Neeta Rao 4A CHLP 2004 A.pdf
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Introduction -
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to the needs of the affordable class making
The private sector in health primarily caters
. While public health service is the only facility
the services inaccessible to the poor,
old decaying public hospital and health care centres are
available to them, the decades c...
unable to serve their needs.
AS an alternative to provide qual.ty health care servrces to the needy the^ concept of
•Rogi kalyan Samiti’ evolved during the catastrophic plague event of Surat m
People’s contribution was utilized for providing services that were mihally unavar a e
them, ronowmg the success of the Maharaja Yeshwantr.o hospital, i< other hospitals graduaUy. The scheme spread to more .ban 1000 osp an 6^
„ith an objective of providing different health care system (pubhe)
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autonomy to function at their best.
The sche-ne is operas in MP, Ci-isg- since mid-nineties. U assumed the form of
Xi Relief Societies in Rajasthan m 1995 »h.ch seas followed by 68 more sos.eti a
In March 2003, Childlsa Prabhodan Samiti (formerly known as -Chrkrtsa Sudhar am.
covering disrrict and combmed and base hospitals was formed m Uttaraneha .
The basic objective of all these initiatives is to improve and strengthen the Pubhe System
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through people’s participation- It thus re,u,res a nominal contribution from the people ■„
X of user fees at the time of seeking health care services from the govemmen
hospitais The fund collected Is used for improving the hospital mfmstrueture and
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of other related services. In such a scenario it is found imperative to know how
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implementation it is important to know the cost of the servrces, e '
government and by the people. This would also aid in assessmg the efficacy
scheme and in examining different alternatives.
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What is Rogi Kalyan Samiti?
Rogi Kalyan Samiti are the registered societies constituted in the hospitals as an
innovative mechanism to involve the peoples representatives in the management of the
hospital with a view to improve its functioning through levying user charges (3).
Instead of assuming a zero-sum relationship between Government involvement and
private co-operative efforts, some social capital theorists argue about the possibility of
state -society synergy. They hold the view that an active government and mobilised
communities can enhance each other’s developmental efforts. In the construction of
synergy, micro level social capital has an important place. The Rogi Kalyan Samiti
scheme in the health department is an example of how this synergy can be harnessed at
the micro level.
Inception -
Maharaja Yeshwantrao hospital a 750 bedded hospital, established in 1955, known to be
a premier institute was gradually deteriorating---- it had become a home for the rodents!
The plague scare of Surat in 1994 raised an alarm and soon attention was driven towards
the appalling condition of hygiene in the hospital. The then collector S. R. Mohanty with
the district administrator took up the task of revamping the system to change the
condition of the hospital. An appeal was made to the people for their cooperation and in
turn would also ensure transparency and accountability. Donations started pouring in,
patients were shifted to the neighbouring government and private hospitals, the complex
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was cleaned, tons of rubbish, truckloads (around 150) of junk, furniture were removed
and deweeding, external and internal baiting, sealing of the sewerage system were
undertaken to trap the rodents. Finally the rodents were killed by using poisonous gas and
disposed off in electronic crematorium. The general public was involved at every stage of
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planning. Though the physical facilities were restored there was still a general
apprehension that the system might again collapse unless an administrative structure is
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inbuilt within the system to ensure its permanency. It was thus decided to adopt the
following strategy
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Undertake a scientific reallocation of available space to improve efficiency.
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Redefine administrative responsibilities.
•
Introduce user charges to strengthen resource base.
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Establish a management structure to ensure smooth running of the hospital.
This was named as ‘Rogi Kalyan Samiti.’
In the first year, a handful of districts, especially those close to medical colleges adopted
the scheme. In 97-98 almost all the district in the state adopted it, while in most districts
the initial work was done in the district level hospitals, there were several smaller
hospitals where local officials started the scheme. After a review in 1999, the government
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issued instructions that gave sweeping powers to the Samitis and the objectives and the
duties were expanded1.
Highly impressed with this novel programme, Chief Minister Digvijay Singh issued
directive for the implementation of this program in all the district level public hospitals in
the state. The RKS was reportedly formed in “more than half of the nearly 1,200 public
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hospitals in the state and “an estimated Rs. 37 — 40 crore” was raised across undivided
Madhya Pradesh in the five years and spent on the improvement of the hospital (India
Today, January 8, 2001)
We see decentralisation as the strategic architecture for democracy to become articulate
in our country. It is essential architecture to make democracy full-blooded and fullthroated. Decentralisation has intrinsic merit as an enabler of democracy by maximising
participation.’
- Digvijay Singh.
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The poor patients who could not afford to pay for the services were exempted from
paying the user fees and treated free of cost. They were not required to bring any
testimony to prove their poor state of being.
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‘Rogi Kalyan Samiti.’- Structure1-
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The basic structure of the Rogi Kalyan Samitis is as follows
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RKS would be a registered society and be set up in all medical colleges, district
hospitals and community health centres.
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It would have people’s representative, health officials, local district officials,
leading members of the community, representatives of the IMA, members of the
urban local bodies and Panchayat Raj representatives as well as leading donors as
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their members.
For its functioning it shall be deemed not as a government agency, but almost as
an NGO.
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It could utilize all the government assets and services to impose user charges. It
would be free to determine the quantum of charges on the basis of the local
circumstances.
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It could raise funds additionally through donations, loans from financial
institutions, grants from government as well as other donor agencies.
It could utilise surplus land available in the hospital for commercial purposes or to
construct shops and lease them out.
It could take over and manage canteens, rest houses, stands, ambulance services
and other facilities within the hospital complex owned or managed by the
government.
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Private organizations offering high tech services like Pathology, MRI, CAT Scan,
Sonography etc. could be permitted to set up their units within the hospital
premises in return for providing their services at a rate fixed by the RKS.
The funds received by the RKS will not be deposited in the state exchequer but
will be available by the executive committee constituted by the RKS.
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As a result of the RKS system coming into effect, the government would not
reduce its budgetary allocation traditionally received by the hospital.
Objectives of RKS2 -
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1. Improve the management of the hospitals with community participation.
2. Up gradation of health institution, modernisation of health facilities and purchase of
equipment for institutions. Effect a continual up gradation of facilities.
3. To ensure discipline and monitor accountability.
4. Provide assured ambulance services for emergencies and during accidents.
5. To establish public private partnership for betterment of the institution.
6. Maintenance & expansion of hospital building.
7. To develop the unused extra land of the hospital for commercial purposes as per the
guidelines of the state government for strengthening the financial condition of RKS.
8. Increase community participation.
9. Organise training & workshops for staff members.
10. Ensure adequate and safe disposal of hospital wastes.
11. Arrange for good quality diet and drugs and stay arrangements for the relatives of the
patients. Ensure equity through provision of free treatment to patients below poverty
line.
12. Ensure proper maintenance of hospital, wards, beds, equipment, cleanliness of
premises.
13. Monitoring & supervision of National Health Programs.
14. To obtain loans from banks & financial institutions for development & up gradation
of medical facilities in hospitals.
Constitution of RKS2-
Rogi Kalyan Samiti have been set up at vari
various level of hospital
1. District hospital.
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2. Civil hospital.
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3. Community Health Centre.
4. Primary Health Centre.
Rogi Kalyan Samiti at each level has two bodies for its effective functioning, General
body and Executive body.
District hospital
General body -
I/C Minister of the district
Chairman
President Jila Panchayat
Member
Mayor of Municipal Corporation
Member
Collector
Member
Superintendent Police
Member
Chief Medical Officer
Member
MLAs of district
Member
President of Health Committee
Member
Municipal Corporation/Municipality
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Senior MO of hospital
Member
Municipal Commissioner
Member
CEO Zila Panchayat
Member
Ex. Eng. PWD & PHED
Member
Secretary Red Cross
Member
President IMA
Member
Two Donors (donated Rs. 50,000)
Member
Nominated by Chairman
Two social workers nominated by the chairman
Member
Civil Surgeon cum Hospital Superintendent.
Member
Executive body -
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For managing day to day functioning of the Rogi Kalyan Samiti Executive Committee
have been given certain powers. The composition of executive body is as follows -
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Collector
Chairman
Municipal Commissioner
Member
CEO Zila Panchayat
Member
Chief Medical Officer
Member
Senior MO of hospital
Member
Ex. Eng. PWD
Member
One Donor (donated Rs. 50,000)
Member
Nominated by Chairman
Civil Surgeon cum Hospital Superintendent
Member
Tehsil & Block Level Hospital Rogi Kalyan Samiti
The Community health centres, Civil hospitals and other hospitals at the tehsi & Block
level come under this category. The composition is as follows -
MLA of the area
Chairman
S.D.M.
Member
President Janpad Panchayat
Member
President of Municipality
Member
President of Health Committee of Municipality
Member
CEO Janpad Panchayat
Member
One parshad of area
Member
S.D.O., PWD, PHED
Member
Two Donors (donated Rs. 80,000)
Nominated by Chairman
Member
Senior MO nominated by CMHO
Member
Block MO I/C MO Hospital
Member Secretary
Executive body
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SDM
Chairman
President Janpad
Member
CEO Janpad Panchayat
Member
S.D.O., PWD
Member
Senior MO nominated by CMHO
Member
Block MO I/C MO Hospital
Member Secretary
Other Health Institutions/Dispensary/PHC
General Body -
Janpad Panchayat member of area
Chairman
President Nagar/ Gram Panchayat
Member
President of Municipality
Member
President of Health Committee of Nagar/ Gram Panchayat
Member
Nagar/ Gram Panchayat female member
Member
Sub Eng. PWD & MPEB
Member
Two Donors (donated Rs. 10,000)
Member
Nominated by Chairman
Tehsildar/Nayab Tehsildar
Member
I/C MO Hospital
Member Secretary
Executive body -
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Tehsildar/Nayab Tehsildar
Chairman
President of Health Committee of Nagar/ Gram Panchayat
Member
Sub Eng. PWD & MPEB
Member
I/C MO Hospital
Member Secretary
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District Level Rogi Kalyan Samiti2
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Chairman Executive
Committee
Collector
ZP President Mayor
President Health
Committee MC
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MLA 2 Non Govt.
