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Technical due diligence

District : Keonjhar

September 2016
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1
SUMMARY
• The district of Keonjhar has 46 government health care facilities and 26 private hospitals with a
bed strength of 779 beds only.
 CHC’s comprise of 41.3% of the total OP consultations at government facilities, indicating a good
health seeking behavior of the people at the district.
• OP to IP conversion has been higher than industry standards at all the public health facilities.
• BOR at all public health facilities is much above the optimum level of 80%, indicating an immediate
need for beds at secondary care level.
• Surgeries performed at government facilities are mostly minor in nature, for FY 2015-16,81% of the
total surgeries performed at government facilities were minor in nature.
• Less than 2 surgeries per surgeon per day at DHH and SDH and less than 1 surgery per surgeon per
day at CHCs indicate under utilization of surgeons.
• Institutional deliveries at the studied facilities have increased by 15% since 2013-14.
• Proportion of C-Sections to normal deliveries at secondary care public health facilities is 7.5%,
which is a healthy trend.
• Overall Lab tests accounts for majority (97%) of total diagnostics at the studied facilities, whereas
CT-Scan facility is not available at any of the healthcare facilities in the district.
• It can be inferred that at secondary care level only 31% of the existing demand is being met for OPD
and 25% for IPD.

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SUMMARY

 Considering the WHO norm of 3.5 beds per 1000 population, the district has a shortfall of 6144
beds (i.e. a gap of 90% beds).
 Considering the WHO norm of 1 doctor per 1000 population, the district has a shortfall of 1726
doctors.
 Considering the WHO norm of 2 nurses per 1000 population, the district has a shortfall of 3850
nurses.
 For gaps under service facilities, when compared with IPHS for district hospitals, major gaps are in
the areas of Diagnostics and Specialty OPDs.
 Low pricing of services stands the most voted reason for choosing a government hospital, whereas
availability of preferred doctor and proximity to residence is the reason for interviewees choosing
a private facility.
 While Majority of the respondents depend on savings for their healthcare spending only 33% of the
patients surveyed had health insurance as a primary source of health related costs, which indicates
a need for awareness in insurance coverage.
 All the surveyed physicians indicated that patients from the district go to other districts / cities for
availing tertiary level healthcare, of which majority ailments pertain to cardiology and neurology
followed by gastroenterology and endocrinology.

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SECTION 1:
PROJECT
SNAPSHOT

4
PROJECT BACKGROUND
 As a part of a broader health sector enhancement program, the Government of Odisha (GoO), wants
to strengthen and enlarge the private health sector facilities and promote the participation of
quality private health providers across all the 30 districts in the state and therefore has signed an
agreement with the International Finance Corporation (IFC), a part of the World Bank Group, to
assist the Department of Health and Family Welfare (DoHFW), GoO to enhance the health
infrastructure in the state by structuring and implementing the rollout of low cost hospitals across
the state in a PPP model which will offer decent quality care at affordable prices.

 IFC has thus contracted in the consortium of Medica Synergie Private Limited and Jones Lang LaSalle
Property Consultants (India) Pvt. Ltd. (JLL) as the Technical consultants and Cyril Amarchand
Mangaldas (CAM) as Legal Consultants to conduct Technical and Legal due diligence for the project.

 The project will look at the entire state as a whole and based on detailed financial, fiscal, logistics
and operational due diligence a network will be developed with recommendations on the number,
size, type and locations of the hospitals

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SECTION 2:
METHODOLOGY FOR TECHNICAL
AND MARKET DUE DILIGENCE

6
TECHNICAL DUE DILIGENCE
Demand & Supply Assessment Paying Capacity Assessment

• Assessment of district level demand for health services, • Assessment of patient profile – APL
through primary research such as surveys, interviews of & BPL
patient/ doctor and review of available clinical data at • Prevailing market rates, CGHS and
hospitals and MIS data from NHM various industry empanelled rates
• No. of patients referred outside
•Assessment of existing clinical services, infrastructure Odisha for secondary and high
and resources secondary care
• Additional sources such as Centre &
• Capacity Utilisation Assessment of existing capacity State’s healthcare support schemes
including OPD and IPD Numbers, bed occupancy, average – RSBY, BKKY, ESIS etc
length of stay, OT utilisation, major and minor surgeries
and other clinical procedures

Assessment of Gap in Health Facilities with respect to existing and future demand

7
METHODOLOGY

• Secondary data survey: based on information available over public domain


• Primary data survey: Onsite healthcare facility assessment, data collection from
government offices, interviews with hospital administrators, clinicians and
Step 1 general population

• Preliminary assessment to cover the functional feasibility of developing a


hospital along with the mapping of road and rail connectivity.
Step 2

• Correlation of primary and secondary data that is already collected from districts
and state
• Data analysis the overall state and each of the 30 districts.
Step 3 • Presentation on the findings of the market assessment to IFC and Government
of Odisha.

