WAITING FOR HEALTH CARE:

A SURVEY OF A PUBLIC HOSPITAL IN

KOLKATA.

Mansi Shah
Table of Contents

I. Introduction

II. Executive Summary

III. Research Objectives

IV. Research Methodology

V. An overview of healthcare statistics of West Bengal

VI. Sample Survey and Analysis

VII. Cost Comparison with Private Healthcare Institutes

VIII.Conclusion

IX. Recommendations

X. References
INTRODUCTION

With a population of 1.13 billion India not only requires an effective and easily
accessible health care system but also one which can deliver health care facilities
to the masses in remote areas of the country as well as to the robustly growing
cities at low costs. This is a challenge not just for developing nations but also for
many developed countries who are still trying to formulate an effective health
care model which would satisfy the needs of diverse groups within their
population.

However the Indian health care policy primarily suffers from neglect. The public
expenditure on health care is extremely low, coupled with inefficient use of
resources; the problem of providing effective health care services to the majority
of its citizens has become an impossible task for the Indian Government.

In the face of a yawning gap between the demand for health care facilities by a
growing population and the supply by the government, private heath care
facilities have grown tremendously in the past decade and it is now an accepted
fact that the Indian system of health care is already highly privatized and the
state has a small presence in this sector1. Though, private health care provides
services to varied sections of the society at a better quality than their public
counterparts, it also has its share of problems.

There seems to exist no efficient regulation of private health care services

resulting in wide spread inequalities in services offered by private health care
providers and wide spread corruption. The cost of private health care has
created a highly differentiated market for health services2 where reliable but
expensive services co- exist with unregulated and exploitative services.

It is also important to remember that in India, Health care is a state subject and
any improvement in the levels of public health care facility depends on the
capacity of the state governments and the extent to which they can increase
their expenditure on health care.

This paper attempts to analyze the health facilities and challenges in West
Bengal, where the inequalities in income distribution in the capital city of Kolkata
has created a highly differentiated market for health services making affordable
and reliable health care service an unfeasible reality for its citizens.

1
India: Development and Participation Amartya Sen
2
Population, health and Envrironment Amartya Sen
EXECUTIVE SUMMARY

The Public Hospital however handles a patient population in excess of its

infrastructural capability and is hence unable to provide services to all the
patients.

The waiting period in the public hospital for doctors attention as well as
investigative services is implausibly high, extending to months in some of
cases.

The costs at private hospitals/nursing homes are significantly higher than

public hospitals making it accessible only to the prosperous small faction
of the citys population.

The public hospital is not able to effectively provide basic services but the
difference in cost when compared to private medical institutions is so high
that people especially from the economically weaker sections have no
choice but to undergo the long waiting period and sub standard services
of the public hospital.

RESEARCH OBJECTIVES

The aim of the paper is to analyze the health care options available to a citizen
living in Kolkata, while bringing out the disparity between public and private
health care options in terms of service and cost.

The paper will seek to explain the following questions:

What are the cost and the quality of services provided by a public hospital
in Kolkata?

What is the primary problem faced by the hospital and reason behind its
inability to provide effective health care?

What is the difference in the cost of basic services between the public
hospital and the private hospital?
Research Methodology:

To compare the costs of services of a public and private hospital in Kolkata and
to answer the following questions these measures were taken:

Reviewing the provision of public hospitals in Kolkata.

Surveying a public hospital located at the heart of the city.

Interviewing patients at the hospital to determine cost and the quality of

services provided.

Collecting data about the average cost of services at private hospitals

across the city.

An Overview of Health care statistics of West Bengal:

The state of West Bengal has seen rapid growth over the past two decades and
the population of the state has been rising consistently in all its districts. The
table below indicates the rise in overall population as well as the density of
population from 1991 to 2001 in West Bengals seven districts.
Table I.3: Population, decennial growth rate, density of in the districts of
West Bengal, 1991 and 20013

Density of
Total population Decennial growth rate population
District per sq. km.