Member 2 Donors
Chairman
Minister
I/C of the
District
Sec. Red Cross
President IMA
Suptd. Police
EE PWD
EE MPEB
CEO ZP
Municipal Comm.
CMHO
1-Senior doctor
Member Secretary
Civil Surgeon cum
Hosp. Suptd.
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Powers and responsibilities of General body of RKS-
1. The general body shall meet at least twice in a year. However the Executive
Committee or 1 /3rd members on request can call meetings of RKS.
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2. The newly constituted RKS shall hold its meeting within 3 months and shall elect its
office bearers.
3. The Executive committee can call the special meeting of the old RKS General body
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and this body can amend objectives, membership, change in rules and regulations or
it can approve the removal of the left out members from the list.
4. The chorum of the General body shall be l/3rd of the members.
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5. The General body shall take the policy decisions and it will be implemented by
Executive Committee under rule 10 of the constitution of RKS.
6. General body can authorise the Executive Committee for implementation of
functions, it can delegate financial powers to members of Executive Committee and
also approve financial proposals that are that are beyond the powers of the Executive
Committee.
7. The General body shall review the financial account at least once in a financial year,
review the income & expenditure statements and shall approve the budget for the next
year.
8. General body shall have powers to appoint chartered accountant and can constitute
sub committees for specific purposes such as new construction and commercial use of
land.
Powers and Responsibilities of Executive Committee -
1. The Executive Committee will meet at least once in two months. The chorum will be
of 50% members. The presence of the Chairman will be essential.
2. Executive Committee will perform its day to day functions with existing manpower.
3. Executive Committee will implement the decisions taken by GB and will function
within its powers invested by GB.
4. Executive Committee can delegate its financial powers to the member secretary.
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5. Executive Committee shall have authority of raising the funds for the activities
approved by GB e.g. new construction, equipment purchase, and modern
investigative facilities. It shall have the authority to take loan from banks.
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6. The Executive Committee can appoint cleanliness staff, para medical staff, and
security guard and part time employees on contract.
7. Executive Committee will levy user charges from the patients and facilities given for
their relatives.
8. Executive Committee can purchase equipment, drugs, furniture, pathological
reagents, X-Ray films in consultation with the Sr. MO for quality purchase.
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Devolution ofpowers
The government authorised the RKS to manage the existing facilities and assets of the
concerned hospital. RKS has been given the freedom for operations, management and
investment to meet service requirements. The RKS is empowered to mobilise resources
through levy of user charges.
It allows commercial use of assets like land of the institution, donations in cash or kind
from the public at large and allotments/Grants from the government or non-government
bodies & loans from financial institutions.
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Levy of user charges -
User fees are considered not only a tool for ensuring efficient use and equitable financing
of public services, but also as an investment, guide, because consumers’ willingness to
pay for services in many instances is considered to be the only way in which the benefits
of a service can be ascertained and compared with the cost of providing the service.
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The guidelines for user charges are as follows —
Charges must be levied for all facilities provided in the hospital including the outdoor
patient ticket, pathological tests, indoor beds, specialised treatment, operation, etc.
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The economically weaker sections of the society and other groups as determined by the
government (for e.g. persons below the poverty line, freedom fighters, etc.) would be
exempt from the levy. Identification would be based on self-certification. The charges for
general ward would be nominal while those for private wards would be higher. Funds so
received would be deposited with the RKS and not in the government exchequer.
Implementation -
The Executive Committee acts as a watchdog to oversee the day to day functioning.
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People’s representatives on the RKS facilitate social audit. The activities of RKS are
monitored by the members of the district government and the Minister In-charge of a
district is also the President of district level RKS which ensures effective supervision.
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Other studies on Rogi Kalyan Samiti -
A study conducted by Girish Kumar3, for the 18th European Conference on Modern South
Asian Studies, is based on data collected from 9 hospitals in selected five districts of
Madhya Pradesh which is primarily a documentation of the innovative reform scheme
critically examining the decision making process and sharing of responsibilities by the
different stakeholders. It also aims at assessing the strength of institutional arrangements,
transparency and accountability of the new management structure. The study shows that
the scheme has heralded a major initiative to reform the near defunct government
hospitals in Madhya Pradesh by enforcing accountability of the staff, transparency in the
use of available resources, and above all providing more facilities to the patients without
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putting financial burden on the state exchequer. However the patients interviewed in few
hospitals were not content, monitoring is limited as it is more attuned to observing
procedures than an exercise in ushering dynamism in the functioning of the RKS. The
main actors of the scheme seem to be complacent, even saturated with their performance
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as if they have reached the end of the journey. There is hardly any organised effort to
bring about a change in the behavioural pattern, work ethics, inject the sense of duty and
mould the traditional mindset of the health functionaries in order to make them de facto
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agents of change. However it has been able to demonstrate that the huge infrastructure
created in 1970s and 1980s could be saved from going waste in the face of ever shrinking budgetary allocation if reforms in these lines are introduced with little
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innovation.
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An article on Rogi Kalyan Samiti1 states that a total of Rs. 350-400 million have been
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collected by the various districts through donations and user charges, MPs and MLAs
have earmarked funds out of their discretionary local area development funds for
improvement of the health institutions. The district Red Cross Societies have been
functioning in tandem with RKS and in fact been more active of late with the expenditure
jumping to Rs. 70-80million in 94-99 from 4 million in 1990-1994. Daily collection in
each of the hospital depending on the location is around Rs. 500 to 25000 and a
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conservative estimate of monthly collection of Rs. 25 to 30 million which is still on
increase. It states that the social benefits due to the implementation of RKS is both direct
and indirect, improving both the quality of service the acceptance and the willingness to
pay. However there is no evidence of any study showing the willingness to pay or for the
acceptance of service and satisfaction. It has been assumed that it is acceptable, as there
have been no protests in the entire state over the introduction of user fees. The study
states that there has been improvement in the efficiency of the doctors, arresting the
deterioration in the hospitals and increase in the number of patients coming to the
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government hospitals after the introduction of user charges reflecting their willingness to
pay.
Similarly some hospitals have been adopted by Rajasthan State to provide better services
in medical field which has been documented by Dr. A.S. Bapna in a Handbook for
General guidelines for Rajasthan Medicare Relief Societies4. It states that to improve
resources to primary health care it is necessary to evolve a process by which state
resources can be conserved at secondary and tertiary level of health care and hence
RMRS was constituted. However the irony is that to improve primary health care,
resources are being generated and utilised at secondary and tertiary level. It aims to
provide autonomy and convenience in utilisation of resources. However all the
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requirements to utilise the resources is reserved with the community composed of
technocrats thereby breeding hierarchy and systemic approach.
An exhaustive study2 on the RKS in Madhya Pradesh since the time of inception to 2001,
suggests that once the management of the hospitals improved, the MPs and the MLAs too
came forward in earmarking funds out of their discretionary local area development funds
for improvements of health institutions. District Red Cross Societies too started
functioning in tandem; and around Rs. 40 lacs were spent on the hospitals. Various
ancillary services like Pathology, Sanitation, MIS, Security and Canteen services have
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been introduced in phased manner. The net gainer being the consumer as the rates are
almost 30% lower than elsewhere. On an average Rs. 10 lakhs have been generated per
district per year. The pattern of resource mobilisation does not indicate sustainability as
the major amount of funds were generated from non medical sources like donation. The
resource mobilisation is only up to 50% from medical resources. It is stated that there is a
need to augment the resource mobilisation from medical sources like special
investigations, surgical procedures, ambulance services & pathological investigations.
There is a mis match in income generation and expenditure pattern. The study shows an
improvement in the utilisation as the number of patients from middle class have
increased, though there is no direct evidence of increase in below poverty line patients.
As the below poverty line patients are exempted from user charges, the number of BPL
patients is believed to not have reduced.
Analysis of the report shows the positive evidence of increase in the specialised
investigations like ECG, X-Ray, number of blood transfusions but there is a decline in the
routine blood test in many districts.
Aim of the study -
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To estimate the cost effectiveness of the Scheme.
Objective of the study —
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& To analyse the costing pattern of the government health care providers (district
hospitals/CHCs) vis-a-vis the collections made under the Rogi Kalyan Samiti.
To study the utilization of the funds from Rogi Kalyan Samiti.
Sampling -
For the purpose of the study three CHCs from three different districts- Raigarh (Pusaur),
Jhanjgir (Baloda) and Ranker (Charama) were selected and district hospital of Raigarh
and Jhanjgir were selected. This is a purposive sampling based on the criterion of
availability of information and accessibility.
The CHC is conceived as a 30-bed secondary referral centre, the most important
component of secondary referral along with the district hospital, though the norm expects
a CHC to cover one lakh population, on an average 1.5 lakh population are covered per
CHC in Chattisgarh. There are 121 CHCs in 16 districts of the state.
Methodology -
The following information was obtained from the health centres 1. The salary of the overall hospital staff and those specially appointed by RKS.
2. The staff pattern and the different units in the hospital and the number of hours
spent by the staff especially the doctors in different activities.
3. The tariff rate for the different services provided under RKS.
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4. A statement of the income earned and the expenditure made under RKS.
5. The number of OPD patients, IPD patients, Operations conducted (both major
and minor)
6. The number of deliveries conducted and number of L.S.CS.
7. The total number of injections administered to the Out patients and the number of
X-Rays, USGs and CT Scans conducted.
