Experiences

from
STATE HEALTH SYSTEM
DEVELOPMENT PROJECT

WEST BENGAL

Selected indicators

Average no. of outpatient attendance

per month per hospital

Percentage of major surgeries to

admission

Distribution of DHs by CUP sectors

1998

2003

Average monthly X-rays done, 1997-2003

About one quarter of

project cost was
invested in
equipment
The impact is quite
visible in terms of
increase in utilization

1400
1200
1000
800

1997
2003

600
400
200
0

DH

SDH

RH

Average monthly USGs done, 1997-2003

350
300
250
200

1997
2003

150
100

50
0

DH

SDH

Before project, some

of the diagonstic
services were almost
unavailable (e.g.,
USG) even at DH
level.
After project, change
is dramatic.

Continued.

IMPROVEMENT IN HOSPITAL UTILIZATION

Indicator
Base line (1997)
2003
% change
USG
D.H

1878
242

43009
64366

2190.15
26497.52

Total
X-ray

2120

107375

4964.86

D.H

134325

260136

93.66

S.D.H/S.G.H

229674

378213

64.67

R.H

39002

143549

268.06

Total
Laboratory tests

403001

781898

94.02

D.H

493150

940255

90.66

S.D.H/S.G.H

489756

1187223

142.41

R.H

246552

618447

150.84

Total

1229458

2745925

123.34

S.D.H/S.G.H

Access to the Poor

Majority comes from the weaker section of the

community

Asset Index: Rural Patients

28
24

25

20 21

19
12

Poorest 20%

Asset Index: Urban Patients

19

18

14

Next 20%

Middle 20%
IPD(%)

OPD(%)

Next 20%

Richest 20%

Gain in healthy man-days per year per

hospital

Poverty alleviation
0.2

million additional poor

patients served per year
0.9

million additional healthy

man-days created per year for
poor patients

Percentage of satisfied hospital

users
OPD

IPD

Satisfied

Satisfied

Factors determining patients

satisfaction - Indoor

Source: Patient satisfaction survey, BMF

Factors determining patients

satisfaction - Outdoor

Source: Patient satisfaction survey, BMF

Patient Satisfaction:
Cleanliness
% of Patients Highly Satisfied
Hos
pital
Type
s

Target

DH

100

SD/S
GH

100

RH

100

Patient Satisfaction: Adequate

Nursing
Care
% of Patients Highly Satisfied
Hos
pital
Type
s

Targe
t

DH

100

SD/S
GH

100

RH

100

Patient Satisfaction: Medical

Care
in
Appropriate
Time
% of Patients Highly Satisfied

Hosp
ital
Target
Type
s
DH

100

SD/S
GH

100

RH

100

Patient Satisfaction:
Doctors Attention Towards Patients Queries
% of Patients Highly Satisfied

Hosp
ital
Target
Type
s
DH

100

SD/S
GH

100

RH

100

A few examples

Equipment maintenance
Impact

Innovations

weakened the major

bottleneck in maintenance

eased the stress especially

at higher levels.

AMC procedure

Additional technical
staff on contract basis

Health management information system

Impact

Innovations

Monthly report from all

hospitals on performance
indicators

A quarterly report compiling

data from all hospitals on
performance and efficiency
indicators.

A major breakthrough-shift
towards a objective, evidencebased, professional approach of
data utilisation

An immense scope for planning,

monitoring and evaluation

Computerization accelerated the

data management process and
ensured efficient, fast, transparent
hospital care for the patients

Initiating e- governance

Computerization at hospital level

Private Public Partnership

Innovations

Collaborations with private

institutions like Asia Heart
Foundation to establish telecardiology units.

Scavenging, sanitary, security,

and diet services contracted out

Outsourced operations and

maintenance of generators,
laundry services, and staff car
etc

Impact

Adds to quality of service and

patient satisfaction

Waste management
Impact

Innovations

Substantial effort to introduce basic

tools and techniques for waste
management at all levels.

Series of training to generate

positive perception and awareness
among hospital staff.