1991 2001 1981-91 1991-01 1991 2001

Bankura 2805065 3192695 + 18.12 + 13.82 408 464

Barddhaman 6050605 6895514 + 25.13 + 13.96 861 982

Birbhum 2555664 3015422 + 21.94 + 17.99 562 663

Kolkata 4399819 4572876 + 6.61 + 3.93 23783 24718

Darjiling 1299919 1609172 + 26.91 + 23.79 413 511

Haora 3729644 4273099 + 25.71 +14.57 2542 2913

Hugli 4355230 5041976 + 22.43 + 15.77 1383 1601

West Bengal 68077965 80176197 + 24.73 + 17.77 767 903

From the table above, we can see that in Kolkata though the Decennial growth
rate is not as high as other districts and it has fallen considerably from 1991 to
2001, however, the density of population per sq Km in Kolkata is phenomenally
high: While the state of West Bengal had an overall population density of 903 in
2001 the population density of Kolkata district in 2001 was 24,718.

3
Source: West Bengal Health Department Website
 With such soaring population figures it is evident that there must be a heavy
demand for Health care infrastructure in the state. Table 1.2, gives an
overview of the health care facilities available to the people of West Bengal
provided by the state as well as the central government.

Table 1.2 Medical Institutions in West Bengal

Hospitals/Health centres Number of Total Number of beds

under the Department of Hospitals/Health sanctioned
Health and Family Centres
Welfare
9 11130
Medical College Hospitals
District Hospitals 15 7402
Sub Divisional 45 8926
State General Hospitals 35 4019
Other Hospitals 32 7553
Rural Hospitals 96 3554
Block Primary Health 252
4774
Centres
Primary Health Centres 921 5593
Sub Centres 10,356 0
Hospitals under other
departments of the State 67 6044
Government
Hospitals under other Local
Bodies 31 960

Hospitals under
Government of India 58 6235

Hospitals which are

NGO/Private
1789 29,891

Total
13,706 96,081

From the above table and keeping in mind the population of West Bengal
mentioned in the earlier table, it can easily be discerned that there is a serious
shortage in infrastructure especially hospital beds available to the citizens of
West Bengal. It should also be noted that the Private or NGO hospitals supply
the most number of beds in West Bengal.
Table 1.3 : Population served per bed in select districts in West Bengal

Estimated Population, 2007 Total no. beds Population served per bed
District
Rural Urban Total Rural Urban Total Rural Urban Total
Bankura 3239857 245254 3485111 914 2572 3486 3545 95 1000
Bardhaman 4763706 2655382 7419087 1337 7503 8840 3563 354 839
Birbhum 3020271 269411 3289682 914 1714 2628 3304 157 1252
Darjeeling 1192705 542568 1735273 441 3909 4350 2705 139 399
Hooghly 3674526 1759534 5434060 924 4724 5648 3977 372 962
Howrah 2323656 2243521 4567177 613 3882 4495 3791 578 1016
Kolkata 0 4767375 4767375 0 25698 25698 0 186 186
Total 63263453 23381152 86644605 13921 82160 96081 4544 285 902

Table 1.3, reveals some disturbing statistics about the availability of health
facilities to citizens of the state. The condition in the rural areas is far worse in
the districts throughout the state. In the capital city/district of Kolkata which has
the lowest number of people served per bed still has an extremely high figure of
186 people for one bed, while the total figure for the state of West Bengal is 902
people served per bed.
SAMPLE SURVEY

The West Bengal Government has established 9 Medical Colleges and Hospitals
(MCH) across the state. These large hospitals aim to provide medical services at
lower costs than private hospitals and nursing homes. These MCH are equipped
with better medical equipments and can serve a larger number of people than
district hospitals.

This sample survey is of SSKM Medical College and Hospital or P.G hospital
located at the heart of the city. Eighteen patients and their family members at
the Out Patient Department (OPD) were asked questions related to

Waiting time( to determine how fast a patient is able to get medical

attention.)
Where the patient is coming from (to determine the efficacy of other
medical institutes across the state.)
If any medical tests had to be conducted outside the hospital at private
health care providers.