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8. The details from the stock register as to the number of equipments purchased, the
medicines purchased and dispensed, etc.
With the aid of the aforementioned data, and making the following assumptions the cost
for the different services were computed-
1. The annual capital expenditure by the hospital in the form of depreciation for its assets
is assumed to be 10% of the total, while that for the staff salary is assumed to be 60% and
the expenses on water/electricity/maintenance/repair and consumables is estimated as 5
and 25% respectively. Though this is not expected to be same for all the institutions
especially the district hospitals and the CHCs, the assumption has been kept uniform.
Based on the aforementioned assumptions, the total expenditure made by the hospital has
been estimated.
2. The total number of patients having sought services from different units is multiplied
with the rate of service to obtain the total income in the respective units. This figure has
been further discounted by around 60% (43% for BPL and remaining for other waive off)
to estimate the net income under Rogi Kalyan Samiti. This figure is very close to the
income mentioned in the statement of income and expenditure of RKS, though not the
same.
The computation of the income unit wise was essential to estimate the cost recovery per
unit and to compare with the actual allocation of the fund to the respective units.
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3. The data was available for different periods and hence has been adjusted to obtain the
annual figure to allow comparison.
4. The expenditure has been apportioned for different units as follows OPD
IPD
OT
LAB
PHR
INJ
X-RAY ADMIN Total
25%
22%
16%
6%
6%
To%
7%
8%
100%
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1. Jhanjgir -
Premises -
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As mentioned before based the Jhanjgir district hospital was selected on the geographical
accessibility and availability of information. The district Jhanjgir-Champa is situated in
the center of Chattisgarh and so it is considered as heart of Chattisgarh and the district
hospital is situated at the heart of the district around 2 kms. from Naila station which is
around 175 kms from the state capital Raipur. The district covers 13,16,140 population in
9 blocks, of which 43% are below poverty line (Article by Myra MacDonald - New
Indian State Pioneers free market reforms - Internet). The health care facilities available
to the people are around 10 PHCs, 6 CHCs, 211 SCs and one district hospital besides
other private services.
District Hospital-
The district hospital building is located on
acres of land of which
acres is
unutilized. The building was constructed in 1956 to serve the primary health care needs
of the people. It was converted to district hospital in 1998 and is manned by 45
employees. The remuneration for 3 staff viz - 1 radiographer and 2 sweepers is met
through Rogi Kalyan Samiti and hence they are called contractual employees under Rogi
Kalyan Samiti. The staff pattern has been given in the Annexure I. As per the existing
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staff both the manpower and the infrastructure are far below the requirements of the
hospital.
It is a 28 bedded hospital with the following units under the control of the Civil Surgeon.
The different departments in the hospital Outdoor services. Indoor facilities, Laboratory services, Operation Theatre, Labour room,
Pharmacy, X-Ray Centre, Dressing room, Injection room, Ophthalmic centre,
Administration.
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As mentioned before in the general description of RKS, the charges for different services
are fixed by the Committees.
The tariff for different services in Jhanjgir district hospital is as follows -
2
Unit/Service____________
Haemoglobin___________
Total & Differential counts
ESR__________________
Urine-Sugar/Albumin____
Urine-Routine/Microscopic
Blood Grouping_________
UPT__________________
Urine Bile salt pigments
Blood- B.T.C.T._________
Blood sugar - Calorimeter
Blood sugar - Glucometer
Serum bilirubin_________
Blood urea_____________
Widal_________________
V.D.R.L._______________
Australian Antigen ‘B’
Hepatitis ‘C’____________
X-Ray charges__________
12X15_________________
10X12_________________
8X10__________________
4
6X8
Sr. No.
J___
2 ____
3 ____
4 ____
5 ____
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6 ____
7 ____
8 ____
9 ____
10 ___
11 ___
12 ___
13 ___
14 ___
15 ____
16 ____
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Current rates in Rs.
_5______________
5______________
10_____________
5______________
10_____________
10_____________
30_____________
10_____________
10_____________
10_____________
30____
15_____________
10_____________
10_____________
10_____________
45
45
45
25
25
Revised rates in Rs
5______________
10_____________
10___________
5______________
10_____________
20____________
40_____________
10_____________
10_____________
20_____________
30_____________
20_____________
20_____________
20_____________
20_____________
60_____________
140
35
35
20
20
Unit wise Cost analysis -
OPP Clinic -
The OPD services are provided in two rooms, one in which the Civil surgeon sees his
patient and the other larger one in which 4 Medical Officers examine their patients. None
of the rooms have an examination table and there is a lack of privacy for the patients.
However, while the larger room is well illuminated and ventilated the smaller room lacks
appropriate light supply. There is only 1 small 4 feet long bench for the patients to be
seated, while waiting to be seen by the doctors.
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The OPD timings are 8.00 am. to 14.00 pm. and from 16.00 pm. to 18.00 pm. thereby
amounting to 8 hours. However the clinic starts not before 10.00 am and closes around
17.30 pm.
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The total number of patients seen in nine months (April to Dec, 03) is 37523. The
average number of patients seen in a month is around 4169. Thus the average number of
patients examined/treated in a day is around 175.
Assuming that of the total expenditure 25% is spent on OPD services the annual
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expenditure on OPD is Rs. 1743049. Thus expenditure per patient comes to Rs. 35. This
however excludes the cost for pathology and X-Ray. The cost of these services would be
taken separately. As the data for Indoor and Outdoor patients getting services in the
aforementioned units is not separately available, it is not possible to estimate the separate
cost for these services (X-Ray, pathology, etc.) for Out door patients. Rs. 35 per patient is
inclusive of the staff salary, maintenance & repair, cost of consumables and the capital
cost.
The registration charge per patient is Rs. 2 for out patient service. This amounts to around
Rs. 1,00,061 in a year. If 60% of the total patients were given free treatment (BPL,
pensioners, etc.) the income through OPD would be Rs. 40024. Thus of the total
expenditure on Out patient services around 2.3% is recovered from the patients.
Indoor Services -
It has two wards one for the male patients and the other of the female patients. In all there
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are 28 beds, the average bed occupancy being---- The average length of stay is around 3
to 4 days. The total number of patients admitted in 9 months (April to Dec, 03) is 154.
The average number of admission per day is either one or nil while the monthly
admission is around 17.
Assuming that of the total expenditure, 22% is spent on IPD services the annual
expenditure on Indoor patients is Rs. 1533883. Thus expenditure per patient comes to Rs.
19
I
1643. This is inclusive of only the staff salary, building cost, maintenance & repair cost
and cost of consumables. The recovery from the patient’s contribution is 0.21%. This
excludes the cost of X-Ray, lab investigations, surgical procedures & delivery (including
L.S.C.S).
Laboratory -
The laboratory is located in a small room close to the entrance and is congested. The
laboratory can conduct normal tests like blood, sputum, urine, malaria, etc. but
microbiological cultures and histopathology are not available. The total number of
investigations done in seven months (Jan, 04 to July, 04) is 12651, the details being
available in the Annexure. The total income generated through the laboratory could be
around Rs. 96119. If 60% of the patients being either pensioners or BPL were waived off
the fees, the income from pathological tests would amount to Rs. 98865.
Assuming 6% of the total expenditure would be on laboratory the net expenditure comes
to Rs. 418332. Thus the cost recovery from the patients contribution amounts to 15.76%.
[As the detailed profile of the Pathological tests is not available, to estimate the
collections from the lab facility the following assumptions have been made.
1. If around 350 ANC cases are seen, and assuming that at least 80% of them would have
done UPT, the actual number of UPT done in a year would be around 280.
Assuming that the remaining 60% would be for Routine/Microscopic Urine. 20% for bile
salt and remaining 13% for blood sugar the total collection from Urine examination sums
I
I
to Rs. 38744
2. For blood investigations assuming that the cost of each test could have been Rs. 10, the
total income from blood investigations could be taken as Rs. 44600.
20
I
3. From other blood investigations considering that only around 5% would have
:T'
1
undergone Australia Antigen test for Hepatitis ‘B’, and around 20% for Serum bilirubin,
the income under this head amounts to Rs. 11615. ]
X-Ray-
The X-Ray department is manned by a radiographer appointed under Rogi Kalyan Samiti
on contractual basis. He therefore does not enjoy other benefits like pension, provident
fund, etc. Moreover his salary is lower than the other technicians.
The total number of X-Rays done in a year is 2320. The detailed classification of X-Rays
done in the month of Oct, 2004 is available in the Annexure. The estimated income from
X-Rays for a year after discounting for the free patients is Rs. 41520. The total
expenditure on the patients for X-Ray being Rs. 488054, the cost recovery is 8.51%.
Operation Theatre —
There is only one OT in which both minor and major surgeries are conducted. The total
number of Major surgeries conducted in 2003- 2004 is 30, while only 28 minor surgeries
I
I
have been conducted. The total number of Caesarean Sections done is 3.
The minor surgeries are not charged and for major surgeries Rs. 25 is charged. For 30
major surgeries this sums to Rs. 750 which on discounting for waive off comes to Rs.
300.
21
Li
Allocation of funds for different units from RKS -
I
I
I
Unit
Fund Allocation in Rs.
Medicines
X-Ray
51716(30%)
33001 (19%)
2467(1%)
Lab
Labour
Estimated fund generation in
Rs.
41520 (27.49%)
65910(43.64%)
32884 (19%)
2837 (22%)
Advertisement/Publication
Hospital Exp and Meetings
38057 (1%)
NA
1720 (2%)
NA
BPL
3784 (2%)
NA
Other Exp
3477 (4%)
NA
The fund allocation is independent of the fund generated by each of the units. The
hospital was converted from a community health centre to a district hospital around 5 yrs.
ago and the requisite number of manpower and infrastructure are yet to be increased.
