MFCM085: A Study of the Health Sector in Kerala: Distribution of Health Care Facilities and Financing.pdf
Media
- extracted text
-
COMMUNITY HEALTH CELL
47/1,(First Floor)St. Marks Road
BANGAlO.TE - 560 Oul
'<3 5BAOKGROUND mEttt-vii
XV ANNUAL MEET.OF MEDICO FRIEND CIRCLE
ASTUDY OF THE HEALTH SECTOR IN KERALA: DISTRIBUTION OF HEALTH
CARE FACILITIES AND FINANCING.
1 . DISTRIBUTION OF HEALTH CARE FACILITIES IN KERALA:
r
1.1. Introduction; The state of Kerala in India has attracted
worldwide attention because of its achievements in the public
health sector. It has one of the lowest crude mortality and infant
mortality rates among underdeveloped cormunities, the figures
being 6.4/1000 and 32/1000 respectively . This has been achieved
in spite of very low'levels of other indicators of economic
development like per capita income: Kerala's per capita income
is below' the all India figutes, which itself is one of the
lowest in the worldz(see footnote).
•pinion in public health circles a.ttribitte this achievement
to several social peculiarities in the state, like better levels
of education including women's education, better position of
women in society, policies »f successive governments which tended
to favour equitable distribution of resources, etc. The implied
thesis is that good health has been achieved at low cos^, 4bV a
better application of the principles of healthy living ’
This paper attempts to bring out another aspect of the
health situation in Kerala: i.e., the great emphasis on curative
health services. This is examined from the distribution of private
health care facilities in ,'the state. There is also an additional
attempt to estimate the health expenditure in the state, to show
how the nature in which health facilities•are established, and
the reasons for their thriving, .also determine, how health services
are financed. The attempt shall.be to show that adhievements
in health sector in the state has paralleled a growth in demand
for curative health care in the state. Whether such care has'
contributed to marginal reduction in death rates or other indices
in the state is a debatable issue. But nevertheless,- the fact that
a large service in curative health care is supported by
direct charging of the people, as I shall attempt to show, means
that there is great demand for curative health services. Two
points about this, deserve attention: (1 ) doctors in government
service are legitimately allowed to charge private patients for
consultation fees in their spare time, though extracting money
from patients admitted in government hospitals has been made
illegal;, and (2) there being no risk sharing institutions like
health insurance, private care is mainly supported by directly
.charging the patients. This means that the large private sector
in health, which even in quantity- outweig.hts the government sector,
is an indication of the huge demand for curative health care,
since this is something which cannot be statisfied even with the
private practice of government doctors. Thus the thesis that good
health has been achieved at low cost, is suspect. One may argue
that good health has been achieved not'because of the proliferating
health care institutions, but-without them, But the fact remains
that some of the very same factors that have been hypothesized
■to contribute to better health status, like better education,
greater transport facilities, have also been associated with the
growth of privatised medical care.
1*2 Distribution of private medical care in the state: We shall
take a cross sectional look aT the distribution of private and
government medical facilities in the state. Ideally, data on the
growth and expaasioi ofprivate medical care over the years,
especially in comparison to government medical facilities, would '
have provided meaningful insights into the reasons and stimuli,
for such growth or lack of it. But as it is, such data are hard
to come by, and we have to content with a cross sectional analysis.
...2r
( 2 )
Having chosen to- study private care, there are x
several aspects -which c.o-u-ld be analysed. For the purpose
of this -paper, I "shall confine myself to the distribution
ofloeds. This is primarily dictated by the- dase of obtaining
reliable data, but this means that -svvSral interesting
aspects relating to the demand for outpatient services
in the private sector in necessarily left out.
There is another important question in relation to
the number of beds that needs to be answered: that of
occupancy. Numbers of beds in medical Institutions have no
meaning if a significant proportion remain unoccupied for
major part of the year. We do not have any kind of data
available on the occupancy or turnover.rat A But most gover
nment hospitals -in the state are forced to take incpatients
in excess of the prescribed number of beds because of the
excess demand. Private hospitals, since they arise out of
a need to fulfill an expressed, demand) and are mostly self
financing, only sui-port.,the number of beds which could be
occupied most of the time. Therefore we .can assume that
the problem of nonoccupancy doesnot arise in both sectors,
eventhough the turnover.rate may be quite different in the
2- sectors due to different reasons.
The study proceeds, on the-.assumption that ..the 'supply'
of private beds arisbs.primarily out of- a demand;for such
■services. This is largely true, e.venthough some private
hospitals' do function as charitable institutions. But by
ahc" large almost alV'are func.ticni.ngd in the free market
for curative health service's, and arc self supporting
through patient charges, it not profit .making.
We shall .nc^attempt to analyse the traditional and
parallel systems of medicine in the state. These, include ,
ayurvedic physicians ant' hospitals, homoeopaths, . naturopath^ 9
and ethers... In the private sector, some of them have an
important presence, especially ayurveda. .But by and large
the' modern medical sector remains the largest, system in
the health sector by both number of practitioners • and
number of beds.