To answer certain questions such as delay in investigative services, it was not

possible to conduct surveys to determine the exact figures; hence to answer
these questions auditing reports on hospital services by the Comptroller and
Auditor General of India have been used.
ANALYSIS

How long do the patients have to wait for in the Out Patients
Department?

Out the eighteen patients who were surveyed graph 1.1 below shows how long
the patients had been waiting at the time of the survey.

Graph 1.1: Waiting time at the OPD of surveyed patients

Waiting Tim e

5
Number pf Patients

3 Number of Patients

0
1--2 3--4 4--5 5--6 more
than 8
Hours

It is evident from the above graph that the waiting time at the SSKM hospital
OPD is extremely high with 55.5% of the patients surveyed waiting from 1 to 4
hours. During the survey, the patients complained that they had to visit the
hospital for 2 to 3 hours everyday for at least 2 days to be able to meet a doctor.

Another disturbing factor was that 22% of the patients surveyed were staying in
the hospital premises for a number of weeks since they could not afford to travel
everyday to the hospital, these are patients who have been waiting for more
than 8 hours and their total waiting time is difficult to calculate.

When asked during the survey if they had received any medical attention at all,
44% of the patients complained that they not been able to meet the doctor for
even a preliminary diagnosis and not knowing the cause of their illness, they
could not begin any treatment.
Where are the patients coming from?

When asked where the patients were coming from, 44% of the patients came
from areas outside the city limits.

Patients coming from

Outside Kolkata

From Kolkata

This data can be used to infer two things. Firstly, the hospitals and other medical
care centres in other parts of the state are not functioning effectively and hence
people from other areas have to visit the hospital in the city. A large number of
patients from state hospitals are sent as referral cases to SSKM and the non
availability of equipment is one of the main causes of these referrals.4

Secondly, the SSKM hospital itself has to cater not only to the people in Kolkata
but also from people outside the city which is creating an immense pressure on
its resources. It is because of this that the hospital cannot give timely medical
assistance to the people of the city or to the people who travel all the way to the
city.

How many critical patients are being admitted in the hospital?

During the survey of the emergency ward in the SSKM hospital, it was found that
patients were only diagnosed with the problem but were not admitted into the
hospital for proper medical treatment.

4
CAG performance audit on the Health and Family Department, Government of West Bengal
Although, it was difficult to calculate how many patients were not being admitted
into the hospital during a day, Data has been found on how many critical
patients were not admitted in the hospital from January 2003 to December 2006.

SSKM hospital was only able to admit 11% of the critical patients who were
brought to the emergency ward. This clearly indicates that the hospital cannot
support the huge demand on its resources and has the lowest admittance rate
among the 5 hospitals which were surveyed. Due to unavailability of beds,
patients have to be redirected in critical condition to other hospitals.

Other Delays

A review of the other basic hospital services brings to light an even more grisly
picture of the state of the SSKM hospital.

There was a severe delay in investigative and diagnostic services in SSKM. The
table given below shows the average waiting period for various tests.

5
CAG Performance Audit of Health and Family Welfare Department, Government of West Bengal, 2007.
6

In SSKM hospital, the average time for a X ray or even an Ultra sonogram ranges
from a week to two weeks. In a survey of the average waiting time for surgery in
different departments of various MCHs including SSKM hospital during 2002 to
2007, the following statistics emerge:

The waiting time for surgery in the various departments of SSKM is a minimum
of one month while orthopaedic surgery had a waiting time of 2 months.