Provision of medicines, which is primarily government’s responsibility, is met by the
fund collected from RKS.
With the expansion of services more facilities are required to handle the additional
caseload, especially in the provision of Lab services. However over the past five years no
attempt has been made either to provide more technicians or to improve the
infrastructure.
Total income generated under the scheme is Rs. 172867 while the amount spent from this
fund is Rs. 169943, which is 98% of the total. The estimated overall hospital expenditure
is Rs. 6972196 and hence the cost recovery is estimated to be 2.5%, i.e. of the total
expenditure only 2.5% is met through the RKS fund.
22
I
■
■
Allocation of funds for different units from RKS -
r
Unit
Fund Allocation in Rs.
I
Medicines
X-Ray
Lab
51716(30%)
33001 (19%)
2467(1%)
32884 (19%)
2837 (22%)
38057 (1%)
1720 (2%)
3784 (2%)
3477 (4%)
Labour
I
Advertisement/Publication
Hospital Exp and Meetings
BPL
Other Exp
Estimated fund generation in
Rs.
41520 (27.49%)
65910(43.64%)
NA
NA
NA
NA
The fund allocation is independent of the fund generated by each of the units. The
hospital was converted from a community health centre to a district hospital around 5 yrs.
ago and the requisite number of manpower and infrastructure are yet to be increased.
Provision of medicines, which is primarily government’s responsibility, is met by the
fund collected from RKS.
With the expansion of services more facilities are required to handle the additional
caseload, especially in the provision of Lab services. However over the past five years no
attempt has been made either to provide more technicians or to improve the
infrastructure.
Total income generated under the scheme is Rs. 172867 while the amount spent from this
fund is Rs. 169943, which is 98% of the total. The estimated overall hospital expenditure
is Rs. 6972196 and hence the cost recovery is estimated to be 2.5%, i.e. of the total
expenditure only 2.5% is met through the RKS fund.
22
I
i.
f'
The cost recovery from different units is as follows -
I
Cost Recovery from user fees
r
20
E
t
I
15.76
_
15
F
§o o5 w
£ §.
V)
o
O
8-5.1
5
—2.3 ~
r n
0.21
0
i K_.r-
OPD
Indoor service
Laboratory
n-___ __
X-Ray
Units
The estimated cost recovery is more from Laboratory services and X-ray. This implies
that the number of investigations suggested to the patients is more. These are supportive
services and though aid in diagnosis and hence in treatment, they do not directly benefit
the patients in terms of relief from diseases. These departments can also be seen as
revenue generating units!
Community Health Centre-
On an average 1.18 lakh population are covered per CHC in Jhanjgir. Baloda CHC is
located around 50 kms. from Naila station. The RKS was constituted here in 1996.
It is a — bedded hospital with the following units - Outdoor services, Indoor facilities,
Laboratory services, Operation Theatre, Labour room, Pharmacy, X-Ray Centre,
Dressing room, Injection room, Administration.
Note- As the number of indoor patients is par less than the out door patients and the
number of minor surgeries conducted are also less, the expenditure apportioned for
different units in a CHC are as follows -
23
I
I
I
I
OPD
IPD
OT
40%"
5%~
5%
LAB
PHR
INJ
X-RAY ADMIN Total
To%
10%
To%
100%
OPP Clinic -
The total number of patients seen in a year (April 03 to March 04) is 33172. The average
number of patients seen in a month is around 2764. Thus the average number of patients
examined/treated in a day is around 92.
Assuming that of the total expenditure 40% is spent on OPD services the annual
expenditure on OPD is Rs. 3947625. Thus expenditure per patient comes to Rs. 119. This
however excludes the cost for pathology and X-Ray. The cost of these services would be
I
taken separately. Rs. 119 per patient is inclusive of the staff salary, maintenance & repair,
cost of consumables and the capital cost.
The registration charges per patient is Rs. 2 for out patient service. This amounts to
I
I
around Rs. 66344 in a year. 14% of the total patients were given free treatment (8% BPL,
pensioners and others 6%) the income through OPD would be Rs. 57056. Thus of the
total expenditure on Out patient services around 1.4 % is recovered from the patients.
Indoor Services —
The total number of patients admitted in a year (April 03 to March 04) is 76. Assuming
that of the total expenditure 5% is spent on IPD services the annual expenditure on
Indoor patients is Rs. 493453. Thus expenditure per patient comes to Rs. 6493. This is
inclusive of only the staff salary, building cost, maintenance & repair cost and cost of
consumables. The recovery from the patient’s contribution is 0.21%. This excludes the
cost of X-Ray, lab investigations, and surgical procedures.
24
The details on income expenditure are as follows !
RKS - Expenditure___________
Ambulance-Maintenance_______
Equipment-Repair & Maintenance
Medicines___________________
Hospital Maintenance__________
Eye Camp___________________
Staff salary___________________
Other expenses_______________
Total
t
I
RKS-Incomc____
Donation________
OPD Registration
IPD Registration
Delivery charge
Other income_____
X-Ray__________
Blood Investigation
Urine___________
Other Investigation
Eye Exam_______
Eye camp________
Ambulance charge
Others__________
Total
2001-02
2002-03
1315
2340
380
37358
200
4778
43651
2001-02
16556
23836
1415
Total
14813
3655
1795
Percentage
14.29
3.53
1.73
9589
2400
4063
18772
2100
17800
5133
41261
49047
20400
13974
103684
47.30
19.68
13.48
100
2002-03
2003-04
2220
45768
500
1300
850
340
440
350
3650
1540
4725
11050
3096
75829
Total
18776
111752
950
2200
870
4290
1255
925
6235
3820
25375
11050
3504
191002
Percentage
9.83
58.51
0.50
1.15
0.46
2.25
0.66
0.48
3.26
2.00
13.29
5.79
1.83
100
1170
175
65__
300
860
10000
42148
450
750
20
2780
640
510
2285
1420
10650
53112
408
62061
150
2003-04
14813
The maximum income is from OPD patients while the maximum expenditure is on eye
camp.
A generator has been purchased from the contribution of patients. However during power
cut it could not be used as it was out of order. The accountant was very displeased with
the system and stated that though a scheme like this is operational for patient’s welfare,
even despite of frequent power cut the officials do not grant permission to buy even
inexpensive candles.
25
I
Trend in Income Vs. Exp
250000
200000
OT
Qi
.E 150000
3
O
□ Income
100000
O Expenditure
E
<
50000
0
2001-02
2002-03
2003-04
Total
Year
The income through RKS has shown consistent increase over the years, which is not
I
I
congruous with the expenditure pattern. A huge amount is left unspent.
Raigarh -
Premises Situated on the eastern border of Chattisgarh, Raigarh district covers an area of around
6,836 sq km. It covers a population of 12,65,084 and is around
kms. from the state
capital Raipur. There are 7 CHCs covering on an average 1.8 lakh population per CHC.
District Hospital -
It was started as a 117 bedded hospital, which was further, expanded to 190 beds in 1995.
Facilities of delivery, eye, child, surgical, medical, T.B. and burn unit are available here.
Dental treatment facilities are also available in this Hospital along with those of X-Ray,
Blood Bank, Pathology and I.C.U. Ward. District Rogi Kalyan Samiti at district hospital,
Raigarh for the welfare of the patients was established during the month of October, 1995
with public contribution. The Samiti with the help of public collected Rs. 42,92,969.00
for different facilities. In 1998-99, the District Rogi Kalyan Samiti made available an
amount of Rs. 2,45,392.00 for construction of two I.C.U. Rooms.
26
i
L-
Indian Red Cross Society, Raigarh branch was established during the year 1991-92 and
with the help of public Rs. 1,27,53,952.00 was collected till 2002 of which Rs.
91,14,869.00 was expended. During the year 1997-98 an amount of Rs. 12,09,023.00 and
I
during the year 1998-99 an amount of Rs. 11,43,337.00 has been expended for different
types of works.
!
Unit wise costing
OPP Clinic -
I
The OPD timings are 8.00 am. to 14.00 pm. and from 16.00 pm. to 18.00 pm. thereby
amounting to 8 hours. However the clinic starts not before 9.30 am and closes around
17.30 pm.
The total number of patients seen in a year (Jan to Dec, 03) is 136555. The average
number of patients seen in a month is around 11380. Thus the average number of patients
examined/treated in a day is around 438 in different departments.
Assuming that of the total expenditure 25% is spent on OPD services the annual
expenditure on OPD is Rs. 6730984. Thus expenditure per patient comes to Rs. 49. This
however excludes the cost for pathology and X-Ray. The cost of these services would be
taken separately. As the data for Indoor and Outdoor patients getting services in the
aforementioned units is not separately available, it is not possible to estimate the separate
cost for these services for Out door patients. Rs. 49 per patient is inclusive of the staff
salary, maintenance & repair, cost of consumables and the capital cost.
I
The registration charges per patient is Rs. 2 for out patient service. This amounts to
around Rs. 2,73,110 in a year. Around 53% of the total patients were given free treatment
(BPL, pensioners, etc.) thus the net income from out patients is Rs. 129440. Thus of the
I
total expenditure on Out patient services around 1.9% is recovered from the patients.
27
I
I
Indoor Services -
Assuming that of the total expenditure 22% is spent on IPD services the annual
expenditure on Indoor patients is Rs. 5923266. Thus expenditure per patient comes to Rs.
I
365. This is inclusive of only the staff salary, building cost, maintenance & repair cost
and cost of consumables. The recovery from the patient’s contribution is 5.41%. This
excludes the cost of X-Ray, lab investigations, surgical procedures & delivery (including
L.S.C.S).