8
Keonjhar district headquarter hospital and
district HQT

SECTION 3:
DISTRICT PROFILE

9
DEMOGRAPHIC PROFILE
Particulars Odisha Kendujhar District HQT Town

Total Population 4,19,74,218 1,801,733

Urban population 16.6%


14.05%
Decadal
population growth 14.05%
15.35%
rate
Mean household
4.35
size 4.45
BPL households* 44,08,070 211,132

BPL Population* 1,91,75,105 938,637

BPL % 46%
52%

• Keonjhar is the 4th district in terms of size and 8th


in terms of population.
• Keonjhar is the 11th urbanized district in state
having only 14.05 percent of its population live in
urban areas as against 16.69 percent of state’s
population living in urban areas.
• Keonjhar is 18th densely populated district in the
state.
• Keonjhar has 12th rank in terms of sex ratio in the
state.

Source :
10 Census of India – 2011, Odisha
* RSBY status 2015-16, Odisha
HEALTH INDICATORS
Key Health Indicators
District Odisha India

230
212

178

81 79
57 59 55
43 39 44
31
20.319.822.2
9.3 8.2 7.1

Maternal Neonatal Morality Infant Mortality Under 5 Mortality Crude Birth Rate Crude Death Rate
Mortality Ratio* Rate Rate Rate

Source : Annual Health Survey Report 2011-12

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Causes of deaths (Infants & Child)

Keonjhar - Causes of Infant & Child Deaths - Odisha - Keonjhar - Causes of Infant & Child Deaths against
Apr'15 to Mar'16 Total Reported Infant & Child Deaths-Apr'15 to Mar'16

Measles 0 Sepsis
6.7% Asphyxia
Diarrhoea 4 14.0%
Others
Fever 25 48.4%

Pneumonia 41

Sepsis 49
LBW
Asphyxia 102 21.3%

Others (for age upto 4 weeks of birth) 142

Low Birth Weight (LBW) 155


Pneumonia
Fever related
Others (for 1 month to 5 years) 210 5.6%
3.4% Diarrhoea
0.5%
Total 728

Source : HMIS Data Analysis 2015-16

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Causes of deaths (above 6 years of age)
Causes of deaths (above 6 yrs of age) Apr'2015-March'16
15-55 Above
Causes 6-14 yrs yrs. 55yrs Total
HIV/AIDS - - - -
Malaria - - - -
Tuberculosis - 6 4 10
Diarrhoeal Diseases - 1 10 11
Animal Bites & Stings 1 2 - 3
Other fever Related 1 3 - 4
Respiratory
Diseases(other than TB) - 8 4 12
Suicide - 3 6 9
Trauma/Accidents/ Burn
Cases - 12 1 13
Neurological Disease
including strokes - - 2 2
Known Acute Disease - 8 1 9
Known Chronic Disease 2 32 174 208
Heart Disease/
Hypertension related - 14 11 25
Causes not known - - - -
Total Deaths 4 89 213 306

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Source : HMIS Data Analysis 2015-16, District Dhenkanal
SECTION 4:
SUPPLY ASSESSMENT

14
BEDS AVAILABILITY
Number of Number of
Facility type
facilities beds
Share of Govt. Vs. Pvt. beds in
District Headquarters district
1 160
Hospital
Sub-divisional hospitals 2 118
Pvt. Beds
Community Health 23%
17 230
Centers
Primary Health Centers
0 0
& IDH Govt.
Beds
Other hospitals / Area 77%
6 0
Hospital

Private Hospitals 12 153

Total 38 661 Functional Beds at DHH Kendhujhar: 209

Source: Primary data from DHH & Pvt. hospital & Secondary data from
NHM, DHS & DMET Odisha

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ABOUT DISTRICT HEADQUARTERS HOSPITAL,KENDHUJHAR

Total number of Sanctioned 160


beds Functional 209
Service specialties Internal medicine, General
surgery, Gynecology and
obstetrics, Pediatrics,
Orthopedics, Ophthalmology,
ENT, Ortho, Psychiatry, Dentistry,
TB & Chest, Emergency & Trauma
Diagnostic facilities X-ray, USG, ECG, A-scan,
Audiometry, Hematology lab,
Biochemistry lab, Microbiology
Operating rooms and 2 major OT 1 Minor OT, 4 labour
Labour tables tables

Other clinical Blood bank, OP & IP Pharmacy


facilities

Outsourced Support Laundry, Dietary, Biomedical


facilities waste management, Security,
Housekeeping

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PRIVATE HOSPITALS STUDIED IN KEONJHAR
Particulars Swasthi Hospital JMJ Hospital Aarti Hospital
Total number of
10 beds 6 beds 50 Beds
beds
Internal medicine, General surgery,
Internal medicine, General surgery,
Service Gynecology and obstetrics, Internal medicine, General Surgery,
Gynecology and obstetrics,
specialties Pediatrics, Paediatrics, Dermatology
Dentistry
Diabetology
X-Ray, ECH, Biochemistry Lab,
Diagnostic X-Ray, ECG, Hematology,
USG, ECG, Biochemistry lab, Microbiology lab, Histopathology
facilities Biochemistry
Lab, Immunology & Serology Lab
Operating rooms
1 Major, OT 1 Minor OT and 1
and Labour 1 major OT and 1 Labor tables 1 Major OT
Labor Table
tables

Other clinical
Pharmacy Pharmacy Pharmacy
facilities

Outsourced Laundry, Dietary, Biomedical waste Laundry, Dietary, Biomedical waste Laundry, Dietary, Biomedical waste
Support facilities management, Housekeeping management, Housekeeping management, Housekeeping

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OPD Consultation & IPD Admission
OPD Consultations IPD Admissions
500,000
450,000
400,000 60,000
350,000 50,000
300,000
250,000 40,000
200,000 30,000
150,000
100,000 20,000
50,000 10,000
0 0
Swasthi Swasthi
DHH SDH CHC Health JMJ Arti DHH SDH CHC Health JMJ Arti
Care
Care
2013-14 141,544 82,043 363,996 5,500 6,500 0
2013-14 31,669 27,105 47,553 100 90 0
2014-15 148,004 117,965 396,153 6,000 7,500 0
2014-15 33,524 34,246 52,419 170 70 0
2015-16 164,703 100,280 448,404 7,000 9,000 3,000
2015-16 35,809 34,031 51,252 210 100 250

 OPD consultations have consistently


Facility wise share of OPDs Facility wise share of IPDs increased over the years at all the studied
Swasthi JMJ Arti faciloities except at SDH.
Health
Swasthi JMJ Arti Care
0% 0%  During FY 2015-16, per day OP consultations
Health 1% 0% 0% at DHH was 549 and whereas on an average
Care DHH
CHC 30% per day OPD per SDH and per CHC was 167 &
1% DHH 42% 88 respectively.
23%  OP consultations during 2015-16 at
SDH Swasthi, JMJ and Arti were 23, 30, 10 per
CHC 14% day respectively.
SDH
 IP admissions per day at DHH were
61% 28%
maximum (98) followed with 47 per SDH, 8
per CHC.
 Govt hospitals accounted for almost 97% of
OPDs and 99% of IP admissions among the
studied facilities during FY 2015-16.

Source: Primary data from DHH & Pvt hospital &


Secondary data from NHM Odisha
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BED UTILIZATION
OPD to IPD Conversion (FY 2015-16)
34%

 OP to IP conversion has been higher


22% than industry standards at all the public
health facilities, however at SDH it has
11% been significantly higher compared to
8%
3% other public health facilities because most
1% of the referrals from PHCs are directly sent
to SDH.
DHH SDH CHC Swasthi JMJ Arti
Health Care

Bed Occupancy Rate (FY 2015-16


104.9%

 The BOR of DHH is calculated against the


sanctioned beds (160 beds) considering
ALOS of 1.71 as per the HMIS data
23.0% provided by the facility. However, such a
16.0% short of 1.71 at DHH level is one among
4.8%
the lowest in the state.
DHH Swasthi Health JMJ Arti
Care

Note :-As per functional beds (209) BOR is 80.3%


Source: Primary data from DHH & Pvt. hospital & Secondary
data from NHM Odisha

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GENERAL SURGERIES
Facility Name Major Minor TOTAL Proportion of Major & Monor
DHH 1,640 2,454 4,094 Surgeries (FY 2015-16)
SDH 704 362 1,066 Major
CHC 83 3,026 3,109 29%

Swasthi Health Care 20 50 70


Minor
JMJ 10 70 80 71%
Arti 20 80 100
TOTAL 2,477 6,042 8,519

Facility wise proportion of Major & Minor


Surgeries (FY 2015-16)
 DHH accounts for 48% of the total surgeries among
Major Minor the studied facilities.

DHH 40% 60%  Among all the studied facilities, 66% of the major
surgeries and 41% of the minor surgeries happened
SDH 66% 34% at DHH.
CHC 3% 97%
 On an average, 6 major surgeries and 8 minor
Swasthi Health Care 29% 71% surgeries have been conducted at DHH.

JMJ 13% 88%  Private hospital accounts for only 3close to 3% of


Arti 20% 80% total surgeries among the studied facilities.
Source: Primary data from DHH & Pvt. hospital & Secondary data
from NHM Odisha

20
OT UTILIZATION
Procedure per
Name of Number of Total number Procedures per Number of OT Surgeries per
surgeon per
Facility surgeon of procedures day in the facility OT per day
day
DHH 9 5,547 18.5 2.1 3 6.2
SDH 10 1,724 5.7 0.6 2 2.9
CHC 56 3,109 10.4 0.2 17 0.6
Swasthi Health
Care
1 70 0.2 0.2 1 0.2
JMJ 1 80 0.3 0.3 1 0.3
Arti 1 100 0.3 0.3 2 0.2

IPD to Surgery Conversion (FY 2015-16)  Data indicate a healthy utilization of OT at DHH with 6
procedures per day per OT but surgeon utlization is a
80%
bit of concern considering most of the procedures
(60%) are minor in nature.

 IPD to surgery conversion at public health facility is a


40% concern especially at SDH and CHC level considering
33%
industry standards of more than 11% at secondary
15% care hospital.
5% 6%
 Higher IPD to Surgery conversion at private facilities is
indicate most of the admissions happen for surgical
DHH SDH CHC Swasthi JMJ Arti
Health Care interventions.
Source: Primary data from DHH & Pvt. hospital &
. Secondary data from NHM Odisha

21
INSTITUTIONAL DELIVERIES
2013-14 2014-15 2014-15 Category of Institutional Deliveries (FY
Name of 2015-16)
Facility Normal C - Normal C- Normal C-
Delivery Section Delivery Section Delivery Section C - Section
9%
DHH 3,253 1,143 3,259 1,066 3,612 1,453

SDH 6,821 668 6,539 876 6,323 658 Normal


Delivery
91%
CHC 12,433 0 12,318 0 12,128 0

Sub Total 22,507 1,811 22,116 1,942 22,063 2,111

Facility wise proportion of Institutional


deliveries (FY 2015-16)  Institutional deliveries among the studied facilities
indicate flat tend with an average 24183 deliveries per
Normal C-Section year.
 Of total, DHH conducted 21% of total institutional
deliveries.
DHH 71% 29%  In 2015–16, DHH performed 14 deliveries per day
(@10normal and 4 C-section per day).
SDH 91% 9%  69% of the total C-sections during FY 2015-16 has been
carried out at DHH.
CHC 100% 0%
Source: Primary data from DHH & Pvt. hospital & Secondary
data from NHM and DHS Odisha

22
DIAGNOSTICS PROCEDURES

Diagnostic Test X Ray USG ECG CT Scan Lab Tests

DHH 4,754 0 1,371 0 62,121


SDH 0 0 0 0 20,214  Overall Lab tests accounts for majority (97%) of total
CHC 0 0 0 0 137,401 diagnostics.

Swasthi Health  X-ray and ECG constitute of only 2% and 1% of the total
490 0 295 0 820
Care diagnostic procedures conducted at the district which
is far below industry standards. USG services are not
JMJ 150 0 75 0 6,000 available among the studied facilities.
Arti 300 0 50 0 2,500  Among the studied facilities, govt. hospitals accounts for
NA: Data not available 95% of the total diagnostics

Facility wise total diagnostics  29% of the diagnostics procedures among the studied
facilities are conducted at DHH.
137,401
 83% of all X-Rays and 22% of all Lab Tests are
conducted at DHH among the studied facilities.
68,246
 CT Scan facility is not available in the entire district.
20,214
1,605 6,225 2,850

DHH SDH CHC Swasthi JMJ Arti


Health
Source: Primary data from DHH & Pvt. hospital & Secondary
Care data from NHM Odisha

23
REVENUE AT DHH and District (in Rs.)
Facility Name Revenue Revenue Revenue Revenue Revenue Revenue Total
from User from Self/ from from RSBY from BKKY from OSTF
fee Pvt. Corporate
Insurance Insurance /
Sponsored

DHH 3,171,164 0 0 2,452,825 2,123,750 117,830 7,865,569

Revenue per bed per Rs.


day at DHH 134.68/-

Overall District Revenue from Public Insurance


Schemes during FY 2015-16 (Rs.)
RSBY 37,940,498
BKKY 1,798,200
OSTF 208,963
TOTAL 39,947,661

24
EXPENSES OF DHH (in Rs.)
Particulars DHH
Staff Salary 73,883,368 Trend of Hospital Expenses
92,839,694
Medicine /Consumables 10,020,881
Staff Incentives 780,000
Electricity 2,184,369
85738281
BMW Management 404,978
Housekeeping 1,321,681
80793427
Printing & Stationary 4,000
Bed Linen 210,525
Staff uniform 17,650
Patient food charges 3,813,300 2013-14 2014-15 2015-16

Furniture Maintenance 41,980


Transport 81,720 Expense per bed per day
Rs1589.72/-
IT & Communication 25,272
at DHH
Computer & Upgrades 49,970
Total 92,839,694 Source :
a) Expense data received from accounts (DDO wise allotment
and expenditure details) under ADMO Medical.

25
ECONOMIC SEGMENT & MODE OF PAYMENT
Economic Segment of Patients

DHH JMJ
BPL (Below
10% poverty line) 20% 10%
30% APL - Low
20% APL - Low Income
Income
APL - Middle APL - Middle
income income
40% 70% APL - High
APL - High
income income

Swasthi Health Care Arti

5%
35% 10%
APL - Low
Income BPL (Below
APL - Middle poverty line)
60% income APL - Low
APL - High 90% Income
income

Note: estimations given above are based on


discussion with ADMO Medical and Hospital Manager
26
ECONOMIC SEGMENT & MODE OF PAYMENT
Mode of Payment by Patients to the Hospital

DHH JMJ
2%
6%
22%
Free 100%
Cash
70% Cash
RSBY
BKKY

Swasthi Health Care Arti


10% 10%

100% Cash
Cash 80% RSBY
BKKY

27
SECTION 5:
CATCHMENT AREA & REFERRALS

28
CATCHMENT OF DHH

District Headquarters Hospital

Distance Block Headquarters


Catchmen Name of
Population from
t Type the block
district HQ
Primary Keonjhar 161931 -
Joda 125728 70
Champua 115321 60
Jhumpura 113149 25
Banspal 102527 50
Telkoi 167705 45
Harichanda
Secondary 142150 40
npur
Ghatgaon 118307 55
Patna 101518 20
Saharapada 159429 60
Anandpur 180784 90
Ghasipura 148555 85
Hatadih 164629 100

29
SOURCE OF PATIENT INFLOW
Source of Patient Inflow

DHH Swasthi Health Care

From within the


5% From within the 5% district town
district town 30%
50% From the district
45% From the district
other than the
65% other than the
district town
district town
Other districts
Other districts

JMJ Arti
From within the
5% district town 10% 5% From within the
30% district town
From the district
other than the From the district
65% other than the
district town 85% district town
Other districts
Other districts

Source: estimations given above are based on discussion with Management of concerned hospitals

30
POINTS OF REFERRAL

176km
3h34m

210km
4h

SCB, AHRCC & Sishu-bhawan at Cuttack


Various private empanelled hospitals
in Bhubaneswar

31
Top specialties of referral from DHH to other district

No. of Top 5 specialties for which patients are referred out of


Specialty patients district (Monthly)
reffered 31%

Cardiology 165
Gynaecology and 15%
80 13% 11%
obstetrics 9%
6% 5% 4%
TOP 5 2% 1% 3%
Urology/Nephrology 68
SPECIALTIES
General/Internal

Neurology

Others
Neurosurgery
Cardiology

Orthopedics
Gynaecology and

enterology/surgery
Urology/Nephrology

General/Internal

General Surgery
Pulmonology/Chest
60
medicine

obstetrics

medicine

medicine

Gastro
Neurology 47
Neurosurgery 33
Pulmonology/Chest
26
medicine TOP 5 SPECIALTIES OTHER SPECIALTIES

OTHER Gastro-
23
SPECIALTIESenterology/surgery
 Top 5 specialties of referrals accounts close to 79% of total referrals.
Orthopedics 8
General Surgery 7
Others 15
Total referral per month 532

Source: Interviews from ADMO (Med.), Specialist Physicians and General Physicians.

32
CONNECTIVITY & TRANSPORT

 Nearest railway station : Kendujhar


railway station is on the Padapahar-
Jakhapura branch line of Tatanagar–
Bilaspur section of Howrah-Nagpur-
Mumbai line. It is connected by broad
gauge line to Jakhpura, Barabil,
Japura, Bhadrak, Bhubaneswar by
daily trains.

 Road ways: Kendujhar is situated


the National Highway No 49 (formerly
it was 6) and 215. It well connected
with Bhadrak by SH 11, Sambalpur by
NH 6.

 Airport : The nearest airport is in in


Bhubaneswar which is approx 220 km
away.

 Nearest government referral


centre: SCB Cuttack (176 km)

33
SECTION 6:
DEMAND-SUPPLY-GAP ASSESSMENT

34
DEMAND - OPD and IPD
 Out Patients: As per NSSO 60th round data, the estimates of spells of ailment in Odisha
population and percentage of the spells of aliment seeking non-institutional treatment i.e.,
ambulatory care, applied to the catchment population gives estimates of OP demand in the
population. The PAP (proportion of ailing person) per 1000 population in 15 days is 77 for
Odisha and spells of ailments treated during 15 days is 76%.

 Percentage of specialty mix for OPD is derived from morbidity rate of NSSO data 2004-05, 60th
Round, increased by a factor of 1.5 to develop a conservative estimate of patient need.

 Further the OP estimates has been extrapolated to include the load of estimated pregnant
women in a population, to cover ANC visits as OPD in health facilities.

 In patient: For the FY 2015-16, OP to IP conversion rate for 30 DHHs in Odisha has been 15%.
Hence for the calculation purpose OP to IP conversion rate is taken on an average to be at
15%.

 Diagnostics: Diagnostics demand is extrapolated as per industry standards.

 Population: Projected population for 2016 has been considered for estimation of OPD and IPD
demand

 * Other specialties include: Skin & VD, Psychiatry and Dental

35
Demand – Supply – Gap of OPD consultations

Department/ Estimated % Estimated Actual Estimated Gap assessment of OPD specialty mix
Specialties of OPD demand Supply Gap
Estimated Demand Actual Suppy
Gen Med 22 646,005 163,465 482,540 Gen Med
OBG 14 411,094 101,374 309,720
OBG
Pediatrics 12 352,367 88,286 264,080
Paediatrics
Gen. Surgery 11 323,003 82,333 240,670
Gen. Surgery
Orthopedic 9 264,275 64,205 200,070
Orthopaedic
ENT 7 205,547 49,937 155,610

Ophthalmology 7 205,547 49,937 155,610 ENT


Others
18 528,550 132,850 395,700 Opthalmology
specialties
TOTAL 100% 2,936,388 732,387 2,204,001 Others specialties

Total OPD Gap 75%

Source :
-NSSO 60th Round data
36 -Journal: the cost of universal healthcare in India –
A model based estimate, 2012
Demand – Supply – Gap of IPD admissions

Estimated IPD Gap assessment of IPD specialty mix


Department/ demand (@ Actual Estimated
Specialties 15% OP-IP Supply Gap Estimated Demand Actual Supply
conversion)
Gen Med 96,901 26,840 70,061 Gen Med

OBG 61,664 16,953 44,711 OBG

Pediatrics 52,855 14,551 38,304 Paediatrics


Gen. Surgery 48,450 13,660 34,790
Gen. Surgery
Orthopedic 39,641 10,898 28,743
Orthopaedic
ENT 30,832 8,476 22,356
ENT
Ophthalmology 30,832 8,476 22,356
Others Opthalmology
79,282 21,797 57,486
specialties
Others specialties
TOTAL 440,458 121,652 318,806

Total IPD Gap 72%


Source :
-NSSO 60th Round data
37 -Journal: the cost of universal healthcare in India –
A model based estimate, 2012
Demand – Supply – Gap of Diagnostics (OPD+IPD)

Key Demand OPD Demand IPD Total Total


Actual
diagnostics Estimated Estimated
services Total % of Estimated Total % of Estimated Demand
Supply
Gap
OPD Demand IPD Demand

X Ray 15% 440,458 50% 220,229 660,687 5,694 654,993

USG 20% 587,278 35% 154,160 741,438 0 741,438

ECG 10% 293,639 60% 264,275 557,914 1,791 556,123

CT Scan 2% 58,728 5% 22,023 80,751 0 80,751

Lab Tests
(number of 60% 1,761,833* 100% 440,458** 2,202,291 229,056 1,973,235
patients)

* Considering industry standards 60% of OPD patients undergo at least 2 tests per patient. Hence,
demand number of OPD lab tests would be 3,523,665 tests.

** Considering industry standards 100% of IPD patients undergo at least 5 lab tests per patient.
Hence, demand number of IPD lab test would be 2,202,291

38
GAP - HOSPITAL BEDS
Hospital beds available in the district

Primary Community Sub district District Other Private Total Bed


health health centers Hospital hospital Hospital Hospital strength
centers &
IDH

45 16 1 01 0 12
0 beds 230beds 118 beds 160 beds 0 beds 153 beds 661

Gap in bed availibility The district of Keonjhar has 63 public and 12


6805 private health care facilities with a total bed
strength of 661 beds only.
7000
6000 Considering the WHO norm of 3.5 beds per 1000
population, the district with a population of
5000
15,76,869 has a huge shortfall of 6144 beds
4000
(i.e. a gap of 90% beds).
3000
661
2000
1000
0
Beds available Beds required as per
WHO norm
* Source : Bed Strength, DHS Odisha and Clinical
Establishment, DMET Odisha

39
GAP – DOCTORS AND NURSES

Gap in doctors availibility Gap in nurses availibility


1944 3889

2000 4000
3500
1500 3000
2500
1000
218 2000
1500
500 39
1000
0 500
Doctors available Doctors required as 0
per WHO norm Nurses available Nurses required

 As per primary and secondary data collected There


 There are 218 sanctioned positions for doctors, of
are only 38 nurses posted in the district. (5 nursing
which 78 positions are vacant.
sister and 33staff nurse, 1 Asst Matron).
 Considering the WHO norm of 1 doctor per 1000
 Considering the WHO norm of 2 nurses per 1000
population, the district has a shortfall of 1726 doctors
population, the district has a shortfall of 3850 nurses.

* Source : Staff position list received from DHH and nursing staff
list from directorate of nursing, Odisha.
* Source : District wise Incumbency list , DHS Odisha

40
SERVICE AVAILIBILITY AND GAPS
Diagnostic Facility Clinical Facility
Name of facility IPHS Requirement Available Name of facility IPHS Available
500 M.A X-ray machine 1 0 Requirement
300 M.A. X-ray machine 1 1 General OPD 1 1
100 M.A. X-ray machine 1 0 Speciality OPD 8-10 3
60 M.A. X-ray machine (Mobile) 1 1 Major OT 2 1
Dental X-ray machine 1 0 Emergency OT 1 0
USG with colour doppler 3 1
Ophthalmology/ ENT OT 1 0
ECG computerized 1 1
Minor OT 1 1
ECG ordinary 2 1
Gyneaecology OT 1 0
TMT 1 1
Labour Table 11 4
A Scan 1 1
Pharmacy 1 1
B Scan 1 0 Blood Bank 1 1
Audiometry 1 1 Ambulance (BLS) 1 4
PFT 1 0
Bronchoscope 1 0
Haematology lab 1 1 When compared with IPHS for district
hospitals, major gaps are in the areas of
Biochemistry lab 1 1
Diagnostics and Specialty OPDs
Microbiology lab 1 0
Histopathology lab 1 0
Immunology and Serology lab 1 0 Source : IPHS for District Hospital, Equipment norms 201 – 300
bedded

41
SECTION 7:
FINDINGS OF GENERAL POPULATION
SURVEY

42
INCOME AND OCCUPATION
Occupation of the respondents Source of health related costs
23%
20%
17%
77%
13% 13%

7% 7%

23%

0% 0%

From savings Loan from Sold assets Health


family/friends insurance

Annual family income of the


 Majority of the respondents has agriculture
respondents
as there source of income followed by daily
80% wager with an annual income not more than
1,00,000.
17%
0% 0% 3% 0%
 23% of the patients surveyed had health
insurance as a primary source of health
related costs, which indicates there is a
moderate awareness among the population
of Keonjhar district.

43
HEALTH SEEKING BEHAVIOUR
Do you visit a doctor / health facility whenever Why, Not always?
someone is sick in your family?
100%
97%

0% 0%

The Visiting a The clinical


3%
doctor/hospital is doctor/hospital is condition is
far from my expensive always not that
Yes always Not always
residence serious

Have you consulted /visited any other doctor What is the type of healthcare
/hospital before coming to this hospital,in facility that you had visited before
this instance and for this ailment? coming to this hospital?
50% 50%
70%

30%
0% 0%

A private A private A local govt. District


Yes No practitioner hospital hospital hospital

The survey response indicates that 97% of the population surveyed is quite aware bout health issues and they always visit
a facility whenever someone is sick in their family and there is an equal trend of visiting the government and private facility
which point s toward that good health seeking behavior among people.

44
HEALTH SEEKING BEHAVIOUR
Reason for choosing a hospital
Govt. hospital Pvt. Hospital

100%

78%

11% 11%
0% 0%

The facility is large and most The facility is proximate to my Low pricing of services and
services offered under one residence free medicines
roof

 The reason for choosing a health care is divided in to multiple factors. Service availability, large
infrastructure ,proximity to residence these were the factors for choosing Govt. healthcare facility. But the
proximity of the facility to the residence is the root cause for choosing a private facility

45
VISITING EXTERNAL FACILITIES
Did you have to visit any other Did you have to buy any medicine
hospital/diagnostic center for any from an external pharmacy?
diagnostic test?
55%
75%
45%

25%

Yes No Yes No

Tests that has been performed from


other hospital/diagnostic centres  25% of the respondents at DHH, had
33% 33% 33% visited external diagnostic centre for
Blood test ,USG and X-ray.

 55% of respondents had to purchase


medicines from external pharmacy due
to unavailability of the required
medications.
USG X-ray Blood test

46
REGULAR MEDICATION BEHAVIOUR
Does any member of your family Common specialities of
take regular medications? consultation
33%
50% 50% 23%
10% 13%
7% 7% 7%

Yes No

Conditions for which patients take  The findings indicate a prevalence of chronic
regular medications
diseases requiring continued treatment, with
diabetes and hypertensions being the entire
67% condition for which people take regular
medications.
33%
 Majority of the respondents replied they have
consulted health care facilities majorly for
general medicine ailments followed by pediatrics
Diabetes Hyper tension
consultation.

47
IP ADMISSIONS
There was atleast one hospital Frequency of hospital visit before this
admission in the family in the last one admission
year
40%
80% 35%
25%

20%
0%

Yes No This is the first 2-6 visits 7-12 visits >12 visits

Place of admission Specialty of admission at hospital


100% 50% 50%

0%

Government hospital Private hospital General Medicine Cardiology/cardiac surgery

The survey response indicates that there has been at least 20% of respondents who got admitted atleast once in last one
year mostly chose a government hospital for general medicine ailment followed by cardiac problem. The respondents had
undergone atleast two OP consultations before getting admitted in the hospital. So it proves that people in Keonjhar
district is quite aware with their health related issues.

48
SECTION 8:
FINDINGS OF OUTPATIENT AND INPATIENT SURVEY

49
Specialty of the ailment of admission Amount spent during admission
100%
50%

30%

0% 0% 0% 0% 0%
10% 10%

General General Surgery Orthopedics/joint Diabetes


Medicine replacement

Specialty of consultation Amount spent on visit to the hospital


217
30% 30% 30%
141

48
2 0 0

10%

General Medicine General Surgery Orthopedics/joint Paediatrics and


replacement neonataology Average (Rs)
 Majority of inpatient respondents at DHH were admitted for General Medicine ,followed by general surgery, orthopedics and
diabetes.
 Patients tend to spend mostly on diagnostic tests, medicines and travel to healthcare facility. This indicates that people are ready to
purchase healthcare if services are available.
 The amount spent during this admission is less than 30,000. The average amount spent during an inpatient admission was found
Rs 2530/-.

50
SECTION 9:
FINDINGS OF PHYSICIAN SURVEY

51
COMMON SPECIALITIES OF CONSULTATION BY GENERAL PHYSICIAN

COMMON SPECIALITIES OF CONSULTATION BY GENERAL PHYSICIAN

20% 20% 20%

15%

10%

5% 5% 5%

0% 0% 0% 0% 0% 0%

52
ECONOMIC AND GEOGRAPHIC STRATIFICATION OF PATIENTS
GENERAL PHYSICIAN RESPONSE SPECIALIST PHYSICIAN RESPONSE

Economic class of patients Economic class of patients


63% 51%

31%
23% 18%
15%

Upper economic Middle economic Low economic Upper economic Middle economic Low economic
class class class class class class

Geographic classification of patients Geographic classification of patients


68% 48%
40%

25%
12%
8%

From within the From the district From adjacent From within the From the district From adjacent
town/city other than the districts town/city other than the districts
town/city town/city

53
REASON FOR REFERRAL
Reasons to refer a patient to a particular hospital
Genearl Physician Specialist Physician
33%

27%
25% 25%

20% 20% 20%

13%

8% 8%

Low pricing of Availability of Availability of Good infrastructure and Good clinical serice
services/price discounts known/reputed comprehensive high end facilities quality
to your patients physicians in the treatment facilities and
hospital capability to handle
complications

54
SPECIALITIES OF CARE FOR WHICH PATEINT TRAVEL TO OTHER CITIES

SPECIALITIES OF CARE FOR WHICH PATEINT TRAVEL TO OTHER CITIES

20%
16%
13% 13%
11%
9%
7%
4% 4%
2%

The above are averages of the responses from both general and specialist physicians. All the surveyed
physicians indicated that patients from the district go to other districts / cities for availing tertiary
level healthcare, of which majority ailments pertain to cardiology and neurology.

55
SPECIALTIES THAT A NEW HOSPITAL SHOULD FOCUS

SPECIALTIES THAT A NEW HOSPITAL SHOULD FOCUS


General Physician Specialist Physician

21% 21%
20% 20% 20%

17% 17%

10% 10%
8% 8% 8%

5% 5% 5% 5%

0% 0% 0% 0%

Cardiology / Pulmonology Neurology / Gastro Cancer Urology Nephrology Orthopaedics Gynaecology ENT
cardiac / Thoracic Neuro enterology / & Obstetrics
surgery Surgery Surgery surgery

A mix of higher secondary and tertiary care facilities is what doctors voted for an upcoming hospital to
focus on.

56
FACILITIES RECOMMENDED BY THE PHYSICIANS

Specialities General Physician Specialist Physician


ECHO, TMT, Cath Lab, ECHO, TMT, Cath Lab,
Cardiology / cardiac surgery Hotler Hotler,ECG
Pulmonology / Thoracic Spirometry,
Surgery Broncoscopy
Neurology / Neuro Surgery EEG, EMG EEG, EMG
Endoscopy, Colnoscopy,
Gastro enterology / surgery Endoscopy, Colnoscopy ERCP
Cancer Chemotherapy Chemotherapy
Urology Lithotripsy
Nephrology Dialysis Dialysis
C-arm, Joint
Orthopaedics replacement OT Joint Replacement, C-arm
Gynaecology & Obstetrics USG

The physicians opined that any hospital proposed should focus on the above
facilities for the corresponding specialties.

57
THANK YOU

58