Level I
OP
Contact
Test
89.57 ______ 2.1
Obst & Gyn
0.47 ‘
17.1
Bed/Day
14.75
16.44
2.15
0.39
0.01
0.32
0.04
0.16
50.8
1.02
Family Planning
12.68
0.35
14.75
16.44
2.25
0.39
0.01
0.32
0.04
0.16
46.48
0.9
Paying Cubic es
74.44 ’
15.14
16.44
Level II
Test
X-Ray
Annex 2
Page 25 of 28
Table 16 (continued)
Salary Component
Bed/Day
Furnishing and other
Equipment_______
Generator and Lifts
Other Electrical
Equipment______
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
2.62
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Furnishing and
Hospital Equipment.
OP Block_________
Total
Staff excluding
Doctor
Other Staff
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
OP
Contact
0.01
0.32
0.04
109.1
Endocrinology'
66.75
1.85
14.75
16.44
1.74
0.39
0.01
0.32
0.04
0.16
100.01
80.1
14.75
16.44
3.27
0.01
0.32
0.04
2.4
Nephrology
nr
0.39
Level I
Test
Level II
Test
X-Ray
Annex 2
Page 26 of 28
Table 16 (continued)
Salary Component
Furnishing and
Hospital Equipment.
OP Block_________
Total
Bed/Day
OP
Contact
Level I
Test
Level II
Test
X-Ray
0J6
114.93
2.78
Causality
2,242
Staff (including
doctors)
Building Space
Furnishing and other
Equipment
Generator and Lifts
Other Electrical
Equipment
Minor Equipment
and Furnishing
Total
16.44
3.38
0.01
0.32
0.04
i'-'
2,262
ICCU
Staff_________
Lab Equipment
225.3
4.48
Ward Furnishing
Total
176.12
402.9
Calculation of Cost of Equipment used in Operation Theater by Different
Departments
29.
The method applied for arriving at these figures is same as for secondary level
hospitals: The cost of the equipment per year is obtained by dividing the total cost of it by
the life expectancy of the equipment used. The cost/day and cost/hour is then
determined.
Annex 2
Page 27 of 28
Table 17: Equipment used by the Specialists for different activities expressed in
hours (Not included in IP or OP day)
OT
Cost Per Hour
46.72
16.75
64.37
49.39
80.97
48.26
425.14
6.48
166.54
37.58
General ’
Dental
ENT
Ophthalmology
Urology’
Gynecology OT
Cardio thoracic
Labor Room
Neonatal Equipment
Surgical Equipment Pack
”
Specialists Time:
30.
In almost all the departments the specialists are professors and assistant
professors. Their salary is the same for all the departments, In addition there are also
specialists in ICCU. The results have been given in Table 18 below.
Table 18: Specialists Costs per Hour
___________ Special is ts
Professors of all the Departments
Asst. Professors of all Departments
Medical officer in ICCU
Cost per hour
34.54
26.97
26.92
Vehicle Hours:
31.
There are 2 ambulances and 1 jeep in a tertiary level hospital. Assuming that the
Iffe expectancy of the vehicles to be 10 years and working hours as 24 hours the
following are the hourly costs of vehicles available in a tertiary level hospital.
Table 19: Vehicle Cost per Hour
Type of Vehicle
Ambulance
Jeep
______________ Cost per Hour (Rs.)
7"
3.42
Annex 2
Page 28 of 28
Table 20: The Final Cost Estimates at Tertiary’ Level Hospital
Unit Cost (Rs.)
52.7
Bed Day
OP Contact
Level I Test
Level II Test
X-ray
Major OT
14.24__________________
27.21
38.28
76.66
125
Summary Findings of Section B
32.
The focus of this analysis was to show that substantial cost savings can result if
health care services are provided at the lower tiers of the health care system. This is
particularly true between the tertiary' and first referral/secondary tiers where the range of
services provided are similar. Comparisons between secondary and primary tiers are
more difficult since the services offered at these two levels are quite different.
33.
The summary table shows that except for bed day, where unit costs at tertiary
facilities are somewhat lower, unit costs for all categories are considerably lower at the
secondary level. For example: In terms of unit costs, the cost of outpatient contact at the
tertiary level are almost six times more expensive than at the secondary level, level I tests
are twice as expensive at the tertiary level compared to the secondary level, level II tests
are 50 percent higher, x-ray costs are 40 percent higher, and major OT is more than twice
as expensive as at the secondary level. Costs are higher at the tertiary level because
infrastructure costs and some recurrent costs such as buildings and facilities are much
higher at the tertiary level.
34.
As noted above, it is not possible to compare unit costs between primary and
secondary levels since the services provided at the PHCs are preventive in nature, while
those at the secondary levels are often more curative. However, some comparisons are
possible. These show that unit costs per bed day at the primary and secondary levels are
similar, while the costs for outpatient contact and level I tests are lower at the secondary
level.
Table 21: Final Costs at the PHC, Secondary, and Tertiary' Levels (Unit cost: Rs.)
Bed Day
OP Contact
Level I test
Level II test
X-ray
Major OT
PHC
73.18
9.65
12.88
48.45
Secondary
69.52
2.45
I 1.95
24.86
55.45
55.67
Tertiary
52.70”
14.24
27.21
38.28
76.66
125.00
Annex 3
Page 1 of 46
Clinical and Diagnostic Service Norms
The analysis of cost savings as a result of streamlining and rationalization of
serv^e norms is shown in Annex 2. This Annex presents the clinical and service norms
at the different tiers of the health system that were developed in each of the four states of
An?^a P7deSh‘ Karnalaka- Wes[ BenSal and PunJab through a panicipatory approach
and based largely on the major disease burden. They provide examples of how decisions
with regard to a basic package of services can be developed at the state level. The basis
for rationalizing the range of clinical and diagnostic service norms appropriate for the
rPp^’
referTa' and
leVe' °f heaith Care is based 00 the burden of disease
(BOD) and the evolving epidemiological pattern in each state. Service norms for the four
states in this study were arrived at through a consultative and collaborative process
involving leading health practitioners and policy-makers from different levels of the
health care delivery system, including the private and NGO sectors. Workshops were held
to determine a specific set of service norms suitable for each state. These proposed
Subs'quentl>' Provided t0 the Department of Heaith and Fam.lv Welfare
(DOHFW) m each state. The DOHFW reviewed the technical norms through a farther
consultative process and estimated the associated costs of providing these services
These were then reviewed by the Department of Finance to assess the financial
imphcat.on of providing the package of sendees. The World Bank provided technical
assistance and advice, parucularly with regard to cost-effectiveness analvses and analysis
of financial implications for the state. The final result was a specific set of senice norms
tor each ot the tour states, as shown in Tables 1-4 below’:
Tabic 1: Andhra Pradesh Sendee Norms
Surgical Services
SECONDARY
C 'odJGoa /
Primary Hcahb Cart
Tertiary krd (adliiks
CaiMaaity HoapUaJ
I.
ioclitoo de Drufiaft
loctiioc A drainage
Arxa Hoapital
Same u CH
Wound deCndcmcnt
2.
Trauma A Life
Suppon
fUMcuaic. uaftduc ami
refer
Same a* CH ♦
airway; circulatory
ln«e*iigaie A manage
tiabihuuion of frsciuiei
2
PunTabtnd'wnrR"0™5 Sh°"n
Spin ikm (r«h
N/A
B»op5y o( Hid
Same a* PHC ♦ uxruruig
uippon.
Diflrict HmpitaJ
•• Eapiorarory iaporaiomy
Same aa CH 4- (oilow up
Severe head ui^ncj A
mana feme oi. ipcciaJiu
injixnci of tpin-d cord
onhopacdrcian
ICVCl racilities- For Karnataka,
Punjab and West Bengal, service norms are shown for first referral level facilities.
Annex 3
Page 2 of 46
Table 1: Andhra Pradesh Service Norms
Continued
Surgical Services
SECONDARY
Tertiary level (•ciiitlcs
Mmery Health Care
Coekdilloo / Procedure
Area Hospital
CoaatMily Hospital
3. Eye
lafca sons
Removal of foreign
Cooimuairy eye care
programme
bodies
Sane as CH
District Hospital
Maoagcment of corocaJ
ComeaJ gnhtng
abrasion, ulcer:
Rama! diseases
*
cataract A glaucoma
Vitreous surgery
surgery
Intra-ocuiar foreign
bodies
4.
Ear Nose it. Throat
Removal of foreign
I A D of pcruoasdlar A
As AH 4- Laryogoscopsc
bodies
retropharyngeal
removal of FB 4c
Epniaxis control
abscesses, tonsillectomy
drainage of mastoid
All requuuig
microsurgery
abscess.
3.
Teeth A la*
NA
Conservative dentistry
same as CH
6.
Chest
As AH 4- tnanaicmcnt
N/A
of jaw fractures
Tooth cstraaion
Mediastinal injstrics and
Rcsuscuatc
Rib fracture
Same as CH 4* slab due
Il refer
Breast abscess
A
tuoaoun. Heart A lung
refer mediastinal injuries
surgery
Same as AH
Trachcostoeny.
Tbocaeocenieai s
7.
GastrouumuiaJ
N/A
All surgical procedures
Same as AH
Abdoauoal tnaltgoaocics.
Hepatic surgery
luted
(incl. •appendectomy)
8. Gcxuto-unaary
Acute unoary mcniioo
Same as PHC +
Same as CH ♦ urethral
Same as CH
cystotomy, hydrocele,
dilitation
management of ruptured
GU maliiAAocia
bladder de urethra.
circumcision, vasectomy
Urolithiasis,
prostatectomy
9.
MuacuiosAeUial
N/A
Closed reducitoc of
uncomplicated fractures.
POP. traction
•
If poistble
** Tratowi to be provided to jencraJ dury cncdtcal offiem
Same as CH
Open reduction of
Spinal fraesura
fractures
Joint reconstructions
Annex 3
Page 3 of 46
Table 1: Andhra Pradesh Service Norms
Continued
Obstetrics and Gynaecology
Condition /
SECONDARY
Primary Health Care
Tertiary level facilities
PtiKedurt
Comm unity Hoapilal
I.
Complicated deliveries
Refer
Area Hospital
District Hospital
Forceps, vacuum
extraction, evacuation of
retained products.
* Caesarean
2. Threatened or
Refer
incomplete abortion
Conservative
management
D4C
3.
4.
Family planning
Lower abdomenal pin
Tubcctomy
Same as PHC +
IUD
Ixpraacopic lubeciomy
Refer
Stabilise A refer
Exploratory laparotomy
Diagnosis A
Exam under anaeihcsia
A ectopic pregnarKy
5.
Vaginal diseases
Refer
management
6.
High risk pregnancy
Early diagnosis A
Same as PHC
timely referrra]
lovcingaic
iouiate management
7
PID
Refer
Diagnosis A therapy
8.
Mctmrual irrcgulaniscs
Refer
Refer
Dta^oosn A
management
Infemliiy
9.
Refer
Refer
Diagnosis A
management
10. Cervical crutioo
I 1. Malignanru-i
Refer
Refer
PAP smear it • biopsy
Refer
Refer
Dta^oosn
As AH + biopsy
Cancer surgery
Surgery radiotherapy
Anasthesea
SECONDARY
Coodiliou / Procedure
Primary Health Care
Tertiary level facilities
Commuaity Hoapilal
I.
Bauc tcehAiquc
Area Hospital
•Care of ain«ay
Iruubaiicn
Equipment handling
2.
General A reg tonal
anaeuhenu
*
If possible
•• Training io be provided to genenl duty medical officers
Management
District Hoeptial
Annex 3
Page 4 of 46
Table 1: Andhra Pradesh Service Norms
Co fitin ued
Clinical Services
TRIM ARY
HEALTH
CARE
CONDITION
SECONDARY HEALTH CaR£ HOSPITALS
CH
I. CoovuiUQQl
SymptoovMK A refer
AH
TERTIARY
HEALTH CARE
DH
facilities
Symptomatic treatment A
laveutgatc. inmate. L.P..
refer
nfer
Advanced invcutgatioa.
manage. L.P.. refer
CT acaa. advanced
aotrological treatment
Initiate treatment, manage,
refer
Inmaic ircaimeni.
manage.refer
CT Scan advanced
•euroiogicai treatment
2. Lom of erw wtrfot if^n i /
coma
Sym^MookUic A wppomve
3. EncepAalito.
menuigiuca. CNS
in lea io ru
Symptocnaric irearmeor.
refer
Symptomatic ircarmctu A
refer
Mmije. refer
Mxrufc. tuppon
CT Scan, advanced
neurological ircattncru
Firu Aid. refer
laiiUic. otMcr>e. refer
Manage, uabtltac. refer for
advanced management
Manage. sLabdiac. refer for
advanced manage men i
Advaoced managemcre
wfo> abam amaancm wan
fracture
UMiMe. akiAAfc A refer
Inveuigatc. manage
compile at ioru
pH dua(c. kvctc diuren
pH chMgc. *c*cre diwccu
Head uijurta
S. Rcspcraiory lalcaioai
6.