!
I
Laboratory The total number of investigations done in a year (Jan, 03 to Dec, 03) is 15581, the
details being available in the Annexure. The total income generated through the
laboratory is Rs. 67790.
Assuming 6% of the total expenditure would be on laboratory the net expenditure comes
to Rs. 1615436. Thus the cost recovery from the patients contribution amounts to 4.19%.
X-Ray -
The total number of X-Rays done in a year is 9492. The detailed classification of X-Rays
done in the month of Oct 2004 is available in the Annexure. The estimated income from
X-Rays is Rs. 345475. The total expenditure on the patients for X-Ray being Rs.
1884676, the cost recovery is 18.33%.
CT Scan -
I
This service is charged even for the BPL population and the pensioners. The charges are
Rs. 800 for general category with an additional Rs. 200 for the plate and computerised
report, while for BPL population Rs. 400 plus Rs. 200 is charged. For contrast media
another Rs. 400 is charged. Around 852 patients underwent CAT scan and the total
revenue generated through this is Rs. 767800. Assuming that of the total hospital
expenditure if 10% were utilised for providing this service, the estimated expenditure is
28
I
I
I
I
Rs. 2692394. Thus the cost recovery for the hospital from the patients contribution is
28.51%.
The cost recovery from different departments are as follows
Cost recovery from the user fees
30
I
f
I
I
_______
28.52
25
,E
18.31
20
® S’
o c 15
O <p
0>
O
W Q. 10
o
o
5.41
5
”T.9~
0
r~i
OPD
■■
4.19
I
_____
IPD
Laboratory
J
X-Ray
CT Scan
Units
The cost recovery is more from CT Scan & X-Ray department while that from Indoor
patients is also considerable. This implies that a lot of patients are suggested
investigations like X-ray & scan.
29
The statement of income from Rogi Kalyan Samiti for the year 2003 (Jan, 2003 - Dec,
T’
I
I
2003) is as follows Unit Head
OPP________
IPD
Pvt. Ward
ICU_________
Labour chg.
Plaster chg.
Investigations
X-Ray_______
ECG________
Pathology____
Blood Inv.
Other Inv_____
Cycle stand
Ambulance
Attendant Entry
CT Scan______
Rent-Shop
ARV_________
Others_______
Interest
Amount collected in Rs.
129440______________
400510______________
229220______________
79365_______________
67790_______________
3825
Proportion in percentage
4,24__________________
13.13_________________
7.51
_______________
2,60_______________
2.22________________
0.13
345475
18320
11.32
0.60
665349
10050
59666
83108
88868
767800
58747
7195
11652
24999
3051379
21.80
0.33
1.96
2.72
2.91
25.16
1.93
0.24
0.38
0.82
100.00
Income generated through RKS
900 —
800
g 700
3 600
w 500
or
.E 400
300
Z3
o 200 —I
_
J,00 llf,,—I
V. z
r
<
0 d
,—
■ II
CT
Units
The maximum income is made through CT Scan, following which is blood investigation
and X-Ray. Thus it is seen that maximum income is through investigative procedures,
which aid in diagnosing and not in treating the patients. (Though it indirectly aids in
30
I
treatment.) However the irony is that in many cases even after the ailment is diagnosed
1
the hospital is not equipped enough to handle the case and provide appropriate treatment.
For instance though the Raigarh district hospital has high tech diagnostics like CT Scan it
is not equipped to handle L.S.C.S.
The fund collected through RKS is utilised for various purposes like new construction,
maintenance and repair and purchase of medicines, which is as follows -
I
I
Unit Head
Maintenance/N ew
construction_______
Repair____________
Medicines_________
Equipments/materials
Labour chg________
Others _________
Total
o
o
G>
w
or
tC
Amount in Rs.
Proportion in percentage
1516374
195867
393762
97220
68.73
8.88
17.85
4.41
3053
2206276
0.14
100.00
1600 —
1400 ---- 1
1200 ---1000 —
800 —
Expenses under RKS
_____ •
:
:
■
____________________
7........................................................................................................................................
-
600 —
2
O
E
<
400 —J
200
I
0 —I
z
z
/
X Units
J
A huge proportion of the amount collected through RKS is spent on New construction
and maintenance of the building and major equipment.
The sanitation and hygiene conditions of the hospital is appalling with the infective and
the non infective wastes being dumped in the open space at the centre of the hospital
building which is flanked by wards on all its sides. On enquiring the justification given
for the poor sanitary condition was that the Class IV staff were on strike for a hike in the
31
&
salary. Though the hospital is able to collect a considerable amount through user fees a
huge chunk of around Rs. 10 lakh is earmarked for the maintenance of CT scan machine.
It is well known that not many patients need to undergo this investigation and while the
general state of the hospital in terms of manpower and basic sanitation is so poor, it
r
seems ridiculous to hold back such a big amount of people’s contribution which is meant
to serve people’s needs. Moreover the charges for CT Scan though is less than market
price is not subsidised to a great extent.
i
Monthly trend of Inc vs. Exp
3.50
i
J 3.00
« 2.50
U)
2.00
1-50
■H
□ Income
■ Expenditure
c 1.00
3
E 0.50
<
0.00 -«■
72% of the total contribution is utilised though the utility of the services for which the
amount is spent could not be assessed. The income generated from the patients has never
been less than Rs. 2 lakhs while in almost 4 months the expenditure has been maintained
less than Rs. 1.5 lakhs. The expenditure surpassed the income in the month of Sep &
i
March. However the gap between income and expenditure has been consistently
maintained, despite of the fact that the staff is discontent with the pay package, the
hospital is unkempt.
i
In some hospitals every unit enjoys the autonomy with respect to utilisation of resources
generated by it. However in Raigarh hospital the resource generated through different
units are pooled and utilised for different purposes based on the decision of the
committee. It was therefore not possible to compare the unit wise resource utilisation.
32
I
I
R1
b;
Community Health Centre -
■
Pusaur CHC is located around 35 kms. from Raigarh station. The RKS was constituted
I
here in 1997.
The tariff chart for the user fees as decided by the committee Sr. No.
_!______
2 ____
3 ___
4
5 ____
6 ____
7 ____
8 ____
9 ____
10 ___
n__
12___
J3___
14
15____
16
Unit/Service____________
Haemoglobin___________
Total & Differential counts
ESR__________________
Urine-Sugar/Albumin
Urine Bile salt pigments
Serum bilirubin_________
Widal_________________
V.D.R.L.______________
Major surgery__________
Minor surgery__________
OPP__________________
IPD___________________
X-Ray________________
Sickle cell_____________
RA___________________
Serum Cholesterol
Current rates in Rs.
5______________
5______________
5______________
5______________
5______________
20_____________
30_____________
15_____________
50_____________
25_____________
2______________
10/day__________
40/50/60________
15_____________
15_____________
20
OPP Clinic -
The increase in the number of out patients has been consistent from the time of inception
of RKS in 97, which is around 20% increase every year. However in 2001-2002 the
number of patients fell by 11% in comparison to the preceding year and in 2002-2003 the
number of out patients increased by 47% which showed a mere increase of 8% in the
subsequent year.
Currently on an average around 60 patients are treated each day. Assuming that of the
total expenditure 25% is spent on OPD services the annual expenditure on OPD is Rs.
813810. Thus expenditure per patient comes to Rs. 49. This however excludes the cost
for pathology and X-Ray. The cost of these services would be taken separately. Rs. 49
33
I
1
1
I
I
I
I
I
I
i
per patient is inclusive of the staff salary, maintenance & repair, cost of consumables and
the capital cost.
The registration charge per patient is Rs. 2 for out patient service. The total number of
patients seen in a year (April 03 to March 04) is 16776. 59% of the total patients i.e. 9904
patients were given free treatment. The revenue generated through OPD in 2003-2004 is
Rs. 12182. Thus of the total expenditure on Out patient services around 1.5% is
recovered from the patients.
Indoor Services -
The total number of patients admitted in a year (Jan 03 to Dec 03) is 801. Assuming that
of the total expenditure 22% is spent on IPD services the annual expenditure on Indoor
patients is Rs. 716152. Thus expenditure per patient comes to Rs. 894. This is inclusive
of only the staff salary, building cost, maintenance & repair cost and cost of
consumables. The recovery from the patient’s contribution is 2.17%. This excludes the
cost of X-Ray, lab investigations, and surgical procedures.
The income from 801 indoor patients being Rs. 15520 the average fees per patient can be
estimated to be Rs. 19, which means that the average length of stay could be 2 days
(Indoor fees per patient per day is Rs. 10).
Laboratory -
The total income generated through the pathological investigations in 2003-2004 is Rs.
2455. Assuming 6% of the total expenditure would be on laboratory the net expenditure
comes to Rs. 195314. Thus the cost recovery from the patients contribution amounts to
1.26%.
X-Ray -
34
■
i
The revenue generated from X-Rays in 2003-2004 is Rs. 26890. As per the assumption
I
the total expenditure on the patients for X-Ray is estimated to be Rs. 227867, and hence
the cost recovery is 11.8%.
The details on income expenditure are as follows -
I
Income
OPD
l
IPD_______
Labour____
Investigation
X-Ray
Pathological
Blood_____
Others_____
From other
sources____
Total
97-98
1460
1180
5001
1970
565
20280
26890
47170
15
335
500
980
345
212
535
810
238
1395
875
1061
1180
1275
999
4440
3805
2510
3155
3370
8365
7891
36311
59706
118798
Expenditure 97-98
Medicine
Consumables
Total______
Balance
Total
2002200320012004
2002
2003
12182
25348
2438
6380
2888
5140
15520
29560
2680
3070
5965
1180
1660
870
1190
00-01
99-00
98-99
99-00
98-99
475
1145
1620
1535
20012002
00-01
3046
3046
5319
3370
560
3682
4242
3649
20022003
11026
11026
25285
20032004
44614
44614
15092
Total
1035
63513
64548
54250
Income from various units
Pathology Others
4% A 2%
X-Ray
45%
OPD
20%
IPD
26%
Labour
3%
35
■
■
-
The maximum income is from X-Ray while the contributions from Indoor patients is the
next higher revenue generating unit.