Cost Comparison with Private Healthcare Institutes

One of the reasons behind the excess demand on the SSKM hospital and public
hospitals in Kolkata in general is the lower cost at which these public hospitals
provide services to patients. There is definitely no dearth of private nursing
homes and hospitals in Kolkata and in fact as pointed out in table 1.2, they form
an enormous share of the total medical institutions available to the people in the
city but a comparison between the cost of services in a public hospital and that

6
CAG Performance Audit Report on the Health and Family Welfare Department, Government of WB,
2007
7
CAG Performance Audit Report on the Health and Family Welfare Department, Government of WB,
2007
of a private hospital reveals why there is an excess demand on the fewer
number of public hospitals.

For the purpose of cost comparison three investigation tests a regular blood test,
x ray and a Sonogram for OPD patients were compared in the SSKM hospital, a
small nursing home and a private large hospital. The graphs below reveal the
difference the costs between the three medical institutions.

Blood Test Charges

The general costs of a regular blood test at the three different medical institutes
were compared and the graph below reveals the cost disparity between the
three.

Graph 1.2: Cost Comparison of a blood test

Cost comparison of a blood test

400

350

300
cost in Rupees

250 SSKM
200 Small Nursing Home

150 Large Private Hospital

100

50

0
Blood Test
8

Hence, the costs of a regular blood test in a large private hospital almost 79%
more than the cost of a blood test in the SSKM hospital. The difference does not
reduce much for a small nursing home, where the cost of a running a blood test
is 70% more than the cost at SSKM.

8
Source of MCH data: Personal Survey and Government of West Bengal document on fixation of hospital charges for
government hospital
Source of private hospital data: Dr. Nilesh Mehta, member of the All India Medical Association, practioner in Kolkata
X Ray Charges

Similarly, the cost of an ordinary X ray in a Public MCH and nursing home and a
digital X Ray in a large private hospital were compared. The graph below shows
the results of the comparison:

Graph 1.3: Cost Comparison of a X Ray

cost comparison of a X Ray

400

350

300
cost in Rupees

250 SSKM
200 Small Nursing Home
150 Large Private Hospital

100

50

0
X Ray
9

Hence, the cost of performing a digital X ray at a large private hospital is 73%
more than the cost of a ordinary X ray at SSKM hospital. The difference is lower
with a small nursing home where the cost is 52% more than the cost at SSKM.

9
Source of MCH data: Personal Survey Government of West Bengal document on fixation of hospital charges for
government hospital
Source of private hospital data: Dr. Nilesh Mehta, member of the All India Medical Association, practioner in Kolkata
Sonogram Charges:

The cost of a sonogram of the whole abdomen is compared in the third graph.

Graph 1.4: Cost Comparison of a Sonogram

1400

1200

1000
Cost in Rupees

800 SSKM
Small Nursing Home
600 Large Private Hospital

400

200

0
Sonogram (w hole abdomen)
10

A comparison of sonogram charges reveals that the cost of conducting a

sonogram at a private hospital is 73% more than the cost at SSKM, while the
cost of performing it in a small nursing home is 64% more than the cost at
SSKM.

10
Source of MCH data: Personal Government of West Bengal document on fixation of hospital charges for government
hospital
Source of private hospital data: Dr. Nilesh Mehta, member of the All India Medical Association, practioner
in Kolkata
Given the above cost disparities, it should also be remembered that even though
services in public hospitals are subsidised, patients have to pay a considerable
cost for medicines which increases their cost of treatment considerably, but this
is also applicable to patients who use services of private medical institutions.

Nevertheless, the cost of treatment imposes a heavier burden on the poor. In a

study it was estimated that for the poorest tenth of the population cost of
treatment amounted between 10% in Kerala and 230% in states like Punjab,
Uttar Pradesh, Rajasthan and Bihar of annual per capita consumption
expenditure. The top 10% of the population bore a relatively lighter burden as
the average cost of treatment was between 5% and 40% of annual per capita
consumption expenditure of that class.11

11
Analysis of public expenditure on health using state level data, Ramesh Bhat and Nishant Jain, IIM-A,
June 2004
Conclusion:

This paper has attempted to show, based on certain parameters, the efficacy of
a public heath care institute in Kolkata. Given the population of the city the
severe demand on health services is expected, however in the city at least
private health care institutes including both large private hospitals and small
nursing homes out number public hospitals drastically -but the demand on the
services of the public hospital has not reduced despite the availability of private
health care options.