AjMA*4
C.O.P 0
Symprotruuic. refer
Severe condition (unuil
Supponi.c. symptomatic
Sympiomaiic rrearmcru A
refer
I. Ejtr ia/eaiQQ
Maoage
Manage
9. Cardao-vascular
pnWwTTB, faypcruxuKxi
Mild moderate: manage
btild moderate: manage.
10 C.V.A.
Sympuxnatic management,
refer
Sy automat k managemou.
loveuigatc. manage, follow
up
Invcvigatc. manage, follow
up
Accricrwod and ur»tre
Accekrwod and acvire
condittoni
Symptomatic managetneot,
refer
Manage. foJIow up
Manage, folio* up
InvesttgatKxi. management,
refer
Investigate, manage, refer,
follow up
follow up
SymptOMK management,
refer
Ian cue. manage, refer
Complicaicd. follow up
CotaplKaxcd: follow up
I J RAcumatK few aad
rbeu matic hcan
Symptomatic management,
refer
Syo^MomatK .aaanagement.
refer, follow up
Investigate, manage, refer,
follow up
InvcMigacc. manage
Compl tcaiuMu
II Cl bleeding. uiCEn.
Diaeaam
Symptomatic
Sympiornuuc
Endoicopc tavcaiigation.
treat meru
Endotcopic investigation,
manage
Comp! «cai torn
Manage ould. moder arc
refer
Manage mild, moderate
refer
Sc*cte
Severe
SymptocnaiK Uxaimesi
Inniaic managcraenj, refer
Confirm diagnotu. manage
Confirm diagnotu. manage
I I Aaigiaa, lafarauxu
follow up
I refer
12 C.H.F.
IS C E.
16 Hepaenu
Invcwigate, manage, refer,
CoMpIxamni
Annex 3
Page 5 of 46
Table 1: Andhra Pradesh Service Norms
Continued
Clinical Services
PRIMARY
HEALTH
CONDITION
SECONDARY HEALTH CARE HOSPITALS
TERTIARY
health Care
Care
CH
17 Cirrhoiu
IS RcmJ UT1
19 Acajic RcajJ fodure
?0 MiuoUoUxicxAi
Sympcoouiic
Sytnp<oaiMic. refer
Symp'otruitc. refer
SytnpcotnMtc. refer
AH
DH
Invcutgaie. manage, follow
•P
Invesitgaic. manage, follow
up
SytnptonujK. refer
Dujnoin. awujc
Dutnoiii. muugc
ImiMic. refer
lovemgatc. management,
refer
SymfHonuiic
SytnprofTLuic. refer
MA/uge
FACILITIES
Compltcatioru
Dialytir and advanced
managcmcTM
MAAage
Recurrent; funner
evaiuanoo .complication*
21 A
22
21 Malaria
Privuutve and primary
Manage tnoUcrare
Manage ac-»ere
Manage tcvcrc
SywpuMaMK. uuiiaee
SympuxnarK. Iomi
Manage
Manage
Manage
Manage
Severe
Severe
Dragnoau. ramate
managcmcru
Diagnotii. uunaic.
management
24 AIDS
2J Pryetuainc
26 Piycruarnc diaorxlcT
27 Pxxaonjog
2S Neonatal rewwa
SymproraaiK managemexu
Manage crukj. mode tare
laaiiarc. manage, refer
Ina tare and refer
29 NcooaaaJ cardrononary dcfecu
ioaiare and refer
JO Dianoo
Diagnoau. imtiMc
J I Snaie box A dog buc
32 Sk io diaortlcn
3) S T D •
Manage
Refer
SympronxMic managemexu
Dragrvme and manage
Severe
Manage mild, mod er are
refer
Severe
In.iiatc and manage, refer
lovcMigau. manage
Invcuigaic. manage
Inmate, refer
Manage
Manage
Inmate, refer
lovcMigau. manage, follow
up
Invcatigarc. manage, follow
up
Diagnoiu. mtnarc
Coenpitcaruxu
Coan^iKaiMMu
Manage
Complicar mni
Comp I tear «om
Refer
Symp«omatK. refer
Manage
Manage
Diagnore
Manage
Corng»laCM*o«>
□Btuo y uaajopqe "Xo/qo
••A
ON
ON
(a/BMyot yjiM) 7"buiuuros jocjos TiSurj
ON
“A
ON
(ajBM^OS MJ4M) rbuJUUEOK JC53®S JB^UT^
r
□•ujopqw -XrvQO
Z
UBiuoppB •■Xryt30
••A
ON
HO
ON
MV
(ajBMVos u>m)
HO
••A
ON
ON
••A
••A
ON
••A
«A
ON
••A
••A
ON
»»A
••A
ON
»A
••A
ON
••A
»A
ON
■•A
«A
ON
••A
••A
ON
rbuiuuos J■•tn')
I
AHdVHDONOSVMlin
(pj» mins)
AydruSc^Ayv
0L
auAuejtefrig
01
X u d ej 6o 6 mp^ ■ *-qj
>1
XydcjSc^aAd dpkj6cu)»^
Cl
XuOtiSofaX^ rnoue/vepui
Z1
olmw ej 5axsAoej cmg
11
bu>bu0 cur^jrg
01
cmjw [bolu lunprg
8
tunurg
a
isvulnOS
••A
••A
••A
uMuopqy
Z
»A
"A
»»A
joppe/g 7 jojajf) *X®upr^
9
»A
»»A
caA
cau»dS
0
■•A
••A
^A
cauog
—k
»A
«A
••A
«A
••A
»A
••A
«A
(□a» cnmc) ooeag f«PN
>
C
WS
Z
I
^SAVirX NIYld
WO
HV
HO
SN0LLyDLLS3ANI AY*rx
S3OIAJ3§ DIJSOU^CtQ
paniniuoj
suijo\i aoiAjag qsapcuj cjqpuy
9t7jO 9 9§Ed
£ xaany
:j a|quj^
Annex 3
Page 7 of 46
Table 1: Andhra Pradesh Service Norms
Continued
Diagnostic Services
IMAGING STAFF REQUIRED
1
Radiograpner
2
Darkroom Assistant
CH
AH
DH
1
2
1
2
3
1
1
2
SPACE REQUIRED:
1
X-Ray room
2
Dark room
3
Changing room wnn W C.
4
Office
5
Drying room / stones
LAB INVESTIGATIONS
1
Malana parasite
2
Common parasites.
1
1
1
1
2
2
No
1
1
No
1
1
CH
AH
OH
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yea
Yes
Yes
No
met eggs, large cysts etc
3
V
Common bactenology
(stool examination)
4
Protein <1 glucose tn unne
5
Urine deposits, crystals, casts
& bacxena celts
6
Haemoglobin concentranon
7
Erythrocyte Sedimentation Rate,
8
a) Diffenenoal
count
(WBC 4 RBC)
b) Red ceil morpnoiogy
9
a) Platelet count
b) Total WBC
c) Protfiromom
10
11
12
Reticulocyte count
Packed Cell Volume
Blood grouping & cress
No
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
matching
13
Blood glucose A urea
14
Mantoux reacaon (TB test)
S®iSdOlQ fuinig-iir-i
C®A
ON
ON
*’A
ON
(iej3U36) XboiounBdajpH
uiqrun|iQ uuruoc;
0>
(ZQ91 DnuAJOf Aq)
on
ON
ON
ON
ON
ON
c»A
ON
ON
junop Lujad^
zr
C&a
ON
ON
(jraius de^) uouBiuus® ibuouuoh
9£
ON
ON
ON
ON
ON
ON
uontnuaouop |oqcp|r poojg
(A/uo /®a®/ Ajbujo))
(A/uo i*A»t Ajbojs))
is®)
6C
oieuocurp uinmi’l
8C
EisajoudQXjpaja uiruag
(Afuo iBABf Ajbw - buns®; ipjed) Afiuane upfg
(ibun; 'Buocpeq B®)
o»A
ON
ON
Ahaqjsu®! 7 qi - ns®) ajnyra n®3
CC
«A
«®A
ON
ouun ;o |_jd
EC
C»A
«A
«A
®uun ;o AdabjS pyo®ds
LC
SOA
ON
ON
(g snaeday) uabnue uri;tJ3sny
OC
«A
*®A
^N
(joa®; pioud/4 jq^ ica;)
«A
ON
ON
Uoae; pidJBwnauj jc;) is®) jwreMBtoy
«A
«A
ON
uogpboj sjbpim
(0 icajis o: Apoquue)
6E
BE
a/jq ‘O'S'V
ZE
s®A
s».A
ON
sasAjeue ai/jcuaojg
9Z
s»A
ON
ON
&iyajd pdf-]
9Z
«A
s»A
ON
«A
soA
ON
ouiuorso 7 iojie»|OU3 poojg
CE
SOA
ON
ON
nsAjcue seb-poojg
EE
s»A
s® A
ON
(eajn 7 asoon|5) J S 3
IE
ON
(OLuujQj5aj3 ibuouou oiejoaes - ggiy) ’/vru
OE
61
soa
ON
(CIOAdl qluAzus)
C1S»1 UOQDunj
>E
s»A
ON
ON
eiujo^no"]
S®A
ON
ON
li»o ojipig
81
SOA
SOA
ON
(sipudAs) -TH-q a
Zl
ON
ON
ON
(Qiuujej£)aja ib3uj»a S]aj8d0S)Asajd9~]
91
soa
SOA
s®A
g _£ Ajeuoiujncj
91
HO
HV
(pouiaiu uaqaaN-ftprz)
(P.juop) saE®j qr-|
HD
saoiAJag aiJSOuSeia
pdninjuoj
SdiJO\T aDiAJ3$ qsapujj cjqpuy .’I ^iq^JL
9t-jo 8a§Ed
£ xauuy
Tabic 2: Kat rinlaka Service Norms
I (a)
('«indilii»r»/l’n»ccdurc
fopii.ifury mfcclioii
■I
■ I I <•»*<» fo|iiraiory niicitinit
I
Ayilmi.i
lubcfculoiij *
('onimimity hospital
Community hospital
S’uls-disfricI hospital
JU Ih-iIs
50 Ixils
Kill beds
District hospital
>2511 llctls
Kt .iii.igc
Kl.liugc
Manage
Kl.iimgc
lic.it Ilium Inli» X pneumonia
I icai bronchitis X pneumonia
I ic.il i clef led
lieal icfetied seveie cases
Kl.m.ige mild cases symptom-
Manage mild cases symptom
Invesiigalc X tic.it seveie cases
Investigate X Heal severe cases
atitall)
)
Medical conditions A proccdnrvs
Hctei seveie cases
atic all)
Held seveie cases
Sputum test. X-ray and t:SR.
Sputum test. X'uy and l:SH,
Sputum lest. X uy and l:SK.
Sputum test. X-ray and I.SH,
ni.uuge X heat
m.ougc X hcai
manage X tie.n
manage X tieat
) L’tytiiiluKL
i) Pleural aspiration
M.hi age X
iicji
M.iiijgc X tic.ii
Manage X iic.it
M.ill.igc X Iicut
No
No
No
M.in.ige X heal
No
No
No
Manage X neat
Supportive X syDiplomatic
Supportive X sytnpionuiic
liivcslig.ile*. iiijii.I|;c X Gillo
hcaliiiint itico rcfei
ticalinciil llicu refer
n| I'liiral biopsy
nt) llronchoscopy
(Ol’l)
I (l>)
AHI
Treat X refer if no improvement
I HI
Childhood asthma X
liivcsliijaie, in.iiiage X follow-up
I'acdialiics
Treat X refer if no i mpi o vcmenl
Investigate X manage
Investigate X manage
Investigate X in.mage
Investigate X manage
Milil syDiplomatic iieainienl. refer
Mild symptomatic ticalmcnt. refer
if no impiCMemeitl
il no iiitpio* eineiif
II ho respiratoiy distress, manage
II no icspitaiuiy distress, manage
II no icspiiaiuiy distress, manage
II no respiratoiy disliess. manage
Suspected cases to be referred
Without respiratory distress,
Investigate X neat
Investigate X treat
(because of no sputum)
manage
allergic bronchitis
I uhcrculusis *
up
dQ
>
o
\ t» •/«/</«< •«/•««!
««i| JfiLhrtr
t
III |
•*
D
D
IT
-U
X
O\
UJ
Service Norms (continued)
Tnl,le2:
I (C)
:
Medical conditions A
procedures (cont'd)
Condition/Proccdure
Community hospital
Community hospital
Sub-district hospital
JO beds
50 beds
•M hcfcdntfi.
• ) Pericardial lap
• •I I ntctgn body
removal
• '•I I umhar puncture
lv) l‘hyStulherjpy
>25(1 Beds
No
Do simple cases
Yes (peiform)
No
No
' e> (peituimi
Bo simple cases
Do simple c.u.
Ves (peiform)
Yes (pct lot in |
No
Yes
Malignancy / Neoplasm
I
District hospital
100 beds
e» (peiluiiiij
Yes (peiform)
Ves (perfoim)
Yes
Symptomatic treatment X refer
Symptomatic treatment X refer
I c) Rhemnaiic fever including
Treat
pi«*pliyl.ixis •
d) l iientiAl hypertension
li eat
0
Slable/unsluble/posi
myocardial infatclion angina
gl Acme myocanli.il iiif.nciion
h| Kheiimatie heail disc.i>e
uitli piegn.iiKy
Symptomatic ireaimem X refer
I teal
Symptomatic ireaiment X refer
I feat
Treat
I feat
Malignant hypertension
____
liefer
H efer
• *y*at X manage
•Icier Depending on advice.
I'dhu* up ,n second.ny level
Treat
Refer
liefer
Treat
Refer
I real X manage
Rcfci
Treat
liefer
Depending on advice,
hdluu up ji jeeondary level
Hefei to ternary level if neeessjiy
1 real X manage
Refer
Depending on advice,
lollmv up .H setomlaiy level
I real X manage
I real
Refer il necessary to
leitiacs level
Depending on
ads ice. folloiv up at secondaiy
•I
Il
Congenital heart disease
Cl I
11 Convulsions including
epilepsy
Symptomatic treatment and refer
Symptomatic treatment and refer
1 real Xmanagc
level
Symptomatic treatment and refer
Symptomatic treatment and refer
Symptomatic treatment and refer
to ternary level
Symplon,..in,- tieaimeni and refer
Symptuinatic treatment and refer
licat
If necessary refer to
let liar y level
I teat X manage
Treat Xrnanage
Treat X manage
-0
W
GQ
- >
O D
o s
-h rt>
■U X
Ox GJ
ruble 2: l<;irn;it;ik;i Service Norms (continited)
I (c)
:
Medical conditions A procedures (conf'd)
j
Condiliun/I’roccdurc
('•hii.i
i)
Community hospital
Community hospital
Sub-dislricl hospital
District hospital
JO Ixds
50 beds
1011 beds
>250 Beds
Imiul irvJiiHciii Ami icfcr
Initial iicJliiiciii Jiiil icfci
Initial iic.iliiiviit .mil ivlcr
Initial ircJlincnl and m.in.iye
If
no iniprovciiieni. lelci hi leinaiy
lev el
■•J
I'lmomn^
I Ijiccpli.ililn
■J MviHiiipm
I tc.il
I f C JI
T icji
It c;ii
SyiiipioiiiJiic ircJimciil
SyniplumJiiC itcJlinciil
Syiiipioiiijik ttcJiiiiciii
Syiiipionuiic licjiiiicni
SynipluiiiJIic ItcJlmcnt
SyniplumJiic ifcJiniciil
Syinploiiijhc licjiiiicni
liefer if
compile aiions
* Hf/ft ihritmiif /h'imI ■/■ir.tiri
I lend injuries
Hefet if
I. . .1
I (<D
indiliitn/l'iuccdurv
SympioniJlic Iteainieiit
| complications
:
Medical conditions A procedures (conl'd)
Community hospital
(.'urnmunity hospital
5ul>-district hospital
District hospital
3(1 Ik di
50 Ix-da
1011 buds
>25(l Beds
Initial treaiincni
Observe X refer if Initial l.'ealment
Observe X refer if
lnvcslii;3’c A iii.iii.ir.c
Invcsllg.llc X lil.1il.1i;c
Observe X refer if
hivc^llijufc A III.HIJIJC
Invcsiiipte X iiiait;ii;c
nee ess.ii y
(’ V
aiLidciilS
lnili.il ire.ihiieiil
Observe X refer il lniii.il licjtmeiil
iccessaiy
necessary
Psychosis *
heal minor cases, refet Olliers
HcjI imiioi cases, tefet Olliers
Heal itiiiiot cases, icfer others
I te.il nttnor cases, refer Olliers
Neurosis
fieal minor cases, refer others
freai minor cases, refer others
heal minor cases, refer others
freai minor cases, refer Olliers
^0
P
(JQ
rt>
Leprosy •*
fieal X manaye
freat X manage
jfreal A manaye
I real X manai;e
>
o a
rt>
B
X
Cm
Table 2: Karnataka Service Norms
I (tl)
undi lion/l'mccduH.1
:
(continued)
Medical conditions A procedures (confd)
Cuitiiiiiinhy huj|MLd
Cunimunity liospiul
30 lx-ds
■SvjIuc.x x
I
I
mrcciinii
I »c.»i
11 CAI
l*eiii|iliiLnt
l,lll* uc ircahiUHi X icier
........
Hcainieni X refer
( ollai^cii diaejkcs
Hclcr
llclcr
Skin allcrijy
I real
Sarcoidosis
)
STDs
Blood screening
HIV testing
(raslroinieshnal bleeding
Invc4iij«jic X weal
11 cal
Invcsiiyaic X ircai
ficai
(real
Yes
No
I real
Ileal
lieai
Ves
>2511 Beds
I real
I real
Il tier
rrc.ii
Treat
I’rcai
I leal
liefer
FfCJl
District hospital
100 beds
lleler
Ircai
•tufci
Psoriasis
)
Sub-district lmspil;il
50 iK’ds
I real
Yes
Yes
.No
Yes (peifoiin)
Yes (peilbrin)
Kcsuscilation X conservative
llcsusci.ation X conservative
n.iii.igenicnt if (deeding is
management if bleeding is minimum
miiiinnni (aIhihI l00-20Unil) with
Di.tijiiosiic investigation X
ireainienl
liiidoscopy. ircai X manage
Kvfei if iiccessjiy
l.dhiui 100-?t)(iml) with good vital
If bleeding is rmor» t.ign» II bleeding is moie than 50(Jnd
han .Mlbnd. refer for endoscopy
/
refer lor endoscopy
;uud vital signs
(iustm cnlcriiis X dysentery
llepaiiiis
heal X man.igc
I ic.il X m.mjgc
l.css than one month duiation. (real
"idi steroids
Hepatic coma
treat with
sieioids
Initiate Ireaimenl X refer
Aniocbiasis
I.css Ilian one monili
I real X mnnjge
Inihaie ireainienl X refer
Treat X manage
freai X manage
freai X manage
More llian one nionili
'iivcsiigaic X
ncai
More than one niomh. investigate X
I IL* at
Invesiigaie. Ucai X manage
fieat X manage
Investigate, neat X manage
co
(TQ
rt>
heal X manage
K>
1
..
■•••Av
■ ilh ft—tt a. ••fi.mt.J
•
««,i,
O
tt f. t
I l r;
It.-1
O\
>
D
D
o
X
•.a
Table 2: Karnataka Service Norms (continued)
I (c)
o ndiliuii/Pnicvdii iv
Medical conditions A proccduivs
(coin'd)
(umniunity ItuspiLd
Community liuspilul
.Sul>-ilis(iicl lius|iital
Dishicl ItospiLal
JU beds
50 beds
I 0<l beds
>250 Beds
(*liuk*cy»iilis
Synipioni.iiic iic.iiniciii X icfer
Sytiipionuiic iic.iiinciii X icfct
lnvcsii|;aic X itc.ii
I'.WiIC.IHIH
>) nipiuiH.Hic iicjiiiicnl X iclei
'lyiiiploiii.ilic ncjiiiiciii X iclei
IIIvCililJ.ile X ni.iii.irc
Invcsiiipte X lie.H
Investigate X man.ige
l or
ilicrupciilie endoscopy ui suigciy
icfer to letlKwy level
Ch diosts
Sympiomaiic Ireaifnent X refer
Sympioinaiic Ireaimeni X tefer
InvcMHjote X
hi.'iiioijc
Investig.itc X in.iii.ige Keter it
w omplic.iliiiii
tlCXsJutCLi) Abdominal tapping
Vcs
H) I iver biopsy
No
No
No
Yes
lii) I ibre oplic endoscopy
No
No
Yci
Yes
iv) llimc lll.'iriiiw ilst.iy
Nn
No
Dinbeics
M.ina^c
M jnaix
M.in3|;c
Manayc with complications
III I
S> nipioni.iiic ne.Tliiieiil X tefet
Syiiipiomjiic Hcaiineni X tcfci
Itivohiple X iiun.i^c
liivcsiig.iic X iiianai’c
Inve^liyaie X iii.m.iije
liivciiii'.iic X niaiiaijc
Invi'sliiplc X maiiayc
Invesiiyaitf X iiianji;e
Ai’iilc nepltfilis
Ncpliroiic syndrome
Kciul failure
Yes
Manage if no compile.mon
.m.ige if no compilealion
Dihcrwi-.e refer
)diciwi«c rcfci
Inmaie treatment X manage for one
liiitiaic treatment X manage for one
month
iionth
If disease persists, refer
Si.iIhIizc X refer
II disease persists, refer
Sl.iliilize X refer
Subilne X icier
Invesiigalc and mait.ige , using
|pcfil<iiic;il dialysis if required
Anaemia
l.cukaeinia
1 lial assacmia
Manage X treat
Refer if no
Manage X Heat
Refer if no
Investigate and manage severe
improvement
tnpiovenicnt
anaemia
Hcfcr suspcci cases
Hcfcr suspect cases
Investigate X manage
blood iMiikfusion and refer
nve blood tiaiisfusion and refer
Refer if nccessaiy
Hefei
Invcslig.itc and manage severe
inaeima
Refer tf iicces>iny
to
CTQ
o
UJ
Refer if no
Investigate X manage
iiiipiuvctnciii
niipiovcmciii
I icai X refer
Treat X refer
Refer if no
o
CT\
>
D
D
o
X
Cm
Table 2: Karnataka S erviec Norms (continueil)
I (e)
ondillon/Procedurr
:
Medico! conditions A
Community hospiul
Sub-district hospital
50 beds
• (0
Dorn
I'rciiiature < 2 Lg
Jaundice within 24 hours
(onvulsiuns
Manage Refer if any complicaiioiu
: Neonatal
Refer
Refer
Hcfer
'miMte treatment and refer if not
ontr o 11 ed
Community hospital
Inciiion &; drainage
Irauma A life support
Musculoskeletal
Manage
Manage
Investigate A manage
Inmate treatment and refer if not
untiolled
:
Manage
Manage
M.itiagc
Kefer
perianal
Wound dcbtidciiiciii
Manage
Manage Refer if any complications
Diagnose X ire.it
Investigate A manage
Diagnose A treat
Surgical conditions A procedures
Community hospilal
30 Ik-Js
Abscess including breast A
>25trik(ls
Maiuge
2 (n)
ilidort/Procedurc
District hospital
100 bells
Manage
Prcmatiirc >2Lg
(cont'd)
Community hospital
30 beds
Normal Nc
procedures
50 IkiJs
Incision JL drainage
S'iil>-dislrict hospital
District hospital
100 beds
Incision A: drainage
>250 Beds
Incision A drainage
to
Simple wounds
Resuscitate, stabtlixe A ufet
Simple manage
vfcr
era
Simple wounds
Complicated
Major X com|»uuiid wounds
Resuscitate, stabilize A refer
Simple manage
Complicated refer
rt>
Major A compound wounds
Investigate A manage, if needed refer Investigate A
■Manage, refer d iicces>.wy
Manage
manage
>
4x D
O D
x
Ox t>a
1
.<•
*•
I able 2: Karnataka Sen ice Norms (continued)
£
2 (o)
('ondillua/l'nicedurc
Ahdununal injuries
J
:
Surgical conditions & procedures
>
Community hosjillal
Cuniinunity liosjntul
Sul»-dis(ric< hospital
District hospital
30 tacds
50 Iseds
1011 beds
>25(1 Bctls
Subilizc X relet
Subdue X rcfci
Mature
Manage
liefer
Yc> (d* anjesiheiisi available)
Yes
Yes
(emergency)
)
Abdominal surgeries
(planned)
)
Appendectomy
No
(Jplioiul
Ye>
Yes
I
I laemordiuids
Kufer
Ophoiul (if aniesihelisi available)
Manage
M .in age
Anal fissure
Manage
Manage
Maiiai*c
Manage
Acute rclcnlion of urine
l'.iilieierise X ictct
(.'allieferise X icfer
Manai;c
Manaije
Circumcision
Yes
Yes
Yes
Yes
Yes
Yes
—
I
Ilydrueele
)
I
— -
I lerniorrliapliy
defer
Yes
Yes
Yes
I Ireihral dihuiiion
K el er
defer
Yes
Yes
Rupture of bladder X uretlii.s liefer
liefer
liefer
Manage
Major uinlogical procedures
liefer
liefer
liefer
Manage if necessary
Traciurcd spine
Siabdue X refer
Stabilize X refer
liefer if necessary
Manage
Ophthalmic procedures *
11 e 11 io v a I of foreign bodies
llcnioval of foreign bodies
Dental surgery
Management of corneal aberration,
Management of corneal aberration,
ulcer X ijuiacl
nleei X caiauci. and gljuconu
w
iiHgcry
(JQ
rt>
Us
o
I'nnscrvative dentistry, tooth
Conservative dentistry, tooth
Cunscivalive dentistry, lootli
All types of extractions, imp.ictions
.-xlraction, all types of fillings
extraction, all types of fillings
extraction, all types of fillings
X j.iw fractures
O\
• 7
•
>
D
D
n>
X
GJ
Tabic 2: Karnataka Service Norins (continued)
2 (b)
:
Surgical conditions A procedures
|<'undiiiun/!*ruccdun.Community liuspital
Cuniniunily liuspital
30 beds
>'|
!
Castro-Enterology
(endostopy)
An.icilliciiolnuy
Kcfer
Sitjmoidmcopy
laie of airway equipment
are of airway equipment
1 (c)
•I
Intercostal under-water seal
Manigc
I lad chest
4
Mediastinal injury
I
Acute empyema
:
Chronic empyema
Hciusriiait Ac refer
XcMiscitate X lU'siiscil.ile
refer
X refer
Manage by intercostal drainage
M.in.igcnicnt of genet al X regional
inaesthesia
Manage
Yes *
Hciusciiate A refer
Keler
maesrliesia
I liur.tcic sin^cty
Manage by ICD
ICD)
)
Oesophago-gastruMiip}.
Management of general X regional
Manage
Yes •
th miiage
I
>25(1 Herts
uduntiscnpy
pnaesthesia if possible
Simple fraciure ribs
Districl hospital
I Oil bells
H cfcr
Management of general X regional
>)
Snb-ilistricl hospital
50 Ix-ds
Kel’cr
Manage
Yes’
Kc>incit.iic Sz refer
Manage with ventilatory support
Kcstiscilaie X refer
Manage, refer if lliotacoloiny needet
Manage by ICD
Manage by ICD
Refer
Rib resection X drainage Refer if
decalcification present
I
I
Thoracotomy
Other elective thoracic
Yes, only in emergency
Refer
pioccdurcs •*
)
I oteign hmhes in the
uesophagiis and
iracho-bronchial tree
Refer
Yes. only in emergency
Huih emergency X elective
liefer
Refer
Relet
Refer
Doth emergency X elective
■Manage, reler il necessaiy
•ns
Manage, reler if uecessaiy
to
(TO
rt>
Os
O
>
D
5
n>
4^ X
Os Ua
Annex 3
Page 17 of 46
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Annex 3
Page 18 of 46
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1 able 2: Karnataka Service Norms (continued)
J.
undifiun/l'ruccdurv
:
Obstetrics & Gynaecology
Community ho s pi Lal
Cunt in unily liospiul
Sub-district hospiLil
JO beds
50 beds
District hospital
10(1 beds
>25(1 Beds
Cervical erosion
Hefef
Hefet
I’AP snicoi,
rtn
PAP smear, bmps)-, X iiijnai*e
Maiuye 1 refer
\tjiU|*e X refer
AI jiijijc
M ;hi jije
Milignancy / Neoplasm
Refer for diaunosis; to tertiary level
fur surgciy Jr radioiheripy
liefer for diagnosis; to ternary level
loi Suryeiy X radiotherapy
Duynosis Refer io ternary level for Diagnosis X management Refer to
Mir|»eiy X radiulhei.ipy
leiliary level for surgery X
i adiot her apy
Colposcopy A hyslcfoscopy
Kcfcr
defer
liefer
Yes (perforin)
Keconslrudive surgery
liefer
liefer
liefer
Al.inaije if possible
i
-I
K
(JQ
<T>
VO
o
Ov
>
□
D
O
X
CM
I
Annex 3
Page 20 of 46
Table 2: Karnataka Service Norms (continued)
4 (a)
: Diagnostic services
Specialty
Tests
Community
Hospital
b«ds : |
I
Clinical Pathology :
| Blood haemoyiobin
| WBC, Differentials. ESR, BT X CT
|
| Peripheral blooo smear
|
| Absolute eosmopnil count
|
| Platelet count
count and
and PTT
PTT
|
| Clot retraction time
| PCV
Ye$
|
|
I
| Reticuiocvie count
|
| LE cell phenomenon
|
Blood oank (cross matching) HIV.
__ HbAg. VDRL. malaria paraevtes
Urine for sugar, albumin, micro, pile
salt and bilirubin pigment
| Urine for ketone bodies
0 Aspirated fluid anau sis
Pattiolo®y
a) PAP smear
y«
|
Yes
Yes
I
\o
I
Yes
|
Yes
Yes
\o
I
v°
I
Yes
|
'
I
•
I
•
| Yes
I
[
Yes
|
Yes
Yes
I
Yes
|
Yes
Yes
I
Yes
Yes
I
-
I
Yes
Yes
Yes
1
I
Yes
I
Yes
I
Yes
I
Yes
Yes
I ■ T • i V« I Yes
I • I • I Y« I Yes
| For parasites (ova and evsts)
Yes
|
I •
I
I
Yes
• I
| Yes
Yes
Yes
| Hanging drop (X V.b Cholera»
Yes
I
Yes
|
Yes
| Morphology, reaction and count
Yes
Yes
T
■
I
■
Yes
Yes
I
•
I •
Yes
Yes
Yes
Yes
r
(Pleural, peritoneal, etc I Cell count
X sedimention cytology malignxnt
cells.
I
I----------------
I
T
b) FNAC X yuioes
aspirated fluids
c) Sputum cvroloev
I
|
Y» l y» I
|
Yes
| For occult blood
e) CSF anaivsis
Yes
\o
|
[
| Specific graviry and pH
d) Semen anaivsis
rI Y« TI
|
Blood smear for maiaru /
microfilaria
c) Stool anaivsis
I >250
III Yes
I Blood Group and Rh typing
b) Urine analysis
100
Yes
I
—
Dist
rict
I
50
II
Il
a) Haematoioey
|
JO
JO
SubDist
I
I
T
I
Yes
Yes
Yes
| Malienant cells
I
I
i
I
T
I
i
Yes
LZJ
Annex 3
Page 21 of 46
Table?: Karnataka Senice Norms (continued)
4 (b) : Diagnosric services (cont'd)
Specialty
Tests
I
Haemntoioey i
a)
Bone marrow aspiration
b) Immuno naematofocy
c) Coagulation cisorder
bods :
I
i
I
I
|
Community
Sut>-
Dist
Hospital
Dist
rict
100
>250
30
50
I
I
d) Sickle ceil anaemia
Y«
I
|
Yes
I
|
Yes
Yes
j
I Y» I
I Y» I
e) Thalassaemia
Histopathology of nil
Yes
specimens :
Microbiology
—
| Direct smear exam iaFB. ZN. KLBI |
Yes
I
Y« I
C/S ot all specimens (blood, urine,
pus. etc )
Direct exam of specimen for funvai
infections
| Bacteriological anaivsis of water
Yes
Yes
Yes
I
i
Preparation and .*uppiy of proper
| VDRL
~
| WIDAL
—
I
Y» I
Yes
transoon media for all peripneral
levels (VR. Cary Blair)
Serology
1
I
Yes
I
| Stool culture for V Cholera
I
Yes
“
Yes
Yes
I Also: C-Reacnve protein. RA
I
Yes
i Y» i
i
Yes
Brucella. Weilfelix. Coombs test
1
|
Yes
i
Yes
Yes
i
Yes
Y» I
Yes
|
Yes
HbsAg. HIV. Preg.test ANA and
DNA
Biochrmiiny
Blood suvpr. BUN. urea creatinine
Yes
total and direct bilirubin
I TSF analysis (protein a; suyari
I
I
Yes
I
LET. S cholesterol. GTT. Iipia
Yes
Yes
Yes
|
Yes
profile
| Blood cas analysis
Yes
CPK. CPK-.MB. SCOT. SGPT.
Yes
Serum electrolytes, acid phosphatase,
alk phosphatase, lithium carbonate
level in blood
Estimation ot resiaual chlorine
dnnkmc \saier at all levels
tn
Yes
Yes
Yes
Yes
‘•■Utt
’
««l
v
Annex 3
Page 22 of 46
Table 2: Karnataka Service Norms (continued)
4 (c) : Diagnosnc services (corn'd)
Special rv
Tests
\
I
Community
Hospital
I______ _______________ beds : |
Cardiac Invesngndon
Ophthalmology
Audiometer
Radiology
|
a) Stress • rest system
|
|
b)ECC___________
|
|
Snellen s Test Chart
-I1 Chest.
7__
Yes
I
Yes
Yes
|
Yes
|
too
>250
|
Yes
|
I
Yes
I vT i
sku
Yes
I
I
■
I
Yes
Dist
rict
I
|
I
II. PS'S, bones, spine. KL’D I
I ano abdomen
Conrrasr odiolo^y
50
Sut>DiSt
Yes
Yes
Barium swallow, barium meal,
Yes
barium enema, cholecysroijram. IVP.
HSC. siaiogram. sinogram.
_
Endoscopy
myelograpny. angiography
Oesopnagus. stomacn. colon,
duodenum
I Broncmal tree and
I
cvnoscooy
1
| Sigmoiooscopy
Ulrrasonofraphy
| Ob.Cv and abdomen ponaole
Linesr/Sectorsl
| Qb.Gv abdomen
7
1
| Ob G\' . abdomen <£ cardiac
/
Blood alcohol ftu^auo,, cur^tcal anaivtn Oi
•>pp^pnO,f ,f,eci^tn,
Yes
1 ■ I
I
1 - I
7
J_ y» I_____7
Yes
l_ ■
I •
Yes
Yes
1
I
I
y«
I
Yes
I
•
I
Yes
,rmrtenQn c5. .................
9*d\-.
Ftrthhti io, eoi/ecHO" o!
I
I
J.ipatci,,.,, ,o
mc.TT,/ ioi)
a -"thoHtcc! -<«• .AomZ,/ bf
ccHtn-i
1 able 3: Punjab Service Norms
r
I. Diseases of Cenlnl Nervous System
Diieajci
a)
(*onia/i er cbio
vascular accidcnl
b) Mcningilis
CIICs
Sub-DithioiiaJ lloi|MLdi
Maintain vital signs A; airway (Ambu bag, oxygen)
Cxcliidc diabetes X renal failure
I laic f.Klimes fur tiacheustoiny X laryngoscope h»i intubation
l.xcluJc head uquiy by doing X-ray skull
Stan medical decompression treatment
heat coma case caused by poisoning
Dili if coma doe» not improve.
to District hospital
Inmate symptomatic treatment and refer to district hospital for
further investigation
Same as CHC
Do CSF examination start treatment
Out if no improvement after 41 hours,
Dislitcf I-eve I
Hospitals
Caary on treatment and smgical
decompression
If recpuied. investigate ami ionium
diagnosis ul ( V accident llram tumour
cases refer to leitiary level if indicated
To do culture and sensitivity test,
diagnose and treat
refer to District Imsptlal
c) Lpilepsy
d) Polio and other
acute flaccid
Inmate medical ticaimenl and first aid treatment, refer to District
hospital for further investigation
Sarne as CHC
Manage, invesligale, refer to ternary
level for HEG and surgery if requited
Initiate medical treatment, maintain vital signs, remove discomfort
Same as CHC
Investigate and neat
Hefei to Dismci hospital lor CST examination and stool culture
paralysis
2. Psychiatric Ailments
a)
Psychotic patients
l») Depression St
allied disoideis
c)
Start crisis management X refer to psychiatrist at District hospital
Same as CHC
Treat
Sedate and refer to psychiatrist and follow up action on
psychiatrist's advice
Same as CHC
Regular psychiatric Ireafiiicnl
Same ClIC
I'/uviJc tci^ulai iiuahiiciit
Same as CHC
I'iuvkK* rcijiil.ir irc.itmcm
Addiction pioblcms Sedate if patient is sliovsing withdrawal symptoms, then refer to
Distiict hospital
d) Mental
retardation
Symptomatic treatment and counselling, and iclei Io psychiatrist
and/or neimiphysictan
to
TQ
O
CM
O
>
<T>
X
C7> UJ
Table 3: Punjab Service Norms (continued)
J.
Hespiratory Diseases
Diseases
CIIC1
Sub-Divisional lliis|iitals
District Level
a)
Ihoiicliial usiliina
Inmate medical treatment, but if
no iclief. send to Disirici hospital
f«»i flintier invextigation
••I
D|»|»e» am] lower
fespiraiory tract
infection
c)
Tuberculosis
^'.rc
........... ...
j. . ......... ..
Hospitals
Same as ( lie
tK.jh||
bs.-r.u for U hour,, bur if no ,t|,cr. ,ck-r lo Orsrr.c, l.osp.sol
Sjhic js CUC
Investiyaic <£. heat
liivolig.iic X Iic.il
lnveI"i:"i« by sputum eximinnion ind/or Xny c|iell
Same as CMC
Inmate antiduberculosis treatment
(NH
IJ,,,,/,.
Inveshgalc I: neat
tfm, UW.MU. ..................... I1O1|„U1
u//ocllllicl iuiJ
Htumnal 1 II fnj^qHnic ihnhU be avt.uk J )
d)
Lung cancer
In.ust. symptom,^ 1ICJ(nKnt A olIlcr Iu(,po(llvc 1|lcU|ly
Jn()-
Same as CHC
teter to lenmy level institution
cl
I’kural effusion
0
Poisonous gas
Jo x.iay c|it>) x J 3
»-■■■
1 ,uk, IO dlt„K, |.o,p„,|
Ia cunf„,n ||rii;no(.> •
Bl
Same as CHC
Sun Grst i,d ircstmcH. tive respiratory support
inhalation
Live Ills! JHj rcr..f |O
iiili.ilsiinn
facilities .ire available
Io confirm diagnosis start itcaimcnt. if
malignant refer to tertiary level hospital
Same as CHC
l uieign hu«ly
Same as CHC
-
Same as CHC
District liuspit.il ulicre bionchoscopic
S.ime j* CHC
Same as CHC
*■0
to
era
a
txj
*
.ta
o
O\
rt>
X
Cm
Table 3: Punjab Service Norms (continued)
4.
Dheues
Cnnlio Vnscular Diseases
CIICi
Sub-Divisional Hospitals
Dislrict Level
llospitnls
□)
I lypcflciisiuii
Initiate medical treatment of mild and moderate hypertension
Refer
Investigate and lre.il
to sub-divisional level for treatment of acce leratedhypenension
b)
Coronary artery
Inmate medical treatment on clinical suspicion of disease, refer to
diseases
(hstiici hospital fin other tests eg
Same as CMC
treadmill sirtss*
Investigate and ue:il
Investigate X maintain therapy
Refer lo
tertiary level lor more active
irilcivcnliim. if iet|iiuvj (eg m
angiogt.iph). .iiigiapl.i>t) eK and by pass
surgery)
c)
Myocardial
infarction
d)
e)
Initiate treatment by sedation, vaso dilator, thrombolytic therapy
(Slreplokin.ise)
If within 14 hours there is no improvement or then
Manage myocardial infarction
Invcstig.iie and ire.it
If evidence of heart Iduck. refer m
;«re luiiiplicaimns. lelei io sub-divisiuii.sl le»el
Disiiici huspit.il I'm p.iiviu Aer
Congest ive heart
Initiate treatment and observe II decompensation persists. re£cr to
Same as CHC
failure
District hospital
Invesiiipltf and treat
Same as CHI*
Investigate and ire.it
Same u CHC
Investigate and treat
Acute pulmoii.iiy
Inmate ircaimenl with broncho dilator, diuretics, ocygen
ocdema/cardiac
improvement, refer to district hospital
If no
asthnia
0
Rheumatic fever
Start initial medical Ireatmenl, and refer to district level for
• nd rheumatic
confirmation of diagnosis
hemt disease
g)
li)
Dysrtliymia
Shock
Mjiniain vital signs, and refer stable cases to sub-divisional hospital Medical treatment including
for cardioversion (with defibrillator)
defibrill ation
Initiate ireatmenl. maintain vital signs and functions. IV fluids,
ncygen
mid obscive
Same as CHC
Medical ireatmenl including
defibrillation
Insestigaie and treat
If no impicivemenl within reasonable lime,
refer to Disliict hospital
P
OQ
o
Ul
o
ON
>
□
□
rt>
X
Ul
Table 3: l,iJnj:ib Scrvi
ice Norms (contiiiueil)
Cushu
Inteseinal Diseases
DiscMJci
CIICj
a)
Sub-Divisional Hospitals
Gasifu-lnicsiinal
Start medical treatment and t
supptiihve therapy |f no
^’tliin reasonable lime, refer
intprovcmcni
f 10 D,s,r'« le*cl hosp.tal
for endoscopn
investigation
bleeding and ulcer
b)
Dishict Ixvcl
S«nic ai ( lit
_
Hospitals
Investigate and ne.it
Jaundice / llcpjunj
bisirict
Sune u CHC
Gastroententis /
Investigate and treat
Dehydration
S«n»e as CHC
Inw^iiyuie and Heal
•U
CJ“
Amoebic tnfcciion
uiu3lu;'1,d";;;;"c-k-1
......... .
,o
Investigate and treat
''-i-i
Investigate and treat
6.
Hcnal Disonlcrs
IHscuci
CIICs
Sub-Divisional Huspiuij
3)
District Ixvcl
Urinjiy |(3v|
in fcciion
b)
loither investigation
lhemaiuna
nulmem and ,efc, l0 Disuici hospital for
Investigate and tieat
Symptomatic t—
irejuse is nut■ identified
fCffef
ial-CaalB t - * I
J)
<cnal failtne
>
»0 District hospital
Acute and chrome
i'lvesiigaie
Some as CHC
Investigate and treat
M-imtam s.ial ngns. and refer
i
Hospitals
Sime as ( III
IJ
rJC1illy |.,11.,,,^ k.v<|J
Same as CHC
'nvcsiigme and lie.ii by pentoneal
Arihriiis
dialysis Refer
- 1
hacnmdi.dysis
Start palliative therapy,
-efe. !0 Ormic. Ilotp.m for ,n„,l,l!lllon
*nd physioiherapy
’einary level for
Same as CHC
Investigate and treat (eg physiotherapy)
P
(JQ
rt>
txJ
Os
O
O\
>
b
□
o
X
GJ
Table 3: Punjab Service Norms (continued)
7.
Discues
I laeniiifology
CIICi
Sub-Divisional lluspilals
/■
District l-cvcl
Hospitals
ill
Anaemia I
Infestation
h)
l.ciik.icmia and HI: Give symptomatic treatment, and refer to District hospital for
system disorder
investigation
c)
lllecding disorder
Treat nutritional anaemia
Treat worms
Sime is ClIC
Investigate and Kcal
Same as Cl IC
lnvcsiiyaic and Kcal
Same as CIIC
liivcsiiipie and Heal
II no response, refer to District hospital for investigation
I real anaemia and give haemostatic agents
Kcfer in District hospital for investigation
8.
Diseises
Inli'Clions
CIICi
Sub-Divisional Ilospilals
District txvcl
Hospitals
a|
Mnlana
Diignose and treat malaria
If complications develop, or fever does
not respond, or G-G-PD deficiency is suspected,
Dismcl hospital for investigation
Sime as CIIC
Investigate .and Kcal
the tefer cases to
l»)
SIDs
Give Kcalmcnl for the symptoms
If no response, refer to District hospital
Same as CIIC
Investigate and Kcal
c)
Leprosy
Give treatment for the symptoms, but if no response, refer to
District hospital
{Nil I lii/ihi uthiit t>J /tklhlici tUhl ri/m/uiii Hi
mi./, r
A/ii/mnii/ lA-jtnuy
he avuh/cd )
Same as CIIC
Investigate and Kcal
d)
HIV/AIDS
All patients suspected of HIV infection should be refeircd to Distric Sime as CIIC
hospital and/or HIV 1 citing Centre foi diagnosis and counselling
(Nil I hi/ilictiJiiiii tj fuihlici ivid cgiii/inicni piiiridcJ under
UiUntnai AIDS ('untrvl l'n>^n»nnic »/mu/./ be <n aided )
Investigate and diagnose
NACO guidelines
Manage as per
co
GQ
rt>
O
>
□
□
rt>
X
L.J
Tabic 3: Punjab Service Norms (continued)
10.
Diseases
Acute lespiiatory
I’nediahics
CIICs
I real JL relcr if no impro vcmcni
nfcction
1 oner respiratory
Mikl
.Syiniihiin.il
'act infection
Inldliood asthma
Mmiag.
Kc.iliiiciil. icfcr if no Hiiprovciiitfiil
iihout rcspitaiory. distress
< allergic
Sub-Divisional Hospitals
District l-cvcl
Hospitals
Same as ( IK
Same a> Cl IC
Same as Cl IC
Investigate X in.mage
Investigate X manage
Same as ClIC
•ItilH Intis
' nlicli'idosiS
Suspected cases to be investigated by sputum exam and radiography
Manage
Same as CIIC
Invesiiipie & treat
(Xll
NtUhmul I II 1'n^fiunnu Jhh.IJ be uvuiJcd )
to
(JQ
o>
>
00 Q
O
»-h
■U x
O\ Gj
Annex 3
Page 29 of 46
Table 3: Punjab Service Norms (continued)
11. Neonatal Services
CHCs
Sub-D ivisionai
Diseases
Hospitals
District Level
Hospitals
Resusciuoon of New Bom Babies
Kogv score > 4 | Resuscttation to oe cone
b)
Apgar score < 4
d: minagea.| Same as CHC
Resuscitation to be done. If vitals
Same as CHC
maintained, manage; otherwise refer
to District level.
| Same as CHC
Manage in Special
Care Nursery (SCN)
Uncomplicated low binh-we^ht babies
4)
More man I 8kg | Manage witn roommg-in service ano I Same as CHC
|
observe
b)
Lass tnxn i 8kg
j Resuscitation
.Maintain vitals
| Same as CHC
I Refer to District level
| Same' as CHC
| Manage m SCN
Uncomplicated pitmarure
i
babies
a)
b)
Gestation less
than 34 weeks
I Resuscitate, t----------mamtxn vitals ana refer I Same as CHC
I to District level
J
|
Gestation more
than 34 weeks
I If anv problem, refer to Distnct level!
Comphcarrd LBW and
premature babies
I Manage and keep under observation ,
Manage and observe.
Refer if
problem is unmanageable.
Care in SCN
Same as CHC
Same is CHC
Same as CHC
Menace m SCN
Same as CHC
Same as CHC
NewcLoouj Jauadjfe
*)
'A’ithin 7 days
Treat with phototnerapy
and serum
bilirubin less than
lOOmg
(clirucailv)
b)
Early deep
jaundice
Phototnerapy. then review.
Refer to Sub-Divisional hospital
Phototnerapy xnd
Investigate and manage
monitoring of serum
in SCN
bilirubin. If this increases
by more than Jmg/hour
requiring exchange
Sepacaemia
transfusion, then refer to
Distnct hospital
Climcaiiv assess & start therapy
If no response or condinon
Same as CHC
Manage in SCN
Same as CHC
Manage tn SCN
deteriorates after 24 hours, refer
to
District hospital.
For septicaemia
associated wuh serious
problem like meningitis
Inmate preliminary treatment,
manage vuais. and refer to SCN at
Distnct level
Congemud Defects
*)
Not life
Manage xnd advise
threatening
b)
Life threatening
Try to maintain vitals, avoid
eg defects like
cardiac
hypotnermia: then refer to SCN at
pulmonary
Distnct level.
| Same as CHC
Same as CHC
Manage d; refer to
teniarv level
Manage in SCN.
Refer io teniarv- level
I
Annex 3
Page 30 of 46
Table 3: Punjab Service Norms (continued)
12. Miscellaneous medical
conditions and procedures
Diseases
CHCs
a) Pleural aspiratton
I Yes (perform)
|b) Pertcaroial tao
Jno
c)
foreign bodv
removal
Sub-Divisional j
District Level
Hospitals
J_
Hospitals
| Same as CHC
| Same as CHC
| Same as CHC
I Yes I perform i
|
| Undenaxe simple cases
d) Lumoar ouncture
I Same as CHC
, Yes i perform i
e) Neoplasm /
Malignancy
Symptomatic tr-atment d- refer
I 0 Organic brain
I
svndrome
Treat svmproms as far as possiole
I e) Pempmgus
I initiate treatment a: refer
S) Collagen aiseases
( Refer
h) Skin allergy
"Jlreat
I *)
Sarcoicosis
I Refer
j)
Blood screening
I Refer to Jsstmg centre at District
I level
H Cholecystitis
I)
Pancreatitis
m) Cirrhosis
I Symptomatic treatment d; refer
Symptomatic treatment d: refer
| Same as CHC
| Sarne as CHC7
Same as CHC
Investigate xno drug
treatment Refer to teniarv
level tor specialist sen-ices
I Investigate and refer to
I
| teniarv level facility
|
j Same as CHC
| Same as CHC
| Treat.
| Investigate d: treat.
I Same as CHC
I Investigate cause d: treat
| Refer tor specialist services
[Same as CHC
| Investigate d: treat.
I Same as CHC
| Same as CHC
Head injuries
Perform tests
~~ I Investigate d: treat.
treatment £ refer.
I Investigate d: manage.
For therapeutic endoscopy
or surgery, refer to tertiary
level.
j Same as CHC
I Investigate d: imanage,
----| Refer if comp11cani
■'wwjons.
I Same as CHC
I Sam e as CHC
treatment d: refer
I Same as CHC
Inuui trwtment 3nd observa„on
Refer it necessary
j Same as CHC
Symptomatic
"
| Same as CHC
n) Abdominal toping | Yes < performi
n) Congenital heart
diseases
I
Yes (undertake operations, (
(Same as CHC
j Symptomatic
1
Symptomatic treatment; d:
refer ip ternary level for
specialist investigation and
treatment.
Investigate d; manage.
I
i
Annex 3
Page 31 of 46
Table 3: Punjab Service Norms (continued)
13. General types of surgical services
Problem Area
CHCs
Sub-Divisional
Hospitals
a) Surutcai procedures
District Level
Hospitals
Basic teenmques
| Same as CHC
| Same as CHC
Incise dt dram
| Same as CHC
| Same as CHC
Wouno debridement
| Same as CHC
| Same as CHC
Same as CHC
Same as CHC
Biopsy or skin ana subcutaneous
lesions
I
I
I
b)
Spin skin grattmu
| No. refer
| No. reter
| Yes i perform i
j
c)
Trauma and life
Resuscitation ano staodisation
| Same as CHC
| Same as CHC
f
Securing airwav
| Same as CHC
| Same as CHC
|
Circulatory suoport
| Same as CHC
| Same as CHC
|
Suppon
d)
Reduction and
No. reter
Yes iperform i
stabilisation of
fractures
e)
Exploratory
No. reter
laparotomv
c)
Chest
refer
| Breast aoscess
e)
Management of
No. refer
Acute empyema
") Management of rib
mjunes
Yes
I Yes
Yes
Yes
——
I
I yes_____________
Yes (perform)
Same as Sub-Division
Yes (perform)
Same as Sub-Division
level
No. refer
I.Yes (perform)
Same as Sub*Division
level
No. refer
fracture
h) Stabilise mediastinal
Yes (perform)
level
No. refer
haemothorix
0
No. reter
} Tracheostomv
Stabilisation ot pneumothorax
d) Thoracocentesis
Same as Sub-Division
level
Yes (perform)
Same as Sub-Diviston
level
No. refer
No
Perform and/or refer
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aujojojsAj
(q
uonusisj Ajruun □mat jo luauiabruTj^
(<
2
2
2
2
*91
_______________ AUJOJOSt/\
__________________ sninAjo^
(u
uonanjjsoo icuiissiui ainoy
(j
sjaasqr icujtuopqr jo aSruirjg
7
2
£
£
£
£
£
l
sinidtoH
lecoiji.ua-qn;
ssunpaocLid jcoixUnsjo .Gutmung •M
(pdnuijuoD) suuo\ aortas qufunj :£ ajqujL
9t}° c£ 92bj
£ xanuy
(o
uoijcsanjsruuj (tu
«A
»A
Q
AUJ0)39JTA (3
___ ap3cnurA__ (p
ox
ox
U0ISJ3tun3JQ
_
s^jnp^Dajd juiin^S-ojn jo /uctntnn^
I
(q
(S
1
»A
7
7
Aiuojaajqda^
tjujsjn ajnicn; jo luatusfetu?^
___________
°A
»A
*91
°N
7
7
7
»A
I
7
7
°N
(r
Atrnjir jo 93uvu3iurY|q
sainpjjQjd 3Q3tpsarue jo .uBtucunc;
«A
(3
ojnjdnj 19/aoq smoy
((
aani jsatQ
(1
AUJ0J33)SAO3|0q3
(q
□jnssy |ruy
(S
sssosqr trutuaj
g
Adossoxaojd
(9
ssariojd rrjosy
(p
ciujaq iraipqujf)
(3
ttujaq rrutnSuj
(q
AUJO1393tOU9dd y
(e
Annex 3
Page 33 of 46
Table 3: Punjab Sen ice Norms (continued)
17. AdditionalI details oi surgical acriviries
and referrals
|
CHC
j"
Sub-Disc Hospital
| District Hospital I
30 Beds
50 Beds
100 Beds
100 Beds dt
Conditions /- Procedures
Above
I. Surgery
a)
Abscess including oreast
and perianal
b) Wound deondement
C)
Trauma 6. life support
d) Muscuio-sxeietal
e) Abdominal injuries
D
Abdominal surgeries
(planned!
g) Haemorrnoids
h) Urethral dilation
•)
j)
Incision i drainage
j Simple wounds
Incision
drainage
Simple wounds
Incision <sL
drainage
Incision &. drainage
Major jc compound
wouncs
Major di compound
wounds
! Resuscitate, stabilise Resuscitate.
s:aoiiise Investigate d:
hfc refer
refer
manage, if needed
refer
Simple manage
I Complicated: refer
| Stabilise d: refer
Invest'gate d:
manage, it needed
refer
Simple manage
I Compticatea: refer
Manage, refer if
necessary
Manage
Stabilise d: refer
| Manage
Refer
| Manage
Yes. it anaesthetist
available
"y^
"y^
Refer
Optional, if
anaesthetist
available
Manage
Manage
I Yes___________
| Refer
I Refer/yes
Rupture of bladder
urethra
I Y«
Refer
Refer
Refer
Manage, if necessx'v
Major uroiogicai
procedures
Refer
Refer
Refer
Manage, if necessar.
Stabilise £ refer
Refer it necessary
k) Fracture of spine
•• Ophthalmology
Stabilise d: refer
Removal of foreign
bodies
Removal or toreicn
bodies, manage
Management of
comeal abrasions,
ulcer
cataract
Management of
comeal abrasions,
ulcer & cataract,
glaucoma surgery
Conservative
dentistry, tooth
Conservative
denustrv. tooth
extraction, ail tvpe$
of Fillings
extraction, all rvpes
of fillings
All types of
extractions,
impactions &. jaw
fractures
comeal abrasions,
ulcer
3. Dental
Conservative
dentistry, tooth
extraction, all types
of fillings
Manage
* •
• • Tw- •
I
Annex 3
Page 34 of 46
Table 3: Punjab Service Norms (continued)
17. (confd)
|
Conditions / Procedures
Additional details of surgical activities and referrals
CMC
|
Sub-Dist Hospital
50 Beds
’
100 Beds
30 Beds
District Hospital I
I 100 Beds
Abovej
4. Castro Enterology
a) Endoscopy
Refer
Refer
Sigmoiaoscopy
Oesopnago*
gastroscopy,
colonoscopy
5. Anaesthcsiolog)
Care of airway
equipment
Care of airway
equipment,
management of
general ± regional
anaestnesia
Management of
general &. regional
Anaesthesia
Pain Clinic
Management i
general regional
Anaesthesia, and
blocks for pain relief
6. Thoracic
a)
Simple fracture rms
| Manage
b) Intercostal underwater seat Yes *
drainace tICD)
c)
Flail chest
Re$usau:e
d) Medixsunai injury
| Manage
| Manage
| Manace
Yes ’
Yes ’
Yes ’
refer | Resuscitate dL refer
Resuscueie
refer
Manage with
ventilatory suppon
| Resuscitate dL refer
Resuscitate & refer
Resuscitate dL refer
Manage, refer if
thoracotomv needed
e)
Acute empyaema
| Manage oy ICD
| Manage ov ICD
| Manage ov ICD
| Manage by ICD
f)
Chronic empyaema
Refer
Refer
Refer
Rjb resection dL
drainage. Refer if
decalcification
present.
I Yes oniy in
| emercencv
Both emergency i
elective
Both emergency <£
elective
| Refer
Refer
Manage, refer if
necessary
I Refer
Refer
Manage, if necessary
g) Thoracotomy
h) Thoracotomv
i)
Yes. oniy in
| emercencv
procedures) Refer
Foreign oodies in me
oesophagus and tracheo
bronchial tree ”
Refer
7. ENT
a) Foreign oodies m nose
ears
Nose remo\ e Ear
| remove refer
Nose a; Ear remove) Manage
b) Epistaxis
| Manage
| Manage
| Manage
| Manage
c) Peritonsillar abscess
| Refer
| Manage
| Manage
| Manace
d)
Tonsillectomy
Refer
Refer.
Manage, if ENT
specialist available
Manage
e) Mastoid aoscess
Refer
Refer
I Manage, if ENT
| specialist available
Manage
Initiate dL refer
Manage, stabilise,
refer for advanced
management
Manage, stabilise,
refer for advanced
management
Manage, stabilise,
refer for advanced
8.
Head Injury
• •••
If trainee in thoracic surcerv for one or two montns
Refer ail maior moracic
I-
|
.Manaee
management
Refer to tentarv level
I
Annex 3
Page 35 of 46
Table 3: Punjab Serv ice Norms (continued)
18. Details of Obs./Gynae problems, procedures and referrals
j
CHC
Sub-Dist Hospital
I District Hospital
f
50 Beds
30 Beds
{
100 Beds
Condirions / Procedures I
3)
High risk pregnancies,
including APH. PPH.
eclampsia
I
| 100 Beds & Above
Early diagnosis a
refer
Refer if necessary
Investigate d:
manage tf possible
Manage
b) Cenerai obstetric
I Repair
procedures eg. episiotomies)
Same as CHC
Same as CHC
Same as CHC
c) Craniotomy (dead foetus.
hydrocephalus)
| No
No
Yes
Yes
d) Forceps delivery
I Yes (performi
c)
| Yes (performi
Vacuum extraction
g) Breacn deliveries
| Refer
h) Manual removal of
placenta
Refer
«) Inversion of uterus
| Refer
J)
Rupture of uterus
| Refer
k)
i hreatened or incomplete
abortion
| Conservative D«LC
Ruptured ectopic
pregnanev
| Stabilise «£• refer
l)
m) Femue sterilisation. (CD
I Same as CHC
| Same as CHC
I Same as CHC
Same as CHC
| Same as CHC
| Same as CHC
Refer it comoiicateo I Manage
.Manage
Refer
| Refer tf complicated | Manage
o) Menstrual irregularities
Refer
I Manage
| |Manage
Same as CHC
Same as CHC
Stabilise &: refer
Laparotomy
Laparotomv
Same as CHC
Same as CHC
Same as CHC
Same as CHC
Diagnosis d:
management
Diagnosis i
management
Yes: arrange special Same as CHC
Yes: arrange special Same as CHC
programmes
I Refer
p) Infertility
| Refer
q) Planneo surgery for
prolapsed UT. DL^. etc.
Refer
r)
s)
Cervical erosion
Malignancies
(NB. Refer to tentary level
surgery
t)
Refer
Refer
Manage
Same as CHC
programmes
n) Vasectomy, laparoscopic
stenhsation
| Manage
Manage tf
anaesthetist
available
Refer
Refer
| Manage
| Manage
Refer
Manage
Manage
Refer
PAP smear, oiopsy.
&. manage
PAP smear, biopsy.
manage
Diagnose
Diagnose, manage
refer
Refer
refer
radiotherapy)
Colposcopy di
hysteroscopv
u) Reconstructive sureery
Refer
| Refer
Refer
j___
J Refer
| Yes (performi
Refer
Manage if possible
Refer
.
:/
■J
vt ■ •
‘ ~ *r-
I able 3: Punjab Service
Norms (continued)
18. (coin'd) ; Gynaecological and
I’njblcm
‘•mplicakd deliveries
bitriicted labour,
'c-eclampsia, seme
cue
obstetrical (lisonlers
Sub Diviiioimj ||OMli(i,b
District Ix’wl
Nurmal deliveries
lorcejis delivery
V.Kimm c\tr.Kinm
vernal foetal distress, etc
Hospitals
forceps derive,.es, niduemg 1.^
bxlracnon of retained placenta
I SCS
I orceps
vacuum cxirnciimi
( -Section, induced labom
1 o"‘l’''“'cd cases to be .efericd
I'l.iicm j
Kefe. all
Hinly planning
lopic pregnancy
IUD. lubeciomy. laparoscopic
Refer
sevcie hepatitis
Yes
~
laparotomy
”
Abscess drainage
fnM:,Sio" °r c>'sls- su""' of vernal va„hs
|J» risk and complicated
Medical niai.agerneni and delivery
'vic innammatory disease
I berapeimc abortion
Yes
~
JJiagnosis A drug therapy
DXC
"
I iidmiielHal bmp-v)
'vital erosion
Y^
~
y3?
Yes and LSCS
---------------
Yes
--------- -------------"
Yes
----------------------
Mymiiciiimiy
( ouiisclbng, dmg treatnieiH refer
Coniplic.itcil cases
~
- ----------
thug 11c.ilinenl
’•‘•try A secondary
fllllty
laparotomy
Kefer
-i:'»ancy
••Mni.il iiregtilaniics
<,r echnnpuu v.uh u.,11|>l.l,;1h(.,u
Kheu.s .ucompmbihiy, uncuHuolkd dnbeus
lubccioniy
Jjpnal. external genitalia
.iciialion of (clamed
11) •.tcrccimiiy
Yes
'i es
Prnpei treatment and diagnosis
Yes
Keld fo, neannau uf Ce.v.cal ca,lctI
( aiitery biopsy
Kefer for further diagnosis
if eatniciii
£0
(JQ
O
ba
O
•-»> rt>
O\ GJ
Annex 3
Page 37 of 46
Table 3: Punjab Service Norms (continued)
19. Laboratory invesrigarions
Tests
i)
Sut>-Divisional
Hospital
District
Hospital
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes
Routtne haematology
b) Routine urine and stool
c)
Communirv
Health Centre
Semen examination
d) Crme tor pregnancy
e) Sputum examination
0
Basic QiQcnemisfn'•
SugM. ur«. CfMime. cr.olestero, i bd.rub.n
ASO. CRP. VDL. HhA«.
etc.
factor. Widal
Other biochemistry
Calcium, phosphorus, uric acio
0
J)
Haemog;;ram (completei
Ofhcr Serology;
Toxoplasma. Coomb s test, etc
k) Coagulation studies
0
Advanced biochemistry
Lipid profile, liver function
t*st. CPK.
CPK-.MB. electrolytes. -:c
rn) C uliure and Sensitivity
n) Histopathology including r\AC
0) Cytology eg. PAP smear
Tabic 4: West Beng:11 Sen-ice Norms
< linicul Services ivlutcd lu:
j Rural Hospital (RII)
Sub-Divisional lluspiul / State
General Hospital
tnict tlisoiders
District llospiLil
Gastiocnicritis, bacillary
dysentery. Gl disorder (wnhom
complication), imcomplicatcd
curhoos Vn.d hepanns. malaria,
crileiic fever, akoliulic hvp.itins.
amoebic liver abveesv
All cases relened horn RII level
and paticius hum caichiiieni area
□ ml Gl disurdeiv (»villi
complication) Jaun.liic Jo..mt
All cases relened from RII &
Sl)||/SGll levels and p.iiiunis fiom
c.iichmcni .lie.i
active licpahti^ hvei ab^e-.s. G|
haenimihagc. hepato cellular
failure
Respiratory disonJen
I leural effusion, pneumothorax,
Hydro-pneumolhorox. pulmonary
I H. piicunimita. hronchu-
pneumonia, lung ahsccss. brondnal
asthma
( anlioi ascular disoniers
I lypeitension, rheumatic i'ever,
rheumatic valvular diseases
I lacinntulogical disordvis
Deficiency, anaemia
All cases relened from Hit level
and patients from catchment area
and empyema chest, mpimcd
oesophageal v.incei. COPI)
All cases relened fiom RII level
□nd patients from catchment area
□ml myocar.hal iiil.ncimn.
hypcitciisive ciKcph.ilupaih), I | \
All eases referred from l<If kvcl
and from catchment area and
purpura Icukncima. aplasnc
anaemia, haemolytic .-in.icmia
All cases relened from R|| &
SDH/SGII levels and fiom
catchment area
All cases relened from RII A
SDH/SGII levels and fiom
catchment area ami c.isev to he
managed m criiical’recoveiy caie
unit
All cases relened from Rl| &
SDH/SGII levels and from
catchment aiea
15
to
(JQ
O
CM
00
>
B
B
2> XCD
CM
1
Table 4: West Bengal Service Nunns (continued)
I Cllnicol Services related to:
Rural Hospital
Viral Disonlcrs
Sub-Divhionol Hospitals / SGH
District Hospital
chickenpox,
All cases referred from RII levels
and from catchment aica
All cases referred from RII and
SDII/SGH lewis and from
catchment area
Ul i, pyelonephritis, acute
glomenilonephritis. nephrotic
syndrome
All cases referred fiom RII levels
I and from catchment urea
All cases refened from RII and
SDII/SGH levels and from
catchment area Refer acute icnal
failure cases requnmg
haemodialysis to tertiary hospital
Eruptive fevers
measles, mumps
Renal Disoiilcrs
Endocrine disorders
Diabetes (uncomplicated)
Refer acute renal failure cases to
tertiary level lor haenxidialysis
All cases refened from RH levels
and from calchmcnl area, and
thyrotoxicosis, myxocdcina.
All cases referred from RII and
SDII/SGH levels and fioin
catchment area
Addison's disease - to he healed al
Ol’D after investigalmns at icniury
level hospital
I’.i) chulogical disuiikiN
Acute psychosis, obsession,
depression, phobia, anxiety,
All cases icleried liom RII level
and from catchment area
All cases rel'eiied Irum RII ami
SDII/SGH levels and hom
catchment area
All caSif refened lioin RII level
and from catchment area
All cases refened from RII &
SDII/SGH levels and from
catchment area and requiting
physiolliuinpy
neniosis Ciisis management due to
poisoning, intoxication and drug
withdrawal cases
Musculoskeletal disoiden
Oslcuaillii ihs Uncomphcaicd
cases of rheumatic origin
to
OQ
ft
CM >
□
o, D
O\
ft
X
CM
I
Tabic 4: West Bengal Sen-ice No
(■linicul Services related to:
Scaually Transmitted Diseases
Rurjl lluspiul
Syphilis, gonorrhoea. AIDS
(supportive)
Dermatological disonkn
Scabies, etc Drug
I*
induced allergy,
fungal mfcciion.. etc
rms (continued)
Sub-Divisional Hospitals / SGII
All cases referred fiom Illi level
and from catchment area
111V testing
All eases referred from Illi level
and from catchment area
District Hospital
All cases referred from RII &
Sf)||/SGH levels and fiom
catchment area
HIV testing
All cases ieleiicd Iruin Illi &
SDH/SGII levels and from
caiclimeni area
Poisoning eases (oigano-
phosphorous etc.)
Hefei complicated eases to
SDH/SGH and tertiaiy level when
hacmodul) sis is required
All cases referred from Illi level
and from catchment area
Refer io tcitiniy level casc>
requnimj hacmoduh :.is
Lnvirunment rvlated disonlcn
Heat stroke, chemical JL other
poison Snake bile, dog bite
other animal bite I Icctrical injury
Cases requiring haemodialysis refer
to tertiary level
All cases referred from Illi level
and from catchment area
Refer eases for haeniuJial)sis Io
tertiary level
All cases refen cd from Illi &
SDH/SGII level and from
catchment area
liefer to ternary
level Im haemodialysis
All cases referred from Illi &
SDH/SGII levels and from
c.iicliincni area ('axes redlining
haemodialysis relet to tertiary
level
(TQ
rt>
>
O 3
O 3
n>
X
O\
T;iblc4: West Bengal Service Norms (continued)
( linicnl Services rvluicd (u:
Paediatric disorders
— j---------------- -----------------Hural Hospital
’ Sub-Divisional Hospitals / SGII
District Hospital
Gastroenteritis cases Io be treated
in Diarrhoea Treatment Unit
All cases referred from RII level
and from catchment atea, and
All cases relened from RII &
SDH/SGH levels and fiom
(D1U) In patient Ircjltncnt/care
nephrotic syndrome, meningitis,
lor cases of ARI, low birth weight,
malnutrition
catchment area, and acute nephritis
encephalitis, poisoning, ARI
(complicated with stridor,
wheezing and inability io Iced or
drink), and iincunscioui patients
and gastroentetiiis with icnnl
failure
Medical cases to be referred for specialist diagnosis and treatment to tertiary level facility from
I
*
|
I
secondary level hospitals
All cases of iii.ilign.iik j
Neurological cases winch require sophisticated investigation and surgical intervention
;
■
.1
Lndocrinc disorders requiring sophisticated investigations and then referred back
•I
Stroke cases for patients below *10 years of age and unconscious
5
Terminal lung disease
6
Acute hepatic failure
7
Acute pancreatins
8
Jaundice with unconsciousness
to secondary level 01‘Ds lor follow-up
^0
to
o
>
D
Sccondaiy hypertension - cndociinc, icnal
10
Resistant cases of kalaazar
11
All cases requiring haemodialysis
° E
i_
X
i
y
Table 4: West Bengal Service Norms (continued)
( linical Services related to:
Unsic leclinit|ues
Hural Hospital (RII)
Incision <t drainage. Excision Ac
biopsy, emergency trauma patients
etc for rcsusciijtmn and
stabilisation
(•’a3lnj-lntcsiin;il disnnlcts
I IcniiiMilupby, emergency
appendicectomy Surgery on
fistula, piles. Iissuru. anorectal
abscesses, rectal prolapse
Sub-Divisional Hospital / Stale
General Hospital
All cases lefeired horn RII and
fiuni c.ilchmetii aica
All cases referred from RII and
from catchment area, and
exploratory laparotomy, obstitided
hernia, chronic A: acute
District Hospital
All cases referred from RII and
SDII/SGH levels aiid fiom
catchment area
All cases refened from RII and
SDII/SGH levels and fi om
catchment area
appendicitis, peptic pcrfoi aiiuii
mteslinul obslrudion.
intussusception volvulus, gastro
jejunostomy, diamugc of
abdominal abscess,
haem orrhoidcc tom y.
cholecystectomy
Surgery on
pneurno-pyo and haemolborax
PlOCtOsCOpy, Slgmoidtiscop)
endoscopy.
Gcnito-Urinary disonJcis
Acute urinary retention, supra-
pubhc cyslosiomy, liydiocoele.
urethral dilatation, circuincision,
vasectomy
All cases refened fiom RII & frOm
catchment nT*a, and prostatectomy,
hypospadias cases requiring
cystoscopy
All cases referred from RII and
SDII/SGH levels and patients fiom
catchment area, and ruptured
urethra A: bladder, nephrectomy
i
to
era
o
•u >
KJ ej
O
3
i.
X
O\ tu
Table *4:
( linic.tl Services rvhicd to:
( licit (lisuidcn
West Henga! Service Norms (continued)
Rur.it Hospital
Emergency tracheostomy
Sub-Divisional Hospitals / SGII
Refer, if
required, all penetrating injuries to
SDII/SGH/DII or tertiary level
i
facility
Dislrici Hospital
All cases relcrred lioin Rll .md
All cases refeiied from Rll and
from catchment aiea and
SDII/SGII levels and in addition
pneiiinoiliorax. Iiaemoihor.ix
penetfaiiiit* inpiiics rcl’ci to icihaiy
’ level
patients from catchment aiea, and
mastectomy (Ca breast)
Rclui all
pcnetiating injuries ol ihc^i to
tertiary level liospn.il
Head injuries
Hum injuiics
Refer to leitiary level
Refer io ternary level
fie.it if bums less tli.m 20% of
As for Rll
l ieat (in Bums Waid) cases with
skin area; refer oilier cases to OH
( oncer cues
Hefei
Relci to leiliatY Ihibpital
>20% of skin area al fueled
Refer
Suigciy wiih chemuihei.ipy
Hefei
Io tertiary level hospital for
4
radiotherapy
Orthopaedic disorders
Simple fracture, plastering &
All cases referred from Rll and
All cases referred from Rll Jc
reduction under general anaesthetic
from catchment area, and lacerated
SDII/SGII levels and m addition
(GA)
Shock resuscitation, linger
injur)' of limbs, amputation, pm &
patients lium catchment aiea
amputation X- Jisloc.iiiun under
plating and screw of both b.-nc, leg
I’enetiaimg nb liaclurc lefci to
GA
□ nd hands
Piostlicsis, open
turtiaiy level li.ispilal
Spinal
reduction uf clbtnv. palcllei lomy.
iraiinia icompleie tianseiimn)
skeletal tiaciion. needle aspiration
managed at Dll
of |omt & synovial Ihnd
Incomplete
li.induction, requiring surgery, refer
^5
to
QQ
n
to leiliaiy level
° 3
o
C\ CM
Tabic 4: West Bengal Service
Nonns (continued)
( linical Services dialed Io:
Hural Hospital (KII)
Dental Surgery
Constructive dentisuy
Sub-Divisional Hospitals / State
General Hospital
District Hospital
Idling &
As for R||. and jaw. diagnosis of
prcseivation of all canes tccih
Oral Surgety loodi txtmcnun.
oial cancel and oilier neoplasms
Hefcr lo leiliai) level lor
impaction X' oilier minor surgery
As lor Rll/SDII etc, and artificial
piosdicsis
radiotherapy
c g I D under local anaesthetic
All periodontal diseases, scaling X
curettage of ulceis of oial ongm
StHKical cases Io be ivfcnvd
I
In Iciliaiy level Hum svcoiidaiy level
All cases of niahgiijikj
Spinal trauma icqmiuig surgery
.1
Head injury with S 0 L
4
Penetrating injtnies of chest X brain
5
OSG. intra ocuh,. f B optlulmophsry
6
b
q
c,*0P,asry. ^Imal hgc . and cases requiring nuoro-ang.ography.
to
Dental
palnic)
All in.ibeniiii
(JQ
. .........
-U Ro,......................
o
.
g clcli bp, clel'l
>
3
3
X
Cm
I
•f
Tabic 4: West Bengal Service Nunns (conliniieil)
Clinical Scrvicei iclalcd to:
Rund Hospital (RII)
Sub-Divisional Hospital / State
General Hospital
District Hospital
:■
Uiisic services tvlulcd to :
Care of ante-natal mothers, normal
delivery, neonatal care
All cases re fen cd from RII and
from catchment area
All cases refened from RII A
SDII/SGII levels and fioin
catchment area
Complicated delivery : obstructed
labour, prr-eclsm|nia, sevetv
Emergency Caesarean section,
forceps delivery, evacuation of
All cases relet red from RII A
SDH/SGH levels and from
catchment area
iiialenial A foetal distress, etc.
lliivnlencd A incomplcle alxjilion
retained products, induced labour,
All cases refened from RII and
from catchment area, mid
laparotomy for ectopic pregnancy
management of ru.iincd placenta
A ruptured uteius
Coiiscrvatiie ticuiniciil. I) X C
All cases icfcncd liom RII A Horn
catchment area
i
k
All cases refened from RII A
SDH/SGH levels and from
catchment area
X'uginnl A citru-geniuliu
Abscess drainage. Excision of
Dartholin's cyst Repair of vaginal
v.mll, I. II A
All cases refened from RII A from
catchment area
All cases refened from RII A
SDH/SGH levels and ftom
catchment aica
High risk A complicated pregnancy
Including prv-eclampslu, eclampsia,
Rclci lu SDIl/SCilI level
Medical management wiili
delivery, therapeutic abortion
All cases refeired from RII A
SDH/SGH levels and from
catchment area
Diagnosis, DAC, drug therapy,
endometrial biopsy
All cases rcl'crrcd lioin RII and
from catchment area, and
myomectomy, hysterectomy,
All cases rcleircd from RII A
SDH/SGH levels and from
catchment area
diabetes A other medical problems
Mcnslnial invgulaiii)
(amenorrhoea, oligomenonhoea,
IXilytncnonlioca, menorrhagia,
luiitnun of the iv|Muduc(ive oigans,
prolapse of uterus, ovarian tumour
cervical polypectomy, oxaiiotomy,
pelvic Poor repair
M
I
QQ
ft
-U >
Ui D
O D
«-K
O
e\
cm
*
Tabic 4: West UengaJ Service Norms (continued)
Clinical Services rvlated Io:
Primary Jt secondary infertility
Conical erosion
Hural llospiial
Dilatation, insufflation, curettage
(BIC)
PAP smear, biopsy, cauicrisation
Sub-Divislunnl Hospitals / SGII
All eases referred fiom RII and
from catchment area, mid
laparoscopic investigation
All cases referred liom RII level
and from catchment area
District Hospital
All eases rclened from RII X*
SDH/SGII levels and patients hum
catchment area
All cases rclened from RlI &
SDII/SGII levels and patients from
catchment area
Pelvic Influniinulury disease
Management with drug therapy
(P.I.D.)
All eases referred fiom RII level
and from catchment area
All eases rclened from RII &
SDH/SGII levels and patients from
catchment area
Family planning A welfare and
reconstructive surgery
Tubal ligation (mini lap &
laparoscopy) I U C D - Cu T
All cases referred from RII level
and from catchment area
All cases referred from RII &
SDH/SGII levels and patients from
catchment area Hefei all eases
requiring microsnrgical
reconstruction of Fallopian tube
and vas deferns to ternary level
I
Cases : Branch - Gyn. A Obst 10 be n.-fened Io Tertiary Ixrcl Hospital! from Secondary Ixvcl Hospitals.
00
o>
I
All eases of m.ihgtiaiicy
•u >
2
Infertility - requrring soplrtsttcated invest,gations and rntcrosurgery to be referred to tert,ary level
o, D
o
1
Reconstructive surgery
c>
X
GJ
Annex 4
Page 1 of 5
User Charges: Existing Practices In The Four States
1.
Current Government practice in India is to provide free services up to a specific
income and service level in public health care institutions. This implies that user fees are
not charged for primary health care services including preventive and promotive care
services nor for people whose income level is below the poverty line. As a result, the
impetus for adopting user charges in hospitals for those sections of the population above
the poverty line has become increasingly important given the difficulty of securing
adequate resources for the health sector from the general public revenue of the states.
User charges are expected to provide additional revenue for under-funded public
programs, while recognizing the patients’ ability to pay and be targeted specifically for
direct health care utilization. Implementation of these general guidelines is expected to
improve access to health care services and strengthen the quality and efficiency of
services provided.
T. —
While these general principles apply to all states, the policies on user fees do not
go far enough and1 are unlikely to substantially increase supplemental revenue for the
health sector. The state Government’s policies need to take account of the quality of
services to be provided; a significant enhancement in service quality would provide a
strong rationale for enhancing the level of charges and broadening the services for which
user fees can be charged. More importantly, each state has to create a suitable
environment through adequate administrative arrangements and analytical work that
would provide a framework for a continuous review of user fees. The involvement of the
Bank has been catalytic in setting up a framework for review of users charge policies and
practices in the four states where a health system project is in place. Opportunities for
enhancing the level of these charges and the scope of services for which charges can be
levied need to be reviewed within the newly established administrative mechanism. The
existing policies and practices on user charges in the four states are described below,
followed by illustrative examples in two states that estimate the potential revenue that
would be generated by implementing the types of user charges the state Governments will
implement.
2
Karnataka
Outpatient charges. Currently, there is no charge for outpatient services. A
recommendation is before the Government to implement an annual Rs. 2 registration fee.
The intention is both to encourage patients to keep a record of their treatment and to raise
revenues. There is a charge of Rs. 5 for issuing health certificates. Half the revenue raised
as a result is retained by the doctor and half retained by the Government. Such charges
represented 40 percent (Rs. 41 million ) of total revenues collected bv the Department of
Health and Family Welfare during 1992-93.
Annex 4
Page 2 of 5
4.
Inpatient charges. The last revision of charges was made in 1988. A patient who
is a member of a family with an annual income of above Rs. 8,000 a year is to be charged
Rs. 2 per day for a bed in a general ward. Daily charges for four, two and single bedded
rooms are Rs. 5, Rs. 7.5 and Rs. 15 respectively. Of total hospital beds, paying beds
currently constitute only around 4 percent (600 out of 17,500). Fees for medical services
are listed and they are also graded. Patients in special wards pay full fees >vhile those in
paying general wards pay 50 percent of the fee. Patients in general wards pay no fees.
Average annual revenues from all charges over the period 1990-93 were Rs. 66 million —
equivalent to under 2 percent of total DOHFW expenditure. If all the charges were in
practice being levied, revenues would be greater than those actually collected.
Recommendations are before the Government to introduce a small registration fee (with
no exemption), to revise the charges for paying beds and to increase their number through
the designation of 20 percent of all additional beds as paying beds. Revisions of charges
for treatment is to be undertaken shortly, but the immediate priority is to increase the
collection of existing charges.
5.
Exemption for the Poor. The Government has proposed a new criterion for
exempting the poor. It proposes to use the existing green/tricolor card system within the
Public Distribution System (PDS) in the state, which is used to provide nutritional
support through issue of subsidized grain, as a basis for exemption from use’- fees. Green
card holders are also entitled to subsidized cloth and kerosene. AH poor families with an
annual income level of Rs. 11,850 or below (i.e., the nationally accepted norm under the
JRY program) are entitled to such green cards. Comprehensive surveys of the rural
population were undertaken in the past for identifying the beneficiaries. As of now, the
rural population with an annual income of Rs. 11,850 or below has been provided with
green cards. This includes special categories of underprivileged populations kike landless
agricultural laborers, village artisans, small and marginal farmers, old-age pensioners,
widowed pensioners as well as the urban poor. The green card facility has recently been
extended to the non-notified slums. The number of green card holders in the state are
about 5.3 million compared to the 9 million ration card holders of the PDS system. The
Government proposes to carefully monitor the green card system as a basis for exemption
from user fees and ensure that leakages are minimized.
6.
Revenue administration. An important reason why charges are under collected at
hospitals is that the revenues currently revert to the Government treasury, where they
become part of general revenues. There is no direct incentive for collection at the
institution level. The Government is taking necessary action to ensure that the receipts
will be fully transferred to District Health Committees and be reallocated between
hospitals in the district on the basis of both need and level of revenue collection.
Punjab
7.
Outpatient charges. Currently, there is a charge of Rs. 2 for outpatients. A
Government Order (GO) giving notification of (among other things) Rs. 5 registration fee
Annex 4
Page 3 of 5
was prepared in early 1994, but is still pending. The Government proposes to implement
the enhanced outpatient charges as quality improvements are effected through the World
Bank funded State Health Systems Project. In addition, it has proposed to establish ‘pay
clinics’ in Government hospitals to be operated after regular hospital hours by
Government doctors. Of the fees, 50 percent would be retained by the doctor and 50
percent retained by the institution.
8.
Inpatient charges. The GO also established sets of fees for in-service medical
facilities. These included charges for special wards in district and sub-divisional
hospitals, daily visiting charges by doctors and for laboratory investigations such as Xray, diathermy, ECG, CT scan and ultra sound and for various categories of surgery. The
proposed charges are higher than those proposed in some of the other states, but given
Punjab’s higher per capita income and lower incidence of poverty, these charges are not
out of line; moreover, the coverage of treatment is wider.
9.
Exemption for the Poor. Exemptions to the charges noted above include state
Government employees and members of families holding yellow cards which signify a
family income of below Rs. 1 1,850 based on the JRY norms. New lists of families
eligible for these cards are under preparation. Total revenue raised by DOHFW in
199j/94 was Rs. 25 million or just over 1 percent of expenditure. According to the
National Sample Survey 1987/88, almost 50 percent of hospitalized cases are in non
public hospitals. The average payment per case in these institutions was Rs. 1,200,
indicating a willingness to pay among the general population. Because of the higher
income level in Punjab, the ability and willingness to pay for services is greater than in
the other two states. As a result, there exists considerable opportunity to increase revenue
collection through increased charges and better collection methods.
10.
Revenue administration. The Government has determined that for secondary
level hospitals, the Punjab Health Systems Corporation will ensure that revenues will be
retained by the collecting institution and be used for the purpose of non-salary recurrent
expenditures.
West Bengal
11.
Outpatient charges. A structure of hospital charges was implemented with effect
from November 1992. Among the changes implemented was an outpatient charge of Rs.
1 per prescription slip (an OPD ticket, which is used on average 3 times) for teaching and
district hospitals. In 1995, a GO was issued to cover all subdivisional hospitals in the
Calcutta Municipal Corporation and all polyclinics in Calcutta. There are no exemptions
for these OPD charges. Charges for most tests and diagnoses exist - in the range of Rs.
10 to Rs. 50 - but few' are collected. A review body is currently considering some new
charges. The Government proposes to extend user fees to state general hospitals upon
improvement of services under the State Health Systems Project.
Annex 4
12.
Inpatient charges. The review of 1992 also resulted in an upward revision of
charges for private beds, diagnostic services and surgery in district and sub-divisional
hospitals. Fees are charged for 10 percent of beds (mostly in special wards). As a result of
several perceived anomalies in the structure of fees, these were again revised and
extended in early 1995. Paying bed charges in general wards are Rs. 10 a day in most
tertiary teaching hospitals and Rs. 6 in state, district and sub-divisional hospitals.
Separate room charges are Rs. 30 and Rs. 16 respectively. Charges are made for
diagnoses and for surgery for those in private beds and wards. The majority of charges
are below Rs. 50 apart from those for endoscopy and CT scan. More recently, another
review has been initiated which, in addition to surveying the levels of charges, is
attempting to rationalize them across both the secondary and tertiary sectors. Regarding
paying beds, the Government proposes to enhance these to 30 percent of all beds at
district, state general and sub-divisional hospitals. A further extension to rural hospitals
will also be considered. Another avenue for the collection of user charges are the
polyclinics in urban centers staffed largely by doctors of teaching hospitals. These
provide mainly outpatient services and charge Rs. 16-20 per visit. In 1994/95, the largest
of the polyclinics generated almost 15 percent of recurrent
i _
‘
costs with a similar amount
being paid to the doctors. Revenues generated by all charges
~ ; are currently equal to just
under j percent of total DOHFW expenditure.
Io.
Exemptions for the Poor. The existing system for exempting the poor in West
engal is based on an ‘Indigent Certificate’ from the local elected representative given to
families with an mcome level below Rs. 1,500 per month. The West Bengal Government
proposes to use this criterion rather than the JRY criterion because the latter does not
apply to large portions of the urban population of West Bengal.
14.
Revenue administration. Provisions exist for the Government, through the Finance
Department to reallocate 50 percent of the incremental funds collected through user
charges to the collecting institution. The procedures, however, are said to be very tortuous
and are rarely used. The Government has recently issued an order that it will take
necessary' actions to ensure that all revenues collected through user charges at the district,
state general, sub-divisional and rural hospitals will be retained at the district level by
.strict Health Committees, to be reallocated amongst hospitals in the district based on
both need and level of revenue collection.
Andhra Pradesh
1>
Outpatient charges. Currently, no fee is charged for outpatients, but there is a
those whose income are above the poverty line. If 50% of outpatient visits are exempted
and Rs. 1 is charged, an additional Rs. 12.5 million could be collected annually.
Annex 4
Page 5 of 5
4
16.
Inpatient charges. At the secondary level, APVVP has sets of charges for in
service medical sendees. For paying beds and wards, three types of serv.ee:; are offered,
single rooms (category' A), shared rooms (category' B) and cubicles in general wards
(category C). The Government of AP and APVVP are committed to dedicating 20% of
all beds at district and area hospitals as paying bed by the year 2002. In addition, patients
opting for paying beds in categories A and B are also charged for major and minor
surgeries. Charges for drugs, disposables and x-rays and ultrasonography tests are not
included in this package and are charged separately. The Government also proposes to set
up special outpatient clinics and offer diagnostic services for the private sector for fees set
at about the market rate.
17.
Exemption for the poor. The Government has a system for exempting those below
the poverty line on the basis JRY norms. There are some leakages in the system resulting
from the inability of hospital management to determine the income status of patients. If
these leakages are not addressed in a better manner by the Government’s present criterion
of targeting those below the poverty line, APVVP will then consider several options for
exemptions such as women with high risk pregnancies and children under 5 years of age.
18.
Revenue Administration. The Government has determined that for secondary'
level hospitals, the APVVP will ensure that 40% of revenue collected at the institution
level will be retained by the collecting institution and be used for the purpose of non
salary recurrent expenditures. The remaining funds will go to APVVP, not fhe Finance
Department, and be distributed by APVVP to remote hospitals where the needs are great
but which are not able to collect fees because of localized poverty situation of the
population.
Position: 4700 (1 views)