Waste autoclave installed in Govt.

hospital utilised as CTF for private
units

Almost all hospitals are using basic

tools (syringe and needle cutter,
dedicated trolley, burial pits, etc.).

Independent studies show that the

concepts of and rationale behind
segregation, treatment, and disposal
are clear among key hospital staff.

A good system for maintenance

with revenue generated, deserves
replication

Quality Assurance
Innovation

Impact

Introducing
grading of hospitals
on the basis of
quality indicators.

Adds new dimension to

Incorporating
patient satisfaction
indicators.

consciousness among
health care providers

improvement of quality of
health care.

Increases quality

Community participation
Innovation
Capacity

building
of Panchayet Raj
Institution.
Community
involvement through
Samities

Impact
Development

of

ownership and
better monitoring
of public health
programme by the
community

Personnel management
Innovation
A transparent

transfer policy
with computerised
Personnel
Information
System introduced

Impact
Contributed

to
motivation of
staff

User charges
Innovation
User charges
introduced in
lower tiers and
rationalised in all
tiers of hospitals
with exemption
for the poor

Impact
Peoples
confidence in
Govt. health care
services
strengthened

Sunderbans component
Impact

Innovation

Primary health care services are

targeted for intervention.
A Government NGO
partnership established to
provide mobile health care
services in remote and
inaccessible islands.

The experiment with NGOs in

providing mobile services generated
huge benefits (next slide).

Strengthening primary health

centers has a positive effect on the
referral system.

Percentage distribution of patients in

the Sunderbans, by source of
100%
Others
treatment
90%

Govt.

Others

Govt.

80%
70%
60%

Quack

Quack

50%
40%
30%

MHCS

20%
10%
0%

MHCS area
Source: Hijli Inspiration report

Non-MHCS area

Key challenges

The progress in performance is directly linked not only to capital investment, but
also to increased recurrent inputs (maintenance security, drugs, skilled manpower,
etc.) implying that the flow of key recurrent inputs should be assured in future.

Initiatives for referral system should continue with renewed emphasis on IEC

Participation of medical providers (in sustaining the project) based on complete

ownership is a serious challenge.

Monitoring of various norms and procedures at the hospital level needs to be

strengthened.

There should be a mechanism to assess and monitor peoples expectation. The

District Health and FW Society has immense potential in this direction.

Key challenges (continued)

The non-salary recurrent expenditure is still lower than the desired

level.

Primary sector needs to be pulled up to provide appropriate

support and to sustain the benefits of the project.

The qualitative aspects of working force, especially motivation and

attitude, still remain an area of concern.

Quality of private health care services needs to be streamlined and

monitored.

Peoples expectation is upwardly mobile.

Lessons learnt
Civil works

Consultants with experience in hospital constructions should

be engaged for preparing plans, drawings and designs.

Consultants should study in details the shortcomings of the

existing buildings, rearrangement of units required, drainage
system, water supply, power situation and total requirement,
drug storage facility, staff quarters, provisions in terms of
patients charter viz. public telephone booth, fair price shop,
canteen, pay & use toilet, bathroom. The providers are to
be consulted.

The price variation clause in the tender for works with less
than 2 years completion time should be deleted in conformity
with PWD procedure . This may restrain the agency from
delaying construction works.
Contd..2

Lessons learnt
Procurement

Involvement of one Bio-Medical Engineer in

finalization of specification and inspection of equipment
is very important.

Procurement of equipment should be staggered over

12/15 months phasing delivery to sites according to
completion of civil works.
contd3

Lessons learnt

A balanced mix of infrastructure development and system intervention can produce

substantial improvement in efficiency and effectiveness.

General

Total improvement in referral mechanism requires parallel improvement in the primary

health care services. A weak primary sector is a barrier to sustainability of improved
secondary care.

Since the public hospitals in West Bengal are used predominantly by poorer section, most
of the project benefits went to the poor. However, for a full-proof safety net, free
availability of all drugs must be ensured.

Participation of private sector (for-profit and voluntary) is essential. However,

coordination and monitoring at the local level is extremely important to make the
partnership effective.

More involvement of district health staff from the very beginning of a project is necessary.

Thank
you