1-3 The geographic distribution of beds in th* private sector:
In table 2 the density of private beds ( nuniber/1,00, 000
population) in each revenue district in the state is
studied. The revenue district-is the administrative unit
in the state, and I have chosen to follow the same divisions,
since most data are available at the district level. At
the present time, there are 14 districts in Kerala though
only 13 are identified in some tables. This is because
many data were not available separately for the district
was formed out of the eld district of Cannannore. Therefore
for all the tables in the rest of the analysis, the'district
of Kasargod is included in the district Cannannore.
Several sources of official statistics providcslightly different figures for the data provided. As far
as possible, for this analysis, the same source has been
used for all types of statistics.
•'
■
From the table' it can be seen that depending on
the density of private‘beds , the different districts fall
into 4 broad categories:
. . .3
( 3 )
1 .
low density of private beds, low density of government
beds: The district of Malappuram, Palghat and Quilon appear
to be truly backward with respect to the development of
health facilities. In these, districts, the density cf govern
ment beds (government brds/1,00,000 population) and the density
of private beds are both at or below the median value. In
Palghat and Malappuram, the percapita Income, the density of
schools (Schools/1,00,000 population) and the length of roads/
square kilometer arc also below the median value. Quilon seems
to be a borderline case. This could be generally taken to be
a situation of 'low demand' for health care.
2.
High density of government beds, low density of private
beds: in contrast, the districts of Trivandrum, Allpppey,
Kozhikode, and Cannannorc are characterised by a moderate to
high (mostly above- median; density of government beds, and
below median-low-density of private beds. It is interesting
that three of these districts; Trivandrum, Allcpncy, and
Kozhikode, have rm dical schools where there is a concentration
of government facilities for health care comparatively easily'
available.to people. But there are other districts where even
the presence of ade< uate density of government facilieies
does not check the growth of private medical care, as shall be
seen next.
Per capita income-in this group is generally around
the median value, with school arid road density above median.
3.
High density.of bohh government and private beds: The
districts of Ernakulam, Kot-tayam, and Trichur are characterised
by above median values in the density of government and private
beds. Both Kottayam and Trichur have medical schools, with
concentration of government owned medical institutions. But
in spite of this, the.density of privately owned beds is also
high. It is not clear whether private care is perceived as a
separate, 'high quality' care f. r which there is demand from
the affluent sections of society, or whether the demand for
mcdic-al care is so high that oven the- increased provision of
government beds is not sufficient to quantitatively meet the
demand. Two of these districts have per capita income above
the median value, and all have school densities and roads/
sq.km at or above the median value. Ernakulam is also the seat
of the largest urban cent:, o in the state, Cochin. It may not
be too far fetched to hypothesize that income, education and
easy access contribute tr boosting of demand for private care.
4.
High density cf private and low density of government
beds: the hill districts of Icukki, Pathanamthitta, and Wynad
are characterised by sparse population (by Kerala's standards)
and difficult terrain. They are also the region where the state's
export earning cash crops like tea, rubber, cardamom etc. are
concentrated. These perhaps'create islands of prosperity of
the small cultivators (though the plantation workers in the
big estates are exceptionally pour). These districts are chara
cterised by below median values for' density of government beds,
and above median values for the density of private beds. Two
of these have an above median percapita income; the school
density is greater than median in all. But 2 of these also have
road length/sq.km below the median value," probably duo to the
difficult terrain and large areas of plantations. Tn these
districts, the situation would seem to be that private health
. . .4
( 4 )
care has come- in- to fill in the gap where government care h
has been inadequate; this is probably in response to the
demand fuelled by enhanced levels of education and pockets
of properity. Lack of roads and poor accessibility probably ha’s not been an obstacle to the growth of private medical
care. Thus private medical care is mere supply elastic than
government care.
The demand for private care seems to be low in
Cistricts where, education, transportation, and percapita
income are low, even when government faciliti§s are inade
quate. With growing education and income, there is also a
growth in private- health care institutions, eventhc'ugh in
some districts vhere government facilities are concentrated,
this is checked to s mo extent. Where government facilities
are inadequate and incrm-.' ano' @ducaticn are above average,
there is growing demand, for private- care, as exemplified
by the hill, districts.
1.3 The determinants cf the growth of medical facilities;
In the next table, wo look 'at seme of the variables which
have been seen to be important in creating demand for
health care. The Kendall's correlation coefficient between
various variables have be n worked out. Density of govern
ment beds (beds/10,00, 000 population) is strongly correlated
only to density.of population; i.e., government beds, are
concentrated in areas where the population density is high
Here the dynamics of the relation could work either ,way.
It cc.uld be that density of population is high in- these
cistricts because of the very fact that there are greater
medical facilities. Government bed density is not .Correlated
to any of the other variables like percapita income, schools/
1,00,000 population, or length of racds/1,00,000 population.
On the other hand, density of private beds is stronoly
correlated with school density, percapita income, and roads/
1,00,000 population.
If we study the variables related to area ? i *.G •,
government and private beds/square kilometre, we fjijid that
both are correlated to density of population and ro -'ds/
square kilometre. But’governme nt bee’s have a stronger relat
ionship with density of population, whereas private beds
have a stronger relationship with roads/square kilometre.
Thus growth of government and private health’facili
ties have responded to different stimuli. Government infras
tructure has' its cwn logic of growth, responding more to
social and political forces. Private medical care grows in
r<sponse to economic variables like income, accessibility
and'education.
1 .4 The influence of urbanisation; Urbanisation in most
developing country situations can be expected to increase i
the demand for private care. This is because of increasing
incomes, education and morbidity, and the demonstration
effect of living in the city. But in Kerala the situation
is different. On the one hand the state does not have the
industrial growth sufficient to give rise to largo, urban
conglomerates. On the other hand, rural urban differences
in such variables as education are minimal in Kerala, the
rural education level being much higher than other Indian
. . .5
( 5 )
States. The economy of the state being much dependent unon
the plantation sector, the pockets of prosperity lie in
those districts that ate largely covered by plantations and
sparsely populated. Hence these are mostly classified as
rural.
In table 4 we arrange the districts according to de
creasing levels of urbanisation. This is done in the follo
wing way: The districts containing the three large munici
pal corporations of Trivandrum, Kozhikode and Cochin are
in group I. Group II Contains those districts with the
largest ten towns in the state. The ther districts, by
exclusion the least urbanised, are in group III. The figures
in brackets corre spond, to the share . (percentage) of private
beds in the total number of hospital bee's in the district.
V.'e see that there is a g -neral trend of increasing share of
private beds with decreasing urbanisation, with the notable
exception of Ernakulam district which contains the largest
municipal corporation in the state: Cochin. This trend is
statistically significant.
This finding points to . an interesting situation in
the state, where in the comparative absence of industry,
most of the we;-1th is crept;d in the hill districts in the
plantations. These districts also have -a;high school density,
which probably contributes to greater education levels.
This has resulted in a paradoxical finding of greater share
of private beds with docrecsing urbanisation. Another
plausible explanation could be that in the hill districts,
because government facilities arc sparse, missionary and.
other charitable services have sprung up to satisfy the
felt needs of the people. This dees not seem t'o be tenable
in view of the fact that in ether districts like Palghat
and Malappuram, where also government facilities arc sparse S’
but percapita income and education are low, the growth in
private institutions is not seen.
1 .5 Concentration of beds in the 2 sectors: In the govern
ment sector, the ..first 4 districts have more than 50% if
the total number'ef beds. Note that these four-districts :
Trivandrum Kozhikode, Allpppey and. Tri'chur - are all
districts containing medical schools. The first four districts
in the private sector contain just under 50% of the total
beds in this.sector. The 'Concentration in the private
sect r is slioMly' less than that in government sector.
.■«
.
1
-1 ■
1.5
Conclusions: From this look at the-distribution of
private beds in the .state,
emerges that private care has
grown greatl/ in the stMe .of. Kerala. In spite of low
percapitel income'the private ^eds in the state cutnumber t
the government, beds. tV- e can reasonably assume this to be in
response to a demand for medical c^re that is not satisfied
by the government institutions, in- quality quantity, or both.
Income, education and greater transportation facility are
found to be the factors that boost this demand. Share of
private beds in the total is greater in less urbanised
districts in Kerala because of the special nature of the
economy. There are few really (big cities; and islands of
wealth are concentrated iiivthg plantations' in the hill
districts. This is on.e ^possible reason why share of private
beds is highest in the^e districts which are- largely consi
dered rural.
> ,»i . i
z
>
. .6.
( 6 )
As discussed earlier, most private hospitals are
sustained by directly charging fees for services. Risk
sharing institutions like health cr group insurance do not
exist. This moans that resources to insti-tut'e and maintain
private medical care come directly from out of pocket
health care expenditure of the people. This' has great
implications when we try to compute the health core expen
diture in the state, as well as for policy. In spite of
trying economic situation, people are. paying a considerable
amount of money, out of their pocket for largely curative
services. This raises questions ^?f both efficiency and
equity. Is there a way of reorganising the health sector
such that the large portion of the scarce resources spend
. on curative services could be released for investment in
programmes that would yield better health returns in the
long run? Is there a way of getting better services from
the government hospitals which arc run by the.state from
tax revenues, so that the public could save some of the
money which they give to private hospitals, where the cash
charges largely boost the incomes of the proprietors and
the medical professionals, thereby constituting a redistri
bution of income from the poor people to the better off
classes,
2.
RECURRENT EXPENDITURE ON HEALTH IN KERALA:
2.1 Introduction; Study of health care expenditure in Kerala,
as anywhere else, is beset by 2 kinds of problems:
(1) definitional problems and (2) estimation problems.
Definitional problems: It is difficult to decide what types
of activities and hence what types of expenditure constitute
health related ones. This observation is particularly
pertinent to Kerala where the achievements in health have
been attributed by scholars to intersectoral inputs. Many
aspects of human activity have a health component: for eg. 9
the right type of eating habits definitely contribute' to
health. But we cannot include the cost of food as health
related expenditure, eventhough the cost of food may have
an important bearing on the health of the community, Tradi
tionally, we include only those1types of health seeking,
behaviour such as preventive or curative health activities
under the account of health care expenditure. Expenditure
in Kerala under various developmental activities such as
prevision of safe drinking water, provision of sanitary
toilets under various aid schemes etc. have important health
components. This is especially important in a state like
Kerala where coverage of such services is very low, and
there is need'for huge capital investment for expansion of
such services.
Estimation pkxblems: estimation problems- are equally
complicated. Payments in the h.t altfi^s'estor are broadly of
2 categories: (1) indirect: such as those financed by
governments, compulsory1or voluntary insurance, employment
insurance, charity donations,
''foreigt aid etc0.
(2) direct financing: whish include direct payments for
services. In Kerala there are ,2 important sectors in health,
the government health settop., and the private health sector.
The government health sector is supposed to be completely
.. .7
( 7 )
supported from the tax revenues accruing to the government,
and health care expenditure under broad, heads in this sector
are available from government sources. But there are 2 factors
which complicate this further:
a) the presence of a legitimate private practice, facility
for the doctors in the government service. One could even
say that the very reason for'the medical profession conti
nuing to..attract large numbers of bright students in the
state is the attraction . f earning a ha nd sc me;-in come from
private practice. This.’is suggested J»y tha fact that quite
a number of youngsters who cannot find admission to medical
schools in the state are prepared to invest considerable
sums of money e’s capitation fees in medical colleges in the
neighbouring states 'such practice being not allowed in
Kerala) to aquire admission. Vve have no means of directly
estimating this amount of direct payment to doctors for
consultation services, because t^is is not accounted for.
(For the purpose of this discussion we do not talk about
the.payments that are made illegally as bribes to service
personnel in health sector, including doctors.)
b) the- fact that a lot of prescriptions from government
hospitals go out to private medical shops and these are not
reimbursed, adding to the out of pocket expenditure on
health.
Side by side with this, Kerala also has a large and
growing private- health care sector (see previous section).
This accounts for a considerably larger number of doctors
and beds than the government sector. These services are
directly supported by payments from consumers, and are
generally perceived as more efficient, though expensive.
Since these institutions adopt a variety of ways to charge
consumers, and also to pay for the services of doctors who
work in them, it is difficult to generalise about expenses
in the private sector. But the important fact is that there
are no risk sharing arrangements, and no government reimbu
rsements for private health expendtiture, so that this huge
service sector is maintained by out of pocket expenditure
from the people.
Health care expenditure in the government sector is
broadly divided into two categories: the plan sector and the
nonplan sector. The plan sector is supposed, to consist of
capital expenses for .new hospitals, machinery, etc. whereas
the nonplan expenditure consists of the recurrent expenditure
like salaries, purchase of drggs and machinery etc. Besides,
there is also the spillover effect on health, of government
expenditure on family planning activities, and the central
government schemes which have an important health component
in the, .
Besides these divisions, health expenditure in the
state can also be divided along the lines of systems; i.e.,
expenditureori the modern medical care sector, ayurvoda,
horn eopathy etc. Though under government spending these
systems get only a small portion cf the to.tal, it is possible
that out of pocket expenditure from the consumers towards
traditional practioners would be much mere. This is especia
lly likely in the. case of ayurveda which has. some•very
expensive- modalities of treatment.
. . .8
(
( 8 )
It is clear that any attempt at estimating expen
diture on health in Kerala is bound to have wide margins of
error because of the various factors involved. Under the
circumstances, the best one can do is to make a rough estimate
of the expenses for any one year under certain well defined
categories, and based on those, lock at the policy implica
tions of this type of spending.
2.2 Expenditure on- non plan (recurrent) sector for the year
1987-88: Based on these promises, I have attempted to esti
mate the recurrent expenditure on health in the state of
Kerala fcr the. year 1987-88. However, before discussing the
details, it is necessary to record a few words of .caution:
1 . this attempt is not meant as an accurate evaluation of
health expenditure for one year. If anything, it is bound
to be an underestimation of the expenditures involv'd.
Nevertheles, the exercise would demonstrate that the present
estimations of per capita expenditure on health,, based on
government sector figures, are underestimates. Further,
the attempt is to point out the policy implications of the
present growth of the health sector in Kerala.
2. There are certain assumptions underlying the estimations >
which shall be spelt cut. While- all of them are realistic,
it is possible that some cf them may not actually be true.
But even in such cases, the. mistake is likely to. load only
to an underestimation cf expenses and not vice versa.
The estimated expenditure on health for 1987-88 are
given in table 6. At this stage, it may be pertinent to
point out certain assumptions underlying the calculations:
1 . all doctors in government service earn extra income from
private practice. I have estimated this income to b. at
least as much as what they earn as salary from the govern
ment. In reality, this is likc-ly to be much more, s< that t
this covers Up -for the few who de not do private consultat
ions out of their own choice.
2.x- In the private sector, there are different arran aments
for payments to doctors depending upon the ownership pattern,
of the hospital. So I have made an assumption that private
doctors earn as much as government doctors on the average,
which assumption is also likely to lead to an underestimate
of income since mostly they earn much more than government
doctors.
3. I have assumed that the money spent on drugs by the
public out of their own pockets, is'at least equal to the
mceny spent by the hospital sector on drugs. The money spent
on drugs by the private sector is assumed to be proportio
nate- to that in the government sector, which is again is li
kely to lead to an underestimate, since government hospitals
are not well stocked in drugs.
From table 6, wo arrive at a figure of Rs. 80 per
capita in 1987-88 on health in Kerala, Which is more than
200% the amount estimated from government sect-.r. Moreover,
we also find that around 66% of total expenditure nn health
is cut of pocket expenditure,* and this comes tn about 4% of
the state domestic product.
'
.. .9
( 9 )
GENERAL CONCLUSIONS; The findings from the above
can be summed up as follows:
1 . Even in a poor community like Kerala, the- pcopxe
currently spend a groat amount of money out of their pockets
on health care. In Kerala, this amount probably far exceeds
what the government spends cn health care cut of its budget
expenditure.
2.
A large- cart of this money spent on health is appro
priated by the purveyors of private health care. This means
that government control on the spending of money in health
is much less than what is imaninod. Consequently, it is very
difficult to ensure that this money is spent in accordance
with the national health priorities.
3.A larger proportion of money spent cn health in the state
since it is spent on private care, is also likely to be
spent c.n curative services of doubtful value in improving
the primary indicators of health status. This is because
the preventive approach to health is much less marketable
as a commodity.
4. The pattern of spending also suggests that the- greater
prepertionof the total health care facilities available in
the state, including much of the sophisticated care, is
available to the better off sections of the community, since
they are more likely to be able to afford them in the private
market. But since they are also more likely to have a better
off health status to begin with, this amount of money spent
on their health care is likely to contribute marginally
much less to improving the total health status of the state
than if the same amount were to be spent on improving
health care for the poorer sections. Thus it constitutes
an inefficient use of resources for health.
Footnotes
a. Per capital income at current prices for India was esti
mated to be Rs.2354.8 for 1984-85 (Central Bureau of
Health Intelligence Directorate General of Health Services:
Health Information of India 1987, Table 3.1, p.56. The per
: income in the State of Kerala for the same period has
been estimated to be Rs.1951.0 (Department of Economics
and Statistics, Government of Kerala, Trivandrum 1986:
Statistics for Planning., Table 7, Section IX. At the
current rate of exchance, one USS = roughly 13.50 Rupees.
F^^i-i^vocoocncn ^'uj «> h>
*
G) W H o •
«
Z
•»••••.
&
W
(■'
s;
M H W H « 3' hS O 1-3
*
: ?? K
?,O
>
» U O f > c! W
>P
> >.
a N L-1 13 H y q H 13 h3 H H
3' a 3' q n a hj h a r <
K L .UHhjaa^X3;y3'O0
y>c: a hkya a a
o
1-3 a53
:p M !>
ri
Oq
3 H
> 3
0
Fh
0
H
?s°
ct
O
o°
O M
'S
O
I□
O
a
Lj
to g.
is
§
u
H
cn
I
tj
V
H
o
I
■
z
u
fl)
hh
5
“
cd
O
H
o
(!)
o
I
i
e
hi
a
G
tn
Ll.xi.n^
3
tn & (D
h- s:
O tn
rf
O ■
Ch
F—1
4- M VO CA
O) o H xj
I—4
I—4
• rd U
(Ji CO H
y §
Cn o cn kO
03 on in CO
onuiw^oontoo'h
»r'- ch cn
x- O
3 c+
gH-
er O O
• hh ch
3 3
3 ch
o o
h^ o
LO Hi
03
On M
1 8
cn 3
3§
?-0
cn cd
.
UJ
r-h
3
3
P)
3
O
hi
l-'J
M
3
H
111
IQ
O
3' &
3"
n> ?:
>< 0)
tn
3
K
rh
'
ti
ll)
fl)
ct
V
co co
on to 03 co
o U) on
<LQ I
F-4 o o
O N) O Ch GJ’ <1 bO’F-4. |
to '
■'
■
I
<n
PJ-
3
ct-
3"
cn
fi>
o
& <
UJ H HW W
M
m cn
CO GJ CO N) CD <1 -0’ 4^ O O
_ « CO^kO
rrn l n I n z—r~\ rvn' 1_ ■
o kO F-1 co
vo CO
cn en o O Ch'F--
bJ
fi) O
tn rf
OJ
M I- .H ...
IL 41 H LJ 3 M 3 3
...
► •-!
'3
$ <
CO CJ to
to CO 4- 03 45. t_n co LO______
_ Cl
_
CO CD I- CO to on Cn 4s. Cl to 1-5 c. lo
y r
ct
fl)
CO
m
ft
fl)
ct
O
O'
ci
fl1
ch ti
pi)
O' O
hh
O
EJ
n
o o.
I
<= ?
tn-g
Q
hi
O' 0
0
tn ?b
• fin
H
0)
tn
C>
I
3 H W “ H W ffl 3 '31 W u-' h. u; !
4- 3 3 >S o h u> 3 H H C 3 3 ;
IDlOHWHO^NroulMO^
in
ui U)
hi H
u
m
m . -i n
1J
VO .tv H H
H <0
O
or u
G <
£b li
en •
a
t
i
LnHWWHUlRK)(^Ul>MnO\
HPOOH^VOHVO^WUIGVM
•xJW^W'JCOHPWWvO'JlM
& 51
O <
O rt
<S
tn
H
§
fltn L-JI
flQ
(.'• g)
y
<(l) o<
hi G
H- 3
O 3
3
H- 51
3 ti>
W Cl K
tn O
’3 O
h-'M tO h-‘h-‘l-‘ tO M tO t-ih-Jl-^hJ
C 3 O M G CO Ln C to IO ® C c
Ch o --JO'JPO'JCiunooiOLn
_ _
Q (JO cn H K) 9 CA o 'kO kD
Ci). O
o
&
;cn
o
£ '■
F^ CD
fl) Ct .
3 H3 Q
H- CD
hi
|D
25^
hi hh -
■
3
ro
44 <+ '
H- tn
O ri
ch hi
Oj 3
hi (1)
0
6)
> H-
(1) hi H-
ti tn
h’-'O
< |D
V hi
!
3
<+ &
H U
2 sr
° &iu
cn CO gj Ch
o hh H3
3
CD
.. t+ a
Q,
■. Fh cn
o tn to
o o w
P- 3* (1)
Cb (!>
ct
hi
.:
(1; O
- H O
Pu
ft
H- flJ
O 3
CD -£b
- >n ;
o o
oy
lOhJhJtOM
.
....
bO
Cl Ln fL />. o c Ln IC J D H h S
d nn 3 o 4’* - 3 (1; C C O C C
cn
o
a
<+
o
hi
GJ
Q
Q
X
nj
X
H3
£ O
H
H
§
o
u
§IS M
NJ
£ ?,
1------- 1
fe■2 XN ris
H
X
§.
GJ
U'
3
0
§
0
1^-'
■H ■ o
IS
£
hfl
>
e
I
Q
H
A
l-h
u
S H
tn
rr
H-
a
Ct
NJ
CD
o
CJ K
kO
•9
NJ
D
un
CO
xo
un
Sff
c o
C’ff
r-> m
O Q
O tn
NJ
O
GJ
O
|G
NJ
NJ
.03
03
CD
Xo
CH
CH
I-1 o
•3)
Q <
O rr
,'J> IO
■ n' hir+lcn
’fl) rt
• H ]>-<
H- Picn|Q
cr
tn
o O'
O (0
O Qj
tn
Ch
kO
NJ
O
'Jb
H- 'Tl
kO io
O • in
Ch
kO
k0
O
NJ
O
NJ
r° hS
□ fl)
Oh
o
.tn
o
ft
X
fl)
j£b K
IP- [U
;<n
pj
^0 H0) ft
5
3
P.'
iff
■b-’ff
o
o
O
Ln
Ch
h-.
co
o
to
O
X X
Oh
\j
CO
10
X, fl>
r? &
B tn
O
O
iff £
O
B o
H-rb
Ci)
Ob
P
iff 0PJ
in
4^
GJ
0
9
03
GJ
0J
co
Ch
o
Ch
o
GJ
kO
<0
Ch
GJ
Ch
't Q0
h
H- >d X
3 < cn
r+ X
ct.
P
•I-U
o cr h
J
c+ 0 (D
P &
I-1 P O
th
’ 0
• JJ
I?
I
I
Ch
£
kO
Ln
4^
CO
Ch
CO
in
CO
W tl
Ch
in
Ch
o
s&
o o
3 l-h
kO
o
o
o
rt
Uj
i
!
o
co
kO
Ch
I
.6)
p* a
o ff
oo
' o
O I-1
ow
o
c+
O
a
m
<+
H
.
,P
0 HI 3
p: cn
P Cirt^
a
it-1
’<■+ .s
J'iQ
C4
H
W
£
NJ
1
o w
3 Hrt 3
rt a
O P'
H
3d a
ro -<
O
3 rt
fi) 3
ro
cr
ro 3-
Qj ill
>0
&
ro a
h a
■d
GJ 3
o a
KO P>
'D P-
ro o
o 3
'O
a H
ro pi
•
rt
pO
H<45rt
fi)
3
O
CL
H
3
cn
fl)
Q
rt
O
H
p3
■'<) HI i-3
.033
O O P- PH* 3 01 W
no
a 3 h- £
H- ro o
on
h
& a
:n J X
sd- fi) tn
ro
a pl 8
_ o
_
o 3 s; 0
•>
<->t
rn
* 3
rt
0 a
3
ft
no
o 3d rt
3 3 ro o
ct fl)
H 0)
Jo *0., [u r
ro 3d rt H
o |<; p- p>
O ro o rt
H hrt ro o o
- P- Hi
a p>
o
KO 3 0 th
CD
3
o'O ro o
— ro
d
- h >0 ro
th gj|< a
C Off; O
K o H- Q
O O rt
rt
H’R
3d 3 P<
i. ro 3
■d
P'< O >0 3
(1) H Cl
P rt h rt
3
k ro
a cn ro
KO Hi O 3
co o o o
■ —
a
h ro
H CO H
3
3
a-o
P- H cn
P> rt ro
ro n
p) a rt
M
o
Hi H
P> o \
fi)
K
fl'
pj
2
O
hi
X
to
Q|M a tn a
i-t rt. o ro
3d K 3 rt
ro M 3d
3
0 co
P)
□ ro3 Hl p- rt
rt
< H 3 rt
O p- o ro 3d
th n 3 a ro
ro
g
" cd ro o
£b -J 3
rt
□ ct
H 011 <ro a rt
2 rt oi p>
h oj a
□ P) £>
a ui 3
lo
<o rt co w
co H 3 H 3
Ft p- m
i
ro < h
C p) p< ■
rc Hi 3 it O
CD
< co
P-'d
3 fi)
o o
O *0
3 a
CD fl)
ro i-h
(D
P)
o
o th a a
P) ■
o o
x n ro
rt ro rt rt
prood
ah h
PI rt ro oi
a
o ro
F
0. r.
M
p; <
ctm
hX
fl)
ro o
.
o
^0 rh
01
O H
o Q
O
3
§
o
5’
P- oi 3
a o o
p- pi o
H 3d rt
r9
fl)
CT
rood
n < H
rt CD
iR:' ro
.• i
;S-
>■
x
:rt P) EV
!o
-> 3 a
ro
P 3“
3
rt
pi rt H rt
3 ro O 3d
p- a 3 fl)
H
p Hl m fl) 3
CL P)
co 01 '
p. hi
P) ro U - ro
M
H rt
.ro h
3 rt
a 3
0>
3
Pj
£L>
fi)
OOH
IO
O
H fl)
p)
< PI
K
Vro SR"
O
o
< th
H CD
P- 10
3
p) [Hi 3 Hi
fl)
'3 U
01
gaH
§
2 JO
CD ro
H *0
(D o
a H
P) rt
l-h
o _3 3d
K to
to
s:
3 a"
~ Q KO
o
to
O
'< O.
ro roIM o^o,
< U> O~ oi- ft
ro a rt rt ro
;
Q
l£
fl)
a d
ti
ro
o < a
th fl) Ph rt
3 P-
3 o
ro 3
3 PI
rt a
rt
P)
rt
3
fi)
to
&
rt
Q
O
&
3
J)
(+
P<t
3
rt
0
3
cn
0
o
ro
H
3
3
ro
3
rt
01
o
P-
z:
H-
fij rovQ
K O'!
(D
'ft
arQ H
O Pl
<n
l-h
(D
K
PJ
fU
to
. 3:
■ • 'CO
to
#
u
3
c.
. t?
I
s
-
a
o3
J
I
to
uO
00
to
o
cn
H
I
co
co
Ch
CO
Ch
nJ
*
H
<
•
w
oH
§
n 5* nh-3
H
W
“ e-cj'-G;
Ht
;-3‘-=
tO
■
H
3
.2
cn
to
J
GJ
Q
M
!
jo
13
to
co
o
kO
|H
IH-
Jt’
%
GJ
O'
cn
i
£
rt
Ct)
Qj
H H tl
2 hi ra
"01 H-U
Ct < 3
P- ill H
rt 3 rt
C Q.3
rt H re
H*
3
O
ft
3
H U
h £2
H-W
< p)
p h
3 rt
& 3
h
re
g
3 rr
W I—1 o
3 o
o co
co
cn w
- o
o
cn 3
CO Hi
hh ~J [rj
1 8
(1) Jo 3
S H
rh
K
Ch
o
g
O
GJ
cn
cn
4^
CO
to
cn
ch
o
H
Q
in
tO Hh
to
CO
kO
cn
Ch
CD
5 o>toO'.
CO
OJ
co
CO
tO
tO
to
"M -8O 9H- plrt3 O3Hh- n
tn w
PJ H O
•
r+ W
o w
Hi 3
Cb
rt
3" cn
(D Ct
P>
Cn rt
3 HH cn
< 3
a> h'
o
cn
o '
Hi
o
to o
K <
p- re
<pi H3
3 3
re g
6 o
l-h CO
O c+
H pJ
ft
*0 PH cn
P) d-
I
I
I
‘
co !
to
P> «
H O
3
[U
P>
co
cn
to
co
to
co
00
kO
i
J
n o
Ch
O
00
co
GO
00
U1
Ch
kO
Ch
o
U "
cQ Q
O
kO
co
hG
O
co
Ch
to
GJ
On
Ch
00
to
ch
cn
Ch
kO
kO
00
O
cn
co
cn
co
h- cn
<
fi)
H
gre .
i
r+
O
l-h
Ch •I
hG
o
H- 3
re ,
o o
o o o
o
3
5 3
Co
3
P- pi
O 3
W Ch
I
(D
o
Cn
cj
k.0
i
O
o
TLcLS 3.
Kendall's rank correlation coefficient between
Variables relating to distribution of
Health car; in various districts
1 S'
1.
Value
Kendall1s
Tau
Per capita income
40
0.51
Schools/100, 000
2
Length of roads/Km ;
62
0.79
0.28
Pvt.beds/100, OOP
and;
Length of roads/1'00, 000
Pop.
Density of population
2.
35
8
0.45
48
0.62
Schools/100, 000
8
6
Length of roads/100, 000
33
0.10
0.08
0.42
Praarate beds/Square Kilomotcr, and;
Length of roads/sq.KM
density of population.
4.
0.10
Govt, beds/100, 000 and;
density of population
per capita income
3.
22
58
0.74
40
0.51
Length of roads/sq.Km.
40
0.51
Density of population
54
C.69
Govt,beds/Square Kilometer,and;
The 1 P' values are not given since all districts have been
considered and there has been no sampling.
TABLE 4
Urbanisation and relation to share of Private beds
in total,varipus districts of Kerala
Most Urban
Less Urban
Least Urban
TRIVANDRUM ( 38.76)
QUILON( 70.74)
PATHANAMTHITTA (84. 03)
KOZHIKODE (38.76)
ALLEPPEY( 44.11)
KOTT AY. M (67.68)
IDUKKI (88.62)
ERNAKULAM(69.54)
WYNAD ( 80.34)
TRICHUR (57.37)
PALGHAT (39.63)
MALAPPURAM(60.97)
CANNANORE( 54.87)
Figures in brackets indicate percentage share of
private beds in the- total in the state.
Statistically significant trend of increasing
share of private beds in total with
decreasing urbanisation, at 0.05 level
(Jonckheere's test).
r
TABLE 5.A.
Concentration of beds in the Government Sec t o_r
No.
District
Cumulative %
of beds
1.
TRIVANDRUM
17.75
2.
ALLEPPEY
29.75 :■
3 .
KOZHIKODE
41.18
4.
TRICHUR
52.56
5.
E.tNAKULAtf
63.92
6.
KOTTAYAM
72.79
7.
CANNANORE
81.42
8 .
QUILON
87.01
9-.
EtAL'GHAT
’
91.64
10.
MALAPPURAM
95.35
11.
PATHA NAMTHITTA
97.47
12.
IDUILKI
98 .83
13 .
WYNAD
100.00
TABLE 5.B. :.
Concentration of beds in the Private Sector
No.
District
Cumulative %
of beds
1 .
ERNAKULJ^M
17.63
2.
KOTTAYAM
30.26
3 .
TRICHUR
40.66
QUILON
49.85
5.
TRIVANDRUM
5 7.48
6.
PATHA NAMTHITTA
65.07
7.
IDUKKI
72.25
8.
ALLEPPEY
78.69
9.
CANNANORE
85.83
10.
KOZHIKODE
90.74
11.
MALAPPURAM
94.68
12.
WYNAD
97.93
13 .
PALGHAT
100.00
i
TABLE 6'
Expenditure in the-,non-plan (recurrent) sector in health
in Karala, estimated for 198 7-88 from Key f igures ( in
Rupees Millions)
-
•••
— —
Item
1.
2.
Health services department
2
5 Medical Colleges
Expenditure
1
570.00
143.00
Sub total for 33329 Govt.bods3
713.00
3.
Private sector,4903C beds1
1050.00
4.
Estimated income from private
Private practice for 4726
5
Government doctors
5.
6.
75.00
Income inflation factor for
6345 private doctors6
100.00
Out of pocket expenditure
,
7
for drugs
250.00
TOTAL
2188.00
Out of pocket expenditure on .
health8 - Rs.1475 Million(67%)
Percapita expenditure on health
9
Rs.86/-
N otes;
1.
Information provided by Dr.K. STenugopal, Additional Director
of health services, Kerala State.
2.
Assuming spending on 5 Medical Colleges is about 25% of
that spenton peripheral hospitals.
3.
Ignores growth in number of government beds from reported
figures.
Assumes spending on private beds to be proportionate to
that on Government beds. Likely to be underestimate.
4.
5.
According to sourced) above, Rs. 62 million was spent on
salaries of doctors for the year in the. health services
sector. Add Rs. 15 M for salaries of doctors in Medical
Colleges. So Rs. 75 M was spent by the Government on salaries
i
contd..
of doctors. Let us further assume (realistically) that
all of them earn income from private practice, at least
ecual to their salaries. Hence Rs. 75 M was the income
from private practice of government doctors.
6.
Similar to (5) a .over the incomes of private physicians
have to be
inflated by this factor if we assume that
the incomes in private and government sectors are
roughly equivalent.
7.
From source(l) abov^, Rs.100 M was spenton drug in the
health services department. Let us add Rs. 50 M for the
Medical colleges, since they arc better stocked than the
peripheral hospitals. Add another Rs. 100 M for
drugs disbursed from private hospitels. Even then, this
Rs; 250 M is not enough to cover the total expenditure
on drugs in the state, since most illness episodes need
outside prescriptions, Let us assume this amount to be
equal to the Rs. 25CM. So, this was the out of pocket
expenditure in drugs.
8.
Includes everthing except ths expenditure for running
of government hospitals*
9.
Assumes a 1.9% population growth take for 2 years from
the figures in Table.1.
REFERENCES
1.
Central Bureau of Health Intelligence Directorate General
of Health Services Ministry of Health and Family Welfare,
New Delhi (198 7);
Health Information of India, various tables.
2.
Department of Economics and statistics,
Government of Kerala, Trivandrum (1986)
Statistics for planning tables.
3.
Caldwell J.C. (1986) The conditions of ubu sually lew
mortality, Optimum paths to Health for All. Population and
Development review.Vol .12, No.2
4.
Halstead at al(ed) (1985) Good Health at Low Cost.Proceedings
of a conference at Bellagio City,Bellagio,Italy.The
Rockefeller Foundation, New York.
5.
B. Abel-Smith-Poverty, Development and Health Policy*WHO
Public Health Papers No.69,
V.Raman Kutty
Md.MPH, M„ Phil
Kerala Sastra Sahitya .Parishad.
Position: 4501 (1 views)