I
Cost recovery from different units -
I
Cost Recovery
14
11.8
12
.E
>
0)
O)
o 43
c
o
CC
w
o
O
10
8
Q
6
0)
Q.
4
2
0
OPD
IPO
Laboratory
X-Ray
Units
The cost recovery through X-Ray department is maximum as implied even from the
previous graph showing maximum income from the same department. However though
I
the income generated from Indoor wards is more the expenses are also more on the
indoor patients and hence the cost recovery is substantially reduced to 2%.
Trend in Income Vs. Expenditure
70000
60000
50000
or
.E 40000
3
O
E
<
□ Income
30000
□ Expenditure
20000
10000
i
0
1997- 1998- 1999- 2000- 2001- 2002- 20031998 1999 2000 2001 2002 2003 2004
Year
36
I■
No income & expenditure is shown in 1998-1999, the reason is not known. In 97 though
I
some amount has been spent it is negligible, while in 1999-2000 no money has been
spent despite of contribution from the patients. The gap between income & expenditure is
considerable in all the years, i.e. a huge amount is left unspent though the patients are in
dire need of services.
I
No one is exempted from fees as it is felt that everyone should pay for health care
services . This decision is reached at unanimously by the committee as it is felt that if the
BPL population is exempt from the levy everyone will try evading payment on the same
pretext and there will be no source of income. It is also felt that by paying the people will
be able to demand for services. Though patients are compelled to pay for the service
around Rs. 62495 from their contribution is left unutilised.
The doctors are indulged in private practices and pick up medicines from sample packets
as is known to many. Though the CHC is spacious there is no separate room allotted for
injection administration and a corridor outside the female ward is utilised for the same. A
table which is loaded with register, syringes, needles and swabs and a bench adjacent to it
to make the patient lie down while administering the injection are allotted for the
purpose. This is not only unhygienic but also does not allow privacy to the patients both
indoor and outdoor.
Charama - Community Health Centre -
Ranker has a population of 651333 in 7 blocks. It has 6 CHCs with each CHC covering
I
on an average a population of 1 lakh.
OPP Clinic -
J
Assuming that of the total expenditure 25% is spent on OPD services the annual
expenditure on OPD is Rs. 743800. The number of patients seen in 6 days (a week) is
Some patients are treated free on a special consideration from the Medical Officer.
37
I
&
r
446. If this is extrapolated the total number of out patients examined in a year can be
P-
estimated to be around 21408. Thus the expenditure per patient will be Rs. 35.
The registration charge per patient is Rs. 2 for out patient service. The revenue generated
through OPD after discounting for the free patients can be estimated to be Rs. 36672.
Thus of the total expenditure on Out patient services around 4.9% is recovered from the
patients.
Indoor Services -
Assuming that of the total expenditure 22% is spent on IPD services the annual
expenditure on Indoor patients is Rs. 654544. Thus expenditure per patient comes to Rs.
2081. This excludes the cost of X-Ray, lab investigations, and surgical procedures.
Laboratory Assuming 6% of the total expenditure would be on laboratory the net expenditure comes
to Rs. 178512.
As some important information was not available like the charges for various
services, this section is left incomplete.
A Comparative Analysis -
The CHCs and the district hospitals selected for the study being highly varied in terms of
infrastructure, evolution, facilities, etc. serving populations of varied background in terms
of socio-economic conditions and demography they are not comparable. However a
general impression gathered about the functionality of the scheme shows that the scheme
I
I
I
a
has its pros and cons.
38
i
1
I
Comparative Cost Recovery
O> 30 R
U)
l
5
1
5o 25 TI . .
... ............... ..... -..... ......
o 20
I
I
•S 15
_
_ „
_
____
■
£ 10
o
S
5
w
o
O
o
Fl
OPD
1
IPO
!
I
i
□ Rjsaur
i
11
i I—Ft
I ” 11
_h •J1 i
._____
..
□ Jhanjgir
0 Raigarh
a
Laboratory
X-Ray
CT Scan
Units
1. The cost recovery for the hospital is more from the investigative procedures like
pathological tests X-Ray and Scan. This is suggestive of more patients being sent for
diagnosis. Thus it can be considered as a good revenue-generating unit.
2. Not more than 72% of the contribution has been utilised in any of the hospitals, though
the hospital does not seem to be self-sufficient. In the year 2003-2004, in Raigarh, Baloda
and Pusaur 72%, 54% and 72% of the total contribution from the patients have been
utilised. Moreover the income in all these centres are generated from patient contribution,
as there is no record of any donation being received.
Trend in the expenditure
90
80
.E
70
o
60
a
—
a. CT)
r 43 50
w
c
o S
.2
_ 40
30
o
20
10
0
---- Baled a
— Pusaur
I 2.
2001-02
2002-03
2003-04
Year
39
I
fe..
In the two CHCs the amount spent from the total collection dropped to mere 30% in
2002-03, which again increased in the following year.
Conclusion
The user fees are fixed on ad hoc basis by the committee/trust without considering
I
affordability, accessibility to the service and the indirect cost incurred by the people.
Some studies3 also show that decentralization is in turn centralized at the hands of few
like the dean of the hospital or the CMO and thereby leading to improvement in selective
services confined to few departments which in true terms might not benefit the patient,
like provision of CT Scan in a place where there is no facility for provision of basic
services. A large amount of the fund collected is earmarked for maintenance of some
major equipment or service, which in turn is blocking the money for some definite
purpose not actually taking into consideration the immediate and the urgent needs of the
poor patients.
The cost recovery from each the unit is minimal and the chief stated objective of
introducing user fees is to encourage people’s participation in the management of the
hospital and to create a demand for fair services from the hospital. However since the
power of allocation rests with few it still manifests the problems of implementation.
As there is a shortage of staff some are appointed as RKS staff but are employed on
contractual basis and are paid less than others and also are devoid of other additional
benefits. This has led to dissatisfaction among the staff appointed under RKS.
A list of activities2 undertaken in a handful hospitals are commendable, but these are in
few hospitals as compared to the total number of hospitals and more amount is seen to
have been spent on infrastructure development, and investigative procedures which do
not address the immediate needs of the patients.
40
r
As stated in one of the studies* the increase in the number of middle income class patients
r
and lack of protest is seen as an evidence for acceptability & willingness to pay. This
could also be attributed to the fact that people have no other option and in the time of
crises they are compelled to pay. It is also to be noted that the study shows increased
utilisation by middle income patients and not by poor patients which implies that either
even the poor are charged or the quality of treatment given to the poor is unaffordable.
I
I
i
i
One must also be cognisant of the indirect cost to the patient, which could be another
cause of not seeking service, which the scheme fails to reckon.
Some studies suggest augmentation of revenue from ambulance, pathological and
Investigative services. Most of the hospitals are seen doing the same, without strategizing
on how these resources could be effectively spent for the benefit of the patient. It seems
to be more of a revenue generation mechanism.
One of the main objectives of establishing RKS was to provide autonomy to the hospital
so as to increase the efficiency. However the constitution of the committee is a clear
evidence of hierarchical structure. The Executive Committee meets quarterly and the
decisions have to be stalled until then. The CMO has limited power, which he/she utilises
for vested interest, like lakhs of rupees are earmarked for the maintenance of CT scan in a
hospital where basic sanitation is absent, and there is virtually no waste management.
Due to lack of strong civil society presence, there is no pressure for the funds to be spent
for the benefit of the poorer patients or even the hospital development. A sizeable
collection of user fees is used even for petty things like paying of electricity, water and
telephone bills. In most of the hospitals the collected amount has been spent in buying
cooler and generator which might not benefit the patients directly.
Though it was not possible to elicit minute details about the implementation of the
scheme, the findings of similar schemes5 in other states suggest-
41
I
&
It increases the accountability of the hospital staff but in the absence of ‘real powers’;
■'
it unnecessarily increases the burden of the staff.
Though the resources generated are supposed to be utilised for hospital development,
I
I
in bigger hospitals they are used for paying electricity bills and in smaller hospitals to
buy medicines.
There is very little public awareness of the functioning of the scheme and
politicisation of the scheme.
Suggestions for further study -
To analyse the utility of the services from the time of inception of the scheme.
Detailed analysis of trends of expenditure.
Detailed analysis of trends of user fee collection.
Client satisfaction studies.
References -
1. RKS
2. Rogi Kalyan Samiti - A detailed report on RKS in Madhya Pradesh
I
3. Girish Kumar: Public Hospital Reforms in Madhya Pradesh (India)- Perceptions and
trends. Paper prepared for the 18th European Conference on Modern South Asian
Studies Lund University, Sweden.
4. Dr. A.S. Bapna: A Handbook for General guidelines for Rajasthan Medicare Relief
Societies.
5. Initial assessment of Chikitsa Prabhadhan Samiti (CSS) in Uttaranchal.
6. Ramesh Bhat, Harshit Sinha, Dileep Mavalankar: Cost Analysis of government
hospital services at block level. Case study of Community Health Centre at Sanand
Taluka in Ahmedabad district, Gujarat.
7. Edited by Andrew Creese & David Parker: Cost Analysis in Primary Health Care- A
I
training manual for program managers.
42
I
Units
Income
Duration
[
Year
After discounting for Free services @ 60%
Total Exp
1 month
X-Ray
Numbers
Type
113 12X15
Chest
66 10X12
Hip
77 12X15
LS Spine
86 12X15
Thoracic S
75 8X10
Skull
55 8X10
Wrist
53 8X10
Shoulder
45 8X10
Leg
CS Spine
54 12X15
77 8X10
Foot
Thigh
46 10X12
Pelvis
44 12X15
791
Annual
9492
1
OPD
IPD
Pvt. Ward
ICU
Labour chg
Plaster chc
Investigations
X-Ray
ECG
USG
Pathology
Blood Inv
Other Inv
Cycle stanr
Ambulance
Attendant E
CT Scan
Rent-Shop
ARV
Others
Interest
OPD
IPD
Pvt. Ward
ICU
Labour chg
Plaster chc
Investigatic
X-Ray
ECG
USG
Pathology
Blood Inv
Other Inv
Cycle stanc
I
a
Proportion of the total
This has been taken as 60% as one of the artilce mentions the state has 43% BPL. Besides this we
also have to account for those getting free treatment. Morevoer the total income from RKS was not
correspending the income computed by multiplying the number of patients into the cost of care. For it
to match the income figures approxiamtely it had to be dicounted.
OPD
Lab
X-Ray
IPD
OT
Total Income
Income from the Inc-Exp Statement
Income from other sources
I
Recovery
Ambulance
Attendant E
CT Scan
Rent-Shop
ARV
Others
Interest
129440
400510
229220
79365
67790
3825
345475
18320
665349
10050
59666
83108
88868
767800
58747
7195
11652
24999
3051379
129.44
400.51
229.22
79.365
67.79
3.825
0
345.475
18.32
0
0
665.349
10.05
59.666
83.108
88.868
767.8
58.747
7.195
11.652
24.999
129.44
400.51
229.22
79.37
67.79
3.83
0.00
345.48
18.32
0.00
0.00
665.35
10.05
59.67
83.11
88.87
767.80
58.75
7.20
11.65
25.00
Income generated through RKS
900
o 800
o 700
T 600
a 500
c 400
300
200
E 100
0
<
Units
5
r
&
Jan
Feb
Mar
April
May
June
July
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
April
May
June
July
Aug
Sep
Oct
Nov
Dec
Expenditure
Income
128275
295211
164661
215436
293065
235851
219866
118554
190472
212292
147846
212575
117224
317507
202439
293515
312723
295617
172059
242490
247638
254459
111320
256560
Expenditure
Income
1.28
2.95
1.65
2.15
2.93
2.36
1.19
2.20
1.90
2.12
1.48
2.13
1.17
3.18
2.02
2.94
3.13
2.96
1.72
2.42
2.48
2.54
1.11
2.57
1.28
1.65
2.93
1.19
1.90
1.48
1.17
2.02
3.13
1.72
2.48
1.11
2.95
2.15
2.36
2.20
2.12
2.13
3.18
2.94
2.96
2.42
2.54
2.57
Monthly trend of Inc vs. Exp
3.50
I
□ Income
■ Expenditure
3.00
v __ _
I
2.50 -
2.00
'll Di i
& 1.50
.E
I H
— Bl
- Bg
H® '
1.00
| 0.50
0.00
Jan
Feb
Mar April May June July Aug
Sep
Month
OPD
IPD
Laboratory
X-Ray
CT Scan
1.9
5.41
4.19
18.33
28.52
Cost recovery from the user fees
30
c
25
1&33_
£ S>20
if
O 0
15
£ £
v,o 2.10
5
0
5.41
----- T9----I
I
ORD
IPD
Laboratory
Units
852
852000
I
■
X-Ray
CT Scan
Oct
Nov
Dec
Pusaur
OPD
IPD
Laboratory
X-Ray
CT Scan
1.5
2.17
I. 26
II. 8
Jhanjgir
Raigarh
2.3
0.21
15.76
8.51
1.9
5.41
4.19
18.33
28.52
r
Comparative Cost Recovery
V
o>
5 25
4
—
-___________ -
u
Q.
£
Li__
15
____
■
JI
I______
•
■
•
■■
< ■
•..................
J_
'•
g 10
□ Pusaur
□ Jhanjgir
□ Raigarh
5
o
IZJL
o
IPD
OPD
CT Scan
X-Ray
Laboratory
Units
Pusaur
Raigarh
Baloda
Pusaur
Raigarh
Baloda
Baloda
Pusaur
Income
Expenditure
62161
44614
3051379 2206276
75829
41261
71.77168964
72.30422704
54.41321922
72
72
54
2001-02 2002-03 2003-04
82
30
54
30
54
72
Trend in the expenditure
.E
c
q
<A
90
80
70
60
50
40
_
S o
| 30
Q.
2
20
10
0
1
2001-02
2003-04
2002-03
Year
I
I
I
a
Staff
As per the Charama Pusaur
Medical off
4
5
Nurse mid
7
7
Dresser
1
Pharmacis
1
1
Lab techni
2
1
Radiograpl
1
1
Ward boys
2
2
Dhobi
1
Sweepers
3
2
Mali
1
Choukidar
1
1
Aya
1
1
Peon
1
4
4
4
1
2
3
1
1
1
1
1
1
1 11 Baloda
- —Pusamr
•:vi
Income from various units
Pathology
4%
Others
2%
OPD
20%
IPD
26%
Labour
3%
?.•/- ■
r
[
i
ncome___________
OPD_____________
PD______________
Labour___________
nvestigation______
X-Ray___________
Pathological______
Blood____________
Others___________
From other sources
Total_____________
Expenditure______
Medicine_________
Consumables
Total_____________
Bal______________
Statistics
OPD
Free
Calculations
Salary
Sr. MO
BMO
MO
MO
Acct
Computer
Lab Tech
Lab Tech
Lab Tech
Staff Nurse
Staff Nurse
Staff Nurse
Radiographer
Ward boy
Sweeper
OAO
ANM
Compounder
Compounder
Dresser
Driver
Aayah
Mess Servant
Cook
Dhobi
Dep
Sal
Rep
Consumables
Total exp
I
OPD
IP
Patho
X-Ray
2001 -200^ 2002-200 2003-200-4 Total
00-01
25348
6380
12182
2888
2438
29560
15520
5140
3070
2680
1970
5965
1180
1660
565
870
1190
98-99
1997 97-98
99-00
1460
1180
500
20280
15
0
15
3155
1997 97-98
98-99
475
1145
1620
1535
6485
6485
7315
6585
830
12.79876638
11914
11692
12402
10475
7822
5863
8173
4708
6133
8094
7053
6828
5017
4697
3190
3614
6468
4103
5167
5827
4993
5095
3877
3154
2944
3459
142968
140304
148824
125700
93864
70356
98076
56496
73596
97128
84636
81936
60204
56364
38280
43368
77616
49236
62004
69924
59916
61140
46524
37848
35328
41508
1953144
Apportioning
10
60
5
25
100
Apportioning
25
22
6
7
3370
3046
3046
5319
560
3682
4242
3649
11026
11026
25285
Major sur
Minor
156
1920
OPD
1.5
2.17
I. 26
II. 8
IPD
Laboratory
X-Ray
325524
1953144
162762
813810
3255240
Per capita Cost recovery
813810 48.51037
1.49691
716152.8 894.0734 2.167135
195314.4
1.256948
227866.8
11.80075
Cost Recovery
14
h
11.8
12
10
8
2
0
________
i
Laboratory
X-Ray
-------- -----------
S 6
8 1 4
o
44614
44614
17547
15518
16776
10679
11929
10526
8890
9904
12893
9694
11848
8835
8890
1258
-1403
1789 ......................................
1250
4992
1575
21.5311 20.12373 11.70522 -11.7613 47.42542 8.106715
!
I
I
I
26890
1.5
OPD
47170
2455
8245
1345
2270
1325
1395
1180
4440
535
980
3805
1275
345
875
810
1061
999
2510
238
212
127043
8365
36311
62161
3370
7891
2001-200; 2002-2002| 2003-2004 Totaf
99-00
00-01
835
335
500
~~n
IPD
Units
1035
63513
64548
62495
88118
75134
is
II
I
I
I
I
I
I
I
OPD
in 6 days
Free
BPL
Pension
Total
Bal
One month
One year
Salaries
Doctors
DA
Rent Allowance
HRA
Avg
Annual Income of 3 doctors residing in quarters
Annual Income of the remaining two doctors
Total exp on doctors salary
Staff
BEE
Lab Tech
Compounder
Staff Nurse
ANM
MPW
LHV
Computer
LDC
Driver
Radiologist tech
Ward boy
Sweeper
Waterman
Chowkidar
Peon
Aayah
NMA
Number
Amt. Coll Annual Pats
892
21408
446
44
83
1
128
636
2544
30528
8000
4160
100
75
12335
16515
588240
396360
984600
Number
1
2
1
4
2
1
1
1
1
2
1
2
2
2
1
4
1
1
IPD
Smonths
Adm/year
6144
13500
7020
100
75
20695
Sal/emp Annual sal
106080
8840
199560
8315
76332
6361
390672
8139
149676
12473
6600
8840
3050
3640
6193
79200
106080
36600
87360
74316
4013
3555
2550
2550
4132
7919
96312
85320
30600
122400
49584
95028
1785120
131
314
12
29
Deliveries in 5 mths.
Del/year
Lab
May
April
256
Urine
X-Ray
Blood
128
133
88
135
34
27
§
r
r
L
March
Feb
Jan
Annual
!
Dep
Sal
Rep
Consumables
I
I
I
OPD
IPD
Patho
X-Ray
106
141
109
120
77
87
1327
1370
Malaria
Injections
29-Aug
37
56
37
28
27
45
27
44
26
52
62
25
55
24
70
77
10
60
5
25
46
44
27
427
297520
1785120
148760
743800
2975200
Apportionin Exp
Per Pat
25
743800 34.74402093
22
654544 2081.882952
6
178512
208264
7
42816
36672
2000000
Building cost
60000
Dep 30 yrs
100000
Electrical gadgets
7000
Dep 15 yrs
3000000
Others (vehicle, furniture
300000
Dep 10 yrs.
Total exp on captial cost/ 367000
i
F
L
F
Category of Staff
Doctors
Staff Nurse
Paramedical
Class IV
Non technical
Annual salary Proportion of salary
1306778
29
659588
15
1015498
22
844526
19
687147
15
4513537
Staff
Depriciation
Water/Electicity/Maintainence/Repair
Consumables
Total
I
I
I
I
For OPD
For IPD
Lab
X-Ray
OT
4513537
367000
348610
1743049
6972196
1743049
1533883.12
418331.76
488053.72
Proportion of the total
60
10
5
25
25
22
6
7
16
51716 33001
41520
2467
65910
32884 2837 38057 NA
1720 NA
3784 NA
3477 NA
169943
172867
98.30852621
6972196
2.479376656
OPD
Indoor service
Laboratory
X-Ray
2.3
0.21
15.76
8.51
E
H
20
15
o a> 10
n
<0
o
5
0.21
0
OPD
___
Indoor service»
Laboratory
Units
I
I
I
n
Cost Recovery from user fees
X-Ray
I.
OPD
Month
April
May
June
July
Aug
Sep
Oct
Nov
Dec
Total in 9 mths
Avg/month
Per day
Pats/year
Exp/out patient
IPD
New
Income
Old
2738
2561
3092
5113
5397
4668
4366
3837
3464
35236
37523
260
250
240
275
237
245
260
255
265
2287
10
11
7
10
10
10
45
24
27
154
400
440
280
400
400
400
1800
960
1080
6160
4169
17.11111
173.7176
0.712963
50030.67 100061.3 205.3333
34.83938 1743049 8502.678
20012.27
80049.07 1533883
4.592474
156944
337454.3
1643.446
Laboratory
Nos.
Income
Stool
Urine
3788
38744
Blood
4460
44600
Malaria
3371
VDRL
116
1160
HIV
5
Other blood inv
911
11615
Total
12651
96119 19223.84
Charges
Current Revised ch
Haemoglobin
5
5
DLC ' ■
5
10
Urine-Sugar/Alb
Urine - R/M
UPT
Urine - Bile salt
BTCT
Blood sugar (Ca
BS (Glucometer
Widal
VDRL
Australia Antige.
Hepatitis ’C
10
5
10
10
30
10
10
10
30
15
10
10
10
45
X-Ray
No. of patient Type
125 Chest
14 Leg
16 Knee
4 Hip
24 Elbow
5 Shoulder
5 LS Spine
3 CS Spine
3 KUB
2 Pelvis
2 Abdomen
15 Skull
218
OT
Minor
Major
28
30
10
5
10
20
40
10
10
20
30
20
20
20
20
60
140
Plate/Film
12X15
8X10
10X12
10X12
8X10
8X10
12X15
12X15
12X15
12X15
12X15
8X10
25
5625
350
720
180
600
125
225
135
135
90
90
375
8650
750
Urine
3508
2105
702
456
|
8400
21048
7016
2280
38744
76895
46
2050
182.2
2733
683
6832.5
11615
■UKS
'; 'r ' ■’;-
Units
Income
*£46^?
?'
Duration
Year
OPD
100061
Lab
96119 7 months
164775.4
X-Ray
8650 1 month
103800
IPD
6160 9 months
8213.333
OT
750
Total Income
Income from the Inc-Exp Statement
Income from other sources
Wt***
***W
After discounting for Free services @ 60%
Total Exp
This has been taken as 60% as one of the artilce mentions
the state has 43% BPL. Besides this we also have to
account for those getting free treatment.
Morevoer the total income from RKS was not corresponding
the income computed by multiplying the number of patients
into the cost of care. For it to match the income figures
approxiamtely it had to be dicounted.
40024.40
65910.17
41520.00
3285.333333
300
151039.90
172867
21827.10
1743049.00
418331.76
488053.72
1533883.12
WWW
Recovery Proportion of the total
2.30
15.76
8.51
0.21
26.50
43.64
27.49
2.18
0.20
**-*-*^
■ ' ‘. •'p;
RKS
Jan
Maintainence/New construction
Repair
Medicines
Equipments/materials
Labour chg
Others
Total
Salaries
Pay
Gazetted
98724
6190
15421
7940
128275
Staff
Depriciation
Water/Electicity/Maintainence/Repair
Consumables
Total
Building cost
Incinerator
Gnerator
For OPD
For IPD
Lab
X-Ray
OT
Others
CT Scan
Maintainence/New construction
Repair
Medicines
Equipments/materials
Labour chg
Maintainence/New const
Repair
Medicines
Equipments/materials
Labour chg
Others
164661
293065
118554
3053
190472
147846
117224
202439
DA
Pay
Non Gazetted
Class IV
186000
212196
263089
237600
732508
460031
447907
298850
313355
337265
95911
191600
41700
306645
132850
36100
1431345
Others
Feb
Mar
April
May
June
July
Aug
Sep
Oct
Nov
Dec
129142
180724
70355
61664
150410
81250
131369 208676
123130 205543
75387
2220
12050
7899
8325
58190
14645
8154
46516
17325
8595
5758
24739
90619
35077
21626
23944
14100
55075
46872
21719
24337
20233
8560
9672
5223
7058
4048
7229
7841
10659
9885
9163
9942
93908
186895
114081
4908563 5313467
37040
86506
316680 247054
6707237 6915401
376475
180086
1100379 16154362
60 16154362
10 2692394
5 1346197
25 6730984
26923937
1995-96
1998-99
3300000
450000
345000
25 6730984 49 29138
22 5923266
6 1615436
7 1884676
16 4307830
14 3769351
10 2692394
767800 28.51738
1516374 1516.374
195867 195.867
393762 393.762
97220
97.22
0
3053
3.053
1516.374
195.867
393.762
97.22
0
3.053
i
&
I
1600
1400
1200
1000
800
600
400
200
0
Expenses under RKS
312723
172059
247638
111320
1516374
195867
393762
97220
3053
2206276
■fegaaga
Jan
Donations red
Amt. collected
ORD
IRD
Pvt. Ward
ICU
Labour chgs.
Plaster chgs.
Investigations
X-Ray
ECG
USG
Pathology
Blood Inv
Other Inv
Cycle stand
Ambulance
Attendant Entry
CT Scan
Rent-Shop
ARV
Others
Interest
Feb
Mar
April
May
June
279199
10644
33588
23955
10075
4900
100
215436
8552
27998
12720
3900
5960
150
23585
10586
30095
18295
5100
6780
219988
9222
31339
14640
8740
5440
212292
29385
2100
18985
1110
25725
2100
24005
720
64220
450
5460
6944
5510
77400
1500
48275
825
5460
4012
3755
68200
4520
52295
825
5460
4350
4050
63400
6790
27745
825
4675
14000
7815
66800
3900
2968
16012
295211
1014
215436
235851
219866
WW»i
imi
July
Aug
Sep
Oct
Nov
Dec
211775
19426
41779
8200
6675
6040
317507
16470
42282
19775
7275
6050
650
293515
11918
37813
21710
6800
4450
650
296697
12650
38460
33810
3000
6320
400
242690
11282
34183
22965
5500
5210
254459
9992
33860
20205
4500
4380
256560
8698
33193
21280
6300
5300
250
2823703
129440
400510
229220
79365
67790
3825
28085
1000
20750
440
38030
1790
32245
1920
36010
2100
32935
1980
30000
1860
29320
1200
345475
18320
36345
1050
7050
12812
41916
600
74053
1125
74600
1200
16251
6190
9481
62000
1500
77740
1125
4460
712
10105
65000
3530
52620
600
3050
5296
8224
50600
5695
63285
825
5400
8456
7999
55800
7897
52255
600
2400
11500
7129
67800
9335
4787
195
2350
293515
295617
242490
254459
256560
665349
10050
59666
83108
88868
767800
58747
7195
11652
24999
3051379
15920
11665
11500
6960
1625
68800
4440
5040
212292
14929
44400
7420
212575
8836
9871
77600
2220
2155
338
8987
317507
489378
1615436
4.19639
1884676
18.33
^wfikyi
t44 <., .
.
•W
Jan
OPD Patients
Free
BPL
Pensioners
Freedom fighters
Others
IP
Gatepass
Attendor
Laboratory
Blood
Urine
Stool
Sickle
malaria
Positive
PV
PF
Feb
10898
5576
1610
693
12
3261
1430
360
87
Mar
9517
5241
1401
683
24
3133
1393
12165
6872
1826
860
39
4147
1413
April moo May
9288 10484
1R9R
696
2286
1307
1425
125
July
16438
June
10092
via
789
„ 15
3323
1259
1027
100
5057
1«5
552
2550
2550
1381
1381
1190
1190
141
141
8203
Au9
12713
2681
970
7
4545
1811
1453
154
6754
Sep
13050
1917
798
14
4025
1774
1458
152
Nov
10664
Oct
11352
6725
1673
870
12
4170
1698
1930
114
5711
1560
785
8
1407
1487
104
Dec
9894
5545
1502
1469
672
721
27
21
33583467 3334
1357
987
170
22
Total
Income
Net Income Total Exp Cost Recovery
136555
273110
129440 6730984.2 1.923047
71835
143670
16230
11317
1147
292140
22634
5735
320509 5923266.1
5.411018
Numbers
1750
1074
70
9
12678
945
260
685
’
%
Not viewed