Feasibility of continuing Keshod Diagnostic Centre

Acknowledgements
I would like to extend my sincerest gratitude to the Management of AgaKhan Health Service India for their support without which my study and learning would have been incomplete. I express my sincere gratitude to Shrikant Ambekar [Project officer], Mr.Sulemaan [Director,AKHSI] and Ms. Aruna Vijay (HMIS Research Officer & my senior) for giving me permission to commence my summer training at AgaKhan Health Service India and coordinating my visits to various clinical, administrative & support services of the organisation. The staff members & patients in different department and wards had been very cordial to me especially Mr. Anand Anjariya [Field manager, Rajkot (NSR)], Mr. Amir Dinani [Field Manager, Keshod (SSR)]

I am highly grateful to Dr. S.D Gupta (Director, IHMR, Raipur), Dr. P.R.Sodani (Dean, student and Academic Affair & HOD of Health Stream).

I wish to express my sincere gratitude to Dr.Neetu Purohit (Professor and internal mentor) for her unconditional support, guidance and motivation throughout the study period, without which it would have been nearly impossible to complete my summer training project so effectively. I would also like to thank my mentor Mrs. Aruna Vijay who helped me in giving the finishing touches and making the final report.

Last but not the least, my special thanks to all, who contributed their valuable time and effort to make my summer training effective and all my family members for their valuable support and encouragement during my summer training.

Table of contents
Topic Page number

4 Abbreviations Executive Summary 6

Introduction

Objective & Data collection

10

Results & findings

11

Discussion & Suggestions

13

Conclusions

13

Annexure

14

Abbreviations
AKHS =Aga Khan Health Services AKHSI =AgaKhan Health Service India AKDN=Aga Khan Development Network AKRSP= Aga khan rural support programme AKF =Aga Khan Foundation AKU =Aga Khan University AKPBS =Aga Khan Planning and Building Services KDC= Keshod Diagnostic Centre PHC=Primary Health Care RCH=Reproductive & Child Health services ANC=Antenatal care PNC=Postnatal care USAID=United States Agency for International Development CIDA=Canadian International Developmental Agency SWD=Social Welfare Department CHAAYA=Community Health Awareness Action promoted by Young Adults CBC=Complete Blood Count ESR=Erythtrocyte sedimentation rate M.P. by slide=Malarial parasite by slide method Bld grp.=blood group Urine RM=Urine routine microscopy S.Urea=serum urea S.creatinine=Serum creatinine UPT=Urine pregnancy test S.bili=Serum bilirubin

S.G.P.T.=Serum Glutamic Pyruvic transaminase RBS=Random blood sugar, FBS= fasting blood sugar, PP2BS=post prandial blood sugar RA= Rhematoid Antigen HBsAg=Hepatitis B.Antigen S.Widal=Serum widal TSH=Thyroide stimulating hormone BCC= Behavior Change Communication GHSDP=Gujarat Health System Development Project MPW=multipurpose worker LHV=Lady Health Visitor OPD= Outdoor Patient Department

Executive Summary
AKHSI with its motive of serving the general public at large & also with preference to Ismaili community started Keshod Diagnostic centre & PHC services at Keshod village of Junagadh in SSR Gujarat in April 1987.It gained wide acceptance & popularity among the public since its inception. AKHSI with various funds from USAID & CIDA conducted many preventive, curative & promotive health related programmes & campaigns at KDC along with the pathological & radiological investigations. AKHSI at KDC also strengthened the overall economic ,social & cultural status of the residents of Keshod & nearby villages by its AKRSPAgaKhan Rural Support Programme & also actively promoted various RCH services conducted by GSHDP. Since 2006 AKHSI has constrained its approach from health service provider to health service facilitator. Meanwhile, the usage of KDC is decreased to a considerable extent with closure of Radiology services. This report points out the reasons of decrease in utilization of KDC services & solutions thereof. This report also gives an idea about what efforts are

necessary to continue with KDC or is it wise to continue with KDC or to close it.22 local medical practitioner of Keshod were interviewed along with the existing staff of KDC to know the reasons for decrease in utilization of KDC services & also to know any valuable suggestions to improve KDC services. Key findings of the study were-----1) Non availability of M.D. Pathologist & M.D. Radiologist at KDC. 2) Obsolete technology at KDC 3) Closure of Radiology services since September 2010. 4) Various local doctors have started their own pathology services for their patients in their hospital. 5) Increased number of existing pathology & radiology service providers in Keshod. 6) Health service facilitator based approach implemented by AKHSI at KDC instead of Health

care provider approach. 7) Previous focus from general public to Ismaili community. Looking to

all these reasons we may have an idea of whether to continue with KDC services in future & what all may be required for this or Is it wise to have a closure of KDC services.

Introduction
The Aga Khan Health Services (AKHS) is a private not-for-profit health care system in the developing world. Building on the Ismaili Community's health care efforts in the first half of the 20th century, AKHS now provides primary health care and curative medical care in Afghanistan, India, Kenya, Pakistan, and Tanzania, and provides technical assistance to government in health service delivery in Kenya, Syria and Tajikistan. AKHS is one of three agencies of the Aga Khan Development Network (AKDN) that support activities in the field of health, the others being the Aga Khan Foundation (AKF), and the Aga Khan University (AKU). It works closely with both of these agencies on planning, training, and resource development and with the Aga Khan Education Services and the Aga Khan Planning and Building Services (AKPBS) on the integration of health issues into specific projects. AKHS is organized into national service companies in Afghanistan, India, Kenya, Pakistan, Syria, Tajikistan, Tanzania, and Uganda. The Social Welfare Department (SWD) located within the Secretariat of the Aga Khan in France, co-ordinates the activities of the service companies through five-year plans, ten-year projections, annual budget submissions, and the provision of technical assistance. They are also linked internationally through network-wide strategies in human resource development, hospital management, nursing development, and primary health

care. While strengthening its institutions and the links between them, each health service company also joins government health services and other providers in building effective national health systems.

Programmes designed to reach vulnerable groups

AKHS's community health programmes are designed to reach vulnerable groups in society, especially child-bearing women and young children, with low-cost, proven medical technologies: immunization, systematic prenatal care, aseptic deliveries, and oral rehydration therapy for diarrheal disease. Experience with Public Health Centers within the Aga Khan Development Network has confirmed both the efficacy of primary health care in improving health status, and its cost-effectiveness.

Major initiatives
AKHS's overall major initiatives currently include: Assisting communities to develop, manage, and sustain the health care they need.

Providing accessible medical care in modern, efficient, and cost-effective facilities. Working in partnership with other agencies in the development of communities and the enhancement of their health.

Educating physicians, nurses, and allied health professionals. Conducting research relevant to environments in which AKHS institutions exist. Contributing to the development of national and international health policy.

AKHSI with its noble intention of serving the needy started Keshod Health & Diagnostic Centre in Keshod village of Junagadh district of SSR area of Gujarat in India during 1986.

A brief idea of Keshod

Keshod is a city with a municipality in Junagadh district in the Indian state of Gujarat.

Infrastructure ---Development of this city is very fast in terms of population, art,

infrastructures, education and cultural change.

Terrain--Keshod's landscape is mostly dry. It is 45 kilometers from the sea. During the
monsoon months it often rains heavily in and around Keshod but the souring heat means that for a lot of the year there are problems with receiving running water. Farming is the major occupation with ground nut being the most popular crop grown.

Demographics---Total population of Keshod as on census 2001-03-01 is

67352.Keshod has an area of 41.87 sq.km with population density of 1510.8 in./sq.km with an estimated population change of +2.34%/year. Keshod is mostly inhabited by Hindus. About 10% are Muslims.

A brief idea of Keshod Diagnostic Centre (KDC)

Initially AKHSI at KDC started with community need assessment programme & thereafter conducted preventive, basic health awareness & curative RCH services in Ghed area with an aim of increasing immunization & decreasing IMR & MMR. In 1994 influenced by the success of the above programmes, USAID funded for the same programme to be extended to surrounding villages like Maliya & other of Junagadh district. Again this project was extended during 19992005 to cover more villages & provide RCH awareness, Behavior change communication ,develop referral linkages, facilitation of services, Mental Health Project, HIV/AIDS prevention & awareness programme, Women empowerment programmes ,etc . Various RCH programmes like ANC ,PNC ,vaccination services were also provided in collaboration with GHSDP Gujarat Health System Development Project .During this time period KDC gained a wide response & acceptance from the society as there were no or very scarce other health care providers---Number of beneficiaries were plenty. Later, in 2006 the Community Health Awareness Action promoted by Young Adults [CHAAYA] project funded by CIDA was implemented which was primarily facilitation based & not providing of health care like Facilitating vaccination & not providing it .Moreover now the focus from general public was also constricted to the ISMAILI community .Gradually the response of public beneficiaries decreased. Facilities available at Keshod Diagnostic Centre Various Pathology services provided by KDC are

1. CBC, ESR, Bld grp. 2. Urine RM, S.Urea, S.creatinine, UPT 3. S.bili, S.G.P.T. 4. RBS, FBS, PP2BS 5. RA 6. HIV, HBsAg, S.Widal 7. Lipid profile 8. Serum T3, T4, TSH 9. Vit.B12 Most of the pathological investigations done in other pathology labs of Keshod are done at KDC at reasonable & cheaper rates. Other investigations which are not done at KDC are referred to Green cross lab Ahmedabad. . X-ray & USG department are non-functional since last 6-7 months.

Staff at KDC :Previously, KDC had 1 laboratory technician[DMLT],Radiologist[D.M.

radiology],X-ray technician, 3 administrative staff, 2 peons , Project officers as per the ongoing health project, 3-5 MPW ,2-3 LHV Currently due to closure of Radiology services the staff at KDC is 3 administrative persons, 2 peons, 1 laboratory technician,2 MPW. X-ray & USG department closed completely since 6-7 months.

Objective Of Study

The main objective of doing this study is to assess how cost effective is the KDC & to know the reasons of decrease in utilization of KDC services & finally to decide whether it is feasible to continue services at KDC.

Data collection
Respondents- Physicians, Gynecologists, Surgeons, Radiologists & other medical practitioners in Keshod.

Duration- The data collection was done within 5 days [13.05.2011-17.05.2011] of stay at Keshod as the records were already available & it took hardly 3 days to have personal interviews with various medical practitioners of Keshod.

Sample size22 Doctors consisting of 7 M.D. Physician , 4 M.D. (Gyn. & Obst.) , 2 M.S.(Ortho) 3 M.D. (Paed.), 1 M.D. (Radiologist) ,2 B.D.S. ,1 M.S. Ophthalmology , 2 M.B.B.S. 1 lab. technician of KDC & 1 Field manager at KDC. Sample size was selected after discussion with KDC staff & aimed to cover most of the medical practitioners of Keshod.

ProcedureIndepth interviews with the local consultants of Keshod of 15 to 20 minutes each.

PerformaAn interview guide of eight questions was prepared as per the need & discussion with KDC staff. The interview guide is given in annexure.

Primary data collected by personal interview with consultants of Keshod & staff of KDC. Each of the available KDC staff were interviewed personally to know the various services available, the user fees , assess the public need of KDC services , overall utilization of these services , details of various doctors sending patients for lab investigation at Keshod previously & at present, facets & pitfalls at KDC.

All the available registered medical practitioners were interviewed personally at their clinic during OPD hours with prior appointments. Their answers & suggestions for KDC were noted.

Secondary data from the various literature [Brochure of AKHSI, Concept note of CHAAYA project] & records at KDC [Patient utilization and financial records of KDC services of yr. 2008 to 2010].

Results & Findings

Various reasons revealed from the review with staff, records, local consultants are as given below

General Findings:
1. Previously the health care programmes by KDC were service oriented & targeted the society in general. But recently i.e. since 2005 the campaigns done by KDC are just facilitating other prevalent health care services .e.g. facilitating RCH services & immunization provided by GSHDP. Moreover, recently since 2009 the targeted population is decreased to ISMAILI community only.

2. Previous health campaigns covered & strengthened the society in a multi-sectoral approach like providing employment, empowering women by various gruhudyogs, sewing class etc. which focused on an overall uplifting of society which is not a current scenario.

3. 20 out of 22 doctors interviewed said that lack of M.D. Pathologist & M.D. Radiologist was a reason for their referring patients to other laboratory for investigations.

4. 4 doctors had a view that lack of sufficient technologically updated devices was a reason for low utilization of KDC services.

5. 9 doctors said that increased number of competitors [Pathology services] led to low utilization of KDC services.

6. Eight doctors owned their own pathology services so they need not send patients to outside laboratory for investigations. 7. Two doctors also said that No sample collection or pickup service from hospital is provided by KDC & the service of KDC very slow

Financial Findings

900000 800000 700000 600000 500000 400000 300000 200000 100000 0 Pathology 224598 185838 717950

881850

446330 272892 223406

245529 138338

Test Income

10390

1626 3276 12321 X-ray Sonography Pathology

56000 1972 3776 11598 X-ray Sonography Pathology 1201 X-ray 1523 Sonography 0 0 X-ray 0 Test Sonography 0

2327 Pathology

2008 2009

2010

Jan- March 2011

The graph above shows that the utilization of radiology services has been much higher than that pathology services. The pathology income as per the graph above is very uneven .The highest income pathology department has generated was in 2009. After which, the income is showing declining trend in 2010 and 2011. Though Pathology services, despite its low utilization is still continuing at KDC, the major revenue earner (radiology services)is showing sharp decrease in income and is non functional since September 2010 due to unavailability of radiologist and technician.

Discussion & Suggestions

From the above findings it is clear that lack of radiology services, obsolete technology, increasing health awareness in public, new competitors & facilitator based approach for health services in place of previous provider approach of KDC has led to a recent fall in utilization of KDC services. If seen in BCG matrix KDC currently is like the previous old LIFEBUOY soap struggling to survive .But it can be brought back to the market [increased public demand] just as LIFEBUOY did marvelously by change of flavor & design of wrapper. If KDC is to be continued it has to be made technologically updated with a fully fledged team of M.D. Pathologist & Diploma Radiologist which in itself is a costly affair. If we see closely on the figures in the graph above and table (attached in annexure) then it is clear that excluding radiology services the pathology services though functional, its utilization is also reducing since 2 years -----so if one doesnt wish to invest any extra amount in KDC then we can decrease the office space & just continue with the Pathology services which may cost less by decreasing the overall fixed cost [rent of office space].

Suggestions
Prepare a catalogue of services provided with price & distribute to all Practitioners in Keshod Bring a new Pathologist with full fledged lab.

Conclusion
Based on above discussions and findings, we can conclude that if KDC has to be continued it has to be given a new furnished look with latest technology services aided by Pathologist & Diploma radiologist which in itself is a costly affair .Also it needs to be thought upon, whether these investment in up- gradation of KDC services are required given the fact that these services are already available in the community. So, it may be wise to close the KDC as per the scenario of

public demand & existing competitor services i.e. lab services & private laboratories owned by medical practitioners themselves.

Annexure-1 Interview Tool

The following is the list of questionnaire or interview guide used to interview the various medical practitioners of Keshod. The interview guide was made by keeping in mind the objectives of data collection & varied branches of medical practitioners & was kept to the point & brief in order to avoid wasting of consultants time during OPD hours. The questions included in the interview guide are 1.) Sir do you need to have your patients do a pathological or radiological investigation? 2.) How frequently or how many patients at an average are asked for such tests in a day ? 3.) Where do you prefer to get these investigations done by your patient? 4.) Have you ever used KDC servicesPathology/radiology? 5.) If answer to Q.4 is no why? 6.) If answer to Q.4 is yes---were the results of KDC satisfactory? 7.) If answer to Q.6 is no ---Why were they unsatisfactory? 8.) Any suggestions from your side for improving KDC services?

Annexure-2
Below is the table showing department wise records of KDC service utilization with revenue generated since 2009 to April 2011.

Year

Dept.

Budget No. of visits

Test / Patient Attendance 12321 1972 3776 18069 11598 1201 1523 14322 2327 Non functional Non functional 2327

Expenditure

Income

2009

2010

JanMarch 2011

Pathology X-ray Sonography Grand total Pathology X-ray Sonography Grand total Pathology X-ray Sonography Grand total

11664

1046000

16750

783000

272892 223406 881850 1378148 245529 138338 446330 830197 56000 0 0

3753

74000

56000