One of the primary reasons for the excess demand on public hospitals is the
difference in the cost of services when compared to private health care
institutes. While services in government hospitals like the one surveyed are
largely subsidised, private healthcare is largely profit oriented and hence much
more expensive.

The facilities in the public hospital are of poor quality, there have been reports
on the irregularity of doctors and medical staff, inadequate equipment and non
maintenance are some of the factors which plague desired efficiency of these
hospitals. Despite of these facts one must take into account the pressure of
providing healthcare to lakhs of people on everyday basis as a mammoth task.

The SSKM hospital in Kolkata is one of the largest referral hospitals in West
Bengal, hence when medical cases cannot be solved due to lack of equipment or
expertise in a state or district hospital in the state, the patient is asked to visit
SSKM in the city. This is despite the fact that all public hospitals in the city itself
do not have enough infrastructures to cater to the people of the city alone.

Hence, the poor of the city and the state have no option other than to under go
the painstaking long waiting periods in public hospitals at the cost of their health
since they simply cant afford to pay for private services. This in turn creates an
impossible demand on the public hospital and one walk through a public hospital
corridor where sick patients lie on the floor instead of beds and where people
inches away from death are asked to wait for their turn, is not a rare sight.
Recommendations

For several years everyone has largely agreed on the fact that the entire health
care structure and system in India is in need of reform. The survey conducted is
a very small indication of the plight of the poor in Kolkata who are denied the
right to basic, clean and timely medical attention. However it is not entirely
correct to blame one hospital or one state government of under performance
since the malaise of ineffective health care has spread throughout the
government system.

As mentioned earlier expenditure on health care is largely a state subject and the
central government is expected to aid the states and not be expected to be the
primary provider of health care. Recent studies have shown that expenditure on
health care by state government has not increased but on the other has fallen
over the years. The obvious solution to many of the woes in the Indian health
care system is for state governments to increase their expenditure on health
care.

The existing network of healthcare facilities which suffer largely from inefficient
management can be helped through public-private partnerships which have
helped in the improvement of the delivery of services in other aspects of the
Indian economy.

Regulation of private services, which has grown tremendously in the past decade
is also the need of the hour. It is not rare to see touts at the SSKM who try to
cheat ailing patients into using the services of small unrecognised nursing homes
around the city and where if something does go wrong( which is the case more
often than not), the patient or the family has no chance of demanding justice.

The SSKM hospital and the public hospitals in Kolkata can improve if they do
receive more attention and aid from the government and even look at private
partnerships for improving services. The example of AIIMS in Delhi should by
now have become an exemplary example for public hospitals throughout the
country but like for many other reforms in public healthcare, the people are just
waiting.
References:

Dreze Jean, Sen Amartya, 1995, Economic Development and Social Opportunity.
New Delhi

Sen, Amartya, India Development and Participation

Government of India, 2007, State Performance Audit, Comptroller and Auditor

General of India.

Bhat Ramesh, Jain Nishant, 2004, Analysis of public expenditure of Health using
state level data, IIM Ahmadabad

Chaudhuri, S.K, 2006, Health Sector in West Bengal: Mid Term Expenditure
Framework for Public Finance and Some Policy Issues

Mukherjee, Isita, Pain, A.K, Health Care delivery System How has West Bengal
Fared?

Health and Family Welfare Department website, Government of West Bengal.

Annexure 1: Survey Questionnaire.

1. Reason for visiting hospital:

2. Area from where the patient is coming from:

3. Waiting time for doctor attention:

4. Treatment Time:

5. Cost of treatment till now:

6. Bed charges:

7. Testing charges:

8. Medicines:

9. If any of the diagnostic were conducted outside the hospital and why: