Thesis Somnath

STUDY OF HEALTHCARE
MANAGEMENT SYSTEM IN WEST

BENGAL WITH SPECIAL REFERENCE
TO THE DISTRICT OF BURDWAN
THESIS SUBMITTED TO THE UNIVERSITY OF BURDWAN

FOR THE AWARD OF THE DEGREE OF DOCTOR OF
PHILOSOPHY IN ARTS (COMMERCE)
Under the joint supervision of

Prof. Jaydeb Sarkhel and
Dr. Arindam Laha
Department of Commerce
The University of Burdwan
Submitted BY
Somnath Chatterjee
Research Scholar
Burdwan
2015
Prof. Jaydeb Sarkhel Residence:
Professor (Retired) Durga Das Tewari Road
Department of Commerce Kotalhat, P.O. Nutanganj
The University of Burdwan Dist. Burdwan-713102
Golapbag, Burdwan-713104 Cell: +919434100250
West Bengal (INDIA) Email:
[email protected]
I have much pleasure in certifying that Sri Somnath Chatterjee, a registered research
scholar of the Department of Commerce has undertaken the research work entitled,
“Study of Healthcare Management System in West Bengal with Special Reference to
the District of Burdwan” under the joint supervision and guidance of myself and Dr.
Arindam Laha of the Department of Commerce. Mr. Chatterjee, in his study, has
considered a number of theoretical and empirical issues in the domain of healthcare
management. He has collected lots of data from secondary sources. He has also collected
primary data with the help of sample survey of hospitals in the districts of Burdwan. He
has analyzed the data to get meaningful results.
I certify that this research work is an original work done by Sri Somnath Chatterjee. I
also certify that neither this thesis nor any part of it has been submitted to any other
university/ institute for the award of any degree or diploma. I recommend that the thesis
be forwarded to the examiners as per rules of the university.
I wish Sri Chatterjee all success in his endeavor.
Burdwan
Date: ……………………… ………………………………………
Jaydeb Sarkhel
Dr. Arindam Laha The University of Burdwan
Assistant Professor Golapbag, Burdwan-713104
Department of Commerce West Bengal (INDIA)
Email: Cell: +919474601525
[email protected]
TO WHOM IT MAY CONCERN
This is to certify that Sri Somnath Chatterjee has duly completed his research work for
the thesis entitled “Study of Health Care Management System in West Bengal with
Special Reference to the District of Burdwan” under the joint supervision of Prof.
Jaydeb Sarkhel and myself. I have approved the thesis and permitted him to submit it for
the Ph.D. degree in Arts (Commerce) of the University of Burdwan.
Further it is to be certified that neither this thesis nor any part thereof was submitted to
this or any other university in this country or abroad for Ph.D. or any other degree. It
may also be noted that Sri Chatterjee had delivered one pre-submission seminar lecture
on his research work in January, 2015 at the Department of Commerce, The University
of Burdwan, in partial fulfillment of the requirement for the submission of the Ph.D.
thesis. He has also complied with all other relevant conditions specified in the
regulations of the University of Burdwan.
Date: ……………………… ………………………………………

Arindam Laha
Preface
In the framework of human development, health is considered as an individual right, which is
described „not merely the absence of illness but a complete state of physical, psychological and social
well-being‟. Healthcare is indispensable not only to attain the demographic advantage by obtaining a
strong and creative workforce and universal happiness but also to accomplish the purpose of
population stabilization. In view of this backdrop, accessibility to suitable and significant
healthcare service turns out to be a vital aspect in upgrading the excellence of human life,
especially in the developing and under-developed countries.
The healthcare and its reach is constantly an imperative issue of the social thinkers. In 1978,
the Alma-Ata Declaration with the objective of “Health for All” and the subsequent
declaration in 1998 as, “Health for All in the 21st Century” included “to attain health security
for all, to achieve global health equity, to increase healthy life expectancy and to ensure
access of essential healthcare of good quality for all”. Thus, enormous magnitude is there to
create health infrastructure in both qualitative and quantitative deliberation to provide
healthcare facility throughout all corners of the country with an uncomplicated ease of access
and affordability of common people of all income groupings; which would offer an improved
health status and successive better standard of living.
In India, the public healthcare system comprises three tiers of infrastructural setup; the
primary tier, the secondary tier and the third tier or tertiary-level. When this structure is not
evenly distributed in each and every corner of the country, two alternatives do exist to
provide minimum healthcare service to the citizens of the country: first, increasing the
efficiency of the public healthcare institutions and second, introducing more and more
i
private healthcare providers. An increase in efficiency in healthcare domain, not only
improves its performance but also increases the supply side quantity of the healthcare service
and serves more number of people. World Health Organization in their annual report noticed
the significance of efficiency in healthcare system and its all activities and finally
accomplishing the objective of upgraded healthcare status, receptiveness and equality in
healthcare financing.
Hospital efficiency, a particular measure of hospital performance, is considered for the
overall development of healthcare service and its accessibility among the masses. In many
underdeveloped and developing countries where healthcare resource constraints are very
common, the healthcare consumers are not getting appropriate treatment in terms of quantity,
quality and punctuality. It leads to a health imbalance and thus affects the society at large.
Many underdeveloped and developing countries are below the health standard of the
developed countries not only for the reason that there is insufficiency of inputs but also for
the inefficient use of these resources. Thus, it is necessary to emphasize this deficiency and
find the causes behind this and their subsequent rectification, because hospitals are
fundamental to the collective thought of wellbeing and infirmity.
Improved efficiency in healthcare domain can definitely minimize inter-regional variation of
healthcare facilities and provide more output to a larger patient base, but it is simultaneously
important to provide adequate level of satisfaction to the patients or the customers. Patient
satisfaction procedures should be utilized to observe the execution of health services
particularly for hospital. Hospital personnel should identify patients as the most significant
trade associates. But, a large amount of disappointment in patient relationships arises from
the complexity in administering that trust of the patients. Successful healthcare service
ii
providers continuously make every effort for superior intensity of patient service. The
capability of healthcare institutions to convey prompt and efficient patient care is significant
to its achievement.
The objective in this thesis is to present an overview of the scenario of healthcare access in
Indian states, districts of West Bengal and blocks of the district of Burdwan. In addition, the
study attempts to make a comparative analysis on variation of the level of efficiency in the
management of healthcare services across healthcare institutions (i.e., State Government
Hospitals, Other Public Hospitals and Private Hospitals).
We have discussed in this thesis the variation in public healthcare access across states of
India, districts of West Bengal and blocks of the district of Burdwan and its linkages to
healthcare expenditure at inter-state level. The efficiency of the healthcare institutions and
patients‟ perception on healthcare services from alternative healthcare institutions are also
considered for active discussion in this study.
iii
Acknowledgement
In the course of this study I have accumulated many debts of gratitude. First of all, I
acknowledge my profound indebtedness to my supervisors Prof. Jaydeb Sarkhel and Dr.
Arindam Laha for their valuable guidelines and inspiration. Without their profound
knowledge in the subject and their constant encouragement, the work might not have reached
its present stage. There are simply no words by which I can express my gratitude to them. I
owe my gratitude to all my teachers in the Department of Commerce for their help and
support throughout the course of my work. I am also indebted to my father, mother and wife
for the mental support they provided during the tenure of preparation of this thesis. The
cheerful spirits of my youngest family member, my infant daughter Megh Balika, have
always been extraordinary. I owe my gratitude to Prof. Biswanath Ghosh, Prof. A. C.
Ganguli and Dr. Parimalendu Bandyopadhyay. Without their inspiration and constant
encouragement, the work might not have reached this stage. My appreciative thanks are
extended to all my colleagues in Bengal College of Engineering and Technology for selfless
cooperation and encouragement during the course of the study. I am grateful to Mr. Nani
Gopal Adhikary, Mrs. Rina Sarkhel, Mr. Aswini Laha, Mr. Asim Banerje and Mrs.
Geetoshree Banerjee for their continuous encouragement, support and inspiration during the
tenure of my research work. For this study, I have consulted many libraries e.g. Central
Library, The University of Burdwan, IIT, Kharagpur and Central Library, Bengal College of
Engineering and Technology. I express my sincere thanks to the authorities and staffs of all
these institutions for their active help and cooperation in consulting relevant journals and
research reports. Any empirical study ultimately depends on the access to the data. In this
iv
context, I convey my gratitude to the officials and authorities of Swasthya Bhawan,
Government of West Bengal and the management authorities of different state government
hospitals, PSU-run hospitals and the private hospitals of Burdwan District for their kind
cooperation. Last but not the least, I also express my immense gratitude to all those patients
whom I interviewed. However, any error that may remain in this thesis is the sole
responsibility of mine.
Date: ………………… …………………………………………..

Somnath Chatterjee
Research Scholar
v
Contents
Contents
Page Number
Preface i-iii
Acknowledgement iv-v
Contents vi-viii
List of Tables and Charts ix-xii
Chapter 1 Introduction 1–6

Chapter 2 Review of Literature 7 – 33
Chapter 3 Objectives, Methodology and Data Sources 34 - 47
3.1 Objectives of the Study 34
3.2 Hypothesis of the Study 35
3.3 Methodology of the Study 36
3.3.1 Sampling Method in Primary Survey 36
3.3.2 Methodology Regarding Measurement of Public 36
Healthcare Access and Its Linkages to Healthcare
Expenditure
3.3.3 Methodology Regarding Comparison of Efficiency 39
of Hospitals and Determining the Determinants of
the Efficiency
3.3.4 Methodology Regarding Patients’ Perception on 40

Healthcare Services from Alternative Healthcare
Institutions
3.4 Data Sources of the Study 42
Chapter 4 Public Healthcare Access and Its Linkages to 48 – 74

Healthcare Expenditure
4.1 Introduction 48
4.2 Association between Healthcare Access and 50
Healthcare Financing: A Conceptual Framework
4.3 Data Source and Methodology 53
4.4 Access of Public Healthcare Institution 58
4.4.1 Index of Public Healthcare Access: An Inter-state 58
Analysis
vi
Contents
4.4.2 Index of Public Healthcare Access: An Inter- 60

district Analysis
4.4.3 Index of Public Healthcare Access: An Inter-block 63
Analysis
4.5 Public Healthcare Financing in India 66
4.5.1 Inter State Variation of Public Healthcare 66
Expenditure
4.5.2 Index of Public Healthcare Expenditure 68
4.6 Association between Healthcare Access and 69
4.7 Conclusion 73
Chapter 5 Measurement of Efficiency of Healthcare 75 – 100
Institutions & Its Determinants
5.1 Introduction 75
5.2 Methodology of the Chapter 77
5.2.1 Estimation of Hospital Efficiency and Its 77
Determinants
5.2.2 Mann-Whitney U Test (Rank Sum Test) 85
5.3 Result and Discussion 86
5.3.1 Estimates of Efficiency Scores: Data Envelopment 86
Analysis
5.3.2 Differences in Efficiency Level across Hospitals: 95
Mann Whitney U Test
5.3.3 Determinants of Efficiency: Maximum Likelihood 98
- Censored Tobit Analysis
5.4 Conclusion 99
Chapter 6 Patients’ Perception on Healthcare Services from 101 – 133
Alternative Healthcare Institutions
6.1 Introduction 101
6.2 Methodology of the Chapter 103
6.2.1 Perception Study: Analytical Explanation 103
6.2.2 Testing Differences in the Perception Level of the 104
Patients: Kruskal Wallis Test
6.2.3 Determinants on the Access of Healthcare 105
Institution: Ordered Probit Analysis
6.3 Results and Discussion 109
vii
Contents
6.3.1 Patients Access to Healthcare Institutions 109

6.3.2 Patients’ perception on Facilities of Hospital 111
6.3.3 Testing Difference in the Perception of the Patients 118
6.3.4 Factors behind the Patient’s Access to Alternative 121
Healthcare Institutions
6.3.5 Determinants of Access to Healthcare Institutions: 130
An Econometric Analysis
6.4 Conclusion 132
Chapter 7 Summary and Policy Implications 134 – 144
7.1 Summary 134
7.2 Policy Implications 140
Appendices 145 – 191
References 192 - 212
viii
List of Tables and Charts
Tables
Page
Name of the Table Number
Chapter 3: Objectives, Methodology and Data Sources 34 – 47
Table 3.1 Type of Hospitals in the District of Burdwan 36

Table 3.2 Number of Hospitals and Its Coverage in Different Districts of 43
West Bengal
Table 3.3 List of Hospitals Considered under Sample 45
Chapter 4: Public Healthcare Access and Its Linkages to Healthcare 48 – 74

Expenditure
Table 4.1 Description of the indicators and their data sources 55

Table 4.2 Index of Public Healthcare Access and its Dimensions across 59
Major States of India
Table 4.3 Index for Public Healthcare Access across Districts of West 62
Bengal
Table 4.4 Index for Public Healthcare Access across Blocks of Burdwan 64
District
Table 4.5 State-wise Health Indicators and Share of Health Financing 67
Table 4.6 Index of Public Health care Expenditure across States of India 69
Table 4.7 Estimated Values of IPHA and IPHE Associated with Ranks 70
Table 4.8 Classification of States according to the Values of IPHA and 71
IPHE
Chapter 5: Measurement of Efficiency of Healthcare Institutions & Its 75 - 100

Determinants
Table 5.1 The List of Input and Output Variables and Their Definitions 81
Table 5.2 Different Model Designs in DEA 83
Table 5.3 List of Determinants on Hospital Specific Efficiency Estimate 84
Table 5.4 Estimates of Efficiency Scores and Returns to Scale (Model 1) 87
ix

Table 5.10 Results on Testing of Treatment Oriented Technical Efficiency 95
(Result of Mann Whitney U Test)
Table 5.11 Results on Testing of Investigation Oriented Technical 96
Efficiency (Result of Mann Whitney U Test)
Table 5.12 Determinants of Technical Efficiency 98
Chapter 6: Patients’ Perception on Healthcare Services 101 - 133

from Alternative Healthcare Institutions
Table 6.1 The List of Independent Variables and Their Descriptions 107
Table 6.2 Hypotheses and Expected Sign of the Explanatory Variables 108
Table 6.3 Access of Healthcare Service Provider of the Family Members 110
of the Surveyed Patients
Table 6.4 Frequency Distribution of Patients’ Perception on Facilities of 112
Hospitals
Table 6.5 Percentage of Total Patients Willing to Repeat Purchase from 118
Same Healthcare Provider
Table 6.6 Testing Differences in the Perception of Healthcare Facilities 119
among Different Categories of Patients
Table 6.7 Frequency of Factors, Responsible for Taking Decision to 122
Select a Hospital for Treatment
Table 6.8 Result of Preference on Access of Healthcare Institution 130
Appendices 145 - 191
Table A1.1 List of Hospitals in the District of Burdwan 145

Table A2.1 Location and Infrastructural Facilities of the Surveyed 147
Hospitals
Table A2.2 Average Manpower of the Surveyed Hospitals 148
Table A2.3 Average Manpower/ Bed of the Surveyed Hospitals 149
Table A2.4 Average Equipments of the Surveyed Hospitals 150
Table A2.5 Average Hospital Outcome of the Surveyed Hospitals 151
Table A2.6 Average Performance Indicator of the Surveyed Hospitals 152
Table A3.1 Average Family Size and Age Composition of the Surveyed 154
Population
Table A3.2 Literacy Rate and Average Year of Schooling of the Surveyed 156
Population
Table A3.3 Religion and Caste Composition of the Surveyed Population 157
Table A3.4 Employment Status of the Surveyed Population 158
x
Table A3.5 Economic Status & Income Distribution of the Surveyed 160
Population
Table A3.6 Housing Condition of the Surveyed Population 161
Table A3.7 Asset Holding of the Surveyed Population 163
Table A3.8 Access of Insurance Facility 164
Table A3.9 Insurance Details 165
Table A3.10 Availability of Medicine at Hospital and Its Cost 167
Table A3.11 Pathological Tests and Investigations Per Patient 169
Table A3.12 Waiting Time for Operation after Admission of In-Patients 170
Table A3.13 Expenditure and Consumer Surplus 172
Table A4.1 Level and Improvement in Infant Mortality Rate in Selected 176
Indian States
Table A4.2 Health Expenditure of State Governments as a % of Total 176
Government Expenditure
Table A4.3 Correlation Matrix of Different Components of IPHA and 177
IPHE
Table A4.4 Health Indicators and Spending & Share on Health Financing 178
Table A5.1 Land Occupied by Different Category of Hospital 181
Table A5.2 Descriptive Statistics of Input Variables of State Government 181
Hospitals
Table A5.3 Descriptive Statistics of Output Variables of State Government 182
Hospitals
Table A5.4 Descriptive Statistics of Input Variables of Other Public 182
Hospitals
Table A5.5 Descriptive Statistics of Output Variables of Other Public 183
Hospitals
Table A5.6 Descriptive Statistics of Input Variables of Private Hospitals 183
Table A5.7 Descriptive Statistics of Output Variables of Private Hospitals 184
Table A5.8 Descriptive Statistics of Input Variables of All the Hospitals 184
Table A5.9 Descriptive Statistics of Output Variables of All the Hospitals 185
Table A6.1 Correlation Matrix OF Decision Variables 186
Table A6.2 Total Variance Explained by the Principal Components 190
Table A6.3 Component Matrix of Decision Variables 190
Table A6.4 Measurement of Differences among 191
Patients’ Perception about Hospitals (with ANOVA
Framework)
xi
Charts
Page
Name of the Chart/ Figure Number
Chapter 4: Public Healthcare Access and Its Linkages to Healthcare 48 – 74

Expenditure
Figure 4.1 Relationship Between Public and Private Healthcare 52

Financing
Figure 4.2 Conceptual Framework of Health Financing 53
Figure 4.3 Share of Public and Private Spending on Health across 67
States of India
Figure 4.4 Scatter Plot of IPHE and IPHA 72
Chapter 5: Measurement of Efficiency of Healthcare Institutions & Its 75 - 100

Determinants
Figure 5.1 Distributions of Hospitals by their Scale of Operation 94

(Treatment Orientation)
Distributions of Hospitals by their Scale of Operation 94
Figure 5.2
(Investigation Orientation)
Chapter 6: Patients’ Perception on Healthcare Services from Alternative 101 - 133

Healthcare Institutions
Figure 6.1 Bar Diagram Showing Patients’ Perception on Doctor, 117

Nurse, Staff, Hygiene and Their Overall Perception at
Different Categories of Hospitals
Appendices 145 -191
Diagram A4.1 Index for Public Healthcare Access across the States of 179
India
Diagram A4.2 Index for Public Healthcare Access across Districts of 179
West Bengal
Diagram A4.3 Index of Public Healthcare Access across the Blocks of 180
Burdwan district
Diagram A4.4 Index of Public Healthcare Expenditure across the States of 180
India
xii
Introduction
Chapter 1
Introduction
The World Health Organization defined health as a "state of complete physical, mental, and
social well being, and not merely the absence of disease or infirmity.” Healthy people are
believed to be the heart of the growth of the nation. Healthy people do their work effectively
and, in turn, create wealth; the combined prosperity of these healthy people increases the
asset of the country and makes the economy more powerful. Thus health is not just the
nonexistence of ailment and infirmity; it also has significant contribution in the productivity
of the nation. The health outcome is always a key concern of the social thinkers. In 1978, the
Alma-Ata Declaration appeared as a most important landmark of the 20th century in the
domain of public health with the objective of “Health for All” 1. In 1998, a new global health
declaration, “Health for All in the 21st Century” included supplementary aspects not
included in Alma Ata. These aspects include: to attain health security for all, to achieve
global health equity, to increase healthy life expectancy and to ensure access of essential
healthcare of good quality for all (WHO, 1998). The conscious attention regarding public
health is also given in the United Nations Millennium Development Goals, where United
Nations member states gave their consent on accomplishing eight goals; of which, a good
number is focused on healthcare of the population. Thus, immense importance is there to
construct healthcare infrastructure in both quantitative and qualitative consideration to offer
healthcare service throughout all areas of the nation with a trouble-free affordability and
1
The Declaration of Alma-Ata, co-organized by the World Health Organization (WHO), is a concise deed that
articulates" the need for urgent action by all governments, all health and development workers, and the world
community to protect and promote the health of all the people of the world."
1
Introduction
accessibility of populace of all income categories; which would provide a better health
outcome and subsequent superior living standard.
The Constitution of India identifies it as a responsibility of the government to provide
primary healthcare services (Bajpai et al, 2005). Thus the availability of primary health
service is to be confirmed by the government for every individual member of the population.
As one of the highest populated countries of the world, India has immense concern in the
spreading out of healthcare service to ensure the sufficient accessibility of the service at
every part of the country. Considering the intensity of this mission, healthcare service has
been given the utmost priority in the Twelfth Five Year Plan, where the major concern is to
accomplish „faster, sustainable and more inclusive growth‟. Though these proposals are truly
enterprising, but a significant inter-region disparity exists in the access of public healthcare in
India (Kumar et al, 2011). Insufficiencies in the government owned healthcare system2 in
offering healthcare services to the populace are well reported in the existing literature. A
fraction of the population is compelled to search for private healthcare services due to lack of
ability of the public healthcare sector to provide healthcare service to each and every
individual of the nation (Raman et al, 2012). In this context, Public-Private Partnership can
play a significant role in the delivery of healthcare service. In fact, Public-private
partnerships are observed to be playing gradually more and more role in developing the
performance of healthcare systems throughout the world (Mitchell, 2008). Several nations
have followed healthcare services delivery to the inhabitants by only increasing these
healthcare services with the support of the non-governmental partners. However, this is not
considered as a permanent answer, especially in underdeveloped or developing democratic
2
Healthcare system is the organization of people, institutions, and resources to deliver health care services to
meet the health needs of target populations (White, 2015)
2
Introduction
nations like India, where the major responsibility of the government is to deliver improved
and uniformly accessible healthcare services to every individual of the country (Kumar et al,
2011). The insufficient healthcare provision is also the result of insufficient funding from the
central government. In fact, the actual government expenditure on overall health sector in
India being much below the level of requirement (Rao et al, 2012).
West Bengal, the state with high population density shows a wide disparity in the
consumption of healthcare services in both rural and urban areas (Kumar et al, 2011). Again,
a prominent inter-district variation in availability, usage and access does exist and this
disparity is inversely related with the per capita district domestic product in the state
(Chatterjee et al, 2013). The presence of inequality in health through deprivation index and
development index observed that there is a considerable difference in infrastructure as well
as accessibility of health resources in the highly populated blocks of the district of Birbhum
and this necessitates individual attention. (Sheet et al, 2013).
In India, the public healthcare system comprises three tiers of infrastructural setup;
the primary tier (includes sub health centre, primary health centre, and community health
centre), secondary tier (includes district hospitals and sub-divisional hospitals) and third tier,
tertiary-level healthcare service is delivered by medical college hospitals and apex
institutions (GOI, 2011). When this structure is not evenly distributed in each and every
corner of the country, two alternatives do exist to provide minimum healthcare service to the
citizens of the country; first, increasing the efficiency of the public healthcare institutions and
second, introducing more and more private healthcare providers. An increase in efficiency in
healthcare domain, not only improves its performance but also increases the supply side
quantity of the healthcare service and serves more number of people. WHO (2000) in their
3
Introduction
annual report noticed the significance of efficiency in healthcare system and its all activities
and finally accomplishing the objective of upgraded healthcare status, receptiveness and
equality in healthcare financing.
Hospital efficiency, a particular measure of hospital performance, is considered for
the overall development of healthcare service and its accessibility among the masses. In
many underdeveloped and developing countries where healthcare resource constraints are
very common, the healthcare consumers are not getting appropriate treatment in terms of
quantity, quality and punctuality. Hospital management authorities are always keen to have
appropriate mix of inputs to provide better and more services to the patients; searching to
have more human capital, more technical and infrastructural equipments. Due to lack of
fundamental healthcare resources at the right quantity, doctors and nurses become helpless to
provide the best service to the patients. In many cases, patients are directly paying for getting
the healthcare service, but paying more for a less valued service as inefficiency exists in the
hospital‟s performance. It leads to a health imbalance and thus affects the society at large.
Many underdeveloped and developing countries are below the health standard of the
developed countries not only for the reason that there is insufficiency of inputs but also for
the inefficient use of these resources. Thus, it is necessary to emphasize this deficiency and
find the causes behind this and their subsequent rectification, because hospitals are
fundamental to the collective thought of wellbeing and infirmity, the healthcare system, and
the healthcare expenses (Ityavyar 1988).
Improved efficiency in healthcare domain can definitely minimize inter-regional
variation of healthcare facilities and provide more output to a larger patient base, but it is
simultaneously important to provide adequate level of satisfaction through quality healthcare
4
Introduction
service to the patients or the customers. Patient satisfaction procedures should be utilized to
observe the execution of health services particularly for hospital. Hospital personnel should
identify patients as the most significant trade associates. But, a large amount of
disappointment in patient relationships arises from the complexity in administering that trust
of the patients. Successful healthcare service providers continuously make every effort for
superior intensity of patient service. The capability of healthcare institutions to convey
prompt and efficient patient care is significant to its achievement. Proper care needs to be
taken on registration and admission issues, cleanliness and comfort issues of the hospital,
care provided by the physician, care provided by the nursing staffs, final result of the
treatment and the issues related to fees and charges (Singh, 2012).
Patients‟ satisfaction to a health service provider benefits not only its persistent visit
to the healthcare institution but also a better perception and the subsequent satisfaction which
might take a positive step in the process of recovery from the disease. There must have
competition at intra category level for private hospitals. But when different categories of
hospitals with different management approach are taken into consideration, the central
objective varies from one category to another category. From the perspective of welfare state,
the government owned, managed and controlled hospitals have the objective of providing
healthcare service to all the people of the state with no pay or negligible pay. The
heterogeneous group of private hospitals may operate with a different approach depending on
their „for profit‟ or „not for profit‟ organizational structure.
The foregoing discussion centers on a number of theoretical and empirical issues in
the domain of healthcare management; these include public healthcare access and its inter
regional variation, the efficiency analysis to measure the gap between existing achievement
5
Introduction
and the potentiality, and the perception of the patients on healthcare service. An attempt has
been made in the present study to touch upon all these aspects of healthcare management
system in the context of a micro empirical survey on the health economy of West Bengal
with special reference to the district of Burdwan. Specifically, the study seeks to obtain
empirical answers to the following questions: (1) What is the level of outreach of healthcare
institutions in the public sector vis-à-vis private sector across states of India, with a special
emphasis on the state of West Bengal? (2) How can we measure public healthcare access in
order to examine its variations across the states of India, districts of West Bengal and
different blocks within Burdwan district? (3) Does there exist any linkage between public
healthcare access and healthcare expenditure? (4) What is the level of efficiency of the
different healthcare institutions in state government, private and public sector undertaking
hospitals? (5) What are the important factors that can explain the variation in the level of
efficiency across hospitals? (6) What are the crucial factors, influencing the efficiency of
healthcare institution? (7) Do the patients differ in their perceptions on the different services
offered by the healthcare providers?
The outline of the study is as follows. The next chapter contains a review of the
existing literature on scope of the pertinent issues relating to healthcare management.
Chapter 3 deals with the objectives, methodology and data sources of the study. Chapter 4
makes a discussion on the variation in public healthcare access and its linkages to healthcare
expenditure. Chapter 5 deals with efficiency of the healthcare institutions. Chapter 6
considers patients‟ perception on healthcare services from alternative healthcare institutions.
The concluding remarks and policy suggestions have been presented in Chapter 7.
6
Review of Literature
Chapter 2
The subject healthcare management system has received considerable attention in theoretical
framework as well as in empirical works. The pertinent issue on the healthcare management
system in the existing literature can be broadly classified into three major sets of themes: (i)
outreach of healthcare institutions and the problem of health financing, (ii) efficiency of the
health sector and its determinants, and (iii) patients’ perception on healthcare service and
access of healthcare institution. Among these vast literatures, we have reviewed some of
them and made a synoptic assessment on these issues in general. Moreover an emphasis has
been given to review the existing literature on healthcare management system in the state of
West Bengal. An attempt has been made to identify the research gap in this field of domain.
Outreach of Healthcare Institutions and the Problem of Health Financing
The word ‘access’ can be conceptualized as a means of impending, getting or entering a
place, as the opening to achieve, utilize or visit (Canadian Oxford Dictionary, 1998). In
healthcare, access is defined as access to a particular service, to a provider or to an
organization. Thus access is defined as the ease with which customers are able to utilize
proper services according to their needs (Daniels 2001, Whitehead 1992).
Access to healthcare is fundamental in the activity of healthcare management systems
across the globe. More specifically, the value of healthcare service delivery for populace has
outcome in measurement of exploitation and access having a major task in the health
guidelines literatures (Shengelia et al 2003, Penchansky et al 1981). Nevertheless, healthcare
access remains a multifaceted conception as demonstrated by different explanations of the

7
idea across the authors (Daniels 1982). Levesque et al (2013) argues access as the innermost
of the healthcare management systems. In their study an amalgamation of the earlier studies
are considered which leads to the development of the conceptualization of access. They
consider access as the chance to recognize the necessaries in healthcare, to search for
healthcare facilities, to achieve, to attain or utilize healthcare facilities.
The concept of ‘access’ has been presented in several manners. Although access is
frequently utilized to elucidate aspects or characteristics that influence the preliminary
communication or use of services, divergent views exist concerning the facets incorporated
within access and if the importance should be kept further on explaining the distinctiveness
of the service providers or the authentic course of care (Frenk 1992). Frenk (1992) has
considered ‘access’ to indicate the capacity of the mass people to find and acquire healthcare.
So, it leads to the traits of the mass people of prospective or authentic consumers of
healthcare services and is associated with the conception of consumption power and
confrontation. Levesque et al (2013) defined access, which may be considered as the
connection between the prospective consumers and the healthcare resources; and further that
might be influenced by the traits of providers and the consumers of the healthcare services.
Different researchers have viewed access in different ways, considering different
dimensions (Aday et al, 1974; Salkever, 1976; Penchansky et al, 1981; Dutton, 1986;
Margolis et al, 1995; Peters et al, 2007). Salkever (1976) opines that accessibility merges
traits of the available inputs and traits of the people; two issues are considered to illustrate the
access: financial accessibility and physical accessibility. Aday et al (1974) define access as
the ingress into the healthcare sphere and consider three issues in this connection: pre-
organizing issue, facilitating issue and health care necessitating issue. Similarly, Penchansky
8
et al (1981) judge various issues like inexpensiveness, staying facility and suitability to
establish the concept of access. In another research work, Dutton (1986) presents the
monetary, time and managerial issues to enlighten the concept of access. Utilization of
individual health services at appropriate time to accomplish the objective of maximum
achievable outcome; where access is the outcome of three issues, namely monetary,
individual and hierarchical (Margolis et al, 1995). Peters et al (2007) consider five major
issues, namely excellence, physical ease of use, availability, monetary user-friendliness and
suitability of healthcare services to describe the healthcare access.
Different authors have elaborated their micro-empirical cross-country views and
experiences in an effort to analyze the access of healthcare services to the population
(Lamiraud et al, 2005; Mikkonen et al, 2010; Birbeck et al, 2002). Lamiraud et al (2005)
examine the disparities in the access to healthcare between rural and urban areas in South
Africa. The rural population is by and large more dependent on government supplied
healthcare services as compared to the urban population. It is also argued in the study that
there is inadequate support of significant intra-urban discrepancies, with disparity being
shoddier in undersized urban geographical jurisdiction or towns as opposed to larger urban
geographical jurisdictions or metropolitan areas. The study also highlights the significant role
to visualize upcoming decentralization of preferred healthcare services to local government.
The local government is possibly to take part in dealing with these disparities as well as
healthcare service delivery constraint at this level. Mikkonen (2010) views that high class
healthcare facilities are regarded as societal consideration of healthcare as well as a
fundamental human right in Canada. The key objective of a collective healthcare system is to
guard the inhabitants from bad health and spread the financial burden of healthcare over the
9
entire society. A collective healthcare approach is particularly useful to take care of the lower
income group citizens of the country who are unable to afford the cost of healthcare services,
especially from the private providers. Birbeck et al (2002) scrutinize several areas of the
developing countries and view that the access to particular healthcare services through
consultation of physician and neurological specialist is inadequate or does not exist at all.
Authors have performed a primary study in rural areas of Zambia and interpreted that more
than 40% of primary health care workers are engaged with primary health care units without
having a physician obtainable for basic consultation. These patients of rural Zambia need to
move on an average of 50 km to get access a physician’s consultation. Along with the trouble
of physically accessing the healthcare, primary health care workers state that monetary
obstructions to physician recommendation are also significant.
Several researchers have tried to shed some lights on the health care financing in the
context of macro-empirical evidences (Van Tien et al, 2011; Stenberg et al, 2010; Rao et al,
2012; Rice et al, 2001). Van Tien et al (2011) find that several nations are functioning to set
up a healthcare financing structure that will permit them to progress towards widespread
healthcare coverage. Stenberg et al (2010) find that the mean real per capita spending on
health account in low-income countries is $27, whereas there is a need to make a provision of
$54 per capita for a basic package of healthcare services in these countries. Rao et al (2012)
opine that the condition of health sector in low income countries and middle income
countries like India, Bangladesh etc are alarming; the real government spending on the health
segment in India is much less than the requisite level. They also claims that an adverse
impact persist on the arrangement of a precautionary health system because of this modest
expenditure on health account. Authors also have commented that, in spite of the
10
accomplishment of NRHM and efforts to expand government expenses on health account in
India after 2005-06, the spending improved only to 1.2 percent of GDP in 2009-2010. Rice et
al (2001) have studied the ethics and geographical equity in health care and viewed
significant differences in access to healthcare service. The paper scrutinizes the ethical
issues, such as capitation arrangement, which have turned into the most important technique
of allocating financing in healthcare account to constituencies in a good number of countries.
The Organization for Economic Co-operation and Development or OECD (2011) has
viewed that the majority OECD nations intend to supply equal access to healthcare service
for the populace in identical need. In most OECD nations, a greater part of the population has
no unmet healthcare needs. Nevertheless, in a study carried out in 2009 in Europe, important
magnitude in few nations accounted for encompassing unmet needs. Usually, the women and
the low-income group of the population report for not obtaining appropriate requirement of
healthcare services.
National Policy Consensus Center or NPCC (2004) has examined the conventional
delivery and financing model designs for healthcare service in a developed country like the
USA and has found it to be insufficient. Even though the spending is increasing, extremely
superior expertise and equipments exist and a wide assortment of specialized healthcare
service providers is available, a growing number of population does not have access to the
simple basic primary healthcare services. It is argued that these community centered
programs have the ability to spread out access to healthcare efficiently and they can also
decrease the cost of availing healthcare service in long term.
Different authors have conceptualized the problem in access of healthcare service
(Purohit, 2004; Baru et al 2010; Kumar et al, 2011) and insufficient spending on health in
11
Indian context (Tandon et al, 2010; Datar et al, 2007; Hati et al 2013). Purohit (2004) has
conducted a study in states of India to find out the disparity in availability and utilization of
health services and health manpower. He found that this disparity is distinctly marked which
has an adverse effect on achievement of Health for All for the nation as a whole. The author
has mentioned that states with higher income hold a superior position in terms of availability
of healthcare facility, which has a direct impact on access and utilization of healthcare
services. He has suggested for establishing and maintaining proper linkages between socio-
economic developments and healthcare planning in order to mitigate the problem of regional
disparities in healthcare and protecting the poor and vulnerable section of the society.
Baru et al (2010) have conducted a study on health service inequities as challenge to
health security in India. They have observed the inequities in health availability, accessibility
and outcomes and their variation across regional, social, and economic groups. Two major
factors have been identified in this regard; firstly, the weakening of public health services in
terms of availability, accessibility, and quality and secondly, increasing commercialization,
mostly from private healthcare sources. Like NRHM, the authors have also suggested for an
enhancement of investments in infrastructure, human resources, and availability of drugs/
technology. Understanding the forms and extent of the interrelatedness among public
healthcare sector and private sector proper strategy has to be formulated.
Kumar et al (2011) argue that several nations have provided healthcare services
delivery to the people of the country simply by intensifying healthcare services with the
support of the non-governmental institutions. But, this is not a stable answer, particularly in
developing democratic nations like India, where the most important responsibility of the
government is to endow with superior and uniformly accessible healthcare services to all the
12
layers of the inhabitants. Furthermore, authors have performed an inter-state analysis and
observe that a high level of disparity exists in healthcare services, delivered from the
government as well as the private healthcare providers. West Bengal is reported for the
highest level economic disparity in the use of public versus private health services, for
common healthcare issues both in urban and rural parts.
Tandon et al (2010) have assessed that by and large public spending on health
account is static at about one percent of GDP in between 1996-97 and 2005-06, which is less
than the average of low-income countries for the same time span. Datar et al (2007) have
examined the function of healthcare infrastructure and social health workers in increasing
vaccination exposure in rural parts of India. Authors have observed that the availability of
health infrastructure has an unassuming influence on vaccination exposure and thus it is
important for government to focus on this infrastructural set up.
Hati et al (2013) have conducted a district level study in India to analyze the health
Infrastructure and resulting health outcome at all districts of India. The potential relationship
among the indices for health infrastructure and health outcome at district level is
investigated. It is observed from the study that the availability of health infrastructure is
uneven among the districts and further disparity is observed in districts having poor
economic and social status. The authors suggest that the primary amenities should be made
stronger to offer appropriate and effectual preventive and curative healthcare services at the
root level. They also advocate for additional human resource in healthcare service providing
institutions, particularly in rural areas. A direct government intervention to build such
infrastructural set up and other resources is important in this regard. In a similar
recommendation, Baru et al (2010) emphasize that the foremost accountability for financing,
13
provisioning, and supervision of health rests with the concerned states, considering the
centralized character of the state.
Efficiency of the Healthcare Sector and Its Determinants
Considering the healthcare industry, the government health sector in India is suffering from
budgetary limitation and scarcity of qualified healthcare personnel at every tier (GOI 2011).
Scarcity of resources for healthcare is a well recognized crisis; in this circumstance, efficient
use of available financial and human resources becomes important for the healthcare sector.
The measurement of efficiency of healthcare facilities can lead policy makers in ensuring the
best possible use of existing resources (Jat et al, 2013). WHO (2000) in their annual report
has noticed the significance of efficiency in healthcare care system and its all activities and
finally accomplishing the objective of upgraded healthcare status, receptiveness and equality
in healthcare financing. Hollingsworth (2008) estimates a total of three hundred seventeen
papers were reported on frontier efficiency testing of creative components in healthcare
industry, where around fifty percent of these research works on hospitals and the patients got
treatment are considered as the output.
The first empirical literature on measuring efficiency of hospitals appeared in the
1980s (Procházková et al 2011). The efficiency of different type of hospital categories with
different management styles has been estimated. However, even with the uncertain
confirmation on the consequence of hospital rivalry on healthcare service providers’
eminence and efficiency, few countries have endorsed market-oriented modification intended
to make monetary inducement for healthcare providers to develop their overall activity
14
(Gaynor et al, 2011). O’Neil et al (2008), Worthington (2004) etc have used data
envelopment analysis (DEA) in the health industry to widely assess the efficiency issues.
Efficiency studies at international level are observed in the work of different authors.
Vitaliano (1996) and Rosko (2001) have conducted their studies on efficiency in healthcare
sector with US data, whereas in Europe Lopez (1996) and Prior (1996) have scrutinized the
efficiency of Spanish hospitals; Magnussen (1996) have also examined the efficiency of
Norwegian hospitals. The efficiency study of healthcare service providers, either government
or private or any charitable organizations stretch rapidly to other nations after 2000; which
consists of Austrian hospitals (Hofmarcher et al 2002 etc), Swiss hospitals (Farsi et al 2004
etc) or the British hospitals (Jacobs 2001 etc). The record is not comprehensive, further
instance can be observed in Worthington (2004) and Hollingsworth (2008) who present an
outline of empirical research works on efficiency estimation of the healthcare service
providers.
Different authors have examined efficiency with the help of data envelopment
analysis in healthcare sector at international level. (Webster et al, 1998; Valdmanis et al,
2004; Osei et al, 2005; Magnussen, 1996; Ichoku et al, 2011, Masiye, 2007 etc.). Webster et
al (1998) have conducted research work on hospitals in Australia with the help of data
envelopment analysis methodology and observe that efficiency approximation for the
sampled hospitals are not strong enough to alter the combinations of inputs-outputs; but he
also argues, when outputs are scattered and are not aggregated, a minute modification in
input combinations can generate a very dissimilar results. Valdmanis et al. (2004) have
applied data envelopment analysis to examine the performance of sixty eight government
15
hospitals in Thailand on the concern of poor and non-poor patients and observed that there is
no such variation on the quality of treatment offered.
Osei et al (2005) have conducted a pilot study to examine the technical efficiency of
public district hospitals and health centers in Ghana. The objectives of the study includes
measuring the comparative technical efficiency (TE) and scale efficiency (SE) of public
hospitals as well as health centers in Ghana. The data envelopment analysis method has been
applied. The result reveals that 47% and 59% hospitals are technically inefficient and scale
inefficient respectively; whereas 18% and 47% health centers are technically inefficient and
scale inefficient respectively. This pilot study has confirmed to policy-makers the usefulness
of data envelopment analysis in estimating inefficiencies along with individual facilities and
inputs. Continuous supervision of the progress in output, allocative efficiency and technical
efficiency of all its healthcare services for both the hospitals and health centers in during
accomplishment of health sector reforms have also been recommended. Ichoku et al (2011)
have evaluated the technical efficiency and scale efficiencies in 200 hospitals in low income
countries using Nigeria. The results of the study has expressed that large differences in the
efficiency of hospitals with mean efficiency score of around fifty nine percent under the
constant returns to scale and around seventy two percent under variable returns to scale. The
projected intensity of inefficiency calls for far reaching measures to ensure an advanced level
of efficiency in the hospital sector.
Magnussen (1996) has studied the efficiency measurement and the operationalization
of hospital production in Norway over a period from 1989 to 1991. The allocation of
efficiency is observed to be unaltered by the modification in the arrangement of hospital
output. Both the ranking of hospitals and the scale properties of the technology, however, are
16
observed to rely on the preference of output design. Masiye (2007) has investigated the
technical efficiency of Zambian hospitals with the help of data envelopment analysis. Results
reveal that the Zambian hospitals are performing at 67% level of efficiency, explaining that
the important resources are being not used properly. 40% of hospitals are efficient in relative
terms. It is also revealed in the study that the size of hospitals and the input congestion is a
major source of inefficiency. This research work has described that inefficiency of resource
utilization in hospitals is significant. Policy consideration is strained to inappropriate hospital
scale of operation and low productivity of few inputs as aspects that reinforce one another to
make Zambian hospitals technically inefficient at generating and delivering healthcare
services.
In the existing literature, some attempts have been made to compare the efficiency of
healthcare institutions across countries of the world and regional blocks (Hollingsworth,
2003; Tandon et al, 2000; Joumard et al, 2010). Hollingsworth (2003) has reviewed latest
research work on technical efficiency of healthcare service providers throughout the world.
Considering the score of technical efficiency, the author has argued that the mean efficiency
score is at maximum level for hospitals in the United States that is largely featured by
privately offered health insurance; and in countries like the United Kingdom, Greece,
Belgium, Finland, France etc in the European continent, where healthcare system is
maintained by the government is also at high level. These findings reveal that there is further
scope to achieve higher level of efficiency by the healthcare providers of the United States
and the selected European countries. The work also elucidated potentials that may possibly
prejudice these conclusions, like methodological divergence and differentiated observation.
Tandon et al (2000) have also measured the efficiency of the healthcare designs in 191
17
nations across the world. The authors have stated that technical efficiency scores only reveal
the potentials to progress the efficiency and simultaneously the overall healthcare system of
these countries comparing with the highly efficient nations in this connection. Joumard et al
(2010) have applied frontier methodologies to scrutinize the efficiency level of Organization
for Economic Co-operation and Development (OECD) countries. The authors observed that
United Kingdom is less efficient in comparison with several OECD countries.
With regard to clinical quality, different researchers (Gaynor et al, 2010; Kessler et al
2000 etc.) have argued that hospitals situated in less intense area perform in a different way
than the hospitals situated in intense market areas where the hospitals are exposed to the
competitive environment. A recent research in US and England showed that the competitive
environment catalyzes development in clinical quality of the healthcare service providers
when they are operated in a market place with fixed charges (Gaynor et al 2011). Steinmann
et al (2003) have estimated and evaluated the inefficiency of healthcare service providers in
Switzerland and Germany. Authors have considered standard data envelopment analysis and
restricted data envelopment analysis methodologies to minimize the influence of stating error
and find further analogous frontier and revealed that the technical efficiency gap between the
healthcare service providers in sample countries expanded over the period of time. Authors
argue that the gap might reveal the truth that the healthcare service consumers in Switzerland
had a larger alternative of healthcare service providers without being depicted to cost
differentiation; they also argued that there are additional resources for a certain level of
output, i.e., low DEA efficiency, where resources are appreciated by healthcare service
consumers as indicator of quality.
18
Helmig et al (2001) have conducted a research work on efficiency for the first time to
test the relative technical efficiency of the private, the public and the welfare hospitals in
Germany. The findings suggest that private hospitals are less efficient compared to the
welfare and the public sector hospitals in recent years. The rationale behind this outcome
could be the lot of teaching in public sector hospital. Moreover, it is observed that the private
hospitals in recent years are less efficient than it had been previously. However, public
hospitals and welfare hospitals truly enhanced their relative technical efficiency during the
same period of time. A feasible clarification for this trend might have been big investments
of private hospitals into supplies and organizations in order to develop their excellence and
their status.
The impact of competition on efficiency of hospital is critically examined by some
authors (Cooper et al, 2012; Culyer et al, 1993). Cooper et al (2012) utilize a difference-in-
difference approach assessment to investigate individually the influence of competition from
public as well as private hospitals on the efficiency of public hospitals in England. They have
taken the benefit of the current combination of substantive reforms, which is initiated in the
English National Health Service from 2006 onwards. The result of the study has proposed
that competition between public healthcare providers provoke public hospitals to develop
their output by lessening their pre, overall and post surgery average length of stay. On the
contrary, competition from private sector hospitals do not prompt public healthcare providers
to develop their performance and instead leave present public healthcare providers with an
added costly case mix of patients and lead to extension in average length of stay in post-
surgical period. In a similar contribution, Culyer et al (1993) advocated the competitive
market model to ensure efficiency, excellence, customer preference and receptiveness as well
19
as transparency and responsibility. This is necessary as public opinions against private
supplies of healthcare services quote disappointment in the healthcare market (Hsu 2010).
Some studies in the existing literature attempts to compare the efficiency level of
public hospitals vis-à-vis private hospitals (Hollingsworth, 2008; Tiemann et al, 2009;
Helmig et al 2001; Chang et al, 2004; Hu et al, 2004) and ‘for profit’ vis-à-vis ‘non-profit’
organization (Burgess et al, 1996; Lee et al, 2009). Hollingsworth (2008) has conducted a
study judging the public hospitals against private hospitals and argued that the private not-
for-profit and private for-profit hospitals have a lower average efficiency score than the
public hospitals. Tiemann et al (2009) have conducted a study with 1046 hospitals all over
Germany and observed that the government hospitals are performing more efficiently than
the private not-for-profit and private for-profit hospitals and suggested that the government
hospitals concentrate mostly on efficiency of the resources due to their input restrictions. In
another study in Germany, it is suggested that public healthcare providers are more efficient
as they apply comparatively smaller quantity of inputs than the private healthcare service
providers do (Helmig et al 2001). Contrary to the efficient statements mentioned above,
studies reveal that the private hospitals can also be more efficient than the public ones.
Different authors have observed that government healthcare providers have lower level of
efficiency than private healthcare providers in Taiwan (Chang et al, 2004; Hu et al, 2004).
Grosskopf et al. (2004) have stated that private healthcare providers have less resource to
generate outputs, when it is measured against public healthcare providers.
Burgess et al (1996) have used data envelopment analysis in a research work in the
USA to scrutinize whether the management designs i.e., not-for-profit, for-profit, national,
state and local government healthcare providers, vary according to their methodological
20
aptitude to transfer inputs into outputs; the outcome of the study specifies that ‘for-profit’
healthcare providers are more efficient than ‘not-for-profit’ healthcare providers. In a similar
study, Lee et al (2009) defend that ‘not-for-profit’ healthcare providers perform equally well
compared to ‘for-profit’ healthcare providers, while the previous one have been fighting with
cost lessening efforts; authors have argued that not-for-profit healthcare providers show more
efficiency than for-profit healthcare providers in Florida.
Different studies are carried out to identify the determinants of efficiency in
healthcare institutions by applying two-stage data envelopment analysis approach
(Grootendorst, 1997; Hamilton, 1999; Wang et al, 2003; Araújo et al, 2013). Araújo et al
(2013) have studied hospital efficiency in 20 Brazilian private for-profit hospitals. The
findings reveal that efficiency is varied in Brazilian for-profit hospitals. Benchmarks for
upgrading operations of for-profit hospitals that operate poorly have also been provided,
considering the function of related determinants like accreditation, complexity, and
specialization on improved efficiency levels. In a study on the determinants of cost efficiency
of general hospitals in the Czech Republic, Votápková et al (2013) have observed that bigger,
not-for-profit hospitals and hospitals with teaching facilities and hospitals in metropolis with
a major proportion of the elderly population are likely to be less efficient; whereas small
hospitals, hospitals in larger municipalities and hospitals in competitive environment are
likely to be more efficient. There are different factors which are responsible for the efficiency
of the decision making units. Lee (2009) has reported that a larger healthcare institution can
practice an array of strategic management to develop efficiency. Tiemann et al (2009) and
Groff et al (2007) have carried out their study on hospital efficiency and recommend that
there is a positive relationship between the size of the hospital and the efficiency of the
21
hospital. Hu et al (2004) have conducted a research work on hospital efficiency and observe
that the efficiency of the hospital increases with increase in number of beds in the respective
hospital; but, the author also have argued that there must be a sense of balance between the
capacity and the utilization. Lee et al (2008) in their study have supported the scope of
specialization in a hospital and suggest that specialized healthcare providers tend to be more
efficient, as they can achieve competitive advantage over their competitors for the particular
specialization.
In the context of Indian states, several attempts have been made to examine the
efficiency in the healthcare sector (Bhat et al, 2001; Shetty et al, 2010; Jat et al, 2013). Jat et
al (2013) have conducted a study to evaluate the technical efficiency of the forty public
district hospitals in Madhya Pradesh, India, with special importance on maternal health
services. The result has revealed that fifty percent of the total district hospitals are technically
efficient representing the ‘best practice frontier’, whereas the rests are technically inefficient.
With a mean score of 0.81, sixty five percent of the sample district hospitals are observed as
scale inefficient. The authors have concluded that the policy formulators and the bureaucrats
should recognize the causes of the experiential inefficiencies and consider appropriate
measures to enhance efficiency of the hospitals. Bhat et al (2001) has analyzed the efficiency
of 20 district hospitals and 21 grant-in-aid hospitals in Gujarat state of India. The findings
show that the efficiency differences are significant within district hospitals than within the
grant-in-aid hospitals. The general efficiency intensity of grant-in-aid institutions are
significantly more than the district level hospitals. The grant-in-institutions are having
comparatively higher efficiency than the government hospitals. Shetty et al (2010) have
analyzed the technical efficiency of healthcare system in major states of India. The authors
22
have considered four input variables, namely Per capita health expenditure, health centre per
million population, percentage of people below poverty line and literacy rate of the
population in the state and two output variables, namely infant mortality rate and life
expectancy at birth. It is found that 11 out of 19 major states in India are at efficient frontier.
Patients’ Perception on Healthcare Service and Access of Healthcare Institution
Different research works have been carried out to measure the determinant of patients’
preference on healthcare provider across countries of the world (Yip et al, 1998; Escarce et
al, 2009; Yadav, 2007; Dranove et al, 1993; Cohen et al, 1985). Yip et al (1998) have
conducted a study to find out the determinants of patient preference on medical service
providers in the three levels of health management system (i.e. county hospitals, township
health centers and village health posts) in rural areas of China. The result of the study reveal
that compare to self-pay patients, government and labor health insurance recipients utilize
more county hospital facilities. On the other hand, patients who are under the coverage of
cooperative medical system utilize more village level healthcare service. Furthermore, the
patients of high income group prefer to visit country hospitals than the patients of low
income group. The research work also divulges that the patient preference of healthcare
providers is significantly influenced by the type of ailment.
Escarce et al (2009) have conducted a research study to find out the determinants of
inpatient hospital choice in rural California. The study demonstrates that the patients are
more inclined towards nearby hospitals, larger hospitals, and hospitals having more amenities
and technological infrastructure. The authors also reveal that the patients may have adverse
view on quality of care in rural and small urban hospitals, which direct them to avoid these
23
hospitals when they have the alternative provision in this regard. It is thus suggested to make
the local population aware about the abilities of these small urban and rural hospitals. In a
similar study in California, Dranove et al (1993) explore that the possibility that the patients
may be admitted to a particular hospitals on the basis of insurance coverage, specifically
Medicaid and race. Segmentation on the basis of insurance and race is associated with
hospital characteristics, but not associated with the characteristics of the hospital's
community. Medicaid patients are inclined towards the hospitals with lower costs and fewer
healthcare service offerings. Privately insured patients mainly visit hospitals offering more
services, although price concerns are rising. It is also observed that the patients have a
preference for nearby hospitals, more so for some medical conditions than others.
Cohen et al (1985) have conducted a study to find the determinants of spatial
distribution of hospital utilization in a region and view that there are important distinctions in
the models of use of healthcare institutions for different population clusters and health
service groupings. In particular, the analysis in the study signifies that more male people
chose teaching hospitals than the females. The time required to reach the hospital is also a
significant factor in all the cases but is more imperative for elderly persons than for the
children.
In an online survey of around 2,000 patients in US, Grote et al (2007) have found that
most of patients are ready to switch hospitals for better facilities and that many have already
requested their doctors to refer them to particular facilities. According to the authors, the
main two factors responsible for switching hospitals are transparency in providing
information and timeliness.
24
Blizzard (2005) has carried out a research work in the United States to find how the
people choose hospitals. The author has observed that members of the society do not
essentially have a favored healthcare provider for different types of situations. A lot of
people distinguish healthcare amenities on the basis of their proficiency in providing
treatment of a particular type of sickness. The end users have a tendency to be open to use
several hospitals on the basis of their perceptions of the clinical proficiency of each.
Perception of patients regarding the healthcare provider is closely associated with the
quality of the service. Reeves et al (1994) have argued that the service quality has gained an
important amount of concentration by the academic researchers as well as by the industrial
practitioners. The authors have reviewed all the available quality definitions: quality as
excellence, quality as value, quality as conformance to specification, quality as meeting or
exceeding customer’s expectations. Raja et al (2007) opines that the quality management in
healthcare has come forward as the most important and long run tactics for confirming the
existence of the establishment as well as guides towards organizational excellence.
James (2005) finds that there is a shift from cost competition to performance and
excellence competitions in the healthcare sector in recent days. Torcson (2005) has expressed
that the perception regarding satisfaction or disappointment of the end users in healthcare
sector is a measure on the quality of concern and care of the healthcare providers in its entire
facets. Perception of the patients either positive or negative is an important issue that must be
crucial to the measurement of the quality of healthcare in hospitals. Badri et al (2007) have
stated that the level of satisfaction of the patients is believed to be inevitable in preparation,
execution and estimation of healthcare service delivery process and matching the necessities
of the end users. Standardizing the healthcare service delivery is also considered to be vital
25
towards obtaining high quality. Zineldin (2006) has expressed that positive patient perception
is a significant healthcare outcome. Locker et al (1978) have examined that the patient
satisfaction has been considered as an integral component of formulating guidelines; patient
satisfaction may be applied as an assessment of excellence of care, as a resulting variable and
as a technique for upgrading the quality. Raja et al (2007) have observed that the excellence
in healthcare services is associated with actions, interactions and resolution to the troubles
faced by the end users. Bhat et al (2007) have conducted a study on quality of medical
services and reveal the judgment of the patients to support a healthcare institution and the
magnitude of the quality of service provided to the end users by the hospital; the study has
also scrutinized the expectations and the subsequent perceptions of healthcare service
consumers towards the healthcare providers. The study draws the significance of service
quality in tactical planning and for the success of the organization.
Ross et al (1995) in a comparative study of seven measures of patient satisfaction
have scrutinized the inconsistency in patients’ satisfaction assessments associated with seven
different measurement techniques and the influence of reaction favoritisms on stated
satisfaction. The study reveals that various assessment procedures may produce very
dissimilar results in the assessment of patient satisfaction.
Merkel (1984) has conducted a study on physician perception of patient satisfaction
with a sample of 222 adult patients, as well as ten physicians at the university-affiliated
teaching hospital in the United States. The author has observed that there is no major
association between real patient satisfaction and physician perception of patient satisfaction.
The author has stated that physicians can not forecast appropriately their patients' satisfaction
26
level with medical care. The author suggests that the patient-physician association should be
continued if it is to be rewarding to both the parties involved.
Young et al (2000) in their study on patient satisfaction in the United States, have
observed that the demographic features (such as age, health status and race continuously had
a statistically significant influence on satisfaction level) and organizational features of the
hospital (i.e. size of the hospital) continuously has a significant influence on patient
satisfaction status. Cleary et al (1988), Weiss et al (1989) etc. have conducted further
researches and reveal that patient satisfaction is positively associated with the accessibility,
availability, and ease of care. Strasser (1991) has considered the quantitative assessment of
the satisfaction level of the patient; it is described as the assessment of patients’ motivation,
value judgment and responses to their health care occurrence through statistical
demonstration. According to Sitzia et al (1997), elements of satisfaction include structural,
technical and interpersonal features of care. The structural features consist of access, physical
setting, costs, convenience and treatment, offered by non-clinical staffs or the insurers. The
technical features consist of knowledge, competence and quality of care, interventions and
outcomes. The interpersonal aspects consist of communication, empathy and education.
Hall et al (1990) have suggested that patient satisfaction is related to the age and
education of the patients, whereas it is close to the statistical significance level in relation to
the societal and matrimonial status. In another study, Hall et al (1988) have observed that
patients’ satisfaction level improves with the newer physicians as they give more time to the
patients as well as present more scientific and interpersonal proficiency. Authors have also
found that bad experiences, occurred from the provider’s standpoint, are retained in mind for
a longer period by the consumers. Brody et al (1989) have mentioned that the healthcare
27
service consumers are incapable of evaluating technical concern; patients may recognize the
technical concern as so homogeneously that there is a little concern of variability; or that
non-technical or general facets of care are more significant to patients. Inui et al (1985) have
suggested that the communication between the healthcare provider and healthcare consumer
as an enormously imperative facet in healthcare sector. It is essential to enhance measures
that classify a particular category of interface of verbal communication with procedures of
other categories of interface, like gesture, posture etc. Saila et al (2008) have observed that
successful communication as the answer of patient satisfaction. The authors have also
observed that the most important factors that influence the view of the outpatient of the
excellence of hospital care are the appropriate discussion and consultation with the physician.
Different research works have also been carried out to experience the preference and
perception of the patients on healthcare service provider at domestic level in India (Yadav,
2007; Singh et al, 2011). Yadav (2007) outlines several reasons suggested by the patients for
their preference of government hospital in Miraj. The author has argued that the traditional
belief associated with the public healthcare institutions’ coverage only to the poorest section
of the society, is gradually changing; as mindful efforts to develop these healthcare services
quantitatively and qualitatively are being taken up by the government. Increasing costs of
private healthcare providers are also a significant causal matter of discussion. Financial
factors, i.e., not being able to meet the expense of healthcare services from private healthcare
providers, are quoted by 44% of the respondents. A high percentage of respondents belong to
the upper-middle class, who are having preference for the consumption of government
healthcare services, because they cannot afford the expenses required in the private
healthcare institutions and therefore search for healthcare services at a government hospital.
28
In a similar study, Singh et al (2011) observe that patients can have several bases for
preferring a particular healthcare provider in Manipur. The percentage of respondents eager
to search for a certain hospital can be considerably unlike across characteristics such as
physical infrastructural set up, idea by knowledgeable person, proximity, availability of
expert professionals etc. The authors suggest that these hospitals must make an effort to
understand the inclinations of the end users.
State of Healthcare in West Bengal
The Millennium Development Goals (MDGs), obtained from the UN Millennium
Declaration, obligate countries to eliminate severe poverty and to accomplish enhancement in
health by 2015. India is in a far distance place from reaching the goal. Even though the
circumstances in West Bengal is observed to be commonly superior to the Indian average,
but considerable development needs to be implemented in realizing the goal. Along with,
there is necessitate for significant enhancement of all issues of public health, especially in
avoidance of morbidity and mortality as well as delivering remedial healthcare services to
every individual at an affordable cost (GoWB, n.d.).
In the state of West Bengal, different academic studies have been conducted in the
health sector (Nag, 1989; EPW, 1992; Sonam, 2002; Chakraborty et al, 2003; Chakraborty,
2005; Mazumdar et al, 2009; Roy et al, 2011; Sheet et al, 2013; Dutta et al, 2014). Few of
those studies can be summarized as follows. Chakraborty et al (2003) have tried to observe
the ongoing healthcare scenario in West Bengal with special emphasis on government
healthcare services. The authors have observed that almost 80 percent of those who need
hospitalization go to government healthcare institutions for in-patient care in West Bengal,
29
whereas the same is 50 percent for the entire country. Thus the pressure in government
healthcare institutions in West Bengal is very high, which leads to ineffectiveness and
negligence. Authors have recommended for better regulation of the private healthcare
providers to share this pressure. Dutta et al (2014) have conducted a study on public hospital
efficiency in West Bengal where the secondary level state government owned hospitals are
considered as decision making units and show that a majority of state government owned
hospitals are operating below the full efficiency level. An introduction of other healthcare
institutions of different management approach in the same geographical area may be helpful
in providing a broader view and the respective stand point of different categories of
healthcare providers.
In a micro-empirical study in Birbhum district of West Bengal, Sheet et al (2013)
suggest a wide disparity of healthcare services in different blocks of the district. A significant
gap in infrastructure as well as availability of health personnel persists in the populous blocks
of the district. They have recommended for more government hospitals, more primary health
centers and more doctors & nurses to increase the public healthcare access and to reduce the
dependency of private healthcare service provider in certain blocks, as their health cost is
more than their food cost. In another study in the same district, Sonam (2002) observes the
level of initiatives of the government in healthcare sector, even though private sector also
covers a large area for providing healthcare services in the district of Birbhum. The author
has viewed a new initiative from the government to strengthen the government health sector
by handing over responsibilities to the private groups and practitioners. The author has
argued that this privatization process is getting more focus which suppresses the vital issue of
30
inadequacy of healthcare service in rural area of West Bengal as well as its implications on
the health status of the villagers.
However, different authors have viewed differently on the implications of inviting
private partner in government healthcare institutions in the name of PPP model in West
Bengal (Chakraborty, 2005; Roy et al, 2011) and introduction of charging user fee in West
Bengal hospitals (Roy et al, 2011; EPW, 1992; Mazumdar et al, 2009). Chakraborty (2005)
has studied on the proposal of Government of West Bengal regarding greater involvement of
the private sector in public health service in the form of Public-Private-Partnership. The
author has considered this policy as ‘confused’ one, as it has not provided any clarity on
mechanism of performing two different managements, having completely different
philosophy; where the public healthcare institutions are having the intention to provide
access to maximum number of people and the private healthcare sector are more inclined
toward profit maximization. Thus confusion arises in seeking an empirical answer to the
question: whether the policy leads toward private profit on government investment!
Roy et al (2011) have studied on Public-Private-Partnership and the implications of
charging user fees in healthcare sector in the state of West Bengal. Following the
recommendation of the World, the Government of West Bengal has introduced user fees in
the form of paid diagnostic service with private partnership in government hospitals. It leads
towards closure of in-house and hospital owned diagnostic facilities except a very few (viz.
Malaria, Leprosy and TB). It also increases the out- of- pocket expenditure and subsequent
inability of the poor people to access the basic level of health services, even at government
owned healthcare institutions in the state of West Bengal. The ‘reform’ measures of imposing
user charges on healthcare services results in shutting the poor out from this government
31
healthcare service in the state of West Bengal indirectly (EPW, 1992). Mazumdar et al
(2009) has argued similarly in their study at rural West Bengal. According to them, the
poorer the household, the more limited is the choice about provider and the more prone
medical care expenditure shocks even when the cost of care at public healthcare sources is
less than the private healthcare sources.
In a political economic perspective, Nag (1989) has studied the implications of
political awareness on the accessibility of health services in a case study of rural Kerala and
West Bengal. More political awareness in Kerala resulted in more accessibility of health
services in the state in comparison to West Bengal. The author concluded that the political
parties and trade unions should take a more active role by mobilizing the masses not only
around economic issues but also around social issues, e.g., health, education, environment
etc. that previously were not subject matter of mass politics.
Research Gap
From the above survey of literature it is seen that there is a good number of empirical
research work have been conducted by different researchers in the state of West Bengal.
Along with these academic studies, studies have also been conducted in the form of
government report with institutional initiatives (Tripathi et al, n.d.; Government of India,
2010; Government of West Bengal, 2005, 2008).
Micro-empirical studies relating to healthcare management in the districts of West
Bengal is relatively scanty in the literature (Sonam, 2002; Sheet et al, 2013). Some of the
project specific studies (Anchal project, RCH programme) have been conducted at individual
level and organizational initiative in the district of Burdwan (Govt. of West Bengal, ; Essar
32
Foundation, ; Roy, 2014). However, as far as my knowledge, no such systematic studies
have been conducted in the district of Burdwan to explore both the public and private
institutional mechanisms in the healthcare management. The study aimed at evaluating the
relative position of the district in comparison to the access of healthcare services in the
districts of West Bengal. The micro-dimensional evidences are also supplemented by macro-
evidences at state level in India. Research on testing relative efficiency of three unique
categories of hospitals (i.e., State Government Hospital, Other Public Hospital and Private
Hospital) and patients’ perception on healthcare services from these alternative healthcare
institutions have also not been explored in the district of Burdwan. Thus there exists a
research gap and there is scope for research in this area. To fill in this gap the present study is
being carried out.
33
Objectives, Methodology and Data Sources
Chapter 3
3.1 Objectives of the Study:
The main objective of the present work is to present an overview on the scenario of
healthcare access Indian states, districts of West Bengal and blocks of district of Burdwan.
In addition, the study attempts to make a comparative analysis on variation of the level of
efficiency in the management of health care services across healthcare institutions (i.e., State
Government Hospital, Other Public Hospitals and Private Hospital), in the district of
Burdwan of West Bengal. More specifically, it seeks to dwell upon the following issues:
1. To examine the regional disparity in public healthcare access across the states of
India, districts of West Bengal and different blocks within Burdwan district. An
attempt has been made to find its linkages to healthcare financing.
2. To compare the relative efficiency of the different healthcare institutions (viz., State
Government Hospital, Other Public Hospitals and Private Hospital) operating in the
district of Burdwan in West Bengal. An attempt has been made to identify the various
socio-economic factors determining the efficiency level of different form of hospitals.
3. To examine the factors responsible for the choice of healthcare service provider by
the ultimate end users. In addition, the study throws some light on the perception of
the patients regarding the various healthcare services accessed from different types of
hospitals.
4. To suggest a set of policy recommendations to improve the performance of these
healthcare institutions.
34
3.2 Hypotheses of the Study:
The following hypotheses are postulated for testing in the study:
H01 : Regarding difference in the performance across the regions, it is hypothesized that
insignificant variation exists in the public healthcare access across regions (Indian states,
West Bengal districts, Burdwan blocks).
H02 : Regarding efficiency of different forms of hospitals, it is postulated that there is no
difference in the level of performance among different forms of hospitals i.e., state
government hospitals, private hospitals and other public hospitals.
H03 : Regarding impact of socio-economic status on choice of healthcare service provider,
it is hypothesized that there is no inequality in the access of healthcare services across
various socio-economic groups.
H04 : Regarding consumers‟ perception, it is postulated that end users (or, patients) of
healthcare service have the same level of perception about the available healthcare facilities
in alternative healthcare institutions.
35
3.3 Methodology of the Study:
3.3.1 Sampling Method in Primary Survey
The primary survey has been conducted both at the hospital level and at the patient level. In
order to represent three categories of hospital in our sample size, stratified random sampling
method was used. Three strata have been constructed from a comprehensive list of all the
different types of hospitals of the district of Burdwan and from each stratum a representative
sample of 40 percent is selected uniformly through random sampling method. The sample
size of healthcare service providers is comprised of 10 state government hospitals, 10 other
public hospitals and 5 private hospitals. The details are given in the Table 3.1 below:
Table 3.1
Type of Hospitals in the District of Burdwan
Type of Hospital Code Total Number of Total Number of
Hospital in Burdwan Representative
District Sample Selected
State Government Hospital SGH 27 10
Other Public Hospitals OPuH 26 10
Private Hospital PrH 13 05
Total 66 25
On the other hand, quota sampling was used to select the patients from different
hospital, considering their bed-size. After the selecting the number of patients to be surveyed
from particular hospital, judgment sampling has been used to find out the right respondent
who can provide the necessary information.
3.3.2 Methodology Regarding Measurement of Public Healthcare Access and Its
Linkages to Healthcare Expenditure:
To examine the disparity in public healthcare access across the geographic regions in public
healthcare access and to find its linkages to healthcare expenditure, the statistical procedures,
used in our study are measurement of public healthcare access and public healthcare
36
expenditure using Normalized Inverse Euclidean Distance Method, Scatter plotting and Rank
Correlation.
Measurement of Public Healthcare Access and Public Healthcare Expenditure:
In the study, index of public healthcare access (IPHA) and index of public healthcare
expenditure (IPHE) have been constructed by using the method of normalized inverse
Euclidean distance method. The index of public healthcare access is constructed with three
dimensions, namely, penetration dimension (i.e. the number of inpatients per 1000
population), availability dimension (i.e., the number of public health care institutions or beds
per 1000 population) and usage dimension (i.e., the rate of infant stability, which can be
calculated as 1000 - IMR). The index of public healthcare expenditure has been constructed
with two dimensions: per capita state government expenditure on health and per capita
central government expenditure on health. The methodology used in the construction of
IPHA and IPHE is similar to that used by United Nations Development Programme (UNDP)
in the construction of development indices, such as HDI, HPI and GDI 1. Two dimensions are
chosen separately for the formulation of IPHA and IPHE. For each index, at first, i dimension
indices are constructed and then the final index is derived by using normalized inverse
Euclidean distance method. The distance based approach satisfies several interesting and
intuitive properties of a development index, viz. normalization, symmetry, monotonicity,
proximity, uniformity and signaling (collectively termed NAMPUS) (Nathan et al, 2008). To
derive IPHA and IPHE, the dimension index for each dimension ( d i for the ith dimension, i =
1, 2….n) is computed first. Here it can be seen that 0 ≤ di ≤ 1. The higher the value of di, the
1
In a study on cross-country experience of financial inclusion, Sarma (2008) made a significant contribution in
the existing literature by formulating a new index on financial inclusion (IFI). This index is based on the three
dimensions (penetration, availability and usage) of financial inclusion. This index has been widely been used in
the existing literature of financial inclusion (Kuri & Laha, 2011a, 2011b; Chottopadhyay, 2011). However, use
of the same methodology in the literature on health care management is relatively new.
37
higher would be the achievements of the district in dimension i. In our study, we have
considered n dimensions (for state level and block level IPHA calculation, n = 2 and for
district level IPHA calculation, n = 3) for measuring public healthcare access. By considering
the n number of dimensions, district i can be represented as a point (d1, d2, d3 ……dn) in n
dimensional Cartesian space, such that 0≤ d1, d2, d3……dn ≤ 1. In the n dimensional Cartesian
space, the point zero of each dimension would indicate the worst situation while the point
one of each dimension would indicate the best or ideal situation. The Public Healthcare
Access and the Public Healthcare Expenditure are measured to the point (d1, d2, d3……dn)
from the ideal point (11,12,13……1n). In the indices, the numerator of the nth component is the
Euclidean distance of d i from the ideal point 1, normalizing it by n and subtracting by 1
gives the inverse normalized distance (Sarma, 2008). The normalization enables us to make
the value lie between 0 and 1 and the inverse distance is considered so that the higher the
value of the IPHA (IPHE) corresponds to higher health care access (health care expenditure).
Scatter Plotting and Correlation Coefficient:
To establish the relationship between the access of public healthcare and government
healthcare expenditure of major states of India, scatter plotting was done by plotting the
relative positioning of the states on the basis of values of government healthcare expenditure
and access of public healthcare. The rank correlation is undertaken to find out whether the
relationship between the access of public healthcare and government healthcare financing of
major states of India is statistically significant or not. One parametric rank correlation
method (Pearson Correlation) and two non-parametric methods (Kendall‟s tau-b and
Spearman‟s rho) are used to measure the association between health care access and health
care expenditure.
38
3.3.3 Methodology Regarding Comparison of Efficiency of Hospitals and Determining
the Determinants of the Efficiency:
The statistical procedure used in our study to estimate efficiency level and comparing
efficiency across healthcare institutions can be described as follows:
Data Envelopment Analysis:
Data Envelopment Analysis (DEA) is used to estimate technical and scale efficiency of
hospitals in our surveyed area. Technical efficiency reflects the ability of a firm to obtain
maximum output from a given set of inputs. In scale efficiency, a unit can be considered as
scale efficient by its volume of operations at optimal level so that some alteration on its
volume will lowers its efficiency. Following Coelli et al (2002), technical and scale
efficiencies can be measured using the Variable Returns to Scale Input Oriented DEA model.
DEA involves the use of linear programming methods to construct a non-parametric
piecewise frontier over the data, so as to measure efficiencies relative to this surface.
Mann Whitney U Test:
This test is used to analyze the difference of efficiency measures across three categories of
hospitals with both orientations i.e. treatment orientation and investigation orientation.
Mann-Whitney U Test is a non-parametric test alternative to the two-sample t test: H 0 : 1 2 .
To perform the test, first of all ranking of the individual technical efficiency scores of two
types of hospitals is done jointly, taking them as belonging to a single sample in either an
increasing or decreasing order of magnitude. Again the same process is followed for another
pairs of hospitals. The three categories of hospitals, i.e., state government hospitals, other
public hospitals and private hospitals are analyzed in three pairs and then the test is
39
performed. Finally, conclusion on efficiency differences among hospital category is drawn
by comparing the calculated value of Z with its critical value.
Maximum Likelihood Censored Tobit Analysis:
To determine the various determinants of hospital specific technical efficiency, Censored
maximum likelihood estimator is used. Since the estimated value of the efficiency scores are
lies in between zero and unity, hence Censored Tobit model is employed to determine the
value of the coefficients of the hospital specific determinants (viz. category of hospital,
location of the hospital, number of functional beds, number of OPD patients treated, bed
occupancy rate).
3.3.4 Methodology Regarding Patients’ Perception on Healthcare Services from
Alternative Healthcare Institutions:
To examine the factors responsible for the choice of healthcare provider for receiving
treatment and to find the perception of the ultimate end users, i.e., patients regarding the
healthcare service accessed from different types of hospitals, the study employed the
following statistical procedure.
Tabular Representation:
Responses of the patients on healthcare service facilities are placed in appropriate table
format to provide an overall impression of the patients on the quality of health services
provided to them. Tabular presentation also helps us to draw necessary conclusions on the
existence of differences in opinion of the patients on a particular healthcare services availed
from a particular healthcare service provider.
40
Principal Component Analysis:
During primary survey, the patients are asked the reason behind coming to that particular
hospital and multiple responses are obtained. These responses are very close to one another,
which might create a multi-collinearity effect. To eliminate the dilemma of multi-collinearity
effect, which might lead to erroneous and defective outcomes, principal component analysis
is employed to reduce the number of decision variables representing the perception of the
patients. At first, the analysis is performed with all the decision variables of the patients and
finally constructing a single variable with their corresponding loading values. Considering
the component matrix of thirteen decision variables that are identified in the study, six
principal components are derived. Considering only the first component with eight variables,
a new variable is constructed as „decision score‟ (SCORE). A total of ten variables, including
nine demographic variables and one „decision score‟ are considered for further analysis to
find out the determinants of the choice of a particular type of hospital.
Ordered Probit Regression:
To consider the factors determining the choice of healthcare provider, a variety of qualitative
response models can be suggested (Chaudhuri and Maitra, 1997). Ordered Probit Qualitative
Response Model is used to analyze the present problem. The choice of healthcare institution
for getting treatment is a distinct judgment, constant with a qualitative preference. In this
study, several socio-economic characteristics of the patients are identified to explore their
implications on the choice of the patients in selecting one particular hospital category, i.e.,
the state government hospitals, other public hospitals and private hospitals.
41
Kruskal Wallis Test:
Kruskal and Wallis test (1952) is generally employed for comparing multiple numbers of
independent samples with same or different sample sizes. In this study, the statement that the
patients surveyed at three categories of hospitals are having similar perception on different
issues of service delivery is considered as the hypothesis for testing. Kruskal-Wallis test is
used to rank different groups of patients with their respective scores. Ranking of all the
perception data of all the respondents from all three groups of hospitals is done, ignoring
group membership.
3.4 Data Sources of the Study:
The study has utilized both primary2 and secondary data sources. The secondary data have
been used in our study to analyze the prevailing healthcare condition. Secondary data have
been collected from different government and non-government sources. The government
sources include the Department of Health and Family Welfare, Government of India; Office
of the Registrar General, Government of India; The Medical Council of India, New Delhi;
Department of Health and Family Welfare, Government of West Bengal; Directorate of
Census Operations, Government of West Bengal; State Bureau of Health Intelligence,
Government of West Bengal. 3 The empirical part of the study is conducted with the help of
data collected through field survey with the structured questionnaires at the institutional level
and at the patient level.
2
Salient features of the surveyed hospitals are presented in Appendix.2 and salient features of the surveyed
patients in three categories of hospitals are presented in Appendix.3.
3
The non-government sources include wikipedia (http://en.wikipedia.org), hospital khoj
(http://www.hospitalkhoj.com) mediindia (http://www.medindia.net), Bengal students
(http://bengalstudents.com) etc.
42
For this study, the district of Burdwan4 has been purposively selected. The district has
the maximum number hospitals except Kolkata district in the state with all three types i.e.,
State Government Hospitals, Other Public Hospitals and Private Hospitals under study taken
together. The combination of three types of hospitals is also not very prominent in other
districts of West Bengal. The existence of State Government hospitals is common for every
district. The existence of industrial units and collieries allows the existence of PSU hospitals
(here categorized as “Other Public Hospitals”) in large number, unlike other districts. Though
the existence of private nursing homes is very common, but the presence of a good number
of Private Hospitals in this district (like Kolkata district) is also very significant. Coexistence
of three alternative institutions in the delivery of health care has guided us to select
purposively the district of Burdwan as our study area. Considering the area and the
population covered per hospital for every district, the district of Burdwan is placed third in
the ranking of the outreach of hospital to the masses. In fact, the average population covered
by the district is comparatively higher in relation to state average. This district is also
positioned under top six districts of the state, considering the area covered per hospital.
Table 3.2
Number of Hospitals and Its Coverage in Different Districts of West Bengal
Number of Area Covered Per Population Covered
District
Hospitals Hospital (km2) Per Hospital
Bankura 29 237.31 (15) 124010.06 (04)
Birbhum 26 174.80 (10) 134707.19 (06)
Burdwan 72 97.55 (06) 107273.09 (03)
Coochbehar 18 188.16 (11) 156821.11 (10)
Dakshin Dinajpur 11 201.72 (12) 151902.81 (09)
Darjeeling 36 87.47 (05) 51167.61 (02)
Hooghly 37 85.10 (04) 149199.70 (08)
Howrah 37 39.64 (02) 130855.08 (05)
4
Total area of the district is 7,024 km2 (2,712 sq mile). According to the 2011 census Burdwan district has
a population of 7,723,663 which gives it a ranking of 7th in India (out of a total of 640 districts). The district
has a population density of 1,100 inhabitants per square kilometers (2,800 /sq mile) and Muslim population of
19.78%. The urban population is 36.94 percent, while the rural population is 63.06 percent.
43
Jalpaiguri 24 259.45 (17) 161236.45 (11)

Kolkata 126 1.46 (01) 35608.56 (01)
Malda 23 162.30 (09) 173824.78 (13)
Murshidabad 34 156.58 (08) 208895.00 (16)
Nadia 30 130.90 (07) 172282.93 (12)
North 24 Pargana 58 70.58 (03) 173842.27 (14)
Paschim Medinipur 42 222.50 (14) 141507.14 (07)
Purba Medinipur 23 205.91 (13) 221488.60 (18)
Purulia 16 391.18 (19) 182997.81 (15)
South 24 Pargana 39 255.38 (16) 209055.79 (17)
Uttar Dinajpur 10 314.00 (18) 300084.90 (19)
West Bengal 188 190.18 485892.21
Source: Author’s calculation based on data provided by Directory of Medical Institution 2010,
DHS, Government of West Bengal and different websites 5
Note: Figures within the parenthesis represent respective ranks.
In order to represent three categories of hospitals in our sample, stratified random
sampling method has been used. In the first stage, a comprehensive list of all the different
types of hospitals of the district of Burdwan is constructed. The list is placed at Appendix.1
(Table A1.1). Then the present institutional structure of healthcare providers are stratified
into three strata (State Government Hospitals or SGH, Other Public Hospitals or OPuH and
Private Hospitals or PrH) and from each stratum a representative sample of 40 percent is
selected uniformly through random sampling method. Primary data on the basis of a total
sample size of 25 hospitals have been collected from a comprehensive list of 66 hospitals in
the district of Burdwan. In the second stage, ultimate hospitals are chosen on the basis of
random sampling method (proportional sampling procedure). For each category of hospitals,
a fixed proportion of nearly 40 percent of the population is considered as the sample size. In
fact, the sample size is comprised of 10 state government hospitals, 10 other public hospitals
and 5 private hospitals. The list of selected hospitals is given in the table below:
5
www.hospitalkhoj.com, http://rsbywb.gov.in, //www.listbesthospitals.com, www.justdial.com, http://india-
life-health.blogspot.in
44
Table 3.3
List of Hospitals Considered under Sample
Hospital
Patient
Type
Bed-
Name Block Sample
Size
Size
Asansol SDH Jamuria 350 37.2
State Government Hospital
Urban
Katwa SDH Katwa 1 250 26.6
Bhatar RH Bhatar 60 6.3
Memari RH Memari 2 60 6.3
Singot RH Mangalkot 60 6.3
Ban-Nabagram RH Ausgram 2 30 3.2
Rural
Jamalpur RH Jamalpur 30 3.2

Laudoha RH Faridpur 30 3.2
Pithaikeary RH Salanpur 30 3.2
Ballabhpur RH Raniganj 50 5.3
Category Total 950 100
Andal Railway Hospital, Andal Andal 50 3.1
Burnpur Hospital, Bunpur, Hirapur
Asansol 550 34.4
Other Public Hospital
Urban
D P L Hospital, Durgapur Faridpur 103 6.4

D T P S Hospital, Durgapur Faridpur 30 1.8
E S I Hospital, Durgapur Faridpur 150 9.3
K G Hospital, Chittaranjan Salanpur 150 9.3
Kajora Hospital Andal 30 1.8
Central Hospital (Kalla), Asansol Jamuria 450 28.1
Rural
Regional Hospital, Chhora, Andal

Bohula 30 1.8
Satgram Hospital, Jamuria Jamuria 50 3.1
HLG Hospital, Asansol Jamuria 200 14.7
Private Hospital
Urban
I.R.C.S. Hospital, Durgapur Faridpur 30 2.2

The Mission Hospital, Durgapur Faridpur 250 18.3
Vivekananda Hospital, Durgapur Faridpur 100 7.3
Rural
CAMRI Hospital, Burdwan Burdwan-II 100 7.3

TOTAL 3223 250
Source: Calculation based on sanctioned bed size data, provided by Directory of Medical
Institution 2010, DHS, Government of West Bengal and official website of HLG Hospital, The
Mission Hospital, Vivekananda Hospital and CAMRI Hospital
45
A total of 250 patients, who were admitted during the time of field survey at the
above mentioned hospitals, were surveyed. In the institutional level survey we have
considered 10 numbers of state government hospitals, 10 numbers of other public hospitals
and 5 numbers of private hospitals. Accordingly the ultimate sample units i.e., in-patients6
are chosen in the proportion of 2: 2: 1. Thus, 100 patients have been chosen from State
Government Hospitals, 100 patients from Other Public Hospitals and 50 patients from
Private Hospitals. Considering the bed-size of the hospitals, proportionate representation of
patients is surveyed. But, the bed sizes of the hospitals are found to be varying from a
minimum of 20 (at Asansol Special Jail Hospital, Asansol) to a maximum of 550 (at Burnpur
Hospital, Bunpur, Asansol). This wide variation in bed-size also reflects a considerable
variation in the number of respondents to be surveyed from each hospital, which shows a
minimum number of 1 and a maximum number of 37 respondents to be surveyed from a
hospital. Survey of only one inpatient in a particular hospital does not truly authenticate the
real picture prevailing in that hospital. Thus, to have a representative sample size, we have
chosen a floor of 5 respondents and a ceiling of 26 respondents at any hospital. As the
respondents were the in-patients of hospitals, all of them could not respond properly because
of their nature of illness. Thus, the judgment sampling has been used to find out the right
respondent who can provide the necessary information about the services provided by the
hospital.
Two structured questionnaires have been used to collect data from the service
providers and the service consumers. Questionnaire relating to the patients deals with
information concerning socio-economic characteristics of the family, choice of healthcare
6
The patients who are taken admission in the hospital are considered as “in-patient”. It is also to be mentioned
that the patients who visit the out door for the purpose of doctor visit only and not for admission purpose, are
called out-patient and the concerned department is called OPD or Out Patient Department.
46
provider, experience on healthcare service and the overall perception. Again the
questionnaire relating to the hospital deals with the subjects like facilities available, human
resource, equipments and their performance. The second set of data was mainly provided by
the superintendent, chief medical officer or the hospital manager of the hospital with the
cooperation of the data operator and other staffs. The hospital officials were asked about the
socio-economic background of the patients and the locality. In order to ensure the reliability
of information for a study of a very sensitive nature, it is essential to establish and maintain a
good rapport with the hospital officials, government officials and other respected and
knowledgeable persons in this field. 7 Thus, a participatory approach was followed in the
entire course of our field study.
The field survey was conducted in two stages. A pilot survey was conducted at the
first stage on patients and the hospital in the month of July of 2013. The pre-tested survey in
one of the sample hospital, namely Asansol sub-divisional hospital, helped us enormously to
become familiar with the culture, environment and the details of the hospital, hospital
authority as well as the health care consumers. It also helped us to redesign and modify the
questionnaires. In the second stage of the survey the data were collected from the hospital
and the pre-determined number of patients of that hospital. This second stage of survey was
carried out between September 2013 and April 2014. Therefore, the reference period for field
survey is July 2013 to April 2014.
7
Prior to the data collection, permission order was taken from the Director of Health Service, Government of
West Bengal, Swastha Bhavan, Salt Lake, Kolkata and the chief medical officer of health, Burdwan & the chief
medical officer of health, Asansol health district.
47
Public Healthcare Access and Its Linkages to Healthcare Expenditure
Chapter 4
Public Healthcare Access and Its Linkages to

4.1 Introduction
The health status of individuals is always a major component of Human Development Index
(HDI). It also has a great implication in economic development (Iyengar and Dholakia,
2011). The Constitution of India recognizes it as a duty of the government to provide primary
healthcare services (Bajpai et al, 2005). Thus it is important to ensure the availability of
primary health service to every individual. Recently a good number of countries are initiating
universal healthcare service for all their citizens. India, the second highest populated country
of the world, also has a great concern in the expansion of healthcare service to ensure the
adequate accessibility of the service at every geographical corner of the nation. Keeping the
focus on this mission, the healthcare service has been prioritized in Twelfth Five Year Plan
(2012-2017), where the main goal is to achieve ‘faster, sustainable and more inclusive
growth’. Accordingly, the Planning Commission has increased the allocation of fund in the
category of ‘health and child development’ from 7.09% of the total plan allocation in
Eleventh Five Year Plan to 11.45% in Twelfth Five Year Plan, which shows a net growth of
262.66% under this head of expenditure with the focus of “extending medical facilities in the
interior pockets through mobile medical units by conducting health camps and also through
the health centers located in the interior places” (Government of India, 2013). Though these
initiatives show a great deal of improvement, but there exists a significant inter-state
variation in public healthcare access in India (Purohit, 2004; Baru et al, 2010). Deficiencies
in the public sector health system in providing health services to the population are well
documented. The inability of the public health sector has forced a part of the population to
48
seek health services from the private sector (Raman et al, 2012). Public-Private Partnership is
also important in the distribution of healthcare service. Many countries have pursued health
services distribution to their citizens through merely expanding services with non-
governmental organizations’ assistance. However, this solution is not permanent, especially
in developing democratic countries like India, where the primary duty of the government is
to provide better and equally accessible services to every stratum of the population (Kumar et
al, 2011). West Bengal displays top level economic inequality in the utilization of public
versus private healthcare services, for general healthcare indicators both in rural and urban
areas (Kumar et al, 2011). A disparity in the provision of quality health care exists at both the
inter-state and inter-district level of a particular state.
The contradiction at Five Year Plan on fund allocation in healthcare head exists in the
reducing percentage figure of health expenditure in GDP: 4.5% of GDP in 2001,
subsequently 3.9% in 2007 and 4.1% in 2013. These figures show a poor picture than that of
other countries of BRICS (Brazil, Russia, China and South Africa). Even the figure is poor
compared to few small neighboring counties, like Afghanistan (9.6% of GDP in 2011),
Bhutan (4.1%), Nepal (5.4%) and Maldives (8.5%). In India, the share of government
financing in health care sector is only 29.2% whereas the majority of 70.8% share is
attributable to private financing. Thus the objective of providing good healthcare service to
every Indian can only be viable through the government as well as non-government financial
initiatives. In this context, an attempt has been made in the present chapter to examine the
state of public healthcare access across states of India by considering a comprehensive index
of public healthcare access. The attempt is extended to scrutinize the status of public
healthcare access across more profound geographical jurisdiction to articulate the variation
49
under microscopic investigation. In addition, the association between the outreach of health
care access and the financing of the healthcare infrastructure in the context of different states
of India is of particular interest in this chapter.
The outline of the chapter is as follows. The next section deals with the conceptual
framework on the association between healthcare access and health care financing. We will
consider the data and methodological aspects relating to the construction of index of public
health care access (IPHA) and index of public health care expenditure (IPHE) in Section 4.3.
Section 4.4 presents the empirical results and discussion of the study; specifically, an inter-
state (across the states of India), an inter-district (across the districts of West Bengal) and an
inter-block (across the blocks of Burdwan district) variation in the access of health care
facility. The financing of healthcare is analyzed in Section 4.5, where the index of public
healthcare expenditure is constructed. Section 4.6 examines with the association between the
public healthcare access and public healthcare expenditure. The concluding remarks have
been presented in Section 4.7.
4.2 Association between Healthcare Access and Healthcare Financing: A
Conceptual Framework
Across the world 1.3 billion people have no access to effective and affordable health care;
low and middle-income countries bear 93% of the world’s disease burden, yet account for
only 18% of world income and 11% of global health spending (Bele, 2014). Poverty is
clearly the key element behind the lack of access to health care. However, investment in
healthcare is also a contributor to economic growth and social improvement (WHO, 2001).
Many countries are working to establish a health financing system that allows them to move
towards universal coverage – defined as access to key promotive, preventive, curative and
50
rehabilitative health interventions for all at an affordable cost – thereby achieving equity in
access and financial risk protection as well as in health financing (WHO, 2005 and Van Tien
et al 2011).
Stenberg et al (2010) found that the average real per capita health expenditure in low-
income countries is $27, whereas there should have been a spending of $54 per capita for a
fundamental bundle of health services in these countries. According to Rao et al (2012),
conditions of health sector in India, like in other low and middle income countries, are
alarming; the actual government expenditure on overall health sector in India is much below
the level of requirement. Rao (2012) also argued that there has been an unfavorable impact
on the formation of a preventive healthcare set up due to this inadequate spending on health
account. Tandon et al (2010) reviewed that the overall public expenditure on health was
sluggish at about 1 % of GDP in between 1996-97 and 2005-06, which is less than the
average of low-income countries (1.16%) for the same time span. In spite of the
implementation of NRHM and efforts to enlarge government expenditure on health account
in India after 2005-06, the spending improved only to 1.2 percent of GDP in 2009-2010 (Rao
et al 2012). Thus, according to the human development index ranking, India is positioned
119th, whereas positioned at 143 in infant mortality rate, 124 in maternal mortality rate and
132 in life expectancy at birth, out of 193 countries. In addition, the rate of retreat in the
infant mortality rate in 1990-2008 period in India was inferior to those of Nepal, and Bhutan
also (UNDP 2010). This poor health status of India is characterized by low level of public
spending on health. According to WHO (2210), India is positioned at 184 and 164 among
191 countries considering the government spending on health account as a % of GDP and in
per capita terms respectively; government expenditure on health account as a % of GDP in
51
India was sluggish between 0.9 % to 1.2 % of GDP in the past two decades. Thus, health
reforms should have addressed the subject matter of increasing the provision of fund
allotment to health sector, promising superior access to health care by the poor as well as the
masses of the country and considerably developing the efficiency of government spending
(GoI, 2005a, 2005b, 2005c).
The interest of the private sector in the financing of health care management can
reach up to a height by the joint effort of both the government and the non-government
sectors in the form of Public-Private Partnership (PPP) model. The interaction between
provision of service delivery and financing of such services is presented in the figure 4.1.
MATRIX OF RELATIONSHIP
Financing vs Delivery: Public vs Private
Provision of Service Delivery
Delivery
Public Delivery Private Delivery
Financing of Service
Financing
Public health facilities, Contracting of private sector
surveillance programs, health in social insurance (like
Public
education through RSBY) and social marketing
Financing
government hospitals and programs
associates
International disease Fee for service, regulation and
(TB/HIV) participation in national
Private
control initiatives, Activities control programs through
Financing
of charitable, NGO and no- private hospitals and
profit-no-loss hospitals associates
Source: Author’s compilation based on Marc Mitchell’s article on “An Overview of Public Private
Partnerships in Health”
Figure 4.1: Relationship between Public and Private Healthcare Financing
Participation of private healthcare service providers and the health insurance
companies in the Rashtriya Swastha Bima Yojana (RSBY) programme of the government
can be considered as the successful implementation of PPP model in the healthcare sector.
Other than government funded bima yojana or health insurance programs, people can also get
52
the service of private health insurance companies, which in turn increase the “Out Of Pocket”
(OOP) expenditure for the middle, lower-middle and weaker class Indians. Considering the
global standard, the OOP expenditure in India is in the higher side as per National Health
Accounts (NHA, 2009). Thus, a pleasing health financing framework is one which not only
trims down the OOP expenditure on healthcare, but also minimizes the possibility of any
financial insolvency while satisfying the healthcare needs. The framework given below can
be the combination of healthcare financing, where the concentration might be different to get
the final arrangement. The arrangement must have complimentary relationship among the
alternatives to strengthen the expansion of the whole healthcare system.
Figure 2: Conceptual Framework of Health Financing
4.3 Data Source and Methodology
Several indicators have been used in the literature to assess the extent of public healthcare
access. Some of the partial indicators are: number of admitted patients under public health
care system (per 1000 of existing population), no. of health care institutions (per 1000 of
53
existing population), health infrastructure, safe delivery, immunization of children, safe
drinking water, and sanitation facilities. An attempt has been made in this chapter to
construct a comprehensive measure of public health care access that would be able to
incorporate several dimensions of public healthcare access1, viz. penetration, availability and
usage of public health care system. Secondary data, used in this chapter, have been collected
from different government reports, like Five Year Plan documents of Planning Commission
(Government of India), Report of Ministry of Health & Family Welfare (Government of
India), World Bank Data, etc and a few non-government sources, like different websites.
Based on the available secondary data sources, the present study formulates a comprehensive
index of public health care access (IPHA) to measure the outreach of health care access
across the states of India. In an earlier attempt, Rao and Choudhury (2012) constructed an
improvement index of health by considering only one dimension, namely Infant Mortality
Rate (IMR)2. In this study, an attempt has been made to analyze the public healthcare access
considering three sets of geographical jurisdiction: inter-state, inter-district and inter-block.
For inter-state analysis, two important dimensions of health care (i.e., availability of health
care institutions and usage of health service) are considered; for inter-district analysis
penetration dimension, availability dimension and usage dimension are taken into
consideration, while for inter-block analysis penetration dimension, availability dimension
are considered. To examine the association between health care access and government
health financing, we have constructed another index, index of public health care expenditure
(IPHE) by considering per capita state and central government expenditure on health across
1
Secondary data on different dimensions of health access in relation with private hospitals or hospitals under
PPP model are not available. Thus the measurement of healthcare access is restricted in public healthcare
service providers only.
2
On the basis of improvement index, Rao and Choudhury (2012) identified the top four and bottom four states
of India (see Appendix Table A4.1).
54
states of India. For a clear exposition, the description of indicators used in both the indices is
given in the Table 4.1.
Table 4.1
Description of the Indicators and Their Data Sources
Data sources
Index
Dimension Description Inter State Inter District Inter Block

Analysis Analysis Analysis
Penetration of The number of Data not Family Family
healthcare inpatients per available Welfare Welfare
service to 1000 of the total Statistics, Statistics,
patients population 2011; Census 2011;
2011. Census
2011.
Availability of The number of National Family Family
healthcare public health care Health Welfare Welfare
institutions institutions (or, Profile, Statistics, Statistics,
beds) (PHI)3 per 2010, 2011 2011
IPHA
Sample
1000 population
Registration
System,
2010
Usage of The rate of infant Sample Directorate of Data not
healthcare stability (i.e., 1000 Registration Census available
service - IMR) System, Operations,
2010 GoWB.
Sample
Registration
System, GoI
Indicator of Per capita State National Data not Data not
State Govt. Govt. Expenditure Health available available
expenditure on health Account,
IPHE
2009-10
Indicator of Per capita Central National Data not Data not
Central Govt. Govt. Expenditure Health available available
expenditure on health Account,
2009-10
NOTE: IPHA: Index of public health care access; IPHE: Index of public health care expenditure
The methodology used in the construction of IPHA and IPHE is similar to that used
by United Nations Development Programme (UNDP) in the construction of development
3
It includes urban hospital, rural hospital, primary health centre, community health centre, and sub centre.
55
indices, such as HDI, HPI and GDI4. Two dimensions are chosen separately for the
formulation of IPHA and IPHE. For each index, at first, two dimension indices are
constructed and then the final index is derived by using normalized inverse Euclidean
distance method. The distance based approach satisfies several interesting and intuitive
properties of a development index, viz. normalization, symmetry, monotonicity, proximity,
uniformity and signaling (collectively termed NAMPUS) (Nathan et al, 2008). However, to
derive comprehensive index of public health care access (IPHA) and public health care
expenditure (IPHE), the dimension index for each dimension ( d i for the ith dimension, i = 1,
2….n) is computed by the following formula
Ai − mi
di =
M i − mi
where, A i = Actual value of dimension i, M i = Maximum value of dimension i, and m i =
Minimum value of dimension i. This study has used the empirically observed minimum and
maximum values for each dimension. Here it can be seen that 0 ≤ di ≤ 1. The higher the value
of di, the higher would be the achievements of the dimension i. In our study, we have
considered n dimensions5.
By considering the n number of dimensions, region i can be represented as a point
(d1, d2, d3 ……dn) in n dimensional Cartesian space, such that 0≤ d1, d2, d3……dn ≤ 1. In the n
dimensional Cartesian space, the point zero of each dimension would indicate the worst
4
In a study on cross-country experience of financial inclusion, Sarma (2008) made a significant contribution in
the existing literature by formulating a new index on financial inclusion (IFI). This index is based on the three
dimensions (penetration, availability and usage) of financial inclusion. This index has been widely been used in
the existing literature of financial inclusion (Kuri & Laha, 2011a, 2011b; Chottopadhyay, 2011). However, use
of the same methodology in the literature on health care management is relatively new.
5
Two dimensions (n=2) are used to calculate the Index of Public Healthcare Access across the states of India
and blocks of districts of Burdwan. For calculating the same across the districts of West Bengal, three
dimensions (n=3) are used. For calculating the Index of Public Healthcare Expenditure across the states of
India, two dimensions (n=2) are taken into consideration. These differences of number of dimensions occur due
to non availability of appropriate data.
56
situation while the point one of each dimension would indicate the best or ideal situation.
Unlike UNDP Goal Post Method6 of calculating prefixed values for minimum and maximum
values, the study has used empirically observed minimum and maximum for each dimension.
The IPHA (or, IPHE) is measured by the normalized inverse Euclidean distance of the point
(d1, d2, d3……dn) from the ideal point (1,1,1……1). Algebraically,
(1 − d1 )2 + (1 − d 2 )2 + (1 − d 3 )2 + ........ + (1 − d n )2
IPHA (or, IPHE) =1-
n
In the above indices, the numerator of the second component is the Euclidean
distance of d i from the ideal point 1, normalizing it by n and subtracting by 1 gives the
inverse normalized distance (Sarma, 2008). The normalization enables us to make the value
lie between 0 and 1 and the inverse distance is considered so that the higher the value of the
IPHA (IPHE) corresponds to higher health care access (health care financing). Depending on
the estimated value of IPHA and IPHE, regions are categorized into three categories. Regions
with an IPHA (IPHE) value below 0.2 are considered to have a low level of health care
access (public expenditure), those in between 0.2 to 0.4 a medium level, and those above 0.4
a high level.
6
Since 1990’s UNDP used to publish Human Development Index (HDI) to measure the wellbeing of the
population across countries of the world. In the construction of HDI, some prefixed values of life expectancy,
years of schooling and standard of living are considered. However, UNDP’s methodology of fixation of
maximum and minimum per capita income for the standard of living dimension is not free from certain
limitations (Desai, 1991; Luchters & Menkhoff, 1996; Sagar & Najam, 1998). As an alternative, this paper
follows an empirical scheme of choosing maximum and minimum values from the estimated values of each
dimension. Another methodological point of difference with the UNDP methodology is the manner n which
dimension indexes are combined to derive the composite index. Unlike UNDP’s methodology of using an
arithmetic or geometric average, the composite index formulated in this paper is based on a measure of the
distance from the ideal (Sarma, 2008).
57
4.4 Access of Public Healthcare Institution
4.4.1 Index of Public Healthcare Access: An Inter-state Analysis
Inter-state analysis has been worked out considering two major dimensions, namely
‘Availability’ and ‘Usage’. Availability of public healthcare service across the states7 of
India can be considered an important indicator of public healthcare access. Table 4.2
suggests that the states like Himachal Pradesh, Uttarakhand, Odisha, Jammu and Kashmir,
Chhattisgarh etc having higher number of public healthcare institutions than the all India
average of 15.42 number of public healthcare institutions per one lakh population; whereas
states like Maharashtra, Haryana, West Bengal, Punjab etc. counts for less number of public
healthcare institutions than the national average.
Usage of public healthcare service is crucial as it indicates the actual utilisation of the
public health care system subject to the constraints of penetration and avaiability of public
health care services. Usage of public health care services is approximated by the infant
stability (or, survival) rate in the sense that better usage of the system indicates lower infant
mortality rate or higher infant (or, survival) stability rate. Disparity in the inter-state variation
in the actual utilisation of the service is also very prominent. Himachal Pradesh, Kerala,
Uttarakhand, Tamil Nadu, Karnataka, Jammu and Kashmir, Punjab, Andhra Pradesh,
Maharashtra, West Bengal, Jharkhand, Gujarat are above the all India average of infant
stability rate, while rest of the states bear a lower or equal value than the all India average.
Study of both the dimensions i.e., availability and usage suggests that the
performances of the states are not homogeneous in all the indicators of public healthcare
access. Public healthcare service is better utilized in Himachal Pradesh, Uttarakhand, Kerala,
7
20 major states of India are considered in this study based on availability of appropriate data.
58
Karnataka, Tamil Nadu etc. On the other hand, the performances of Bihar, Madhya Pradesh,
Uttar Pradesh, Haryana etc. states are not that much satisfactory in achieving a higher level of
public healthcare access. Thus a composite analysis based on both the indicators is desirable
to provide an overall picture of the level of public healthcare access in the states of India.
Accordingly, the inter-state variations in the level of public healthcare access for 20 major
states of India are shown in Table 4.2.
Table 4.2
Index of Public Healthcare Access and its Dimensions across Major States of India
Availability of
Infant
PHIs Per One
State Rank Stability Rank IPHA Rank
Lakh
Rate
Population
Himachal Pradesh 39.84 1 960 8 0.610 1
Uttarakhand 28.95 2 962 6 0.546 2
Kerala 17.61 9 987 1 0.437 3
Karnataka 18.95 7 962 7 0.359 4
Tamil Nadu 15 12 976 2 0.351 5
Jammu & Kashmir 19.61 5 957 10 0.329 6
Chhattisgarh 22.91 4 949 16 0.304 7
Maharashtra 12.91 17 972 3 0.284 8
West Bengal 13.04 16 969 4 0.273 9
Punjab 13.35 15 966 5 0.264 10
Andhra Pradesh 17.42 10 954 12 0.259 11
Jharkhand 15.04 11 958 9 0.245 12
Gujarat 14.91 13 956 11 0.226 13
Rajasthan 19.4 6 945 17 0.203 14
Odisha 23.6 3 939 19 0.194 15
Assam 18.26 8 942 18 0.151 16
Haryana 12.42 19 952 14 0.141 17
Bihar 11.93 20 952 15 0.131 18
Madhya Pradesh 14.89 14 938 21 0.052 19
Uttar Pradesh 12.72 18 939 20 0.024 20
India 15.42 953 13 0.210
Sources: Authors’ calculation based on statistics collected from Sample Registration System, Office of the
Registrar General of India, (2010) and National Health Profile, Directorate General of State Health Services
(2010)
59
Table 4.2 indicates that Himachal Pradesh occupies the highest ranking in the IPHA with a
value of 0.610. It is followed by Uttarakhand and Kerala which belong to the high IPHA group
with IPHA values of more than 0.4. Another eleven states, viz Karnataka, Tamil Nadu, Jammu
& Kashmir, Chhattisgarh, Maharashtra, West Bengal, Punjab, Andhra Pradesh, Jharkhand, Gujarat,
and Rajasthan form the group of medium IPHA states with IPHA values between 0.2 and 0.4.
All the other states have low IPHA values, lying below 0.2. These include states like Odisha,
Assam, Haryana, Bihar, Madhya Pradesh and Uttar Pradesh. At the lowest rank of IPHA values is
Uttar Pradesh with a low IPHA value of 0.024. The diagrammatic representation of this
analysis is presented in the appendix (Diagram A4.1).
4.4.2 Index of Public Healthcare Access: An Inter-district Analysis
Inter-district analysis has been worked out in the state of West Bengal considering three
major dimensions, namely ‘Penetration’, ‘Availability’ and ‘Usage’.
One of the common measures of penetration of public healthcare access is the number
of inpatients per 1000 of the total population. In the available secondary data, a significant
inter-district variation in the number of inpatients is noticeable. Table 4.3 suggests that
districts like Darjeeling, Birbhum, Purulia, Jalpaiguri, Bankura, Nadia, Coochbehar,
Murshidabad, Dakshin Dinajpur and Malda allow more inpatients per 1000 of population in
comparison to West Bengal’s value of 43.72. Availability of public healthcare service can be
considered an important indicator of public healthcare access from the supply side point of
view. Table 4.3 suggests that districts8 like Bankura, Purulia, Birbhum, Paschim Medinipur,
Dakshin Dinajpur, Burdwan, Coochbehar, Purba Medinipur, Hooghly, Darjeeling and
8
Kolkata district has not been considered in this study. In the district, public health institutions include only five
Medical College Hospitals, not other forms of institutions. As a result, the number of public health care
institutions per 1000 of the population represents a negligible figure. So our analysis is restricted with 18 other
districts of West Bengal.
60
Jalpaiguri have more public health institutions in comparison to West Bengal’s figure of
14.30 public health institutions per one lakh population.
Usage of public healthcare service is crucial as it indicates the actual utilisation of the
public health care system subject to the constraints of penetration and avaiability of public
health care services. Usage of public health care services is approximated by the infant
stability rate in the sense that better usage of the system indicates lower infant mortality rate
or higher infant stability rate. Disparity in the inter-district variation in the actual utilisation
of the service is also very prominent. Districts like Uttar Dinajpur, Bankura, South 24
Parganas, Dakshin Dinajpur, Murshidabad, North 24 Parganas, Hooghly, Paschim Medinipur
and Purba Medinipur are above the figure of West bengal (94.87) in infant stability rate,
while rest of the nine districts bear a lower value than that of West Bengal.
Segregated analysis of all three dimensions suggests that the performances of the
districts are not uniform in all the indicators of public healthcare access. Public healthcare
service is better utilized in Uttar Dinajpur, South 24 Parganas, Dakshin Dinajpur though
there is less number of hospitals compared to other districts like Birbhum, Purulia, Burdwan
etc. On the other hand, even though Darjeeling, Birbhum, Purulia excel in the penetration and
availability in public health care access, but the performance of these districts is not
satisfactory in achieving a higher level of infant stability rate. Again, the highest number of
inpatients i.e., the number of patients taking admission in public health institutions is found
in Darjeeling, though the number of public health institutions is less in number in this district
compared with Birbhum, Bankura, Burdwan etc. Thus a composite analysis based on all the
three indicators is desirable to provide an overall picture of the level of public healthcare
61
access in the districts of West Bengal. Accordingly, the inter-district variations in the level of
public healthcare access for 18 districts of West Bengal are shown in Table 4.3
Table 4.3
Index for Public Healthcare Access across Districts of West Bengal
No of The Number The Rate of Index of
Inpatients at of Public Infant Public
Public Health Health care Stability Healthcare
care System Institutions (i.e., 1000 - Access
District
Per 1000 of Per One Lakh IMR)9 (IPHA)
Population Population (Usage
(Penetration (Availability Dimension)
Dimension) Dimension)
Bankura 57.07(5) 26.10(1) 99.09(2) 0.857(1)
Purulia 58.77(3) 25.20(2) 93.24(14) 0.695(2)
Birbhum 60.04(2) 22.80(3) 91.57(16) 0.612(3)
Dakshin Dinajpur 51.75(9) 16.70(5) 98.55(4) 0.554(4)
Coochbehar 55.31(7) 15.90(7) 93.85(13) 0.490(5)
Murshidabad 54.66(8) 14.20(12) 97.46(5) 0.483(6)
Jalpaiguri 57.99(4) 14.40(11) 94.57(12) 0.469(7)
Paschim Medinipur 41.15(12) 19.30(4) 96.03(8) 0.464(8)
Nadia 56.83(6) 13.10(14) 94.72(11) 0.421(9)
Burdwan 41.84(11) 16.40(6) 91.99(15) 0.337(10)
Hooghly 35.79(13) 15.00(9) 96.13(7) 0.290(11)
Malda 44.62(10) 13.00(15) 90.98(17) 0.257(12)
Purba Medinipur 26.38(18) 15.90(8) 96.03(9) 0.169(13)
Darjeeling 64.64(1) 14.60(10) 83.45(18) 0.158(14)
Howrah 28.49(16) 13.60(13) 94.73(10) 0.139(15)
South 24 Parganas 26.65(17) 11.80(16) 99.02(3) 0.096(16)
Uttar Dinajpur 29.99(15) 9.30(17) 99.77(1) 0.075(17)
North 24 Parganas 32.10(14) 8.30(18) 96.43(6) 0.061(18)
West Bengal State 43.72 14.30 94.87 0.279
Source: Authors’ calculation
Note: Numbers in the parenthesis represent the respective ranks
Table 4.3 indicates that Bankura occupies the highest ranking in the IPHA with a
value of 0.883. It is followed by Purulia and Birbhum and other six districts, viz. Dakshin
Dinajpur, Coochbehar, Murshidabad, Jalpaiguri, Paschim Medinipur and Nadia which form
9
IMR for different districts of West Bengal as on 2001 was collected from the Directorate of Census Operation,
Government of West Bengal (ignoring the incremental growth thereafter). The data of IMR was collected
against 1000 infant birth, which is calculated against 100 and represented on the table.
62
the group of high IPHA districts with IPHA values of more than 0.4. Districts like Burdwan,
Hooghly and Malda form the group of medium IPHA districts with IPHA values between 0.2
and 0.4. All the other districts bear low IPHA values, lying below 0.2. These include districts
like Purba Medinipur (13th), Darjeeling (14th), Howrah (15th), South 24 Parganas (16th), Uttar
Dinajpur (17th). At the lowest rank of IPHA values is North 24 Parganas (18th) with a low
IPHA value of 0.061. It needs to be pointed out that most of the districts with high IPHA
values belong to western and middle region of the state. Overall, the empirical results suggest
that western (Bankura, Purulia, Paschim Medinipur) and northern (Coochbehar, Jalpaiguri,
Dakshin Dinajpur) regions are better performers than the southern (Hooghly, Burdwan,
Howrah, South 24 Parganas, North 24 Parganas, Nadia) region. From the foregoing analysis,
it appears that relatively better-off districts perform poorly in the public health care access
compared to relatively backward ones. The diagrammatic representation of this analysis is
presented in the appendix (Diagram A4.2).
4.4.3 Index of Public Healthcare Access: An Inter-block Analysis
Intra-district analysis has been worked out in the district of Burdwan considering two major
dimensions, namely ‘Penetration’, and ‘Availability’. One of the common measures of
penetration of public healthcare access across the blocks of Burdwan district is the number of
inpatients per 1000 of population. In the available secondary data, a significant inter-block
variation in the number of inpatients is noticeable. Table 4.4 suggests that blocks like
Burdwan-I, Jamuria, Katwa-I, Faridpur-Durgapur, Kalna-I, Memari-I, Raniganj etc have
more inpatients per 1000 of population in comparison to Pandabeshwar, Burdwan-II,
Khandaghosh, Ketugram-II and few other blocks.
63
Table 4.4
Index for Public Healthcare Access across Blocks of Burdwan District
The Number of Index of
No of Inpatients at Beds in Public Public
Public Healthcare Healthcare Healthcare
System Per 1000 Institutions Per One Access
Block
Population Lakh Population (IPHA)
(Penetration (Availability
Dimension) Dimension)
Burdwan-I 672.32(1) 620.223(1) 1.000(1)
Jamuria 357.23(2) 345.748(2) 0.542(2)
Faridpur-Durgapur 223.63(4) 211.749(3) 0.333(3)
Katwa-I 233.33(3) 174.266(4) 0.309(4)
Kalna-I 189.77(5) 120.617(5) 0.232(5)
Raniganj 48.00(7) 73.762(6) 0.090(6)
Memari-I 56.85(6) 30.280(8) 0.061(7)
Galsi-I 32.38(8) 34.469(7) 0.047(8)
Ausgram-I 24.39(13) 28.087(9) 0.035(9)
Bhatar 24.75(12) 25.381(12) 0.034(10)
Mangalkote 21.99(14) 27.784(10) 0.033(11)
Ketugram-I 29.24(10) 20.546(15) 0.033(12)
Raina-II 25.19(11) 21.825(14) 0.031(13)
Barabani 16.06(16) 27.184(11) 0.029(14)
Manteswar 30.55(9) 14.067(22) 0.028(15)
Ondal 18.92(15) 17.772(19) 0.023(16)
Kanksa 14.37(17) 19.834(16) 0.021(17)
Memari-II 11.73(20) 22.121(13) 0.021(18)
Purbasthali-I 14.23(18) 16.390(20) 0.018(19)
Raina-I 11.51(21) 18.414(18) 0.018(20)
Salanpur 8.25(26) 19.189(17) 0.016(21)
Katwa-II 11.48(22) 12.467(24) 0.013(22)
Jamalpur 10.77(24) 12.322(25) 0.012(23)
Purbasthali-II 6.42(27) 15.945(21) 0.012(24)
Galsi-II 11.21(23) 11.198(6) 0.012(25)
Ausgram-II 14.03(19) 7.340(29) 0.011(26)
Ketugram-II 5.61(28) 14.017(23) 0.010(27)
Kalna-II 8.86(25) 9.813(27) 0.009(28)
Khandaghosh 3.54(29) 8.808(28) 0.004(29)
Burdwan-II 1.02(30) 7.199(30) 0.001(30)
Pandabeswar 0.01(31) 6.829(31) 0.000(31)
Burdwan District 67.90 62.170 0.0956
Source: Authors’ calculation
Note: Numbers in the parenthesis represent the respective ranks
64
Availability of public healthcare service across the blocks of Burdwan district can be
considered an important indicator of public healthcare access. Availability dimension is
expressed by the number of public healthcare institutions per one thousand population. But
here the number of institutions is converted into number of sanctioned beds per one lakh
population to maintain uniformity in a small geographical territory, instead of varying size of
different health institutions at block level. Table 4.4 suggests that the blocks like Burdwan-I,
Jamuria, Faridpur-Durgapur, Katwa-I, Kalna-I etc have higher number of beds in public
healthcare institutions compared to blocks Kalna-II, Khandaghosh, Ausgram-II,
Pandabeswar, Khandaghosh, Pandabeswar etc. Thus the analysis on both the dimensions i.e.,
penetration and availability suggests that the performances of the blocks are very much
heterogeneous in all the indicators of public healthcare access.
Public healthcare service is better utilized in Burdwan-I, Jamuria, Faridpur-Durgapur,
Katwa-I and other few blocks, but the scenario is very poor in blocks like Khandaghosh,
Burdwan-II, Pandabeshwar etc. In all aspects i.e., in penetration, availability as well as in
IPHA, Burdwan-I block and Pandabeshwar block consistently hold the first and last positions
respectively. Availability of the only Medical College Hospital of the district in Burdwan-I
block, allows the block to become top of the list. The list shows a great inter-block variation
specially in case of neighboring blocks. This fact can be explained as the geographical
proximity between two blocks can have a greater number of mobility for healthcare under
greater institutional set up. The inter-block variations in the level of public healthcare access
for 31 blocks of Burdwan District are shown in diagram at appendix (Diagram A4.3).
65
4.5 Public Healthcare Financing in India
Considering five countries of BRICS group (Brazil, Russia, India, China and South Africa)
along with two developed countries (the USA and the UK) and one underdeveloped country
(Nigeria), from different continents, India shows an overall poor picture in the healthcare
scenario and in that the contribution of the government itself. Considering the healthcare
financing, the major source is the private participation in the process, which is maximum
(70.8%) for India, out of all the eight countries under discussion. Nigeria, a backward and
underdeveloped country, having a high level of Infant Mortality Rate (72.97), Maternal
Mortality Ratio (630) and low Life Expectancy at Birth (53) incurred 46 USD as per capita
government financing on health which is 18% higher than that of India’s contribution on the
same head with only 39 USD as per capita government financing. BRICS countries are
having different status in healthcare domain, but there also India is having minimum
government financing and maximum private financing in healthcare. South Africa, another
developing country like India, having higher per capita income, spends more than ten times
on the per capita government financing on health; though, South Africa is having higher IMR
and MMR and lower LEB compared to India. With the capitalist economic framework, both
the USA and the UK governments contribute the maximum in the financing of health care
system.
4.5.1 Inter State Variations of Public Healthcare Expenditure
At the state level, the health financing is done by both central and state governments along
with other non-government parties. The following Table (Table 4.5) will illustrate the state-
wise distribution of health financing.
66
Table 4.5
State-wise Health Indicators and Share of Health Financing
Per Per Capita Per Capita
Capita Total Health Health
NSDP Expenditure Expenditure
State IMR LEB MMR (Rs.) (Govt. + Non by the Govt.
Govt.) (Rs.) (Rs.)
State Central
Govt. Govt.
Andhra Pradesh 46 70.0 9.1 27632 1061 359 100
Assam 58 65.3 27.5 16272 774 462 253
Chhattisgarh 51 65.7 27.4 19521 772 281 98
Gujarat 44 69.4 12.8 31780 953 368 112
Haryana 48 72.9 13.5 41869 1078 403 80
Jammu and Kashmir 43 66 N.A. 17590 1090 930 143
Jharkhand 42 66.0 30.1 16294 500 207 57
Karnataka 38 70.9 10.8 27385 830 359 110
Kerala 13 76.8 4.1 35457 2950 499 81
Madhya Pradesh 62 65 27.4 13299 789 208 104
Maharashtra 28 63.4 6.9 33302 1212 320 100
Odisha 61 68.2 19.5 18212 902 239 167
Punjab 34 74.5 11.3 33198 1359 259 142
Rajasthan 55 68.5 35.9 19708 761 302 155
Tamil Nadu 24 72.4 5.6 30652 1259 472 108
Uttar Pradesh 61 65.6 40 12481 974 265 108
West Bengal 31 70.2 9.2 24720 1259 330 80
Bihar 31 66 30.1 10206 513 115 96
Himachal Pradesh 40 73.8 38.3 32343 1511 906 485
Uttarakhand 38 69.8 40 25114 818 477 148
India 42 70 16.3 25494 1201 388. 136.35
05
Source: Ministry of Health & FW and Central Bureau of Health Intelligence (2009-2010)
Figure 4.3: Share of Public and Private Spending on Health across States of India
67
The skewed composition of public spending10 shows that only 40% of the major
Indian states are having a contribution of more than a half in healthcare expenditure. The
share of public expenditure is the highest in the state of Jammu and Kashmir while Kerala
has a major share in the private expenditure in healthcare. In West Bengal, around 67 % of
expenditure is borne by the private sector.
4.5.2 Index of Public Healthcare Expenditure
The healthcare services are divided under State list and Concurrent list in India. While some
items such as public health and hospitals fall in the State list, others such as population
control and family welfare, medical education, and quality control of drugs are included in
the Concurrent list (Bhandari and Dutta, 2007). Considering both the aspects of state and
central government financing, a comprehensive index on public healthcare expenditure
(IPHE) has been constructed. The inter-state variations in the financing of healthcare are
shown in Table 4.6.
There is a wide inter-state variation in the central and state expenditure on
health infrastructure in India. It is evident that Himachal Pradesh, Assam, and Jammu and
Kashmir excel in the performance of health care financing in India. Another seven states, viz.
Uttarakhand, Tamil Nadu, Kerala, Rajasthan, Gujarat, Karnataka, and Odisha perform
moderately in the provision of budgetary support in the health care expenditure. All the other
states bear low IPHE values, lying between 0.044 and 0.194. The diagrammatic
representation of index of public health care expenditure across states of India is presented
in the appendix (Diagram A4.4).
10
The share of expenditure of public and private healthcare is based on data provided by Ministry of Health &
FW and Central Bureau of Health Intelligence (2009-2010). However, the health expenditure of State
governments as a percent of total government expenditure over a period of time 1981-2009 is presented in
Appendix Table A4.2.
68
Table 4.6
Index of Public Health care Expenditure across States of India
Per capita Per capita Central
Rank
Rank
Rank
State Govt. Govt.
State IPHE
Expenditure Expenditure on
on Health Health
Himachal Pradesh 906 2 485 1 0.979 1
Assam 462 6 253 2 0.593 2
Jammu and Kashmir 930 1 143 6 0.434 3
Uttarakhand 477 4 148 5 0.318 4
Tamil Nadu 472 5 108 10 0.261 5
Kerala 499 3 81 17 0.234 6
Rajasthan 302 13 155 4 0.229 7
Gujarat 368 8 112 8 0.214 8
Karnataka 359 10 110 9 0.206 9
Odisha 239 17 167 3 0.202 10
Andhra Pradesh 359 9 100 13 0.193 11
Haryana 403 7 80 18 0.189 12
Punjab 259 16 142 7 0.187 13
Maharashtra 320 12 100 14 0.172 14
West Bengal 330 11 80 19 0.152 15
Uttar Pradesh 265 15 108 11 0.150 16
Chhattisgarh 281 14 98 15 0.148 17
Madhya Pradesh 208 18 104 12 0.112 18
Jharkhand 207 19 57 20 0.054 19
Bihar 115 20 96 16 0.044 20
India 388.05 136.35 0.256
Sources: Author calculation based on the data provided by National Health Accounts, as reported
in Choudhury and Nath (2012).
4.6 Association between Healthcare Access and Healthcare Expenditure
In order to examine whether there exists high degree of statistical correspondence
between two set of ranks based on IPHA and IPHE, the study estimated the values of indices
for 20 major states. The situation of the public healthcare access and the government
healthcare financing in selected states of India is presented in Table 4.7 by considering both
the indices.
69
Table 4.7
Estimated Values of IPHA and IPHE Associated with Ranks
State IPHA Rank IPHE Rank
Himachal Pradesh 0.610 1 0.609 1
Uttarakhand 0.546 2 0.421 4
Kerala 0.437 3 0.443 3
Karnataka 0.359 4 0.360 6
Tamil Nadu 0.351 5 0.374 5
Jammu and Kashmir 0.329 6 0.333 7
Chhattisgarh 0.304 7 0.312 8
Maharashtra 0.284 8 0.271 11
West Bengal 0.273 9 0.268 12
Punjab 0.264 10 0.284 9
Andhra Pradesh 0.259 11 0.282 10
Jharkhand 0.245 12 0.244 13
Gujarat 0.226 13 0.240 14
Rajasthan 0.203 15 0.223 15
Odisha 0.194 16 0.173 16
Assam 0.151 17 0.469 2
Haryana 0.141 18 0.163 17
Bihar 0.131 19 0.145 18
Madhya Pradesh 0.052 20 0.058 19
Uttar Pradesh 0.024 21 0.043 20
Table 4.8 establishes a significant association between the estimated values of IPHA
and IPHE. A comparison of IPHA with IPHE suggests that both the indices seem to move in
the same direction. In the Table, it has been pointed out that the ranks of IPHA and IPHE
values for these selected states move closely with each other11. The state, Himachal Pradesh
11
The state of Assam depicts distinct characteristics in health sector among North-Eastern states of India. It is
evident that all the northeastern states except Assam and Meghalaya are in better position than the national
average in terms of CBR, CDR and IMR in both the rural and urban areas. The rate of institutional delivery and
safe delivery in Assam and Meghalaya are below the national level. Compared to the national average of
population coverage by a health centre in 2011, empirical evidences suggest that all the north-eastern states
except Assam and Meghalaya are in better position in case of Sub-Centres and Community Health Centres. All
the northeastern states except Assam and Tripura are well ahead of the national average in terms of population
served per rural government hospital and, all the states except Assam are in better condition than the national
average in terms of population served per government hospital bed in the rural areas (Saikia & Das, 2014). The
miserable condition in the parameters of health indicators is evident in the state of Assam inspite of securing
second position in per capita central government expenditure and sixth position in per capita state government
expenditure
70
secure first in the ranking of both the indices. The state of Kerala secures a third ranking in
the IPHA and IPHE. Uttarakhand ranked second in the access of healthcare institutions, even
though the state slipped to fourth ranking in the healthcare financing. States having a medium
level of public health care access and a medium extent of public health care expenditure are
Karnataka, Tamil Nadu, Jammu and Kashmir, Chhattisgarh, Maharashtra, West Bengal,
Punjab, Andhra Pradesh, Jharkhand, Gujarat and Rajasthan. Odisha, Haryana, Bihar, Madhya
Pradesh and Uttar Pradesh are some of the states belong to the category of low level of health
care access and low expenditure in health sector.
Table 4.8
Classification of States according to the Values of IPHA and IPHE
Category IPHE
High Medium Low
0.4 < IPHE ≤ 1 0.2 < IPHE ≤ 0.4 0 < IPHE ≤ 0.2
High H.P, UK, -----

-----
0.4 < IPHA ≤ 1 Kerala
Medium Karnataka,
0.2 < IPHA ≤ 0.4 Tamil Nadu,
J&K,
Chhattisgarh,
IPHA
----- Maharashtra, -----

WB, Punjab, AP,
Jharkhand,
Gujarat and
Rajasthan.
Low Odisha, M.P,
0 < IPHA ≤ 0.2 Assam ----- U.P, Haryana,
Bihar
Figure 4.4 simply plots the relationship between the access of public health care and
government healthcare financing of major states of India. It is expected that as we move into
the ranges of states with very high level of health financing, the access of health care will be
at a high levels as well. In the figure, the scatter dots represent the observations of various
states. It has been found that the majority of observations lie within the northeast and
71
southwest portion of the scatter diagram. This suggests that the health care financing is a
powerful correlate of health care access. The evidence is expected to find enough empirical
support if we rank states rather than cardinal measures. In other words, if we rank states
according to their expenditure on health sector and then compute similar ranks based on
some other health access index, then we find a high degree of statistical correspondence
between the two sets of ranks.
Figure 4.4: Scatter Plot of IPHE and IPHA
Some statistical evidences also suggest that the ranking of IPHA and IPHE for major
states move closely with each other. The values of the correlation coefficients between IPHA
and IPHE are estimated to be about 0.725 (Pearson Correlation), 0.389 (Kendall’s tau-b) and
0.610 (Spearman’s rho). All these coefficients are found highly statistically significant at
72
0.01 percent level of significance12. Overall, it can be concluded that states having high level
of health care access are also the states with a relatively high level of government financing
in health care. In other words, it can be suggested that the more healthcare financing by the
government, more the access of the public healthcare.
4.7 Conclusion
In the institutional mechanism of healthcare system, public healthcare institutional plays a
crucial role in extending access of basic healthcare services to the vast sections of the
population. There is observed to be a wide inter-state, inter-district and inter-block variation
in the level of health care access in different geographical territories. An analysis of the
components of public healthcare access suggests that the performance of all the three tiers of
geographical periphery on the basis of different indicators are not the same, i.e., some states,
districts and blocks are performing better in respect of some indicators but their positions are
not found uniform across all indicators. Thus a composite analysis based on different
indicators is desirable to provide a composite picture of the public healthcare access.
Considering the inter-state analysis, the composite indicator of public healthcare access
suggests that Himachal Pradesh is at the top and Uttar Pradesh is at the bottom. Considering
the inter-district analysis in the state of West Bengal, the composite indicator of public
healthcare access suggests that Bankura district is at the top and North 24 Parganas district is
at the bottom. Similarly, at inter-block analysis in the district of Burdwan, the composite
indicator of public healthcare access suggests that Burdwan-I block is at the top and
Pandabeshwar block is at the bottom. But this phenomenon partially represents the overall
12
The correlation matrix of different dimensions of IPHA and IPHE is given in appendix table A4.3.
73
health scenario of a state or a district or a block; without considering the operations of private
healthcare providers, public-private partnerships or activities of charitable trusts.
However, the association between the access to health care services and healthcare
financing across Indian states is a special interest of the chapter. Substantial evidence is
found to emphasize that the ranking of the access of healthcare broadly follows the same
pattern as the financing of healthcare infrastructure, and thereby it is fair to conclude that the
healthcare financing is a powerful correlate of public healthcare access to the population.
Thus allocation of a greater budgetary support to the health sector by both the center and
state government is expected to realize the dream of universal healthcare system for all the
citizens of the country.
74
Measurement of Efficiency of Healthcare Institutions & Its Determinants
Chapter 5
5.1 Introduction
Experience in advanced economies shows that a combination of tighter budget controls and
efficiency enhancing reforms in health care systems help in providing access to high-quality
health care while keeping public spending in check. In other words, all countries should
ensure equitable access to basic health care services and spend more efficiently on public
health (Clements et al 2011). Hospital performance has received distinct academic attention
over the years and across different countries (Hollingsworth, 2003; Tandon et al, 2000;
Joumard et al, 2010 etc.). Hospital efficiency, a particular measure of hospital performance,
is considered for the overall development of healthcare service and its accessibility among
the masses. In many underdeveloped and developing countries where healthcare resource
constraints are very common, hospital administration are keenly interested in selecting
appropriate mix of inputs (i.e. human capital, more technical and infrastructural equipments)
to provide better and more services to the patients. Due to lack of fundamental healthcare
resources at the right quantity, doctors and nurses become helpless to provide the best service
to the patients. In many cases, patients are directly paying for getting the healthcare service,
but they are paying more for a less valued service as inefficiency exists in the operation of
hospitals. It leads to a health imbalance and thus affects the society at large. The
unsatisfactory performance of many underdeveloped and developing countries in health
indicators can not be solely explained by insufficiency of inputs but also by the inefficient
utilization of these resources. Thus, it is necessary to measure the efficiency score of the
hospitals so as to identify the determinants of such inefficiency.
75
There have been strong deliberations on the need for rationalization and support for
increasing competition among healthcare service providers. However, even with the
uncertain implications on the consequence of competition among healthcare service
providers’ on efficiency, few countries have endorsed market-oriented modification intended
to make monetary inducement for healthcare providers to develop their overall activity
(Gaynor and Town, 2011). For encouraging competition among large public hospitals, few
countries have also encouraged the entrance of privately owned hospitals with appropriate
expertise. The discussions on the relative advantages of public and private healthcare service
providers revolve round the question “who would more efficiently provide public goods?”
(Hsu 2010). One of the opinions in favor of superior efficiency of public healthcare
institutions is: government’s firm budgetary allotment makes sure that the public healthcare
institutions function with superior efficiency than other similar hospitals (Lindsay 1976).
There is an opinion, which states that the efficiency of public hospitals is relatively less due
to bureaucratic red tape and extreme structural bindings in the execution of cost management
procedures (Clark 1980). Therefore, it is important to measure the relative efficiency and find
out the determinants which affect that efficiency. Few cross-country evidences are provided
to measure the technical efficiency of the hospitals in Brazil (Araujo, 2013), Nigeria (Ichoku
et al 2011), Ghana (Osei, 2005), Bulgeria (Kundurjiev, 2011) etc. Under this backdrop of
analysis, this chapter attempts to examine the level of efficiency across healthcare institutions
and its determinants using hospital specific information collected from primary survey in the
district of Burdwan of West Bengal.
The outline of the chapter is as follows. The next section deals with the
methodological framework to estimate hospital-specific efficiency score. In the section on
76
empirical results and discussion in 5.3, a comparison of the efficiency scores of different
categories of hospitals is carried out by using data envelopment analysis and subsequently
Mann Whitney U test is used to find the significance of the differences in efficiency. The
determinants of efficiency have also been identified with the help of Maximum Likelihood -
Censored Tobit analysis in the same section. The concluding remarks have been presented in
Section 5.4.
5.2 Methodology of the Chapter
5.2.1 Estimation of Hospital Efficiency and Its Determinants:
A multi-input multi-output Data Envelopment Analysis (DEA) is used in this study to
measure the technical and scale efficiency level of all three types of hospitals, namely State
Government Hospitals, Other Public Hospitals or, Public Sector Undertaking Hospitals and
Private Hospitals. Technical Efficiency (TE) reflects the ability of a firm to obtain maximal
output from a given set of inputs. Its “constant return to scale” (CRS) assumption is only
appropriate when all decision making units (DMU) are operating at an optimal scale.
Imperfect competition, constraint on finance etc. may cause a DMU to be not operating at
optimal scale (Coelli et al, 1999). Banker et al (1984) suggested an extension of the CRS
DEA model to account for variable return to scale (VRS) situations. The use of the CRS
specification when not all DMU’s are operating at the optimal scale will result in measures of
TE which are confounded by scale efficiencies (SE). The use of the VRS specification will
permit the calculation of TE devoid of the SE effects. SE= TECRS / TEVRS. If there is a
differences in the two TE scores (TE CRS and TEVRS) for a particular DMU, then this indicates
that the DMU has scale inefficiency and that can be calculated from the difference between
77
the two scores (Coelli, 2002). If there is a differences in the two TE scores (TE CRS and
TEVRS) for a particular DMU, then this indicates that the DMU has scale inefficiency and that
can be calculated from the difference between the two scores. (Coelli, 2002). In order to
obtain separate estimates of technical efficiency and scale efficiency, we apply the input-
oriented technical efficiency measurement to the data. This measurement satisfies two
different types of scale behavior: constant returns to scale (CRS) and variable returns to scale
(VRS).
The presence of optimal, sub-optimal and supra-optimal scale has been identified in
the calculation of scale efficiency. When the returns to scales are constant, increasing and
decreasing then it is alternatively known as optimal, sub-optimal and supra-optimal scale
respectively. In the analysis part, optimal, sub-optimal and supra-optimal scales are identified
and the relative percentages in each category are also estimated. Sub-optimal firms are
operating below their optimal scale; this means that these firms could increase their technical
efficiency by continuing to increase their size. Supra-optimal firms are operating above their
optimal scale and hence could increase their technical efficiency by decreasing their size.
(Bielik et al 2004).
Let Y be an (M × N) matrix of outputs of hospitals in the sample, where the element
yij represents the ith output of the jth hospital. Let X be a (P × N) matrix of inputs, in which the
element xkj represents the kth input of the jth hospital and z an N-vector of weights to be
defined. Elements of these vectors are z1,…, zN. The vector yj (M × 1) is the vector of outputs
and xj is the (P × 1) vector of inputs of the jth hospital. The CRS input-oriented measurement
of technical efficiency for the jth hospital is calculated as the solution to the following
mathematical programming problem.
78
λjc = minz ,
subject to:
y1i  y11z1  y12z2  ... y1NzN
y2i  y21z1  y22z2  ...  y2NzN
..................................................
yMi  y11z1  y12z 2  ...  yMNzN
x11z1  x12z2  ...  x1NzN  x1i
x21z1  x22z2  ...  x2NzN  x2i
..................................................
xP1z1  xP2z2  ...  xPNzN  xPi
zj  0 for all j.
The scale value  represents a proportional reduction in all inputs such that 01, and λjc is
the minimum value of λ, so that λjc xj represents the vector of technically efficient inputs for
the jth hospital. Maximum technical efficiency is achieved when λjc equals unity. In other
words, if the DEA gives the outcome λjc =1 , the hospital is operating at the best-practice and
it is not able to improve its performance any further, given the existing set of observations.
If λjc <1, we can conclude that the hospital is operating below the best-practice frontier.
The VRS technical efficiency for the jth hospital is computed as:
 jv  min ,z  ,
subject to:
y1i  y11z1  y12z2  .....  y1NzN
y2i  y21z1  y22z2  .....  y2N zN
79
....................................................
yMi  y11z1  y12z2  .....  yMNzN
x11z1  x12z2  .....  x1NzN  x1i
x21z1  x22z2  .....  x2NzN  x2i
.....................................................
xP1z1  xP2z2  ..... xPNzN  xPi
l1z1  l2z2  ..... lNzN  1
z0.
Given these two estimates of technical efficiency, the input-oriented scale efficiency measure
for the jth hospital is calculated as the ratio of CRS technical efficiency to VRS technical
efficiency, i.e. Sj = λjc / λ jv. If the value of this ratio is equal to unity (i.e., Sj = 1), the hospital
is scale-efficient, meaning that the hospital is operating at its optimum size, and hence that
the productivity of inputs cannot be improved by increasing or decreasing the size of the
hospital. If the value of this ratio is less than unity (i.e., Sj < 1), the hospital is considered to
be not operating at its optimum size. In the first of two possible cases, (i), if Sj <1 and, λjc = λ
j
n the scale inefficiency results from increasing returns to scale. In other words, increasing the
size of the hospital helps to improve its productivity and thereby reduces unit costs. In the
second possible case, (ii), if Sj < 1 and λjc < λ jn, the scale inefficiency is due to decreasing
returns to scale, indicating that the hospital can raise its productivity and lessen unit costs by
choosing a smaller size.( Nguyen et al 2004)
The input and output variables used for the estimation of efficiency are listed in
Table 5.1.
80
Table 5.1
The List of Input and Output Variables1 and Their Definitions
Variable Category Code Description
Output Accessibility Indicator IPBD Number of In-Patient/Bed /Day
Output Accessibility Indicator DISC Total no of Discharge/Bed /Day
Output Accessibility Indicator DLVY Number of Delivery/Bed /Day
Output Usage Indicator ECGCS Number of ECG case
Output Usage Indicator XRCS Number of X-Ray case
Human Resource &
Input DOC Number of Doctors / Bed
Infrastructure
Human Resource &
Input NURS Nurse/ Bed
Infrastructure
Input Human Resource PARA Number of Paramedical Staff
Input Technical Equipment NECG Number of ECG Machine
Input Technical Equipment NXRY Number of X-Ray Machine
In this study five input variables have been used. These five input variables are
categorized under three broad heads: Infrastructure, Human Resource and Equipment.
Initially one more input variable is considered and then it is merged with other few input
variables in order to get a relative measure. In this study, the infrastructure head includes the
available bed size of a hospital. Availability of appropriate hospital building or the allotted
amount of land area2 may also be considered as input variable: but only bed size gives an
appropriate measure of functionality of the hospital. Again, all the other facilities in a
hospital are calculated as a proportion of its bed size. Thus, bed size is considered and
amalgamated with few other variables to get a relative measure. Most services are dependent
on people to deliver them successfully (Nargundkar, 2006). In healthcare institution, people
or employee or the available human resource is the most important and significant resource.
Qualified doctor, trained nurse and paramedical staff and the other supporting staffs are
included under the category of human resource. Equipment includes different technical
1
The descriptive statistics for the input and output variables for the state government hospitals are presented in
appendix (see Table A5.2, A5.3, A5.4, A5.5, A5.6, A5.7, A5.8 and A5.9).
2
Land occupied by different category of hospital is presented in Appendix.5 (Table. A5.1)
81
machineries used for clinical investigation of the patients. It includes Number of ECG
Machine, Number of X-Ray Machine and Number of USG Machine. Due to vast difference
among number and modernization of the equipments of pathology testing among State
Government Hospitals, Other Public Hospitals or the Public Sector Undertaking Hospitals
and Private hospitals, these pathological equipments are not considered. For getting a relative
measure the human resource category i.e., the number of doctor, the number of nurses and
the number of paramedical staff are divided by the number of bed size of the hospital. Thus
homogeneous relative manpower availability is calculated. Output includes different
healthcare services provided by the healthcare institution. The healthcare services include
service to the in-patients, service to the out-patients and service related to clinical
investigation. Here, as the output variable, number of in-patient, Number of delivery and
number of discharge are considered under in-patient service, whereas number of out-patient
is considered under out-patient service. The said output variables are again translated into
relative measure by dividing them (except, number of discharge) with bed size of the hospital
and number of days in a year. The clinical investigation service includes number of ECG
case, number of X-Ray case and number of USG case.
In this study a variety of input-output permutation is tested with the help of Data
Envelopment Analysis. All the outputs are not the result of all the inputs. Thus, it is
important not to construct a model where multiple inputs and outputs are used but all the
variables in either side are not having any appropriate relationship. Thus, different analyses
are done with different model designs, consisting of different sets of inputs and outputs. The
Table 5.2 represents the model designs in details.
82
Table 5.2
Different Model Designs in DEA
Model(s)
Treatment Investigation
Variable Details
Oriented Oriented
1 2 3 4 5 6
IPBD Number of In-Patient/Bed /Day O/P × O/P × × ×
DLVY Number of Delivery/Bed /Day × O/P O/P × × ×
ECGCS Number of ECG case × × × O/P × O/P
XRCS Number of X-Ray case × × × × O/P O/P
DOC Number of Doctors / Bed I/P I/P I/P × × ×
NURS Number of Nurse/ Bed I/P I/P I/P × × ×
PARA Number of Paramedical Staff × × × I/P I/P I/P
NECG Number of ECG Machine × × × I/P × I/P
NXRY Number of X-Ray Machine × × × × I/P I/P
I/P: input variable; O/P: output variable; ×: not taken
In the second stage, the following model is used to determine the various
determinants of hospital specific technical efficiency. Censored maximum likelihood
estimator is used to determine the value of the coefficients. The specification of the empirical
model is given by
TE   0   1 DUMMY 1   2 DUMMY 2   3 LOCATION   4 BEDSIZE   5 OPD _ P 

 6 BOR  
where  i (i  1,2,....., 6) are coefficients
TE represents the level of technical efficiency obtained in the first stage
DUMMY 1=1 if the hospital is a State Government Hospital (SGH) and 0 otherwise
DUMMY 2 =1 if the hospital is an Other public Hospital (OPuH) and 0 otherwise
LOCATION =1 if the hospital is situated at urban area and 0 if situated at rural area
BEDSIZE represents number of functional beds
OPD _ P represents number of OPD patients treated
BOR represents bed occupancy rate
83
The list of independent variables along with their expected outcome on the efficiency scores
is presented in the following table 5.3.
Table 5.3
List of Determinants on Hospital Specific Efficiency Estimate
Expected Sign
Determinants Code Description in the
regression
Size of the
BED_SIZE Number of Functional Bed -
Hospital
Bed Occupancy Rate i.e.,
Accessibility Percentage of Beds
BOR +/-
of the Hospital Occupied in a Particular
Time Period
Pressure of Number of Patients Treated
Out-Patient OPD_P in Out-Patient Department -
Department (OPD)
Location of If Urban then 1; If Rural
LOCATION +
the Hospital then 0
If State Government
Ownership of
DUMMY_1 Hospital (SGH) then 1; +
the Hospital
Otherwise 0
If Other Public Hospital
Ownership of
DUMMY_2 (OPuH) then 1; Otherwise +
the Hospital
0
The size of the hospital is approximated by the functional bed size of the hospital. Larger the
size of the hospital (i.e., number of bed is large), higher the chance of accumulation of
resources, which may in turn influences the efficiency of the organization. In the existing
literature, it has been seen that efficiency changes with the size (or, bed size) of the hospital
(Zere, 2000). The accessibility of the hospital is quantified by the bed occupancy rate i.e.
percentage of beds occupied in a specific time period in a particular hospital. When the bed
occupancy rate is high then it is required to perform better with the help of available
resources. Thus the efficiency score might be influenced by the accessibility or the bed
occupancy rate. Zere (2000) has found that the bed occupancy rate has a direct effect in
enhancing efficiency level of hospitals. The pressure of out-patient department is quantified
84
by the patients served at out-patient department. It is hypothesized that pressure of out-
patients may have a negative influence the efficiency score of the healthcare institution. The
influence of the geographical location and ownership categories of the hospital is
conceptualized by using appropriate dummy variables in the regression.
5.2.2 Mann-Whitney U Test (Rank Sum Test)
Mann-Whitney U Test is a non-parametric alternative to the two-sample t test. To perform
the test, first of all ranking of the individual technical efficiency scores of two types of
hospitals is done jointly, taking them as belonging to a single sample in either an increasing
or decreasing order of magnitude. Again the same process is followed for another pairs of
hospitals.
The equal efficiency hypothesis relating to three categories of hospitals, i.e., state
government hospitals (SGH), other public hospitals (OPuH) and private hospitals (PrH) can
be written in the following three pairs as follows:
H01: µSGH = µOPuH
H02: µSGH = µPrH
H03: µOPuH = µPrH
where µ indicates mean efficiency level of the hospital. Then, in the testing procedure, the
sum of ranks assigning to the values of the state government hospital (R1) and other public
hospital (R2) are calculated. Similarly other ranks are calculated for the rest two pairs of
observation. The U test statistic is calculated as
n1 (n1  1)
U  n1n2   R1 .
2
85
n1 n 2
The statistic has a sampling distribution with Mean =  U  ,and
2
n1 n 2 (n1  n 2  1)
Standard error =  U  .
12
n1 and n2 are the two sets of sample.
It can be shown that under null hypothesis, U is asymptotically normally distributed as
n1n2
U
N (  ,  2 ) i.e., Z  U  U  2
U n1n2 (n1  n2  1)
12
Finally, conclusion is drawn by comparing the calculated value of Z with its critical value.
5.3 Result and Discussion
5.3.1 Estimates of Efficiency Scores: Data Envelopment Analysis
Different models of input-output set are considered to estimate hospital specific efficiency.
Though the individual models express the tendency of the result of the study, but all the
results are taken together at the final stage to reach the overall conclusion. In this study,
sample size is 25, of which 10 hospitals are state government hospitals, 10 hospitals are other
public hospitals (or, public sector undertaking hospitals) and 5 hospitals are private hospitals.
But all the 25 hospitals in every model are not used due to non availability of few inputs or
outputs, the analysis rests on less than 25 hospitals in some models.
The study is conducted at a single time period. In this efficiency testing study, only
“input orientation” is used. In private hospitals, it might be possible to increase the input
resource to provide the service to a given maximum level of patients. But the same is not
possible in case of government hospitals. Some time a few departments of a government
hospital may have adequate or even more resources, but most of the other departments suffer
86
from lack of assets. Again, as the healthcare sector is an example of pure service sector, with
the very nature of service, it is not possible to forecast the appropriate demand for such
service at every point of time. Again even if it may be forecasted, the fluctuating demand
pattern of the service sector will not allow a firm to accumulate the resources for the peak
demand. If it happens, the resources will be redundant at the slack periods. A hospital run by
government or even by a private body will not allow its resources to be surplus; rather it
should be sufficiently used or may be over used. Thus, in health sector, the data envelopment
analysis will be judgmental with “input orientation”, rather than “output orientation”
(Zeithaml 2003). The detailed analyses of different input oriented models are given in
following tables.
Table 5.4
Estimates of Efficiency Scores and Returns to Scale (Model 1)
Input(s) and Output
(Input(s): Number of Doctors / Bed, Nurse/ Bed
HOSPITAL
TYPE OF
Output: Number of In-Patient/Bed /Day)

Average Efficiency
Return to Scale
No of Score
Hospital(s) Scale Increasing Decreasing Constant
TEVRS
Efficiency (IRS) (DRS) (CRS)
SGH 10 0.7976 0.8997 06(60.00) 02(20.00) 02(20.00)
OPuH 10 0.3653 0.5541 10(100.00) 00(00.00) 00(00.00)
PrH 05 0.2760 0.7306 05(100.00) 00(00.00) 00(00.00)
ALL 25 0.5200 0.7280 21(84.00) 02(08.00) 02(08.00)
Source: Field Survey 2013-14
Note: The statistical analysis has been made using DEAP statistical package
Note: Figures within the parenthesis represent respective percentage with reference to number of
hospitals in a specific hospital category.
SGH: State Government Hospital; OPuH: Other Public Hospital; PrH: Private Hospital; TE VRS:
Technical Efficiency at Variable Return to Scale; IRS: Increasing Return to Scale; DRS: Decreasing
Return to Scale; CRS: Constant Return to Scale
Model 1 represents two inputs (number of doctors / bed and nurse/ bed) and one
output (number of in-patient/ bed /day). The results show that the state government hospital
has the highest technical efficiency score, followed by other public hospital and private
87
hospital. But the scenario is different in calculation of scale efficiency, where private hospital
is having the second best score. All three types of hospitals are having more than fifty
percent of scale efficiency. In return to scale estimation, sixty percent of hospitals under state
government hospital and hundred percent under both other public hospital category and
private hospital category, are having increasing return to scale, which means all the hospitals
under these category can increase their technical efficiency by an increase into their inputs as
per this model design. Only twenty percent of hospitals under state government hospital
category are having decreasing return to scale, which means all the hospitals under this
category can increase their technical efficiency by a decrease into their inputs. Twenty
percent of all the hospitals, including all under state government hospital are operating at
optimal scale.
Table 5.5
Input and Output
(Input(s): Number of Doctors / Bed, Nurse/Bed
HOSPITAL
TYPE OF
Output: Number of delivery/Bed /Day)

Average Efficiency
Return to Scale
No of Score
TEVRS
SGH 10 0.7685 0.8998 08(80.0) 00(00.00) 02(20.00)
OPuH 08 0.3332 0.0537 08(100.0) 00(00.00) 00(00.00)
PrH 04 0.1530 0.3615 04(100.0) 00(00.00) 00(00.00)
ALL 22 0.4980 0.4940 20(90.91) 00(00.00) 02(09.09)
Model 2 represents two inputs (number of doctors / bed and nurse/ bed) and one
output (number of delivery/ bed /day). Again the results show that the state government
hospital has the highest technical efficiency score, followed by other public hospital and
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private hospital. The state government hospitals are having the maximum score in scale
efficiency. In return to scale estimation, all the hospitals under private hospital category and
other public hospital category and 80 percent under state government hospital category, are
having increasing return to scale. There is no hospital where decreasing return to scale is
observed. Only twenty percent of state government hospitals (which in turn 9.09 percent of
all the hospitals) are found operating at optimal scale.
Table 5.6
Input and Output
(Input(s): Number of Doctors / Bed, Nurse/Bed
HOSPITAL
TYPE OF
Output: Number of In-Patient /Bed /Day, Number of delivery /Bed /Day)

Average Efficiency
Return to Scale
No of Score
TEVRS
SGH 10 0.8324 0.9358 06(60.00) 02(20.00) 02(20.00)
OPuH 8 0.3751 0.5533 08(100.00) 00(00.00) 00(00.00)
PrH 4 0.1965 0.7202 04(100.00) 00(00.00) 00(00.00)
ALL 22 0.5500 0.7580 18(81.82) 02(09.09) 02(09.09)
Model 3 represents two inputs (number of doctors / bed and nurse/ bed) and two
outputs (number of in-patient/ bed/ day and number of delivery/ bed/ day). The results show
that the state government hospital has the highest technical efficiency score, followed by
other public hospital and private hospital. The results also show that the state government
hospital has the highest scale efficiency score, followed by private hospital and other public
hospital. In return to scale estimation, all the hospitals under other public hospital and private
hospital category and sixty percent under state government hospital category are having
increasing return to scale, which means all the hospitals under these categories can increase
89
their technical efficiency by an increase into their inputs as per this model design. Only
twenty percent of hospitals under state government hospital category are having decreasing
return to scale, which means the hospital under this category can increase its technical
efficiency by a decrease into its inputs. Constant return to scale is found in twenty percent
state government other public hospitals. There are no other public hospitals and private
hospital which are operating at optimal scale. The analysis suggests that Ban Nabagram
Rural Hospital and Katwa Sub-Division Hospital are fully technically efficient, whereas Ban
Nabagram Rural Hospital, Katwa Sub-Division Hospital and Bhatar Rural Hospital are fully
scale efficient.
Table 5.7
Input and Output
(Input(s): Number of paramedical staff, Number of ECG machine
HOSPITAL
TYPE OF
Output: Number of ECG case)

Average Efficiency
Return to Scale
No of Score
TEVRS
SGH 06 0.9240 0.2303 06(100.0) 00(00.00) 00(00.00)
OPuH 10 0.5571 0.6733 07(70.00) 02(20.00) 01(10.00)
PrH 05 0.7014 0.6688 03(60.00) 01(20.00) 01(20.00)
ALL 21 0.6960 0.5460 16(76.19) 03(14.29) 02(09.52)
Model 4 considers ECG cases where two inputs (number of paramedical staff,
number of ECG machine) and one output (number of ECG case) is included. Though all the
other public hospitals and private hospitals possess ECG machines but four state government
hospitals those do not posses that are excluded from the calculation. So the calculation is
done with twenty one numbers of DMUs. The results show that the state government
90
hospitals have the highest technical efficiency score, followed by private hospital and other
public hospital. But the other public hospital is having highest scale efficiency score. In
return to scale estimation, all the hospitals under “state government hospital”, seventy
percent of hospitals under “other public hospital” category and sixty four percent under
“private hospital” category, are having increasing return to scale, which means all the
hospitals under these categories can increase their technical efficiency by an increase into
their inputs as per this model design. Only twenty percent of hospitals under “private
hospital” and “other public hospital” category each are having decreasing return to scale,
which means all the hospitals under this category can increase their technical efficiency by a
decrease into their inputs. 9.52 percent of all the hospitals, including ten percent under “other
public hospital” and twenty percent under “private hospital” category are operating at
optimal scale.
Table 5.8
Input and Output
(Input(s): Number of paramedical staff, Number of X-Ray Machine
HOSPITAL
TYPE OF
Output: Number of X-Ray case)

Average Efficiency
Return to Scale
No of Score
TEVRS
SGH 06 0.7116 0.1293 06(100.0) 00(00.00) 00(00.00)
OPuH 10 0.8018 0.3391 10(100.0) 00(00.00) 00(00.00)
PrH 04 0.7082 0.6252 02(50.00) 01(25.00) 01(25.00)
ALL 20 0.7560 0.3330 18(90.00) 01(05.00) 01(05.00)
Technical Efficiency at Variable Return to Scale; IRS: Increasing Return to Scale; DRS:
Decreasing Return to Scale; CRS: Constant Return to Scale
Model 5 considers X Ray cases where two inputs (number of paramedical staff,
number of X Ray machine) and one output (number of X Ray case) is included. There are
91
four state government hospitals and one private hospital, where X Ray machine is not
available. So, those five hospitals are excluded from the calculation and the calculation is
continued with six state government hospital, ten other public hospitals and private hospitals.
Hence a total of twenty DMUs are used for this calculation. The results show that the other
public hospitals have the highest technical efficiency score, followed by private hospital and
state government hospital. But the other public hospitals are having second highest scale
efficiency score and the private hospitals are having the highest scale efficiency score. In
return to scale assessment, all the hospitals under “state government hospital”, “other public
hospital” category and fifty percent under “private hospital” category, are having increasing
return to scale. Only twenty five percent of hospitals under “private hospital” category are
having decreasing return to scale. Only twenty five percent private hospitals are operating at
optimal scale.
Table 5.9
Input and Output
(Input(s): Number of paramedical staff, Number of ECG Machine,
HOSPITAL
Number of X-Ray Machine

TYPE OF
Output: Number of ECG Case, Number of X-Ray case)

Average Efficiency
Return to Scale
No of Score
TEVRS
SGH 05 0.6904 0.2886 05(100.0) 00(00.00) 00(00.00)
OPuH 10 0.8904 0.7989 07(70.00) 00(00.00) 03(30.00)
PrH 04 0.7570 0.8290 02(50.00) 01(20.00) 01(20.00)
ALL 19 0.8100 0.6710 14(73.68) 01(05.27) 04(21.05)
SGH: State Government Hospital; OPuH: Other Public Hospital; PrH: Private Hospital; TEVRS:
92
Model 6 considers multiple inputs and multiple outputs. This model considers three
inputs (number of paramedical staff, number of ECG machine and number of X-Ray
machine) and two outputs (number of ECG case and number of X-Ray case). There are five
state government hospitals, ten other public hospitals and four private hospitals, where both
the ECG machine and X-Ray machine are available. Thus the calculation is done with
nineteen DMUs where both the aforesaid technical equipments are available. The results of
this model illustrate that the other public hospitals have the highest technical efficiency score,
followed by private hospital and state government hospital. But the private hospital is having
highest scale efficiency score, which is very close to the scale efficiency value of the other
public hospital. In return to scale estimation, all the hospitals under “state government
hospital”, seventy percent of hospitals under “other public hospital” category and fifty
percent under “private hospital” category, are operating at sub-optimal scale, which means all
the hospitals under these categories can increase their technical efficiency by an increase into
their inputs as per this model design. Only twenty percent private hospitals are operating at
supra-optimal scale, which means all the hospitals under this category can increase their
technical efficiency by a decrease into their inputs. 21.05 percent of all the hospitals,
including thirty percent under “other public hospital” and twenty percent under “private
hospital” category are operating at optimal scale.
Considering all the model designs and their subsequent results, outcomes of model
design 3 (treatment orientation) and model design 6 (investigation orientation) are considered
for final exposure. Considering the two model designs, the distributions of scale of operation
are presented in Figure 5.1 and Figure 5.2.
93
Fig. 5.1: Distributions of Hospitals by their Scale of Operation (Treatment Orientation)
Fig. 5.2: Distributions of Hospitals by their Scale of Operation (Investigation Orientation)
It is significant to be acquainted with the fact that hospitals in our survey area are
operating in all three categories of scale such as optimal scale, sub-optimal scale and supra-
optimal scale. As revealed by the treatment orientation in Figure 5.1, 81.82 per cent of the
total sample hospitals are operating at sub-optimal condition, 9.09 per cent are operating at
supra-optimal condition and 9.09 per cent are operating at optimal situation. Again as
revealed by the investigation orientation in Figure 5.2, 74 per cent of the total sample
hospitals are operating at sub-optimal condition, 5 per cent are operating at supra-optimal
condition and 21 per cent are operating at optimal situation. Overall, it can be suggested that
there is enough scope of increasing the efficiency of hospitals as the majority of the hospitals
94
belongs to sub-optimal scale. In other words, increasing the scale of operation through
adjustment in the human resources and equipments would ensure efficiency in the operation
of hospitals, both in the cases of treatment and investigation.
5.3.2 Differences in Efficiency Level across Hospitals: Mann Whitney U Test
In the earlier section, the estimates of hospital specific efficiency scores show a clear picture
on the differences among technical efficiency scores. Thus, it is important to judge whether
the difference in technical efficiency is statistically significant or not. Mann Whitney U Test
(Rank Sum Test) is performed to test the difference in mean efficiency estimates of three
categories of hospital. The test is performed six times (three times each for treatment
orientation and investigation orientation) for three pairs of hospitals.
Table 5.10
Results on Testing of Treatment Oriented Technical Efficiency
SGH and OPuH SGH and PrH OPuH and PrH
Hospital SGH OPuH Total SGH PrH Total OPuH PrH Total
N 10 8 18 10 4 14 8 4 12
Mean Rank 13.30 4.75 9.5 9.5 2.5 7.5 8.25 3.00 6.5
Sum of Ranks 133 38 171 95 10 105 66 12 78
Mann-
2.00 .000 2.00
Whitney U
Test Statisticb
Wilcoxon W 38.000 10.000 12.000

z -3.383 -2.841 -2.378
Asymp. Sig.
.001 .004 .017
(2-tailed)
Exact Sig.
[2*(1-tailed .000 a .002 a .016 a
sig.)]
TE of SGH and TE of OPuH and
TE of SGH and PrH
OPuH are PrH are
Remarks are Significantly
Significantly Significantly
Different
Different Different
a
Not corrected for ties.
b
Grouping Variable: Hospital
Note: The statistical analysis has been made using SPSS statistical package for Mann Whitney U Test (Rank
Sum Rest).
95
In the first pair of hospital (i.e. state government hospital and other public hospital)
the calculated z value of Mann Whitney U Test with treatment orientation is more than the
tabulated value of z and thus the hypothesis of performing both categories of hospitals in a
similar fashion is rejected. So, the result shows that these two categories of hospitals perform
differently. Similarly, both in the second and third pair of hospitals (i.e. state government
hospital and private hospital as well as other public hospital and private hospital) the
calculated z value of Mann Whitney U Test with treatment orientation is more than the
tabulated value of z and thus the hypothesis of performing both categories of hospitals in a
similar fashion is rejected. So, the result shows that these two categories of hospitals perform
differently.
Table 5.11
Results on Testing of Investigation Oriented Technical Efficiency
SGH and OPuH SGH and PrH OPuH and PrH
Hospital SGH OPuH Total SGH PrH Total OPuH PrH Total
N 5 10 15 5 4 9 10 4 14
Mean Rank 6.00 9.00 8.00 4.80 5.25 5.00 8.00 6.25 7.5
Sum of Ranks 3. 90 120 24 21 45 80 25 105
Mann-
15.000 9.000 15.000
Whitney U
Test Statisticb
Wilcoxon W 30.000 24.000 25.000

z -1.458 -.256 -.886
Asymp. Sig.
.145 .798 .376
(2-tailed)
Exact Sig.
[2*(1-tailed .254a .905a .539a
sig.)]
TE of SGH and TE of SGH and PrH TE of OPuH and
OPuH are not are not PrH are not
Remarks
Significantly Significantly Significantly
Different Different Different
a
Not corrected for ties.
b
Grouping Variable: Hospital
Note: The statistical analysis has been made using SPSS statistical package for Mann Whitney U Test (Rank
Sum Rest).
96
In the first pair of hospitals (i.e. state government hospital and other public hospital)
the result of Mann Whitney U Test with investigation orientation is less than the tabulated
value of z and thus the hypothesis of performing both categories of hospitals in a similar
fashion is accepted. So, the result shows that these two categories of hospitals perform
similarly. In second pair of hospital (i.e. state government hospital and private hospital) the
calculated z value of Mann Whitney U Test with investigation orientation is again less than
the tabulated value of z and thus the hypothesis of performing both categories of hospitals in
a similar fashion is accepted. So, the result shows that these two categories of hospitals
perform similarly. Finally, the third pair of hospital (i.e. other public hospital and private
hospital) the calculated z value of Mann Whitney U Test with treatment orientation is less
than the tabulated value of z and thus the hypothesis of performing both categories of
hospitals in a similar fashion are accepted. Thus all the combinations under investigation
orientation are not having any significant differences among the efficiencies of those
hospitals.
Therefore, the results show that the three categories of hospitals’ performances are
significantly different in all the cases in treatment orientation; but the same is not applicable
in case of investigation orientation. Thus, from this juncture further analysis will be
conducted, considering the treatment oriented model and results of hospital efficiency. In the
next part, the determinants of the efficiency of the hospitals will be identified; hence the
technical efficiency scores of the hospitals will be considered as the dependant variable in the
next part of the study.
97
5.3.3 Determinants of Efficiency: Maximum Likelihood - Censored Tobit Analysis
In the second stage of analysis, the main objective is to recognize the determinants which
have an effect on the efficiency scores of the firms. Some of the important hospital specific
characteristics are considered, viz. size of the hospital (BED_SIZE), accessibility of the
hospital (BOR), pressure of out-patient department (OPD_P), location of the hospital
(LOCATION) and two dummy variables on ownership categories of the hospital
(DUMMY_1 and DUMMY_2). The Maximum Likelihood - Censored Tobit analysis is used
to calculate the γ coefficients in equation as mentioned in the methodological section. The
values of the coefficients of all the variables are presented in the Table 5.12:
Table 5.12
Determinants of Technical Efficiency
Dependent Variable: TE
Method: Maximum Likelihood - Censored Tobit
Variable Coefficient Std. Error z-Statistic Prob.
BED_SIZE -0.000969 0.000486 -1.995703 0.0460
BOR 0.338867 0.144700 2.341853 0.0192
LOCATION 0.104211 0.075572 1.378956 0.1679
OPD_P 9.56E-07 6.37E-07 1.500767 0.1334
DUMMY_1 0.645055 0.075269 8.570045 0.0000
DUMMY_2 0.207213 0.064853 3.195111 0.0014
Source: Field Survey (2013-14)
The table above shows that the sign of the coefficient of BED_SIZE is negative and
statistically significant at 5% level of significance. Thus the result supports the view that
having more supervision and control in the small hospitals will increase the efficiency of the
hospital, like what was established by Masiye (2007). The coefficient of bed occupancy rate
(BOR) is positive and statistically significant. The explanation of this phenomenon is as
follows: bed occupancy rate is high implies that the demand of the healthcare service is high
and thus with the maximum use of given level of supply side resources, the efficiency of the
hospitals will increase, like what was established by Zere (2000).
98
It is evident that the impact of ownership on efficiency is mixed. The DUMMY-1
variable highly statistically significant, and the DUMMY_2 is also statistically significant at
1% level of significance. Thus, both the state government and other public hospitals are
working more efficiently than private hospital3.
5.4 Conclusion
Efficiency in healthcare services is crucial in outreaching the services to the vast sections of
the population. In this context, this chapter aims at the measurement of efficiency and its
determinants among organizational categories of hospitals in the district of Burdwan, West
Bengal. Empirical results based on data envelopment analysis tend to break the myth of the
frequently held view that government hospitals in developing countries are not efficient. The
study has examined the sensitivity of the estimates of the hospital performance and efficiency
to diverse input output provisions. The input-output provisions are translated into a set of
model designs and the model designs are finally assembled together to frame two unanimous
specifications with two major orientations, considering both healthcare service provider and
the healthcare service consumer. The orientations are checked and statistically verified to
conceptualize the variation and one of the orientations is placed for further analysis of
determining the determinants of the efficiency of the hospitals.
It is feasible to increase the hospital output by altering the scale, either through
“increasing return to scale” or “decreasing return to scale” without any route to new
expertise. Technical efficiency can be measured in different ways: maximizing the output for
a given set of input either with constant return to scale or variable return to scale with cost
3
In the existing literature, non-profit hospitals in the United States were more efficient than for-profit hospitals
(Lee et al, 2009). In contrast, Chang et al (2004) found that the private sector to be more efficient than the
public sector in healthcare institutions of Taiwan.
99
minimization or in multistage, minimizing the input for a given set of output either with
constant return to scale or variable return to scale with cost minimization or in multistage etc.
In this study, the output maximization measure with variable return to scale in multistage
analysis process is deployed to obtain the efficiency of the hospital. Empirical results based
on data envelopment analysis represent that the hospitals are categorically different in their
efficiency, which is at its highest level in state government hospital, followed by other public
hospitals and private hospitals. These three types of hospitals are operating in different scale
efficiency values with different return to scale dimension. Majority of hospitals are operating
at sub-optimal scale; thus the scope of enhancing their technical efficiency by scaling up their
inputs is possible as per the model design in our study is concerned.
It is exciting to note that an assortment of characteristics of hospitals and hospital
specific attributes determines the level of efficiency in the production of healthcare service
by the hospitals. Size of the hospital, as approximated by the bed-size, has a considerable role
to play in influencing the efficiency of the hospital. The management authority at the
organization level of the hospital also acts as an influencing agent to generate a higher level
of efficiency.
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Patients’ Perception on Healthcare Services from Alternative Healthcare Institutions
Chapter 6
Patients’ Perception on Healthcare Services

from Alternative Healthcare Institutions
6.1 Introduction:
In the framework of human development, health is considered as an individual right, which is
described „not merely the absence of illness but a complete state of physical, psychological
and social well-being‟ (Jahoda 1958). Healthcare is essential not only to obtain the
demographic privilege by providing a healthy and prolific labor force and common wellbeing
but also to achieve the objective of population stabilization (GoI 2007). Considering this
background, accessibility to appropriate and worthy healthcare service turns out to be an
important factor in developing the quality of human life, particularly in the developing and
under-developed countries. Populations usually get healthcare service from different sources,
like the government healthcare providers, the private healthcare providers, the voluntary
healthcare providers etc. But, due to overpopulation and a tremendous incidence of diseases,
along with inadequate resources and policies, there has been a perpetual demand-supply gap
of medical professionals as well as health care resources in most parts of the country,
especially in rural India, with demand always exceeding supply (Khandelwal 2014).
Deficiency of healthcare amenities in government, private and other healthcare providers in
the society has been playing a crucial role; even though, a good number of government
healthcare providers are providing healthcare services to the population of the vicinity, the
quality and the quantity of the delivered services are insufficient. The requirement of other
sources of healthcare services, like private healthcare providers etc is increasing every day. It
is due to certain aspects like improved facilities and services offered to the service
101
consumers. Experiencing a private healthcare service provider shows the variation from the
services offered by government healthcare providers. Preference of the consumer for the
access of a particular type of hospital for getting healthcare service differs from patient to
patient due to the locations of the healthcare provider, cost involvement in the service
delivery process, existing infrastructure of the healthcare provider, reference by doctors or
any other important demographic phenomenon.
Among several challenges faced by the healthcare sector, one of the decisive
challenges is to improve the quality and competence of patient care. The healthcare
institutions must understand the benefits of improved patient care in the form of customer
satisfaction and customer loyalty. The intensity of satisfaction and professed service quality
persuade the patient‟s eagerness to obtain healthcare service at future occasion, again from
the particular healthcare service provider. Quality healthcare service provider needs to have
sufficiently trained medical providers, who can provide proper healing to the needy patients.
Different researches have been conducted which reveal that the delivery of quality service
has significant correlation with customer satisfaction (Johns et al., 2004), retention of the
customers (Reichheld and Sasser, 1990), customer loyalty (Boshoff and Gray, 2004;), service
guarantees (Kandampully and Butler, 2001), profitability of the organization (Zeithaml et al.,
1996) and financial performance (Buttle, 1996) of service businesses. So, quality of
performance is one the most important aggressive weapons in the service market (Zeithaml et
al., 1992). Performance quality not only divides firms, but also produces loyal customer base
who spread constructive voice for the organization (Youssef, 1996). Under this backdrop of
analysis, this chapter attempts to examine and the patient‟s perception on healthcare service
using evidence from primary survey on 250 patients in the district of Burdwan of West
102
Bengal. In addition, the factors behind the access of healthcare institution by the patient are
also examined.
The outline of the chapter is as follows. The next section deals with the
methodological framework to analyze the factors behind the access of healthcare institution
and the patient‟s perception on healthcare service. Section 6.3 deals with the responses of the
patients on healthcare service facilities based on the evidence from primary survey
evidences. Section 6.4 analyzes the factors behind the access of healthcare institution through
regression analysis with the help of ordered probit and the patient‟s perception on healthcare
service with Kruskal Wallis method. The concluding remarks have been presented in Section
6.5.
6.2 Methodology of the Chapter:
6.2.1 Perception Study: Analytical Explanation
To carry out the perception study on the patients, we have systematically recorded all sorts of
analytical explanation provided by the patients in tabular form. Likert scale1 is used to get the
perception and responses of the respondents on the service offered by the healthcare
providers. Five point Likert scale is used to get the perception of the patients on doctors,
nurses, staffs, security guards, hygiene & cleanliness and as well as patients‟ overall
perception in this study.
1
A Likert scale is a psychometric scale commonly involved in research that employs questionnaires. It is the
most widely used approach to scaling responses in survey research, such that the term is often used
interchangeably with rating scale, or more accurately the Likert-type scale, even though the two are not
synonymous. Likert distinguished between a scale proper, which emerges from collective responses to a set of
items (usually eight or more), and the format in which responses are scored along a range. (Wikipedia, n.d.)
103
6.2.2 Testing Differences in the Perception Level of the Patients: Kruskal Wallis Test
Kruskal and Wallis test (1952) is employed in our study to test similarity or dissimilarity of
the perception of different categories of patients on the healthcare service. For the purpose
patients are categorized on the basis of their access to public, other public or private
hospitals. The statement that the patients surveyed at three categories of hospitals are having
similar perception on five issues of service delivery (i.e., patients’ perception about doctors,
nurses, staffs, hygiene and patients’ overall perception) is considered as the hypothesis for
testing in this study.
H0: μ SGH = μ OPuH = μ PrH (i.e., there is no significant difference in the mean perception
score of the patients at three hospital categories in respect of five healthcare services), where,
μSGH = perception of patients about different issues at state government hospitals, μOPuH =
perception of patients about different issues at other public hospitals and μDPrH = perception of
patients about different issues at private hospitals.
To conduct the test all the 250 respondents of three categories of hospitals on specific
healthcare service are pooled together and their rankings are obtained by arranging them in
the ascending order. Let ri be the observed sum of the ranks of the elements of the ith sample.
The Kruskal-Wallis test uses the  2 - test to evaluate the null hypothesis. The test statistic is
given by
12 k
ri 2
H=
n(n  1)

i 1 n
 3(n  1)
where n= n1  n 2  n3 i.e. the total number of patients surveyed (i.e. n=100+100+50= 250).
r1 = sum of the ranks of responses of 100 respondents at SGH
r2 = sum of the ranks of responses of 100 respondents at OPuH
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r3 = sum of the ranks of responses of 50 respondents at PrH
The statistic H follows a  2 distribution with (k-1) degrees of freedom. The critical value for
H is obtained from the  2 Table with (k-1) degrees of freedom, k being the number of
samples. The null hypothesis is rejected if the calculated value of H is greater than critical
value of  2 .
6.2.3 Determinants on the Access of Healthcare Institution: Ordered Probit Analysis
It is assumed that the access of healthcare institution (State Government Hospital (SGH),
Other Public Hospital (OPuH), and Private Hospital (PrH)) is a simultaneous decision made
by ultimate beneficiaries. Ordered Probit Qualitative Response Model is used to analyze the
factors determining the access of healthcare provider 2. In the Ordered Probit Model, an
ordered variable “access of healthcare institution” (ACCESS) is defined as follows:
ACCESS = 0 if the access of healthcare institution is from SGH
= 1 if the access of healthcare institution is from OPuH
= 2 if the access of healthcare institution is from PrH
To examine the access of healthcare institution for each patient, we assume that there is an
underlying response variable ACCESS* , defined by the following latent regression
specification, ACCESS *   * x  u where the error term u is distributed normally with zero
mean and unit variance3; x represents the list of explanatory variable. Here ACCESS* is
unobservable latent variable determined by the observed value of the patient‟s access,
ACCESS such that
2
In the context of agrarian tenancy, similar model was used in a number of studies (Choudhuri & Maitra, 1997;
Laffont & Matoussi, 1995; Tibako, 2003) to examine tenants‟ choice of particular rental contract.
3
Logistic distribution could be used as an alternative. Normal distribution is considered purely for convenience.
The logistic and normal distributions generally give similar results in practice.
105
ACCESS = 0 if ACCESS*  0
= 1 if 0  ACCESS *  
= 2 if ACCESS *  
where  is unknown parameter to be estimated with  . Since we assume  is normally
distributed across observations, we now have the following probability that the access of
patients is having alternative forms of hospitals or healthcare providers as
Pr ob( ACCESS  0 / x,  ,  )  F (x)
Pr ob( ACCESS  1 / x,  ,  )  F (    x)  F (  x)
Pr ob( ACCESS  2 / x,  ,  )  1  F (    x)
where F is the cumulative distribution function of u . The threshold value  is estimated
along with the  coefficients by maximizing the log likelihood function:
L(  ,  )   ln{ F ( x)}   ln{ F (   x)  F ( x)}   ln{1  F (  x)}

Access 0 Access 1 Access 2
The access of healthcare institution for getting treatment is a distinct judgment, constant with
a qualitative preference. In this study, the priority depended on three sources of healthcare
access, i.e., the state government hospitals, other public hospitals and private hospitals. The
access of healthcare providers is influenced by different factors which are categorized under
two heads: demographic variable & decision variable. The variables influencing the decision
regarding the access of healthcare provider are presented in Table 6.1.
It is observed that the independent variables chosen as decision variable are
interrelated among themselves and create the problem of multi-collinearity, which might lead
to erroneous and defective outcomes. In the presence of linear relationship among decision
106
variables, the principal component analysis 4 is employed to reduce the number of dimensions
of decision variables. In fact, the analysis is performed with all the decision variables and
finally constructing a single variable with their corresponding loading values. All other
demographic variables are considered as they are measured in different dimensions from one
variable to another. The correlation matrix of the decision variables is presented in Appendix
6 (Table A6.1). The total variance explained and component matrix in tabular form are
presented in Appendix 6 (Table A6.2 and Table A6.3 respectively).
Table 6.1
The List of Independent Variables and Their Descriptions
Variable Code Description
Demographic Variable AGE Age of the patient
Demographic Variable GENDER Sex of the Patient
Demographic Variable RLG Religion
Demographic Variable ECO Economic status
Demographic Variable SCHOOL Year of schooling of the patient
Demographic Variable INCOME Annual income of the patient
Decision Variable RSNPRO Proximity
Decision Variable RSNLP Low price
Decision Variable RSNBD Best doctor
Decision Variable RSNINF Infrastructure
Decision Variable RSNREFF Referred by the doctor
Decision Variable RSNPE Good previous experience
Decision Variable RSNCOA Complexity of the ailment
Decision Variable RSNCHI Coverage of health insurance
Decision Variable RSNEMG Emergency (immediate admission)
Decision Variable RSNES Coverage under employment scheme
Decision Variable RSNSKP Suggestion from knowledgeable person
Known people attached with the service
Decision Variable RSNKP
provider
Decision Variable RSNAHS Unavailability of alternative healthcare provider
4
The estimation procedure usually involves the following three stages. In the first stage, initial solution
(communalities, eigen values, and percentage of variance explained) is estimated. In the second stage, the first
component is selected for the analysis as it has maximum variance. Successive components explain
progressively smaller portions of the variance and are all uncorrelated with each other. In the third stage, the
correlation matrix is calculated for the first component. The values of component matrix are used for deriving
weights of each dimension.
107
Considering the component matrix of thirteen decision variables, it is observed, from
thirteen variables, six components are derived. Depending on the highest variance the first
component comprising eight variables, (i.e., proximity, low price, coverage of health
insurance, infrastructure, emergency (immediate admission), suggestion from knowledgeable
person, complexity of the ailment and known people attached with the service provider) is
selected. Accordingly, a new variable is constructed as „decision score‟ (SCORE), by
employing the following formula:
SCORE = ∑LiXi / ∑Li (where i = 1, 2….8, Li is the loading of the ith variable
and Xi is the value of the ith decision variable)
A total of ten variables, including nine demographic variables namely, age, gender
characteristic, religion, economic status, education level, annual income of the patient and
one composite variable as „decision score‟ are considered for further analysis to identify the
determinants of the access of a particular type of hospital. These aforesaid variables are
placed in Table 6.2 along with their expected signs.
Table 6.2
Hypotheses and Expected Sign of the Explanatory Variables
Independent Expected
Notation Description
Variables Sign
Age of the patient in
Age AGE
DEMOGRAPHIC VARIABLE
year +/-
Sex of the Dummy variable, 0 for
GENDER
Patient male and 1 for female +/-
Dummy variable, 0 for
Religion RLG Hindu and 1 for
Others +/-
Economic Dummy variable, 0 for
ECO
Status BPL and 1 for APL +
Year of schooling of
schooling SCHOOL
the patient +
Annual Annual income of the
INCOME
income patient in Rupee +
Decision Score SCORE Decision Score +
108
In empirical estimation, our particular interest is to verify whether the result confirms
the expected sign of the parameter or not. The preference of a particular type of healthcare
institution over all other categories of healthcare institutions can be explained by the
significance of different explanatory variables. This inference can be tested by examining the
expected signs of different variables.
6.3 Results and Discussion
6.3.1 Patients Access to Healthcare Institutions:
Regarding the access of healthcare service provider of the family members of the surveyed
patients, classification is done with four mutually exclusive categories: Public (In last one
year family members of the patients took healthcare service from public hospitals), Private
(In last one year family members of the patients took healthcare service from private
hospitals), Both (In last one year family members of the patients took healthcare service from
both public hospitals and private hospitals) and None (In last one year family members of the
patients did not took healthcare service from any hospitals).
In this study, total 250 patients are surveyed, of which 100 are from state government
hospitals, 100 are from other public hospitals and 50 are from private hospitals. Considering
the family members and their access of healthcare providers in last one year for getting
admitted, the figures are presented in Table 6.3. It is also mentioned in the table, whether any
of the family members have ever received any service during pre natal or post natal period or
at both the periods from public hospital. Here, the term „public hospital‟ includes both state
government hospital and other public hospital.
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Table 6.3
Access of Healthcare Service Provider of the Family Members of the Surveyed Patients
In last one year family members of the Service taken
patients took healthcare service from by the family
members
Respondents Total
during
(Patients) number of
Public Private pre-natal &
surveyed at respondents Both None
Hospital Hospital post-natal
period from
public hospital
100 69 05 02 24 80
SGH
(100.00) (69.00) (5.00) (2.00) (24.00) (80.00)
100 58 19 04 19 85
OPuH
(100.00) (58.00) (19.00) (4.00) (19.00) (85.00)
50 08 28 01 13 26
PrH
(100.00) (16.00) (56.00) (2.00) (26.00) (52.00)
250 135 52 07 56 191
TOTAL
(100.00) (54.00) (20.80) (2.80) (22.40) (76.40)
Source: Field Survey, 2013-14
Note: Figures in the parentheses indicate percentages with respect to the respondents of different
categories of hospitals.
Considering the last one year, family members of 194 patients (135 at public hospitals
only, 52 at private hospitals only and 7 at both public and private hospitals) were admitted in
different types of hospitals; family members of 135 patients were admitted at public
hospitals, 52 family members of 135 patients admitted at private hospitals, and 7 family
members chose both the providers in last one year for getting healthcare services. Family
members of 56 patients did not receive any healthcare service in last one year.
Taking into account the patients surveyed at state government hospitals, their family
members took services in public, private and both the healthcare service providers holding a
percentage of sixty nine, five and two respectively; there are family members of twenty four
percent of all the patients surveyed at state government hospitals who did not receive any
healthcare service from any provider in last one year. Family members of eighty percent of
all the patients surveyed at state government hospitals, received service from public hospital
during pre-natal & post-natal period.
110
Considering the patients surveyed at other public hospitals, their family members
took services in public, private and both the healthcare service providers holding a
percentage of fifty eight, nineteen and four respectively; family members of nineteen percent
of all the patients surveyed at other public hospital did not receive any healthcare service
from any provider in last one year. Family members of eighty five percent of all the patients
surveyed at other public hospitals, received service from public hospital during pre-natal &
post-natal period.
Patients surveyed at private hospitals, their family members took services in public,
private and both the healthcare service providers holding a percentage of sixteen, fifty six
and two respectively, family members of twenty six percent of all the patients surveyed at
private hospitals did not receive any healthcare service from any provider in last one year.
Family members of fifty two percent of all the patients surveyed at private hospitals, received
service from public hospital during pre-natal & post-natal period.
Finally, when all the surveyed patients in all the three types of hospitals are taken
together, family members of fifty four percent of the respondents took services from public
healthcare service providers, 20.80 percent from private healthcare service providers and
2.80 percent from both the healthcare service providers. Family members of 22.40 percent of
all the patients surveyed at all three types of hospitals did not receive any healthcare service
from any provider in last one year. Family members of 76.40 percent of all the patients
surveyed, received service from public hospitals during pre-natal & post-natal period.
6.3.2 Patients’ perception on Facilities of Hospital
The patients‟ perception on different issues related to healthcare delivery process has been
obtained with the help of five point Likert scale and is ranked in five points; but in the table
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the last point i.e., „worst‟ is not considered due to negligible responses; thus those negligible
responses are merged with the „poor‟ perception point. So the Table represents only four
perception points that include „excellent‟, „good‟, „average‟ and „poor‟ and for sake of
simplicity, the same is presented in the form of frequency distribution in Table 6.4.
Table 6.4
Frequency Distribution of Patients‟ Perception on Facilities of Hospitals
Patients‟ perception on Respondents (Patients) surveyed at
SGH OPuH PrH Total
20 15 25 60
Excellent
(33.33) (25.00) (41.67) (100.00)
59 70 24 153
Good
(38.56) (45.75) (15.69) (100.00)
Doctor
Average 20 15 01 36
(55.56) (41.67) (2.77) (100.00)
Poor 01 00 00 01
(100.00) (00.00) (00.00) (100.00)
05 00 08 13
Excellent
(38.46) (00.00) (61.54) (100.00)
34 16 31 81
Good
(41.98) (19.75) (38.27) (100.00)
Nurse
Average 45 70 10 125
(36.00) (56.00) (8.00) (100.00)
Poor 16 14 01 31
(51.61) (45.16) (3.23) (100.00)
02 00 05 07
Excellent
(28.57) (00.00) (71.43) (100.00)
28 14 32 74
Good
(37.84) (18.92) (43.24) (100.00)
Staff
Average 60 80 12 152
(39.47) (52.63) (7.89) (100.00)
Poor 10 06 01 17
(58.82) (35.29) (5.88) (100.00)
08 02 43 53
Excellent
(15.09) (3.77) (81.13) (100.00)
64 79 04 147
Good
(43.54) (53.74) (2.72) (100.00)
Hygiene 28 19 03 50
Average
(56.00) (38.00) (6.00) (100.00)
00 00 00 00
Poor
(00.00) (00.00) (00.00) (00.00)
112
01 03 10 14
Excellent
(7.14) (21.43) (20.00) (71.43)
38 59 36 133
Good
(28.57) (44.36) (27.07) (100.00)
Overall
48 36 03 87
Average
(55.17) (41.38) (3.45) (100.00)
13 02 01 16
Poor
(81.25) (12.50) (6.25) (100.00)
Taking into consideration the respondents at state government hospitals, twenty
percent of them opine that the hospital is enriched with excellent doctors. Fifty nine percent,
twenty percent and only one percent of the respondents opined that the available doctors in
state government hospitals are good, average and poor respectively. The opinion of the
respondents at other public hospitals is as follows: fifteen percent of them think that the
available doctors in the hospital are excellent. Fifty nine percent of the respondents are
having a good perception about the doctors in other public hospitals. Fifteen percent of the
respondents are of the view that the available doctors in other public hospitals are of average
category. There are no respondents who are having a poor perception about the doctors in the
other public hospitals. Regarding the respondents at private hospitals, fifty percent of them
agreed that the available doctors in the hospital are excellent. Forty eight percent of the
respondents are at the view that the doctors in private hospital are good. Only two percent of
the respondents think that the available doctors in private hospitals are of average category
and no respondents are having a poor perception about the doctors.
Respondents at state government hospitals, five percent of them are of the opinion
that the hospital is enriched with excellent nurses. Thirty four percent, forty five percent and
sixteen percent of the respondents think that the available nurses in state government
hospitals are good, average and poor respectively. In the view of the respondents at other
public hospitals, no respondent thinks that the available nurses in the hospital are excellent.
113
Sixteen percent of the respondents opine that the nurses are good. Seventy percent of the
respondents are of the view that the available nurses in other public hospitals are of average
category. There are fourteen percent of respondents who think that the nurses in the other
public hospitals are poor in quality. Taking into account of the respondents at private
hospitals, sixteen percent of them opine that the available nurses in the hospital are excellent.
Sixty two percent of the respondents are of the view that the nurses in private hospitals are
good. Twenty percent of the respondents think that the available nurses in private hospitals
are of average category and only two percent of the respondents opine that the available
nurses are of poor quality.
Taking into account the respondents at state government hospitals, only two percent
of them think that the hospital is augmented with excellent staffs. Twenty eight percent, sixty
percent and ten percent of the respondents are of the view that the available staffs in state
government hospitals are good, average and poor respectively. In view of the respondents at
other public hospitals, none of them think that the available staffs in the hospital are
excellent. Fourteen percent of the respondents are having a view that the staffs are good in
other public hospitals. Eighty percent of the respondents think that the available staffs in
other public hospitals are of average category. There are six percent of the respondents who
are having perception about the staffs in the other public hospitals to be of poor quality.
Taking into account of the respondents at private hospitals, ten percent of them think that the
available staffs in the hospital are excellent. Sixty four percent of the respondents are of the
view that the staffs in private hospitals are of good standard. Twenty four percent of the
respondents think that the available staffs in private hospitals are of average category and
only two percent of the respondents rank the staffs as poor.
114
Considering the respondents at state government hospitals, eight percent of them
opine that the hygiene and cleanliness of the hospitals are excellent. Sixty four percent and
twenty eight percent of the respondents think that the provision of hygiene and cleanliness in
state government hospitals is good and average respectively. In view of the respondents at
other public hospitals, only two percent respondents think that the hygiene and cleanliness in
the hospital are excellent. Seventy nine percent of the respondents rank the hygiene and
cleanliness in other public hospital as good. Nineteen percent of the respondents rank the
hygiene and cleanliness status in other public hospitals as average category. Taking into
account the respondents at private hospitals, Eighty six percent of them opine that the
hygiene and cleanliness in the hospital are excellent. Only eight percent of the respondents
rank the hygiene and cleanliness in private hospitals as good. Only six percent of the
respondents think that the hygiene and cleanliness in private hospitals are of average
category. There are no respondents who are having a poor perception about hygiene and
cleanliness in all three categories of hospitals.
Considering the respondents at state government hospitals, only one percent of them
think that the overall perception regarding the hospital is at excellent level. Thirty eight
percent, forty eight percent and thirteen percent of the respondents think that the overall
perception about the state government hospital is good, average and poor respectively.
Among the respondents at other public hospitals, three percent of them rank the overall
perception about the hospital as excellent. Fifty nine percent of the respondents rank the
overall perception of the other public hospitals as good. Thirty six percent of the respondents
think that the overall perception about the other public hospitals is of average category. There
are only two percent of respondents who are of the view that the overall perception of other
115
public hospitals is poor. Taking into account of the respondents at private hospitals, twenty
percent of them think that the overall perception about the hospital is excellent. Seventy two
percent of the respondents are having a ranking of good overall perception about the private
hospitals. Only two percent of the respondents think that the overall perception about private
hospitals is of average category and the remaining two percent respondents are having a poor
overall perception about the hospitals.
A consistent and continuous commitment towards the quality of healthcare service is
important for any healthcare service provider to attract and retain customers in the world of
competition. Thus, it is imperative to assess the end result for which the healthcare service
consumers accept different categories of healthcare service providers. So, in this section of
study, the customers‟ perception at three groups of hospitals is examined. As the healthcare
service is considered under a core service sector, the role of people or human activities is
vital in this industry. The human resource issues i.e., doctors, nurses and staffs of the
hospitals and their activities, behavior, presence are deeply focused and patients were asked
to rank their opinions at five point Likert scale. Other than human resources, the hygiene and
cleanliness are given utmost importance. Overall perceptions from all the respondents are
also surveyed. The surveyed data on the aforesaid issues of patients‟ perception are
represented in terms of Figure 6.1.
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Fig. 6.1: Bar Diagram Showing Patients‟ Perception on Doctor, Nurse, Staff, Hygiene and
Their Overall Perception at Different Categories of Hospitals
Though there is a wide variation among the perceptions on different issues among
different categories of hospitals, no such variation is observed when they respond on
utilization of consumption of same service from the same provider in future. Considering the
willingness of repeat consumption of the same healthcare service provider, ninety six percent
of the patients surveyed at state government hospital are willing to do that. The same is
repeated by ninety eight percent of respondents of other public hospitals and ninety six
117
percent of the respondents of private hospitals. The remaining respondents are not willing in
repetition of the same provider. The results are presented in Table 6.5.
Table 6.5
Percentage of Total Patients Willing to Repeat Purchase from Same Healthcare Provider
Patients Percentage (%) of

surveyed at willing patients
SGH 96.0
OPuH 98.0
PrH 96.0
ALL 96.8
6.3.3 Testing Difference in the Perception of the Patients:
Kruskal Wallis test is employed to examine the difference in the perception levels of the
patients grouped at three hospitals on different heads. A parametric ANOVA test is also done
with the same data set, but the results are placed at appendix 6 (Table A6.4).
The intangible services provided by the doctors are considered as the most crucial
aspects of any healthcare services. They are allied with the healthcare service providers
predominantly by a convention for the dispensation to care for patients and responsible for
the quality of care. Doctor-patient bonding is essential for healthcare service providers, for
both the patient and the doctor to get a human and systematic interface. Table 6.6 shows that
the result on patients‟ perception on doctor is significant. So, considering perception of the
customers on doctors, significant difference exists among patients belonging to three groups
of hospitals. Among all three categories of patients perception on doctor is the best for the
patients of private hospitals, followed by perception of the patients having access to other
public hospitals and state government hospitals; though the difference between perception of
patients on doctor at other public hospitals and state government hospitals is very narrow.
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Table 6.6
Testing Differences in the Perception of Healthcare Facilities
among Different Categories of Patients
Test Statistica,b
Perception
Significance
Asymptotic
Patients
about
Mean
surveyed N Chi- Remark
Rank df
at Square
SGH 100 115.27 Significant variation

Doctor
OPuH 100 115.80 on perception about

25.190 2 .000
doctor exists across
PrH 50 165.36
patient category
Nurse

49.537 2 .000
nurse exists across
PrH 50 180.31
patient category
Staff

49.570 2 .000
staff exists across
PrH 50 179.48
patient category
Hygiene

94.842 2 .000
hygiene exists across
PrH 50 204.09
patient category
Perception
on perception about
Overall
OPuH 100 129.38

48.573 2 .000 overall perception
PrH 50 174.87 exists across patient
category
NOTE: aKruskal Wallis Test bGrouping Variable: Hospital Type
SGH: State Government Hospital; OPuH: Other Public Hospital; PrH: Private Hospital: df: Degree of
freedom
In hospitals, the nursing staffs provide care to the patients and come to a decision
regarding which patient needs priority healthcare treatment facility. Customers' expectations
from nursing staffs are dissimilar from those for gate keeper or record keeper. Nurses are
reasonably alarmed about patient safeguard and their welfare. Hence, the services made
available by the nursing staffs of the hospitals are intimately coupled with the positive
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perception of patients. Table 6.6 shows that the result on perception of the customers is
significant. So, considering perception of the customers on nurses, significant difference
exists between three groups of hospitals. Among all three types of hospitals, patients‟
perception on nurse is the best in private hospitals, then perception of the patients having
access to state government hospitals and other public hospitals.
Table 6.6 shows that the result on patients‟ perception on staff is significant. So,
considering perception of the customers on staffs, significant difference exists among three
groups of hospitals. Among all three types of hospitals, patients‟ perception on staffs is the
best in private hospitals, followed by perception of the patients having access to state
government hospitals and other public hospitals.
The deliverance of hygienic environment is a precondition for healthcare service
provision. Improving hygiene in hospitals is vital for both healthcare provider and consumer.
It is considered as a major factor not only for improving the quality of service but also for the
enhancement of the confidence of the patients, which leads to better perception, which in turn
satisfy the customers about the service, that they consume. The result on this issue is
significant. So, considering perception of the customers on hygiene, significant difference
exists among three groups of hospitals. Among all three types of hospitals, patients‟
perception on hygiene is the best in private hospitals, followed by perception of the patients
having access to other public hospitals and state government hospitals.
To realize the overall perception of patients of the hospitals, the analysis was
conducted and a significant result is obtained. So, considering overall perception of the
customers, significant difference exists among three groups of hospitals. Among all three
types of hospitals, patients‟ overall perception is the best in private hospitals, followed by
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perception of the patients having access to other public hospitals and state government
hospitals.
Thus, by and large the scrutiny reveals that all the factors of perception on doctors,
perception on nurses, perception on staffs, perception on hygiene and the overall perception
are found to be significant. Hence, a broad hypothesis that there is no significant variation
among the healthcare service providers as observed in the perception of the customers in the
quality of healthcare service they obtain from the hospitals is rejected. It implies that
variation exists among perception of patients in three types of hospitals and the perception is
the best among patients of private hospitals, followed by perception of the patients having
access to other public hospitals and state government hospitals.
6.3.4 Factors behind the Patient’s Access to Alternative Healthcare Institutions:
There are different factors which are responsible for selecting a particular hospital for
receiving healthcare services, especially for getting admitted. These factors are listed below
in Table 6.7. The respective frequencies on patients‟ responses associated with each factor
are also presented in the table for all three types of hospitals. The factors include: „proximity‟
(„proximity‟ of the hospital from the patient‟s residence), low price (cost of the healthcare
services), best doctor (the service and behavior of the doctor), infrastructure (the physical
assets of the hospital, including buildings, beds, equipments etc), referred by doctor
(reference of the doctor), good previous experience, complexity of the ailment (the criticality
of the disease), coverage of health insurance (availability and accessibility of health
insurance which include both government insurance and private insurance), emergency (the
immediacy of taking admission of the patient and the nature of treatment required), coverage
under employment scheme (provision of health services granted by the employer), suggestion
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from knowledgeable person, known people attached with the service provider and
unavailability of alternative healthcare service provider (lack of enough healthcare
providers).
Table 6.7
Frequency of Factors, Responsible for Taking Decision to Select a Hospital for Treatment
Frequency of the responses of the patients
Factors responsible for selecting a particular
surveyed at
hospital for treatment
SGH OPuH PrH Total
41 20 02 63
Proximity
(41.0) (20.0) (4.0) (25.2)
81 03 02 86
Low Price
(81.0) (3.0) (4.0) (34.4)
33 23 17 73
Best Doctor
(33.0) (23.0) (34.0) (29.2)
16 06 17 39
Infrastructure
(16.0) (6.0) (34.0) (15.6)
11 19 17 47
Referred by doctor
(11.0) (19.0) (34.0) (18.8)
22 21 14 57
Good previous experience
(22.0) (21.0) (28.0) (22.8)
03 00 15 18
Complexity of the ailment
(3.0) (0.00) (30.0) (7.2)
00 00 09 09
Coverage of Health Insurance
(0.00) (0.00) (18.0) (3.6)
09 28 17 54
Emergency
(9.0) (28.0) (34.0) (21.6)
00 77 03 80
Coverage under employment scheme
(0.00) (77.0) (6.0) (32.0)
06 08 17 31
Suggestion from knowledgeable person
(6.0) (8.0) (34.0) (12.4)
Known people attached with the service 05 10 09 24
provider (5.0) (10.0) (18.0) (9.6)
Unavailability of alternative healthcare service 04 13 03 20
provider (4.0) (13.0) (6.0) (8.0)
100 100 50 250
Total Patients Surveyed
(100.00) (100.00) (100.00) (100.00)
Note: Figures in the parentheses indicate percentages with respect to total number of patients surveyed (i.e.,
250).
In the sample of 100 surveyed at state government hospitals, forty one percent agreed
with the „proximity‟ factor influencing the decision making process on selecting a particular
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hospital for getting treatment. Twenty percent of the total patients (i.e., 100) surveyed at
other public hospitals agreed with the „proximity‟ factor influencing decision making
regarding access of hospital; the same is very less in the case of patients surveyed at private
hospitals, that counts only four percent of the total patients (i.e., 50) surveyed at private
hospitals. Considering another view, out of a total of 250 patients have been surveyed from
different types of hospitals, 63 patients (i.e. 25.20 percent) have responded that the
„proximity‟ of the hospital from their residence has influenced them to take admission at the
nearest hospital. But this factor is very prominent in case of the patients surveyed at state
government hospitals, where 16.40 percent of the total respondents on „proximity‟ responded
positively, followed by patients surveyed at other public hospitals (eight percent) and private
hospitals (0.80 percent).
Considering the cost of the healthcare services, „low price‟ is considered an
influencing factor on selecting a particular hospital for getting treatment. In the sample
surveyed at state government hospitals (i.e. 100), eighty one percent agreed with the „low
price‟ factor as it influences the decision making process on selecting a particular hospital for
getting treatment. Only three percent of the total patients surveyed at other public hospitals
and four percent of the total patients surveyed at private hospitals agreed with the „low price‟
as an influencing decision making factor. Considering another view, a total of 86 patients
(i.e., 34.40 percent of total respondents) have responded positively that the „low price‟ of the
hospital has influenced them to take admission at the cheapest hospital. This factor is very
dominant in case of the patients surveyed at state government hospitals, where 32.40 percent
of the total respondents have responded positively, followed by patients surveyed at other
public hospitals (1.20 percent) and private hospitals (0.22 percent).
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The ability to provide appropriate treatment to a patient is a major ingredient of
healthcare service. Thus, the availability of „best doctor‟ in a hospital always influences
patients during selection of healthcare service provider for receiving treatment. Considering
the „best doctor‟ factor, in the sample surveyed at state government hospitals thirty three
percent agreed with the „best doctor‟ factor as influencing the decision making process on
selecting a particular hospital for getting treatment. Twenty three percent of the total patients
surveyed at other public hospitals and thirty four percent of the total patients surveyed at
private hospitals agreed with the „best doctor‟ factor as an influencing decision making
factor. Considering another view, a total of 73 patients (29.20 percent of the total number of
respondents) have responded positively that the „best doctor‟ of the hospital has influenced
them to take admission at this hospital. This factor is very important among the patients,
surveyed at all three types of hospitals. The patients surveyed at state government hospitals,
13.20 percent of the total respondents responded positively, followed by patients surveyed at
other public hospitals (9.20 percent) and private hospitals (6.80 percent).
The healthcare sector is an example of pure service sector where it is important to
have appropriate „physical evidence‟ (Chowdhary 2005) as its marketing-mix strategy.
Moreover, this physical evidence constantly participates in the production process of service
as „essential physical evidence‟. The „infrastructure‟ or the physical assets are considered as
physical evidence, which include buildings, beds, equipments etc in a hospital. In the sample
surveyed at private hospital, thirty four percent agreed with the „infrastructure‟ factor as the
decision making process on selecting a particular hospital for getting treatment. Sixteen
percent of the total patients surveyed at state government hospital, agreed with the
„infrastructure‟ factor as the decision making factor; the same is very less in patients
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surveyed at other public hospitals, that counts only six percent of the total patients surveyed
at other public hospitals. Alternatively, a total of 39 patients (15.60 percent of the total
respondents) have responded positively that the „infrastructure‟ of the hospital has influenced
them to take admission at this hospital. But this factor is the highest in case of the patients
surveyed at private hospitals, where 6.80 percent of the total respondents responded
positively, followed by patients surveyed at state government hospitals (6.40 percent) and
other public hospitals (2.40 percent).
The „reference of a doctor‟ is an important factor in selecting a healthcare service
provider from a patient‟s point of view. Considering the „referred by doctor‟ factor, the
sample surveyed at private hospital, thirty four percent agreed with this factor as it has
influenced the decision making process on selecting a particular hospital for getting
treatment. Nineteen percent of the total patients surveyed at other public hospital, and eleven
percent of the total patients surveyed at state government hospitals agreed with the „referred
by doctor‟ factor as a decision making factor. Considering another view a total of 47 patients
(18.80 percent of total respondents) responded positively that the doctor‟s reference
influenced them to take admission at this hospital. This factor is very important among
patients surveyed at all three types of hospitals. The patients surveyed at other public
hospitals, 7.60 percent of the total respondents responded positively, followed by patients
surveyed at private hospitals (6.80 percent) and state government hospitals (4.40 percent).
The last step of consumer buying behavior is „post purchase resonance‟. So, if the
customer becomes satisfied with the service provided to him, that prompts him in repetition
of the same service from the same provider. Subsequently, this factor is considered as an
important one in selecting the healthcare service provider. In the sample surveyed at private
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hospital, twenty eight percent agreed that „good previous experience‟ influenced the decision
making process on selecting a particular hospital for getting treatment. Twenty two percent
of the total patients surveyed at state government hospitals, agreed with this factor as an
influencing decision making factor; the same is twenty one percent of the total patients
surveyed at other public hospitals. Alternatively, a total of 57 patients (22.80 percent) have
responded positively that the good previous experience in a hospital influenced them to take
admission at this hospital. This is a major factor in case of the patients surveyed at state
government hospitals, where 8.80 percent of the total respondents responded positively,
followed by patients surveyed at other public hospitals (8.40 percent) and private hospitals
(5.60 percent).
The criticality of the disease influences as a factor in selecting a healthcare service
provider, because of provider‟s expertise, specialization and nature of operation. Thus,
considering the „complexity of the ailment‟ as a factor, the sample surveyed at private
hospital, thirty percent agreed with this factor as influencing the decision making process on
selecting a particular hospital for getting treatment. Only three percent of the total patients
surveyed at state government hospitals agreed with the „complexity of the ailment‟ factor as
an influencing decision making factor. The statement is not supported by any of the
respondents who were surveyed at other public hospitals. Considering another view, a total
of 18 patients (7.20 percent of the total respondents) responded positively on „complexity of
the ailment‟ factor. Out of patients surveyed at other public hospitals, no one agreed with this
fact. But 6.20 percent of the total respondents responded positively in private hospitals,
followed by patients surveyed at state government hospitals (1.20 percent of the total
respondents).
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„Coverage of health insurance‟ is considered as a factor that influences the patients to
take admission at any hospital. Eighteen percent of the total patients surveyed at private
hospitals agreed with this factor as an influencing decision making factors. The data reveals
that a total of 9 patients (3.60 percent of the total respondents) agreed with this; and, all of
them belonged to private hospitals.
„Emergency‟ of getting treatment is a very important factor in selecting a healthcare
service provider. In the sample surveyed at state government hospital only nine percent
agreed with the „emergency‟ factor as influencing the decision making process on selecting a
particular hospital for getting treatment. Twenty eight percent of the total patients surveyed at
other public hospitals agreed with this factor as an influencing decision making factor; the
same is thirty four percent of the total patients surveyed at private hospitals. Alternatively, a
total of 54 patients (21.60 percent of the total respondents) have responded positively that the
„emergency‟ of getting treatment influenced them to take admission at a particular hospital.
This factor is prominent in case of the patients surveyed at other public hospitals, where
11.20 percent of the total respondents responded positively, followed by patients surveyed at
private hospitals (6.80 percent of the total respondents) and state government hospitals (3.60
percent of the total respondents).
When an employer protects its employees and their family members from health
related problems, they don‟t need to visit any outside healthcare service provider. As a result,
this factor is considered as an important one in selecting the healthcare service provider. In
the sample surveyed at other public hospitals seventy seven percent agreed with this factor;
whereas only six percent of the total patients surveyed at private hospitals agreed with this
factor as an influencing decision making factor. There is no respondent, who agrees with the
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fact that this factor influenced him or her to take admission at state government hospital.
Considering another view, a total of 80 patients (32.00 percent of the total respondents) have
responded positively that coverage under their employment scheme prompted them to
receive the healthcare service from the enlisted hospitals. This factor is very dominant in case
of the patients surveyed at other public hospitals, where 30.80 percent of the total
respondents responded positively, followed by patients surveyed at private hospitals, where
only 1.20 percent of the total respondents responded positively.
„Suggestion from knowledgeable person‟ is an important aspect in consumer buying
behavior process. So, it is considered as a significant factor in selecting the healthcare service
provider. In the total sample surveyed at other public hospitals, eight percent agreed with this
factor; whereas only six percent of the total patients surveyed at state government hospitals
and thirty four percent of the total patients surveyed at private hospitals agreed with this
factor as an influencing decision making factor. Considering a different view, a total of 31
(12.40 percent of the total respondents) patients have responded positively that this factor has
influenced them to receive the healthcare service from different hospitals. This factor is
important in case of the patients surveyed at private hospitals, where 12.40 percent of the
total respondents responded positively, followed by patients surveyed at other public
hospitals, where 3.20 percent and state government hospitals where 2.40 percent of the total
respondents responded positively.
If a known person of a customer is attached with the healthcare service provider, it
builds the confidence of the customer. Therefore this factor influences in selecting a
healthcare service provider. Thus, considering the „known people attached with the service
provider‟ as a factor, the sample surveyed at private hospitals eighteen percent agreed with
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this factor as it influences the decision making process on selecting a particular hospital for
getting treatment. Ten percent of the total patients surveyed at other public hospitals agreed
with this factor and only 5 percent of total patients surveyed at state government hospitals
also agreed with this factor. Alternatively, a total of 24 patients (9.60 percent of the total
respondents) responded positively. Of the patients surveyed at different hospitals, four
percent, 3.60 percent and two percent of the total respondents responded positively in other
public hospitals, private hospitals and state government hospitals respectively.
Considering the availability or unavailability of alternative healthcare service
provider influencing the decision making process on selecting a healthcare service provider.
Here, the „unavailability of alternative healthcare service provider‟ is considered as an
influencing factor on selecting a particular hospital for getting treatment. In the sample
surveyed at state government hospitals only four percent agreed with the factor as
influencing the decision making process on selecting a particular hospital for getting
treatment. Only six percent of the total patients surveyed at private hospitals and thirteen
percent of the total patients surveyed at other public hospitals agreed with this factor as an
influencing decision making factor. Considering another angle of discussion, a total of 20
patients (eight percent of the total respondents) have responded positively that the
„unavailability of alternative healthcare service provider‟ in the concerned area influenced
them to take admission at this hospital. This factor is dominant in case of the patients
surveyed at other public hospitals, where 5.2 percent of the total respondents responded
positively, followed by patients surveyed at state government hospitals (1.60 percent) and
private hospitals (1.20 percent).
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6.3.5 Determinants of Access to Healthcare Institutions: An Econometric Analysis
In the backdrop of an overview of patients‟ access to health institutions, an attempt has been
made in this section to identify the socio-economic variables which have an effect on the
access of healthcare provider. The Ordered Probit analysis is used to estimate the coefficient
of explanatory variables, mentioned in the methodological section. In Table 6.8, a positive
sign of the estimate coefficient indicates enhanced probability of patient‟s preference on
access to private hospitals, while negative sign indicates that the patient‟s preference on
access is more likely to be state government hospitals.
Table 6.8
Result of Preference on Access of Healthcare Institution
---------------------------------------------------------------------
Preference = 0 for State Government Hospital (SGH)
..
= 1 for Other Public Hospital (OPuH)

= 2 for Private Hospital (PrH)
----------------------------------------------------------------------
Variables Coefficient Std. Error z-Statistic Prob.
GENDER 0.221820 0.204713 1.083563 0.2786
RLG -0.304372 0.236776 -1.285485 0.1986
ECO 1.664881 0.428916 3.881606 0.0001
AGE 0.007932 0.005586 1.419851 0.1557
SCHOOL 0.067358 0.020181 3.337714 0.0008
INCOME 1.04E-06 5.22E-07 1.998920 0.0456
SCORE 1.251506 0.158900 7.876055 0.0000
The positive and significant coefficient of economic status (ECO) suggests that the
probability of the access of the private healthcare provider increases with the betterment in
economic status; in other words, patients living above poverty line are more inclined towards
the healthcare facilities offered by the other public hospitals and private hospitals. This
empirical finding supports our common belief that better economic status influences towards
privatized healthcare facilities. (Prasad 2013)
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The positive and significant coefficient of education level (SCHOOL) suggests that
the probability of the access of the private healthcare provider increases with the increase in
educational level. In other words, patients undergoing more years of schooling are more
tending towards the healthcare facilities offered by the other public hospitals and private
hospitals. This empirical finding supports our common belief that better educational status
influences towards privatized healthcare facilities. (Prasad 2013)
Income of the patient is also an important determinant of access of healthcare
provider. The positive and significant coefficient of income of the patient (INCOME)
suggests that the probability of the access of the private healthcare provider increases with
the increase in the income of the patient. This empirical finding supports our common belief
that the lower income influence towards government healthcare facilities. (Rahaman et al
2005)
The decisions taken before final admission to any type of hospital also strongly
influence the access of healthcare provider. The positive and significant coefficient of
decision score (SCORE) suggests that the probability of the access of the private healthcare
provider increases with the more positive decisions in different issues like proximity, low
price, best doctor, infrastructure, reference of the doctor, previous experience, complexity of
the ailment, coverage of health insurance, emergency, coverage under employment scheme,
suggestion from knowledgeable person, known people attached with the service provider and
unavailability of alternative healthcare service provider before taking admission.
Though the access of healthcare provider towards private sources is with positive
coefficient sign is case of sex of the patient (male to female) and the age (young to old) of the
131
patient; the same in having negative coefficient in case of religion (Hindu to others) of the
patient; but, these results do not stand significantly.
6.4 Conclusion:
The study has scrutinized the health-seeking behavior of the health service consumers and
access of a healthcare service provider. It characterizes an attempt to recognize the aspects in
deciding patients‟ access of healthcare provider in the district of Burdwan in the state of
West Bengal. The statistical analyses identify the factors which are involved in determining
the access of healthcare provider by the patients. The economic status, the education level of
the patients, the income of the patient as well as presence of good doctor, proximity of the
healthcare provider, infrastructure of the hospitals, coverage under employment scheme etc
are the prevailing bases for the access of the healthcare institution by the patients. There are
different motives and penchants that the patients have in choosing and accessing a healthcare
provider. One of the main objectives of hospital is to provide adequate care and treatment of
its patients. Its principal product is medical treatment with surgical and nursing services to
the patient and its central concern is life and health of the patient. As a service organization,
the hospitals need to recognize the importance of consumer preferences. A match between
the preference of the patient and the offer of the healthcare service provider leads to better
delivery of the service with improved quality. In many cases the appropriate awareness also
plays a vital role, especially for government healthcare provider.
End users judge quality service as a prerequisite to their satisfaction. Hospital as a
vital healthcare service provider requires identifying the magnitude of patients‟ preference on
access. Patient satisfaction procedures should be utilized to observe the execution of health
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services particularly for hospital. Hospital personnel should identify patients, who are the
consumers, as the most significant trade associates. But, a large amount of the
disappointment in patient relationships arises from the complexity in achieving that trust of
the patients. Successful healthcare service providers continuously make every effort for
superior intensity of patient service. Health service providers should constantly assess and
verify the requirements of the patients. Patients‟ satisfaction to a health service provider
guarantees benefits not only their persistent visit to the healthcare institution but also
provides a better perception and the subsequent satisfaction which might take a positive step
in the process of recovery from the disease. There must be competition at intra category level
for private hospitals. But when the three separate categories of hospitals i.e. state government
hospitals, other public hospitals and private hospitals with their uniquely directed objective
of providing healthcare service to all the people of the state with no pay or negligible pay,
providing healthcare service to own employees in majority and providing healthcare with pay
and profit motive respectively, the major concern is providing better care and speedy healing
of the patients. In our study, the patient satisfaction is not the main objective to get a
competitive advantage among rival healthcare service providers; rather it leads to better
patient care and service. Again, as the consumerism is gaining potency in healthcare domain,
the notion of patient satisfaction should also be taken into consideration.
133
Summary and Policy Implications
Chapter 7
7.1 Summary:
In the foregoing chapters, a detailed analysis has been made on different issues on healthcare
services at macro level using the secondary data collected from different government and
non-government sources. In particular, the study analyses the regional variation in the public
healthcare access across the states of India, districts of West Bengal and the blocks of
Burdwan district. However, the macro dimension analysis at national level is supplemented
by a micro empirical study on the state of healthcare management system in the Burdwan
district of West Bengal. A primary survey designed both at the level of healthcare service
providers and service receivers are carried out to insights into the problem of healthcare
management system in the district. In particular, the study attempts to shed some light on
issues in healthcare like outreach of healthcare institution, efficiency of healthcare
institutions and patient‟s perception on healthcare services from alternative healthcare
institution.
The whole study is divided into seven chapters. Apart from Introduction (Chapter 1),
Review of Literature (Chapter 2), Objectives, Methodology and Data Sources (Chapter 3),
the main chapters we have dealt with are: public healthcare access and its linkages to
healthcare expenditure in Indian states with special reference to districts of West Bengal
(Chapter 4), Efficiency of Healthcare Institutions (Chapter 5), and Patients‟ Perception on
Healthcare Services from Alternative Healthcare Institutions (Chapter 6). Chapter 4 outlines
the inter-regional variation in the access of healthcare facility across the states of India,
districts of West Bengal and blocks of Burdwan district. The association between the access
134
of such institutions and healthcare financing is a special interest of this chapter. Chapter 5
presents an analysis of technical efficiency comparison among three types of hospitals (State
Government Hospital, Other Public Hospital and Private Hospital) by using Data
Envelopment Analysis. Chapter 6 deals with an investigation on patients‟ perception of
different healthcare services at different hospitals. Finally, Chapter 7 contains a summary of
the main findings of the chapters mentioned above. Some of the policy implications in the
light empirical evidences are suggested. On the basis of the observations made in the
preceding chapters, the major findings and conclusions are summarized below.
Chapter 4 highlights some secondary evidence on the public healthcare access.
Regional variation in the outreach of healthcare access are also outlined in this chapter across
districts of West Bengal and blocks of Burdwan district and healthcare financing across the
major states of India. Important features of public healthcare access and healthcare financing
in our study are as follows:
Firstly, the trend of health indicators (including infant mortality rate, maternal mortality ratio,
life expectancy at birth) represents a poor health condition in India, compared with other
developing countries of the world. The per capita government spending on healthcare is very
low in India; the spending is much below than that in other developing and developed
countries. Even it is at the lower side considering some underdeveloped countries also.
Contrary to other developed, developing and even underdeveloped countries, the percentage
of private expenditure on health, which is 70.80 percent of the total expenditure on health, is
the highest in India (WHO 2013). Per capita state government expenditure on health is the
highest at Jammu and Kashmir, whereas West Bengal is ranked eleventh. The per capita
central government expenditure on health is the highest at Himachal Pradesh, whereas West
135
Bengal is ranked nineteenth. Considering the index of public healthcare access, Himachal
Pradesh stands first, whereas West Bengal is ranked fifteenth. A significant association
between the access of public healthcare access and public healthcare financing is also
established in the study. Considering both IPHA and IPHE, West Bengal is positioned at
medium access - medium expenditure category.
Secondly, West Bengal represents a comparatively better situation on health indicators,
compared to other major states of the country. The infant morality rate in West Bengal (i.e.
31 in 2010) is better than the national average (i.e. 42 in 2010), while the best position is
occupied by Kerala (i.e. 13) and worst by Madhya Pradesh (i.e. 62). The maternal mortality
ratio also gives a similar picture, whose values are 9.2 and 16.3 for West Bengal and India
respectively (GoI 2010). But, considering the share of public and private spending on health
across states of India, West Bengal occupies the third position after Kerala and Punjab.
Thirdly, the availability of public healthcare facility in West Bengal is below the national
average; the number of public health care institutions per one lakh population is only 13.04
(in 2010), whereas for India as a whole it is 15.42 (in 2010). Considering the public
healthcare access, West Bengal holds the ninth rank out of twenty major states.
Fourthly, the penetration of public healthcare service is not satisfactory in the district of
Burdwan; the number of inpatients at public healthcare system per 1000 of population is
41.84. The number of public health care institutions per one lakh population is 16.40, which
is better than the state average, but ranked sixth among 18 districts of West Bengal. The
infant stability rate in Burdwan (91.99) is again below the state average (94.87). Considering
the public healthcare access, Burdwan district holds the tenth rank out of eighteen districts of
the state.
136
Fifthly, a significant inter-block variation exists in the penetration and availability of public
hospitals in the district of West Bengal. The penetration of public healthcare service is the
highest at Burdwan 1 block of Burdwan district and the lowest at Pandabeswar block. In the
availability of public healthcare services (i.e., the number of bed in public health care
institutions per one lakh population) in Burdwan 1 block also stands at the highest position
among thirty one blocks in the district of Burdwan and the same is the lowest at Pandabeswar
block. Thus in both the indicators of the public healthcare access, Burdwan 1 block holds the
first rank out of thirty one blocks of the district.
A comparative analysis of the relative efficiency of alternative healthcare service
providers (i.e., State Government Hospital, Other Public Hospital, and Private Hospital) has
been examined in Chapter 5. Empirically, equal efficiency hypothesis have been tested in the
light of empirical evidences on different types of hospitals. With the help of data
envelopment analysis, the study has scrutinized the sensitivity of the estimates of the hospital
efficiency to diverse input-output provisions. Different sets of models are designed with
various input-output provisions and finally assembled together to frame two major
orientations – treatment orientation and investigation orientation. An attempt has also been
made in this chapter to provide an empirical explanation of the observed differences in
efficiency. Size of the hospital, accessibility of the hospital, pressure of out-patient
departments, location of the hospital and ownership of the hospital are some of the variables
which have been used to explain the variation in the level of hospital specific efficiency.
Salient features of hospital efficiency in our study area are as follows:
Firstly, it has been found that there is a wide variation in efficiency estimates of healthcare
provisions as measured through data envelopment analysis. It is found that, state government
137
hospitals are more efficient in treatment orientation in comparison to other public hospitals
and the private hospitals.
Secondly, the differences in efficiencies at organizational level of hospitals are significant
when the „treatment orientation‟ is considered; but the same is not significant, considering
the „investigation orientation‟. In other words, even though empirical evidences suggest that
private hospitals have generated efficiency in conducting investigations, but the differences
in the level of efficiency across hospital categories is not found statistical support.
Thirdly, the size of the hospital, measured by bed strength has a significant role to play in
influencing the efficiency of the hospital. It is articulated from the study that the efficiency of
the hospital increases with the decrease in bed-strength. The location of the hospital has a
significant role to play in influencing the efficiency of the hospital. The hospital management
has a strong influent in the efficiency of the hospital. The pressure of out-patients in the
hospital and the location of the hospital are statistically insignificant in measuring hospital
efficiency.
Chapter 6 deals with the study of customers‟ perception on healthcare services. It also
attempts to recognize the aspects in deciding patient‟s access of healthcare provider in the
survey area. The economic status, education level of the patient, income of the patient,
proximity of the healthcare provider, infrastructure of the hospital, coverage under
employment scheme etc are the prevailing bases for the access of the healthcare institution by
the patients. There are different motives that the patients have in choosing a healthcare
provider. End users judge quality service as a prerequisite to their satisfaction. Hospital as a
vital healthcare service provider, require identifying the magnitude of patients‟ preference.
Patients‟ perception on services rendered by personnel of the hospital and on the hygiene and
138
overall insight of the hospital is crucial for getting a satisfied customer. Important features of
the customers‟ perception on healthcare service in our study area can be stated as follows:
Firstly, the access of healthcare institutions is significantly influenced by economic status,
the education level of the patients, the income of the patient. Households with better
economic status and higher educational level have shown their preference towards private
healthcare facilities; and, the households in the lower income category have no alternative
rather than to avail government healthcare facilities. Availability of good doctor, proximity
of the healthcare provider, infrastructure of the hospitals, coverage under employment
scheme etc are also the prevailing factors influencing the preference on access of the
healthcare institution by the patients.
Secondly, perception of the patients on the personnel employed at hospital (which includes
doctors, nurses and staffs) and that of the hygiene and overall insight is found satisfactory in
private hospitals. No such significant differences in the level of perception exist on such
services accessed from other public hospitals and state government hospitals.
Thirdly, the availability of health insurance is the highest among the patients of private
hospitals, followed by patients in state government hospitals and other public hospitals. At
state government hospitals, a majority of almost all the health insurance holders are
facilitated by Rashtriya Swasthya Bima Yojana.
Fourthly, the cost of medicine and investigation is found four times at private hospitals in
compared to the average overall cost of medicine as well as investigation in all the hospitals.
The same is at the lowest level at other public hospital. Though the state government hospital
offer most of the services at free of cost, but the cost is never zero due to lack of medicine
and lack of facilities for different pathological tests and investigations in these hospitals.
139
Surprisingly, the study observes that consumer surplus exists for the patients at state
government hospitals and other public hospitals; whereas, the consumer surplus is negative
for patients getting treatment at private hospitals. In state government hospitals, the consumer
surplus is more than double of the actual payment made by those patients. The average
number of pathological tests and investigations per patient is the highest at private hospitals,
followed by other public hospitals and state government hospitals.
7.2 Policy Implications:
Based on the findings of the study, some important policy prescriptions can be offered in
context of healthcare management system in West Bengal.
Firstly, both the central government and the state government should allocate a larger share
of funds on health account throughout their geographical jurisdiction to provide universal
healthcare facility for the people. It is plausible as healthcare financing and access of public
healthcare for the major states move closely with each other. The state of West Bengal,
presenting a low level of public healthcare access, needs considerable support from the
central government in tackling health financing constraint. Leaning from the experience of
better health oriented states (viz. Himachal Pradesh, Uttarakhand etc.), the state government
of West Bengal should accomplish a planned forward movement in this direction.
Secondly, in the state of West Bengal, the number of healthcare institutions with reference to
the population size is less than that of other states (viz. Himachal Pradesh, Uttarakhand,
Odisha, etc.). So, a renewed initiatives should be taken to enhance availability of public
hospitals for all the people, and thereby supporting the universal healthcare mission of WHO,
“health for all”. A decentralized healthcare mission needs to be implemented through
140
modernizing remote health institutions. Any such initiative in this direction would lessen the
burden of State Government Hospitals at capital city by reducing the referral system at local
areas.
Thirdly, though in the district of Burdwan, the availability of public healthcare institutions is
higher than the state average, a wide variation exists at inter-block level. This variation can
be reduced by implementing an intensive healthcare mission specifically designed for those
identified vulnerable blocks (viz. almost all the blocks of Burdwan district, except Burdwan-
I, Jamuria, Faridpur-Durgapur, Katwa-I and Kalna-I).
Fourthly, a broad based needs to be taken in state government hospitals of our survey area to
maintain and increase the efficiency in the working of such hospitals. A right proportion of
input mix (health personnel and equipment) should be continued and deployed to serve a
finite population size as ultimate beneficiary units. Thus, the rule of thumb approach of
appointing all inputs as a proportion of the bed strength should be modified with the practical
experience through forecasted demand. This policy aimed at bridging the gap between input
utilization in large hospitals vis-à-vis small hospitals.
Fifthly, our study reveals that the state government hospitals in the district of Burdwan are
performing efficiently even though there is high pressure of in-patients. Availability of more
qualified doctors is expected to reduce such pressure and provide more qualitative healthcare
service. But, our experience suggests that the fresh medical graduates are not spontaneously
willing to be posted at rural hospitals. Though government has made this rural posting of
newly qualified doctors mandatory, but, this mandatory instruction may not be the answer.1
A proper incentive plan may be formulated by the government, which may include incentives
in the form of monetary gain or linked with the career advancement program. The
1
Similar suggestions are also recommended by Joseph (2013).
141
government can also encourage the large private hospitals to appear as medical college
hospital2 and produce more number of doctors to minimize the shortage of doctors in the
state. Interestingly, our empirical evidence suggests that large private hospitals are operating
inefficiently; the extra effort of the institution needs to be taken in perusing academic
activities. In addition, the government can also encourage the private and charitable hospitals
to open and operate at rural or semi-urban areas at reduced cost. Private initiative has already
been incorporated in government healthcare institution; but, more composed supervision and
regulation should be endorsed to make this PPP model successful, keeping in mind the
objective of providing healthcare service to the people of every tier of the society.
Sixthly, competition in the market is necessary for prospective increase in excellence, user
preference and receptiveness with accountability. But, the rule of competition does not exist
among different categories of hospitals (especially state government hospitals and other
public hospitals) in our study area as the health service sector is fragmented in nature and
used to serve a group of niche customers through market segmentation. However, it is to be
noted that the existence of competition among private hospitals resulted in standardizing the
healthcare service and its subsequent delivery to the consumers. It actually results in the
formation of a group of satisfied customer base, who will revisit the hospital in future
occasion, not forcefully, rather with their good previous experience. So, an innovative and
healthy intra-category and inter-category competition can change the health scenario towards
a positive direction of better customer perception and satisfaction. A financial incentive or an
open recognition scheme may be pioneered in this connection to encourage such competition.
Seventhly, a training module may be scheduled to improve the relationship between the
patients and the human resource personnel (i.e. doctors, nurse and staffs) by the higher
2
Similar suggestions are also recommended by Arun (2015).
142
authority to upgrade the perception level of the patients, especially at state government
hospitals and other public hospitals. Regarding hygiene and cleanliness, private participation
is observed in many cases, but there should be more supervision from the hospital
administration.
Eighthly, public sector hospitals do not charge for medicines supplied to the patients;
however, modest user charges may be imposed as a fraction of the entire cost of treatment.3
Our study is also supporting the proposition of introducing a modest user fee for categorical
patients. A suitable institutional framework for assessing the economic condition of the user
can be constructed. Instrument for recognizing and exempting the really poor people from
user charges should also be well defined.
Ninthly, the patient who is having the facility of health insurance, either voluntarily executed
or provided by the government, always prefers to receive healthcare service from private
providers only; except the case of Employees' State Insurance. In fact, it is always believed
that the health insurance plans are made for reducing government pressure and increasing the
engagement of private providers. After the introduction of Rashtriya Swasthya Bima Yojana
(RSBY) scheme, it is observed that the patients are inclined towards private hospitals and
even private nursing homes, but not the government hospitals. Even though the RSBY
facility is also available at government hospital, the patients take advantage of free facilities
at state government hospitals and keep the RSBY facility for future use at private hospitals.
In this context, a scope of generating revenue at the government hospital (where the pressure
is relatively less) is not explored till now. A proper utilization of the insurance scheme can be
realized through infrastructure development at government hospitals. The unutilized land
available in the premises of some government hospitals can be used for the development of
3
Similar suggestions are also recommended in other studies (Tripathi et al, 2005; Deininger 2004).
143
an alternative hospital infrastructure intended to serve the interests of insurance holders. A
better quality of health service in such hospitals is expected to attract the interests of all the
beneficiaries carrying RSBY card primarily; and, later can be outreached to the voluntary
health insurance holders at an affordable cost, keeping the charges at par with the RSBY
level. A better healthcare arrangement in this direction have the potentiality to generate
revenue in many fold with the allocation of same or little more inputs and strong
administrative supervision. This alternative approach of social entrepreneurship model can
also ensure sustainability of the government hospitals through the incentive of profit making,
and its appropriation at the same institution.
144
Appendices
Appendices
Appendix 1: List of Hospitals

Table A1.1
List of Hospitals in the District of Burdwan
State Government Other Public Hospital Private Hospital (PrH)
Hospital (SGH) (OPuH)
Burdwan MCH Asansol Special Jail Anandalaok Hospital,
Hospital, Asansol Raniganj
Asansol SDH Bankola Area CAMRI Hospital,
Hospital,Khandra, Ondal Burdwan
Durgapur SDH Bansara Hospital, Ranigang Gouridevi Memorial
Hospital, Durgapur
Kalna SDH Barddhaman Jail Hospital HLG Hospital,
Asansol
Katwa SDH Barddhaman Police Hospital I.R.C.S. Hospital,
Burdwan
Ballabhpur RH Barddhaman Railway I.R.C.S. Hospital,
Hospital Kalna
Bhatar RH Burnpur Hospital, Bunpur, I.R.C.S. Hospital,
Asansol Katwa
Mankar RH Central Hospital (Kalla), I.R.C.S. Hospital,
Asansol Durgapur
Memari RH D P L Hospital, Durgapur Lions Club Hospital,
Burdwan
Singot RH D S P Hospital, Durgapur Lions Club Hospital,
Durgapur
Srirampore RH D T P S Hospital, Durgapur Saranya Hospital,
Burdwan
Atghoria RH D V C Hospital, Durgapur The Mission Hospital,
Durgapur
Ban-Nabagram RH Divisional Railway Hospital, Vivekananda Hospital,
Asansol Durgapur
Bahadurpur RH Dr. L Sen Memorial
Leprocy Hospital, Asansol
Jamalpur RH E S I Hospital, Asansol
Kandra (U) RH E S I Hospital, Durgapur
Kelejora RH F C I Hospital, Ondal
Laudoha RH K G Hospital, Chittaranjan
Madhabdihi RH Kajora Hospital
Maheshbati RH Kulti (IISCO) Hospital,
Kulti
145
Appendices
Manteswar RH Andal Railway Hospital,

Andal
Paharhati RH Raniganj Leprocy Hospital,
Ballavpur, Raniganj
Panagarh RH Regional Hospital, Chhora,
Bohula
Pithaikeary RH Sactoria Hospital, Disergarh,
Kulti
Purbastahli RH Satgram Hospital, Jamuria
Pursha RH T B Hospital, Searsol,
Raniganj
Ramjibanpur RH
Note: MCH: Medical College Hospital; SDH: Sub-Division Hospital; RH: Rural Hospital
Source: Directory of Medical Institution 2010, DHS, Government of West Bengal
146
Appendices
Appendix 2: Salient Features of the Surveyed Hospitals
2.1 Characteristics of the Hospitals in the Study Area:

The infrastructural and other information of the surveyed hospitals are presented in this
segment of the study. Twenty five hospitals are surveyed in the district of Burdwan, during
2013-14. These hospitals are categorized under three heads, namely State Government
Hospitals, Other Public Hospitals and Private Hospitals. The analysis exclusively deals with
the location and infrastructural facility, human resource or manpower, equipment,
performance indicator and the outcomes of the hospitals.
2.1.1 Location and Infrastructural Facility

The location of the surveyed hospitals and their infrastructural facilities are presented at table
A2.1
Table A2.1
Location and Infrastructural Facilities of the Surveyed Hospitals
Category Location Bed Strength Area
Rural Urban Total Sanctioned Functional (Acre)
State Government 6 4 10 1050 793 94.00
Hospital (60.00) (26.67) (40.00) (30.66) (33.16) (49.32)
Other Public 3 7 10 1652 1143 86.80
Hospital (30.00) (46.66) (40.00) (48.24) (43.48) (45.54)
Private Hospital 1 4 5 722 693 9.80
(10.00) (26.67) (20.00) (21.10) (26.36) (5.14)
TOTAL 10 15 25 3424 2629 190.60
(100) (100) (100) (100) (100) (100)
In our study we have surveyed a total of 25 hospitals, of which 10 (40.00 %) are State
Government Hospitals, 10 (40.00 %) are Other Public Hospitals and 5 (20.00 %) are Private
Hospitals. The majority of the surveyed hospitals (60.00 %) are located in urban areas. There
are 10 rural hospitals against 15 urban hospitals. Total sanctioned beds in surveyed hospitals
are 3424 and total functional bed count is 2629. In both the cases the maximum share in bed
strength is of Other Public Hospitals. Though only 20.00 % of the total surveyed hospitals
are Private Hospitals, they have 26.36 % of the total functional beds. Area-wise analysis
gives the highest area to the State Government Hospitals (49.32 %), followed by Other
Public Hospitals (45.54 %) and Private Hospitals (5.14 %).
147
Appendices
2.1.2 Manpower
The different types of manpower engaged in hospitals with different numbers are presented in
Table A2.2.
Table A2.2
Average Manpower of the Surveyed Hospitals
Category Average Number
of Doctors Average
Average Average Average
Number
Permanent
Number Number of Number
Vacancy
Visiting
of Paramedical of Group
of
Security
Nurses Staffs D Staffs
Guards
State
Government 10.20 0.20 5.20 27.30 5.00 16.30 1.70
Hospital
Other
Public 19.70 0.80 5.30 37.00 17.50 41.30 10.50
Hospital
Private
34.00 11.00 0.60 120.80 53.60 32.00 23.00
Hospital
TOTAL 18.76 2.60 4.32 49.88 19.72 29.44 9.48
An adequate number of available human resources always have immense significance

in delivering quality health care services. In our survey the human resources are classified
into five major categories as per the job description and job specification, namely doctor,
nurse, paramedical staff, group D staff and security guard. Maximum average number of
available manpower is in case of Private Hospitals, followed by other public hospitals. The
trend is similar for every type of available manpower, except for group D staff where highest
average number (41.30) lies in Other Public Hospitals, followed by Private Hospitals (32.00)
and State Government Hospitals (16.30).
But the in-depth study with the available manpower, where calculation is done based on
available number of bed, provides more comprehensive picture. Thus the average number of
manpower per bed is presented in Table A2.3.
148
Appendices
Table A2.3
Average Manpower/ Bed of the Surveyed Hospitals
Average Number of Manpower/ Bed
Category Paramedical Group D Security
Doctors/ Nurses/
Staffs/ Staffs/ Guards/
Bed Bed
Bed Bed Bed
State
Government 0.13 0.34 0.06 0.20 0.02
Hospital
Other
Public 0.18 0.32 0.15 0.36 0.09
Hospital
Private
0.32 0.87 0.38 0.23 0.16
Hospital
TOTAL 0.20 0.47 0.19 0.28 0.09
The numbers in the table show a similar trend as it was there in the previous table.
But the ratio is better for State Government Hospitals, when calculated based on the bed
strength. Thus, both the tables above represent a wide variation in availability of manpower
in different categories of hospitals.
2.1.3. Equipment
The different types of equipments used in hospitals are presented in Table A2.4
Availability of equipments shows a poor status of the State Government Hospitals,
where they hold third rank out of three in all the heads, except the average number of USG
Machines. Private hospitals are having maximum number of all eight types of equipments,
except the average number of ECG machines and Centrifuge machines, where the maximum
availability is at Other Public Hospitals. On the other hand, Other Public Hospitals are having
maximum number of non working machines, followed by State Government Hospitals and
Private Hospitals. For working equipments, State Government Hospitals are always having
less than the overall average, while the Private Hospitals are standing at the same point
considering the average number of non-working machines.
149
Appendices
Table A2.4
Average Equipments of the Surveyed Hospitals
Average
Number of ECG
Machine
Average
Number of X-
Ray Machine
Average
Number of USG
Machine
Average
Number of
Microscope
Average
Number of Semi
Auto Analyzer
Average
Number of
Colorimeter
Average
Number of Hot
Chamber
Average
Number of
Centrifuge
Machine
N. N. N. N. N. N. N. N.
W W W W W W W W
Category
W W W W W W. W. W.
0.70 0.90 1.20 0.50 0.40 0.10 1.80 1.10 0.30 0.10 0.30 0.20 0.20 0.10 0.60 0.20
State
Government
Hospital
4.40 0.60 1.60 0.50 0.30 0.40 1.90 2.10 1.20 0.00 1.20 0.50 1.20 0.10 1.70 1.00
Other
Public
Hospital
4.00 0.00 2.00 0.00 1.40 0.00 3.80 0.20 1.50 0.00 3.60 0.00 1.40 0.00 1.20 0.00
Private
Hospital
TOTAL 2.84 0.60 1.52 0.40 0.56 0.20 2.54 1.32 0.84 0.04 1.32 0.28 0.84 0.08 1.16 0.48
NOTE: W- Working, N.W.- Not Working

150
Appendices
2.1.4. Average Hospital Outcome

The maximum average of inpatients is in case of State Government Hospitals (10051.0),
followed by Private Hospitals (6498.2) and Other Public Hospitals (6498.2). The trend is little
different in case average number of patients treated at OPD 1, where again the State
Government Hospitals comes first, followed by Other Public Hospitals. But the average
number of death is at the highest level at Private Hospitals (415.8), which is well above the
overall average (218.92). The delivery case is highest at State Government Hospitals
(2103.00), followed by Private Hospital (415.8) and Other Public Hospitals (100.1).
Though the average inpatient and outpatient is less at Private Hospitals, the tendency
of medical investigation is highest here. In Private Hospitals, the highest average number of
X- Ray, average number of ECG, average number of USG and average number of laboratory
test are done. This may be explained as the maximum number of operation case is also at
Private Hospitals (4487.6), which is far ahead from the overall average (1383.72).
Table A2.5
Average Hospital Outcome of the Surveyed Hospitals
Governmen
t Hospital
Hospital
Hospital
TOTAL
Private
Public
Other
State
Average Patients Admission 10051 3984 6498.2 6913.6

Average Out Patient 89091.5 76174.3 19367.6 69979.8
Average Number of Death 227.5 111.9 415.8 218.92
Average Number of Delivery 2103 100.1 482 977.64
Average Number of Operation 771.2 444.3 4487.6 1383.72
Average Number of X- Ray 2952.3 5236 20185 7312.32
Average Number of ECG 1228.5 2232 11360.6 3656.2
Average Number of USG 1038.6 547.2 3360.8 1308.08
Average Number of Lab Test 14663.8 92518.2 163764 75625.6
1
Out Patient Department
151
Appendices
2.1.5 Average Performance Indicator

Average Performance Indicators in the surveyed Hospitals are presented at Table A2.6.
Table A2.6
Average Performance Indicator of the Surveyed Hospitals
Average
Average
Number of Bed Average
Number of
Category Outpatients Occupancy Length
Outpatient
Per Bed Rate of Stay
Per Week
Day
State Government Hospital 1713.30 6.96 0.50 1.73
Other Public Hospital 1464.19 2.23 0.46 4.93
Private Hospital 372.44 0.42 0.62 4.94
TOTAL 1345.48 3.76 0.51 3.76
Maximum average number of outpatients treated per week at OPD is at State

Government Hospitals (1713.30), followed by Other Public Hospitals (1464.19) and
Private Hospitals (372.44). Similarly, average number of outpatients per bed day is
highest at State Government Hospitals (6.96), followed by Other Public Hospitals (2.23)
and Private Hospitals (0.42). The survey result shows the highest bed occupancy as well
as average length of stay at Private Hospitals, which are 0.62 and 4.94 respectively. The
average length of stay is considerably low at State Government Hospitals (1.73),
compared to other two categories of hospitals as well as the overall average.
152
Appendices
Appendix 3: Salient Features of the Surveyed Patients in Three Categories of

Hospitals
3.1 Characteristics of the Population in the Study Area:

The fundamental socio-economic characteristics of the surveyed population are presented in
this segment of the study. 250 numbers of patients are surveyed in the district of Burdwan,
during 2013-14. The analysis exclusively deals with the family size and age composition,
education details, religion and caste composition, employment status, level of income,
housing condition and asset holding of the patients and their households.
3.1.1. Family Size and Age Composition:

The hospital category wise analysis of size of the family and age composition of the patients
and their households is shown in the table A3.1.
The total number of patients covered in the sample is 250, from 25 different hospitals across
the district of Burdwan, which are broadly categorized under three heads, namely State
Government Hospitals (SGH), Other Public Hospitals (OPuH) and Private Hospitals (PrH).
Later, each category is sub divided into two more heads based on their geographical
presence in the rural or urban areas. Out of 250 respondents, 100 (40.00 %) are from State
Government Hospitals, 100 (40.00 %) are from Other Public Hospitals and 50 (25.00 %) are
from Private Hospitals. Out of 100 respondents in State Government Hospitals, 58 (58.00
%) are male patients and 42 (42.00 %) are female patients. Similarly, the numbers of male
and female patients surveyed in Other Public Hospitals are 70 (70.00 %) and 30 (30.00 %)
respectively; the same in case of Private Hospitals is 32 (64.00 %) male and 18 (36 %)
female. The total 250 patients comprise 160 (64.00 %) male patients and 90 (36.00 %)
female patients. State Government Hospitals, Other Public Hospitals and Private Hospitals
cover 58, 70 and 32 male patients as well as 42, 30 and 18 female patients respectively
which are 36.25 %, 43.75 % and 20.00 % of the total male patients surveyed and 46.67 %,
33.33 % and 20.00 % of the total female patients surveyed in this study.
153
Appendices
Table A3.1
Average Family Size and Age Composition of the Surveyed Population
Average Age of the
No. of Patient(s) Total Family Members Average
Patient (in years)
Average Age of the
Category Family Household
Size Member(s)
Male
Male
Male
Total
Total
Total
Female
Female
Female
(in Years)
Rural 11 25 36 82 71 153 4.25 43.45 33.04 36.22 33.76
Urban 47 17 64 146 119 265 4.14 45.12 35.29 42.51 33.91
58 42 100 228 190 418
Hospital
Total 4.18 44.81 33.95 40.25 33.86
State Govt.
(36.25) (46.67) (40.00) (38.45) (40.51) (39.36)
Rural 23 12 35 86 65 151 4.31 41.17 32.83 38.31 28.92

Urban 47 18 65 163 118 281 4.32 47.00 28.50 42.97 33.37
70 30 100 249 183 432
Hospital
Total 4.32 46.05 30.23 41.31 31.81
(43.75) (33.33) (40.00) (41.99) (39.02) (40.68)
Other Public
Rural 4 3 7 16 13 29 4.14 27.25 42.00 33.57 30.14
Urban 28 15 43 100 83 183 4.25 44.32 40.80 43.09 37.54
32 18 50 116 96 212
Private
Hospital
Total 4.24 42.18 41.00 41.76 36.51
(20.00) (20.00) (20.00) (19.56) (20.47) (19.96)
160 90 250 593 469 1062
TOTAL 4.24 44.78 33.87 40.97 33.55
(100) (100) (100) (100) (100) (100)
154
Appendices
Numbers of family members of the surveyed patients are different under different
categorized hospitals. The total family members of all patients covered in the sample is
1062, of which 418 (39.36 %) deal with State Government Hospitals, 432 (40.68 %) deal
with Other Public Hospitals and 212 (19.96 %) deal with Private Hospitals. Out of 418
family members dealing with State Government Hospitals, 228 (54.55 %) are male family
members and 190 (45.45 %) are female family members. Similarly, the numbers of male
and female family members of the patients surveyed in Other Public Hospitals are 249
(57.64 %) and 183 (42.36 %); the same in case of Private Hospitals are 116 (54.72 %) males
and 96 (45.28 %) females. The total 1062 family members comprise 593 (55.84 %) males
and 469 (44.16 %) females. State Government Hospitals, Other Public Hospitals and Private
Hospitals cover 228, 249 and 116 male members as well as 190, 183 and 96 female
members respectively.
Other Public Hospitals are characterized with relatively higher average family size
of the household (4.32). The average family size of the household is same with the total
average (4.24) when dealing with the Private Hospitals. But the average family size of the
household of the patients surveyed in State Government Hospitals (4.18) is little less than
the overall average. The average number of male members in the family gives a similar kind
of picture, but it changes in case of average number of female members in the family; it is
highest in case of Private Hospitals, followed by State Government Hospitals and Other
Public Hospitals. Considering average age of the household members, a similar trend is
observed, where the overall average (33.55 years) of household members is significantly
below than in relation with Private Hospitals.
Age composition of the patients gives a similar impression for all three categories
along with the overall effect with a little fluctuation. Only a considerable difference exists
in case of the average age of the female patients, where it is 33.95 years for State
Government Hospital, 30.23 years for Other Public Hospital and 41.00 years for Private
Hospitals, which is well above the overall average of 33.87 years.
3.1.2. Literacy Rate

The hospital category-wise analysis of literacy rate and average year of schooling of the
patients and their households is shown in Table A3.2.
155
Appendices
Table A3.2
Literacy Rate and Average Year of Schooling of the Surveyed Population
Average Years of Average Average
Schooling of the Years of Years of
Patient Schooling Schooling Literacy
Category
of the of the Head Rate
M F T Household of the
Member(s) Household
State Rural 5.72 3.64 4.27 4.45 3.61 74.12
Govt. Urban 5.72 4.94 5.51 5.75 5.14 76.56
Hospital Total 5.72 4.16 5.07 5.28 4.59 75.68
Other Rural 8.26 10.33 8.97 7.74 8.37 91.30
Public Urban 10.29 9.88 10.18 10.03 10.96 94.40
Hospital Total 9.62 10.06 9.76 9.23 10.06 93.35
Rural 10.25 9.33 9.85 8.86 10.57 88.89
Private
Urban 11.64 12.13 11.81 10.69 12.83 97.05
Hospital
Total 11.46 11.66 11.54 10.44 12.52 95.94
TOTAL 8.58 7.63 8.24 7.91 7.91 86.83
The literacy rate2 of the surveyed population is estimated at 86.83 %. The literacy
rate is the highest when dealing with the households of the patients in Private Hospitals
(95.94 %), which is followed by the households of the patients in Other Public Hospitals
(93.35 %) and households of the patients in State Government Hospitals (75.68 %). The
rural-urban variation is not very significant in literacy rate apart from the household of the
patients in Private Hospitals, where the urban literacy rate is (97.05 %) is distinctly ahead
from the rural literacy rate (88.89 %). The patients surveyed in the Private Hospital (11.54
years) is well ahead when the average years of schooling of the patients are considered
from other two categories (Other Public Hospital: 9.76 years and Private Hospital: 5.07
years) as well as the overall average (8.24 years). But in this respect the position of the
patients of State Government Hospitals confirms a very poor picture. The trend continues
in average years of schooling of the house hold members, where it comes to 7.91 years as
overall average, 5.28 years for the household members of the patients surveyed in State
Government Hospitals, 9.23 years for the household members of the patients surveyed in
Other Public Hospitals and 10.44 years for the household members of the patients
surveyed in Private Hospitals. An interesting fact exists in average years of schooling of
2
Following NSS methodology, Literacy rate is defined as the number of literate population aged seven
years and above divided by the total number of population aged seven years and above.
156
Appendices
female patients in Other Public Hospitals, where it is in the higher side (10.33 years) in
rural periphery than in the urban territory (9.88 years), unlike all the other figures of the
table.
3.1.3. Religion and Caste Composition

The hospital category-wise analysis of Religion and Caste of the patients is shown in the
Table A3.3.
Table A3.3
Religion and Caste Composition of the Surveyed Population
Religion of the Patient Caste of the Patient
Category Muslim
Hindu & TOTAL General OBC SC ST TOTAL
Others
Rural 27 9 36 13 6 13 4 36
State Govt.
Urban
Hospital
46 18 64 37 9 16 2 64
73 27 100 50 15 29 6 100
Total
(35.78) (58.70) (40.00) (32.89) (53.57) (50.00) (50.00) (40.00)
Rural 32 3 35 22 2 9 2 35
Other Public
Urban
Hospital
57 8 65 44 7 11 3 65
89 11 100 66 9 20 5 100
Total
(43.63) (23.91) (40.00) (43.42) (32.14) (34.48) (41.67) (40.00)
Rural 4 3 7 4 2 1 0 7
Urban
Hospital
Private
38 5 43 32 2 8 1 43
42 8 50 36 4 9 1 50
Total
(20.59) (17.39) (20.00) (23.69) (14.29) (15.52) (8.33) (20.00)
204 46 250 152 28 58 12 250
TOTAL
(100) (100) (100) (100) (100) (100) (100) (100)
The religion of the patients surveyed shows that the majority of the patients belong
to Hindu religion (81.60 %) and minority belong to Muslim and others (18.40 %). Out of
204 Hindu patients highest number i.e., 89 (43.63 %) are surveyed at Other Public
Hospitals, followed by State Government Hospitals with 73 patients (35.78 %) and
157
Appendices
Private Hospitals (20.59 %). But the scenario is totally different in case of surveyed
Muslim patients, where the highest number i.e., 27 (58.70 %) of Muslim patients are
surveyed at State Government Hospitals, followed by Other Public Hospitals with 11
numbers (23.91 %) and Private Hospitals with only 8 numbers (17.39 %). The overall
trend also more or less supports the fact when the three categories are considered
individually. At State Government Hospitals, Other Public Hospitals and Private Hospitals
the percentage of surveyed Hindu patients are 73 %, 89 % and 84 % respectively; whereas
the same for surveyed Muslim patients are 27 %, 11 % and 16 %.
The survey result gives the highest 60.80 % score to the general caste category
patients of the total surveyed population. The caste composition of the surveyed
population indicates that the surveyed OBC, SC and ST patients occupy 11.20 %, 23.20 %
and 4.80 % of the total surveyed patients respectively. Highest % of general castes (43.42
%) are surveyed at Other Public Hospitals, whereas the highest OBC (53.57 %), SC
(50.00 %) and ST (50.00 %) patients are surveyed at State Government Hospitals. At
individual category wise study, 50.00 % general caste, 15.00 % OBC, 29.00 % SC, and
6.00 % ST patients are surveyed at State Government Hospitals. The same for Other
Public Hospitals and Private Hospitals are 66.00 %, 9.00 %, 20.00 %, 5.00 % and 36.00
%, 4.00 %, 9.00 %, and 1.00 % respectively.
3.1.4. Employment Status

Employment status is one important dimension of any social study. The employment
details of the surveyed population are broadly presented at table A3.4.
Table A3.4
Employment Status of the Surveyed Population
Family Members of the Household Family Average
Engaged in Workers Working
as Members
Category Percentage in the
Ag. Bu. Ser. Total of Total Family
Family
Members
Rural 39.6 20.0 20.4 80 52.28 2.22
SGH
Urban 56.7 27.5 40.8 125 47.17 1.95

96.3 47.5 61.2 205 49.04 2.05
Total
(83.89) (37.17) (26.22) (43.07)
158
Appendices
Rural08.8 15.2 35.0 59 39.07 1.68
OPuH
Urban02.1 35.0 78.9 116 41.28 1.78
10.9 50.2 113.9 175 40.51 1.75
Total
(9.49) (39.28) (28.68) (36.76)
Rural 04.5 03.9 04.6 13 44.83 1.86
Urban 03.1 26.2 53.7 83 45.36 1.93
PrH
07.6 30.1 58.3 96 45.28 1.92

Total
(6.62) (23.55) (24.98) (20.17)
114.8 127.8 233.4 476 44.82 1.90
TOTAL
(100) (100) (100) (100)
NOTE: Ag.: Agriculture; Bu.: Business; Ser.: Service
The total number of household members of 250 surveyed patients is 1062, of

which 44.82 % i.e., 476 are working population. The dominant occupation is service
(49.03 %), followed by business (26.85 %) and agriculture (24.12 %). But the overall
picture does not match when it is compared with the occupation of the household working
population of the surveyed patients at State Government Hospitals, where the maximum
of 46.98 % working population are engaged in agriculture, 29.85 % are engaged in service
and the rest (23.17 %) are engaged in business. But the other two categories support the
overall trend. Out of total members engaged in agriculture, State Government Hospitals
occupy the highest percentage i.e., 83.89 %, while the shares of other two categories are
only 9.49 % and 7.6 %. The maximum population engaged in business is in the category
of Other Public Hospitals (39.28 %) but the here the distribution is much more equal than
that of agriculture. Again the same trend is followed when the occupation is service.
A little variation exists in case of total family workers as percentage of total family
members, which shows 49.04 % in relation with State Government Hospitals, followed by
Private Hospitals, Other Public Hospitals with 44.82 % and 40.51 % respectively.
Considering average working members in the family, again the participation of the
household members of the surveyed patients at State Government Hospitals have highest
participation with 2.05 members per family, followed by Private Hospitals (1.90) and
Other Public Hospitals (1.75). The inter area variation (rural and urban) in each category
is not very prominent in both the heads namely, total family workers as percentage of total
family members and average working members in the family.
159
Appendices
3.1.5. Income Distribution:

The economic status and the income distribution truly reflect the type of occupational
engagement of the population. Thus the following A3.5 Table is the reflector of the
previous A.34 Table. Out of total 250 surveyed patients, 203 (81.20 %) are APL and 47
(18.80 %) are BPL. Of those 203 APL respondents 100 (49.26 %) are surveyed at Other
Public Hospitals, 54 (26.60 %) are surveyed at State Government Hospitals and 49 (24.14
%) are surveyed at Private Hospitals. The figures related to BPL patients give a peculiar
trend where the State Government Hospitals occupy nearly hundred % (97.87 %) and the
rests are having insignificant percentage.
Table A3.5
Economic Status & Income Distribution of the Surveyed Population
Per Capita Income
Economic Status of the Household
Category
Members Per
APL BPL TOTAL Annum (Rs.)
Rural 20 16 36 26928.26
Urban 34 30 64 29928.30
SGH
54 46 100
Total 28830.20
(26.60) (97.87) (40.00)
Rural 35 0 35 111202.34
Urban 65 0 65 123660.16
OPuH
100 0 100
Total 119299.93
(49.26) (00.00) (40.00)
Rural 7 0 7 128690.42
Urban 42 1 43 156410.20
PrH
49 1 50
Total 152529.44
(24.14) (02.13) (20.00)
203 47 250
TOTAL 83629.02
(100) (100) (100)
The average per capita income of the household members is Rs. 83629.02, which
is around three times more than the per capita household income of the patients surveyed
at State Government Hospitals (Rs. 28830.20). The maximum per capita household
income (Rs. 152529.44) is calculated for the patients surveyed at Private Hospitals and
thereafter for the patients surveyed at Other Public Hospitals (Rs. 119299.93). Average
per capita income for the patients at both Private Hospitals and Other Public Hospitals are
160
Appendices
at the much higher end than the overall average. The rural urban variation is not very
prominent for any category, except a bit at Private Hospitals.
3.1.6. Housing Condition

The housing condition of the surveyed population is presented at Table A3.6.
Table A3.6
Housing Condition of the Surveyed Population
Percentage
Average Percentage
of Percentage
Average Average Distance of
Households of
Area of Number from Households
Category having Households
Housing of Water Having
Toilet Using LPG
(Katha) Rooms Source Electricity
Facilities at as Fuel
(Meter) Facility
Home
Rural 2.02 2.36 55.55 20.83 02.78 75.00
SGH Urban 2.63 2.73 60.93 26.71 15.62 89.06
Total 2.41 2.60 59.00 24.60 11.00 84.00
Rural 2.30 2.62 97.14 4.28 25.71 100.00
OPuH Urban 2.65 2.84 98.46 2.81 61.54 100.00
Total 2.53 2.77 98.00 3.33 58.00 100.00
Rural 4.00 3.28 100.00 1.42 42.85 100.00
PrH Urban 3.04 3.18 97.67 2.67 81.39 100.00
Total 3.18 3.20 98.00 2.50 76.00 100.00
TOTAL 2.61 2.79 82.40 11.67 39.20 93.60
As per the survey data, the area of housing is more or less the same for the patients
surveyed in all categories of hospitals, except in Private Hospitals, where the quantity
(3.18 katha) is at the significantly higher side of the overall average (2.61 katha). The
average number of rooms is also highest in case of the surveyed patients at Private
Hospitals (3.20 rooms), followed by Other Public Hospitals (2.77 rooms) and State
Government Hospitals (2.60 rooms). Most of the surveyed patients are having toilet
facility at home and electricity, except a little variation for patients at State Government
Hospitals. Most of the surveyed patients are having water source at their home only for
Other Public Hospitals and Private Hospitals, thus the distance from water source is
insignificant in both cases, which is 3.33 meters and 2.50 meters respectively. The
scenario has adversely changed for the surveyed patients at State Government Hospitals
where the average distance from water source is 24.60 meters. Considering the fuel
161
Appendices
composition, use of LPG is high for the patients in Private Hospitals (76.00 %), moderate
in Other Public Hospitals (58.00 %) and low enough for surveyed patients at State
Government Hospitals.
3.1.7. Asset Holding

The asset holding of the surveyed population is presented at Table A3.7.
Selected physical assets are considered and multiplied with their average value for
getting the picture regarding asset holding patterns for the patients at different categories
of hospitals. The average value of asset holding is Rs. 694611.60. But inter-category
variation exist where the average value is less than the overall average for the surveyed
patients at State Government Hospitals (Rs.567169.00) and Other Public Hospitals (Rs.
670428.00); but the same is at higher side in relation with Private Hospitals (Rs.
999364.00). Wide rural urban variation in asset valuation, with a similar trend exists in
every category.
162
Appendices
Table A3.7
Asset Holding of the Surveyed Population
Percentage of Household Having
Average
Value of
Category
Asset
Car
Fan
TV
Cycle
Radio
DVD
Mobile
Holdings
Computer
Motorcycle
Own House
Land Phone
Refrigerator
Pressure Cooker
Rural 05.55 72.22 22.22 83.33 50.00 00.00 00.00 83.33 00.00 00.00 11.11 00.00 100.00 136244.44
SGH Urban 43.75 87.50 35.93 75.00 73.43 12.50 01.56 89.06 06.25 01.56 10.93 00.00 92.18 809564.06
Total 30.00 82.00 31.00 78.00 65.00 8.00 01.00 87.00 04.00 01.00 11.00 00.00 95.00 567169.00
Rural 71.42 100.00 05.71 82.85 100.00 57.14 00.00 100.00 65.71 14.28 65.71 02.85 31.42 212342.85
OPuH Urban 86.15 100.00 06.15 83.07 100.00 33.84 13.85 100.00 89.23 24.61 80.00 13.84 86.15 917089.23
Total 81.00 100.00 06.00 83.00 100.00 42.00 09.00 100.00 81.00 21.00 75.00 10.00 81.00 670428.00
Rural 85.71 100.00 14.28 100.00 100.00 28.57 14.28 100.00 71.42 14.28 85.71 28.57 100.00 409185.71
PrH Urban 90.69 100.00 06.97 67.44 100.00 41.86 27.90 100.00 74.41 38.37 62.79 34.88 97.67 1095439.53
Total 90.00 100.00 08.00 72.00 100.00 40.00 26.00 100.00 74.00 35.00 66.00 34.00 98.00 999364.00
TOTAL 62.40 92.80 16.40 77.20 86.00 28.40 09.60 94.80 48.80 15.40 47.60 10.80 90.00 694611.60
Note: Land size instead of own house is considered for asset valuation
163
Appendices
3.1.8 Availability of Insurance Facility:
Health insurance got popularity in recent days for its usefulness; it reduces the burden of
health expenditure by paying an affordable amount of premium every year. The
availability of insurance facility among the surveyed patients is presented in Table A3.8.
Table A3.8
Access of Insurance Facility
Total number Number of
Patients
of Patients Patients having
Surveyed at
Surveyed Insurance Facility
100 21
SGH
(40.00) (38.18)
100 19
OPuH
(40.00) (34.55)
50 15
PrH
(20.00) (27.27)
250 55
TOTAL
(100.00) (100.00)
Note: Figures in the parentheses indicate percentages with
respect to the total respondents having insurance facilities
under different categories of hospitals.
Considering the availability of insurance facilities, 55 patients (twenty two
percent) of total 250 patients surveyed at different types of hospital, are having insurance
facility. Out of total 55 health insurance holder patients, 21 (38.18 percent) are admitted to
state government hospitals, 19 (34.55 percent) are admitted to other public hospitals and
15 (27.27 percent) are admitted to private hospitals. Again from another observation,
twenty one percent of all the patients surveyed at state government hospitals are having
health insurance facility, whereas nineteen percent and thirty percent of all the patients
surveyed at other public hospitals and private hospitals respectively are having health
insurance facilities.
164
Appendices
Table A3.9
Insurance Details
Number of Patients having
Total
Insurance Facilities as
Patients Number of
Surveyed at Patients Government Health Voluntary
Surveyed Insurance Health
RSBY ESI Insurance
100 19 01 01
SGH
(40.00) (100.00) (05.88) (05.27)
100 00 14 05
OPuH
(40.00) (00.00) (82.36) (26.31)
50 00 02 13
PrH
(20.00) (00.00) (11.76) (68.42)
250 19 17 19
TOTAL
(100.00) (100.00) (100.00) (100.00)
Note: Figures in the parentheses indicate percentages with respect to the total
respondents having insurance facilities under different categories of hospitals.
The health insurance can be divided into two heads: government health insurance
and voluntary health insurance. Example of government health insurance includes
Employees' State Insurance (ESI)3 and Rashtriya Swasthya Bima Yojana (RSBY)4. Out of
twenty one health insurance facility holder patients at state government hospital, nineteen
patients are having the facility of Rastriya Swasthya Bima Yojana, one patient is having
the facility of Employees' State Insurance and the remaining one is having the paid or
3
Employees' State Insurance is a self-financing social security and health insurance scheme for Indian
workers. For all employees earning 15000 or less per month as wages, the employer contributes 4.75
percent and employee contributes 1.75 percent of total share 6.5 percent. This fund is managed by the ESI
Corporation (ESIC) according to rules and regulations stipulated therein the ESI Act 1948, which oversees
the provision of medical and cash benefits to the employees and their family through its large network of
branch offices, dispensaries and hospitals throughout India. ESIC is an autonomous corporation by a
statutory creation under Ministry of Labor and Employment, Government of India. (Wikipedia 2014)
(Retrieved from http://en.wikipedia.org/wiki/Employees%27_State_Insurance dated.15.05.2014)
4
The Rashtriya Swasthya Bima Yojana (RSBY) is a health insurance scheme for “Below Poverty Line”
(BPL) workers in the unorganized sector. It was formally launched on the 1st of October, 2007 by the
Central Government and is a part of the ongoing process by which the government at the Centre has initiated
for providing social security for workers in the unorganized sector. All the 600 districts of the country are to
be covered in a phased manner by 2012. The main objective of this scheme is to provide health security for
the BPL workers in the unorganized sector and their families through insurance over for hospital expenses.
It is hoped that the scheme would protect this vulnerable section of the population from catastrophic medical
expenditure. (Devadasan et al 2008) (Devadasan N and Swarup A (2008) Rashtriya Swasthya Bima Yojana:
An overview IRDA Journal Volume VI, No. 4 Hyderabad)
165
Appendices
voluntary health insurance facility; the average premium paid by the patients having
voluntary health insurance facility among the patients surveyed at state government
hospital is Rs. 900 per person per year. Out of nineteen health insurance facility holder
patients at other public hospitals, fourteen patients are having the facility of Employees'
State Insurance and five patients are having the facility of paid or voluntary health
insurance; the average premium paid by the patients having voluntary at other public
hospitals is Rs. 2800 per person per year. Out of fifteen health insurance facility holder
patients at private hospitals, only two patients are having the facility of Employees' State
Insurance and remaining thirteen patients are having the facility of paid or voluntary
health insurance; the average premium paid by the patients having voluntary health
insurance at private hospitals is Rs. 2946.30 per person per year.
3.2 Cost of Medicine, Investigation and Pathological Test:
The availability of medicine at hospital is classified into three mutually exclusive
categories: medicine available (i.e., all the medicines required are available at the hospital
with or without payment), medicine partially available (i.e., part of the medicines required
is available at the hospital with or without payment and the rest are taken from outside),
and medicine not available (i.e., no medicines are available at the hospital with or without
payment). The suggested number of pathological tests and investigations per patient are
classified based on the type of the test and investigation. The costs incurred are considered
separately in both the cases.
The cost of medicine is included as a major component of the total expenditure on
healthcare. The figures are presented in Table A3.10
166
Appendices
Table A3.10
Availability of Medicine at Hospital and Its Cost
Responses on Availability of Average Cost of
Total
Patients Medicine at Hospital Medicine
Number of
Surveyed at Fully Partly Not Purchased
Respondents
Available Available Available (Rs./ Patient/ Day)
100 24 66 10
SGH Rs. 119.11
(100.00) (24.00) (66.00) (10.00)
100 85 14 1
OPuH Rs. 86.31
(100.00) (85.00) (14.00) (1.00)
50 46 4 00
PrH Rs. 1631.36
(100.00) (92.00) (8.00) (00.00)
250 155 84 11
ALL Rs. 408.44
(100.00) (62.00) (33.60) (4.40)
Note: Figures in the parentheses indicate percentages of patients responding on availability of medicine
with respect to the total respondents under different categories of hospitals.
Table A3.10 shows that of the surveyed patients at state government hospitals, the
percentages reporting full availability, partial availability and non-availability of
medicines at that particular hospital are calculated as twenty four percent, sixty six percent
and ten percent respectively. Of the surveyed patients at other public hospitals, the
percentages of respondents reporting in favor of full availability, partial availability and
non-availability of medicines at that particular hospital are eighty five percent, fourteen
percent and one percent respectively. Of the surveyed patients at private hospitals,
percentage reporting full availability and partial availability of medicines at that particular
hospital are calculated as ninety two percent and eight percent respectively. Most
interestingly, there is no incidence of non-availability of medicine at private hospitals. The
same can be discussed from another point of view. A total of 155 patients (sixty two
percent) of all the surveyed patients got all the medicine from the hospital. Out of these
155 patients who got all the medicines from the same hospital, twenty four patients are at
state government hospitals, 85 patients are at other public hospitals and forty six patients
are at private hospitals. Considering partial availability of medicine at the same hospital
167
Appendices
where the patient is admitted, total 84 patients (33.60 percent of all the patients surveyed
at different types of hospitals) reported this fact. Of them sixty six patients are at state
government hospitals, fourteen patients are at other public hospitals and only four patients
are at private hospitals. There are only 11 patients (4.40 percent) of all the surveyed
patients who reported that no medicine is available in the hospital. Of these 10 patients are
at state government hospitals and one patient is at other public hospitals.
The average cost of purchased medicine per patient per day is Rs. 408.44 for all
the patients surveyed at different types of hospitals. Considering individual hospital types,
this cost is low at other public hospitals, which is Rs. 86.31 and also at the lower side for
state government hospitals, which is Rs. 119.11 per patient per day. The same is very high
for the patients surveyed at private hospitals, estimated at Rs. 1631.36 per patient per day.
The cost of medicine per patient is the lowest in case of other public hospitals because
almost all the patients in this category of hospital are covered under health benefit of their
employment scheme. Thus there is no need of purchasing medicine from outside; and if
purchased, the amount spent is reimbursed by the employer. Only a few among all the
surveyed patients at other public hospitals are outsider patient, who pay for medicine as
well all the other services, they rendered.
The average number of pathological tests and investigations (which include USG,
X-Ray and ECG) and their average costs are presented in Table A3.11.
The average number of pathological tests and investigations and their average
costs follow a similar trend for state government hospitals, other public hospitals and
private hospitals. It is observed that the patients surveyed at private hospitals are having
the highest value in every aspect, followed by the patients surveyed at other public
168
Appendices
hospitals and state government hospitals. Considering the average number of pathological
tests suggested per patient, it is the highest in private hospitals, which is 4.68 per patient,
followed by patients surveyed at other public hospitals and state government hospitals
with 2.92 test per patient and 0.97 tests per patient respectively. Considering the average
number of Ultrasonography (USG) suggested per patient, it is the highest in private
hospital, which is 0.22 per patient, followed by patients surveyed at other public hospitals
and state government hospitals with 0.14 test per patient and 0.09 tests per patient
respectively. Considering the average number of X-ray suggested per patient, it is highest
in private hospital, which is 0.64 per patient, followed by patients surveyed at other public
hospitals and state government hospitals with 0.32 tests per patient and 0.09 tests per
patient respectively. Considering the average number of electrocardiography
(ECG) suggested per patient, it is again the highest in private hospital, which is 0.40 per
patient, followed by patients surveyed at other public hospitals and state government
hospitals with 0.24 tests per patient and 0.09 tests per patient respectively.
Table A3.11
Pathological Tests and Investigations Per Patient
Number of Number Number of Number of Average Cost
Respondents
Pathological of USG X-Ray ECG of all the
(Patients)
Test Suggested/ Suggested Suggested Suggested/ Tests and
surveyed at
Patient / Patient / Patient Patient Investigations
SGH 0.97 0.07 0.09 0.09 Rs.177.78
OPuH 2.92 0.14 0.32 0.24 Rs.70.02
PrH 4.68 0.22 0.64 0.40 Rs.3129.60
ALL 2.49 0.13 0.29 0.21 Rs.725.04
Average cost of all the tests and investigations follow a little different trend.
Average expenditure against tests and investigations per patient is the highest at private
hospitals with Rs. 3129.60, followed by state government hospitals (Rs. 177.78) and other
169
Appendices
public hospitals (Rs. 70.02). Thus, like the cost of medicine per patient, the average cost
of all the tests and investigations is also the lowest in case of other public hospitals, the
justification of this phenomenon is that, almost all the patients in this category of hospital
are covered under health benefit of their employment scheme. Thus there is no need to
pay for tests and investigations; and if paid, the amount is reimbursed by the employer.
Only a few among all the surveyed patients at other public hospitals are outsider patients,
who pay for tests and investigations as well as the other services, they consume.
3.3 Waiting Time for Operation
The average waiting times for operation after admission of in-patients are presented in
Table A3.12
Table A3.12
Waiting Time for Operation after Admission of In-Patients
Average
Respondents
Waiting Time
(Patients)
for Operation
Surveyed at
(in Day)
SGH 1.72
OPuH 1.44
PrH 1.82
ALL 1.68
Contrary to our common sense perception, the average waiting time for operation after
admission of in-patients is the highest for the patients surveyed at private hospitals, which
is 1.82 days. The waiting time for operation is little less for the patients surveyed at state
government hospitals, which is estimated at 1.72 days. The average waiting time for
operation after admission of in-patients is the lowest at other public hospitals, which is
estimated as 1.44 days; it is at the lower side of the all average (1.68 days).
170
Appendices
In other public hospitals, the patients are homogeneous in nature, as these hospitals
are made for their employees. The other stake holders of an organization are also
entertained, but the number is negligible. Thus the pressure is comparatively less in this
type of hospital. So, the waiting time for operation after admission is least here. The
pressure of patients is the highest in state government hospitals, where all the patients get
equal opportunity of healthcare service. But the pressure fluctuates with the type of
hospital i.e., medical college hospital, sub divisional hospital and rural hospital; and also
the type of operation i.e., ligation5, vasectomy6, cesarean delivery7 or any other critical
operation. Thus, in our survey, when a good number of patients are surveyed at rural
hospital under the category of state government hospitals, where pressure of patient is less
and number of non-critical operation is more and that can be done promptly, the waiting
time for operation after admission of in-patient is nearby of overall average.
3.4 Expenditure on Healthcare Services and Measurement of Consumer Surplus
Consumer surplus on healthcare service is the difference between the total amount that
consumers are willing and able to pay for a healthcare service (indicated by the demand
curve) and the total amount that they actually do pay for availing that healthcare service
5
Ligation or Tubal ligation is an operation to stop a woman from getting pregnant. It is permanent. The
Fallopian tubes, which carry the eggs from the ovary to the womb (uterus), are burned, clipped, cut or tied
(the tubes are sealed). The tubes are therefore closed so the sperm and egg do not meet. The egg then
dissolves and is absorbed by the body. http://sogc.org/publications/tubal-ligation-female-surgical-
sterilization/ The Society of Obstetricians and Gynecologists of Canada (SOGC); Retrieved on
05.05.2014
6
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the
procedure, the male vasa deferentia are severed and then tied/sealed in a manner so as to prevent sperm from
entering into the seminal stream (ejaculate) and thereby prevent fertilization from occurring.
http://en.wikipedia.org/wiki/Vasectomy Retrieved on 05.05.2014
7
A cesarean delivery is a surgical procedure in which a fetus is delivered through an incision in the mother's
abdomen and uterus. American College of Obstetricians and Gynecologists. (2010). FAQs: Cesarean birth.
Retrieved July 31, 2012, from http://www.acog.org/~/media/For%20Patients/faq006.pdf?dmc=1&ts=
20120731T1617495597;
171
Appendices
(i.e. the market price, which is constant at a certain level in healthcare service). Consumer
surplus is shown by the area under the demand curve and above the price. (Riley, 2014)
The average amount of expenditure and the average amount willing to pay are presented
in Table A3.13. The average consumer surplus is also presented in the same table. The
consumer surplus is estimated by deducting the actual expenditure from the amount
willing to pay.
Table A3.13
Expenditure and Consumer Surplus
Average
Respondents Average Average
Payment Amount
(Patients) Amount Consumer
Heads Willing to Pay
Surveyed at Paid (Rs.) Surplus (Rs.)
(Rs.)
Doctor 1.20 344.10 342.90
Medicine 324.46 414.71 90.25
Testing 165.19 242.66 77.47
SGH
Operation 84.11 488.01 403.90
Bed 5.41 404.50 399.09
Total 580.37 1893.98 1313.61
Doctor 73.50 260.50 187.00
Medicine 224.22 338.72 114.50
Testing 57.50 233.10 175.60
OPuH
Operation 65.00 320.00 255.00
Bed 119.75 490.00 370.25
Total 539.97 1642.32 1102.35
172
Appendices
Doctor 2170.00 2057.00 -113.00

Medicine 4895.60 4861.60 -34.00
Testing 4406.60 2877.80 -1528.80
PrH
Operation 17440.00 14000.00 -3440.00
Bed 5185.00 4670.00 -515.00
Total 34097.20 28466.40 -2815.40
Doctor 463.88 653.24 189.36
Medicine 1198.59 1273.69 75.10
Testing 970.39 765.86 -204.53
ALL
Operation 3547.64 3123.20 -424.44
Bed 1087.06 1291.80 204.73
Total 7267.58 7107.80 -159.78
In state government hospitals, the patients are paying an average of Rs.1.20 as the
fees of the doctors, Rs.324.46 as medicine cost, Rs.165.19 for clinical investigation,
Rs.84.11 for operation purpose and Rs.5.41 as bed charges. So, they are actually paying
an average total cost of Rs.580.37. But the same patients are having a different set of
amounts of willingness to pay against different heads, which include an average of
Rs.344.10 as the fees of the doctors, Rs.414.71 as medicine cost, Rs.242.66 for clinical
investigation, Rs.488.01 for operation purpose and Rs.404.50 as bed charges and thus a
total of Rs.1893.98. These amounts are used to get the following consumer surplus results:
Rs.342.90 in doctor fees, Rs.90.25 in medicine cost, Rs.77.47 in clinical investigation,
Rs.403.90 in operation costs and Rs.399.09 in bed charges and thus Rs.1313.61 in totality.
In other public hospitals, the patients are paying an average of Rs.73.50 as the fees
of the doctors, Rs.224.22 as medicine cost, Rs.57.50 for clinical investigation, Rs.65.00
for operation purpose and Rs.119.75 as bed charges. So, they are actually paying an
average total of Rs.539.97. But the same patients are having a different set of willingness
to pay regarding the payment against different heads, which include an average of
173
Appendices
investigation, Rs.320.00 for operation purpose and Rs.490.00 as bed charges and thus a
total of Rs.1642.32. These amounts are used to get the following consumer surplus results:
Rs.187.00 in doctor fees, Rs.114.50 in medicine cost, Rs.175.60 in clinical investigation,
Rs.255.00 in operation and Rs.370.25 in bed charges and thus Rs.1102.35 in totality.
In private hospitals, the patients are paying an average of Rs.2170.00 as the fees of
the doctors, Rs.4895.60 as medicine cost, Rs.4406.60 for clinical investigation,
Rs.17440.00 for operation purpose and Rs.5185.00 as bed charges. So, they are actually
paying an average total of Rs.34097.20. But the same patients are having a different set of
amount of willingness to pay against different heads, which include an average of
investigation, Rs.14000.00 for operation purpose and Rs.4670.00 as bed charges and thus
a total of Rs.28466.40. These amounts are used to get the following consumer surplus
results: Rs.-113.00 in doctor fees, Rs.-34.00 in medicine cost, Rs.-1528.80 in clinical
investigation, Rs.-3440.00 in operation and Rs.-515.00 in bed charges and thus Rs.-
2815.00 in totality. The negative sign indicates that there is no consumer surplus; rather
consumer deficit exists.
Considering all three types of hospitals taken together, all the surveyed patients are
paying an average of Rs.463.88 as the fees of the doctors, Rs.1198.59 as medicine cost,
Rs.970.39 for clinical investigation, Rs.3547.64 for operation purpose and Rs.1087.06 as
bed charges. So, they are actually paying an average total of Rs.7267.58. But the same
patients are having a different set of amount of willingness to pay against different heads,
which include an average of Rs.653.24 as the fees of the doctors, Rs.1273.69 as medicine
cost, Rs.765.86 for clinical investigation, Rs.3123.20 for operation purpose and
174
Appendices
Rs.1291.80 as bed charges and thus a total of Rs.7107.80. These amounts are used to get
the following consumer surplus results: Rs.189.36 in doctor fees, Rs.75.10 in medicine
cost, Rs.-204.53 in clinical investigation, Rs.-424.44 in operation and Rs.204.73 in bed
charges and thus Rs.-159.78 in totality.
175
Appendices
Appendix 4: Tables and Diagrams related to Public Healthcare Access and Its
Linkages to Healthcare Expenditure
Table A4.1
Level and Improvement in Infant Mortality Rate in Selected Indian States
IMR Improvement Index
Kakwani
1988 2008 (1993) Sen (1981)
Top Four States
Kerala 28 12 0.25 0.7
Tamil Nadu 74 31 0.2 0.62
Maharashtra 69 33 0.17 0.56
West Bengal 68 35 0.16 0.53
Average (Top four) 0.19 0.6
Bottom Four States
Madhya Pradesh 121 70 0.12 0.44
Orissa 122 69 0.13 0.45
Uttar Pradesh 124 67 0.14 0.48
Rajasthan 103 63 0.11 0.41
Average (Bottom four) 0.12 0.45
Source: Collected from Rao and Choudhury (2012)
Note: Kakwani’s index and Sen’s index have been used to compare improvement
in IMR because these indices take into account the differences in IMR in the base
year across states. For calculating the improvement indices, the maximum and
minimum values of IMR have been assumed to be 130 and 5, respectively.
Table A4.2
Health Expenditure of State Governments as a % of Total Government Expenditure
State 1981 1987 1991 1996 1998 2001 2003 2005 2008 2009
Andhra Pradesh 5.80 7.88 5.53 4.65 5.44 4.74 3.96 3.53 3.3 3.3
Arunachal 5.91 9.77 4.89 4.66 5.04 NA 4.68 4.45 3.0 2.7
Pradesh
Assam 3.96 10.21 NA 5.84 5.87 4.66 3.69 3.06 6.0 5.6
Bihar 3.78 8.49 5.10 5.79 5.24 4.01 3.17 3.24 4.1 4.2
Chhattisgarh - - - - - 4.13 3.99 3.74 4.7 4.7
Delhi - - - - - 7.16 6.34 6.65 7.8 7.2
Goa, Daman & 7.19 13.45 8.70 5.39 4.89 3.90 4.02 3.27 3.7 4.2
Diu
Gujarat 4.38 9.58 5.03 4.70 4.57 3.38 3.21 3.05 3.1 3.1
Haryana 4.33 8.25 4.11 2.95 3.27 3.26 2.88 2.59 2.8 2.7
Himachal Pradesh 6.63 13.50 3.32 6.16 7.04 5.64 4.50 5.08 4.5 4.7
Jammu & 3.79 12.50 5.56 5.50 4.97 4.89 5.30 4.78 5.1 5.3
Kashmir
Jharkhand - - - - - NA 4.18 3.65 5.6 5.3
Karnataka 3.79 8.23 5.40 5.28 5.85 5.11 4.17 3.49 3.9 4.1
Kerala 6.56 9.85 7.21 6.53 5.68 5.25 4.74 4.71 4.6 4.7
176
Appendices
Madhya Pradesh 4.94 10.11 5.16 4.81 4.57 5.09 4.11 3.39 3.9 3.9
Maharashtra 4.85 9.38 5.13 4.56 4.29 3.87 3.71 3.51 3.3 3.1
Manipur 2.60 12.61 4.38 4.83 4.48 4.82 2.89 3.72 2.8 4.0
Meghalaya 6.25 13.25 6.26 6.19 6.86 5.65 5.88 5.23 4.6 4.4
Mizoram 7.89 11.85 3.50 4.18 NA 4.96 5.01 3.96 4.0 6.3
Nagaland 5.39 10.88 5.96 5.95 5.68 4.87 4.65 4.68 4.8 4.6
Orissa 5.17 8.50 5.13 5.16 4.82 4.15 3.75 3.90 3.6 3.8
Pondicherry 9.05 10.01 7.82 0.03 0.04 NA NA 5.4 7.2 5.0
Punjab 3.67 10.52 6.73 4.62 4.93 4.54 3.54 3.10 3.1 3.2
Rajasthan 4.85 14.48 6.50 5.70 7.97 5.16 4.24 3.94 4.3 4.6
Sikkim 4.49 6.44 7.89 2.72 1.92 3.67 2.03 2.56 2.6 2.7
Tamil Nadu 6.18 10.04 6.91 6.29 6.28 4.86 4.10 4.20 4.2 4.2
Tripura 2.51 7.37 5.18 14.74 4.79 4.04 3.79 3.79 5.8 5.0
Uttar Pradesh 4.69 9.08 6.31 6.03 1.74 3.98 3.75 4.49 5.2 5.6
Uttarakhand - - - - - 3.08 3.77 4.34 2.9 4.9
West Bengal 6.30 9.73 8.37 6.43 NA 5.63 4.95 3.94 4.4 4.4
Source: For 2003-2009 Public Finance, CMIE, 2005 and State Finances, RBI, 2008 and 2009.
It is to be noted that 2005, 2008 and 2009 are budget estimates.
Table A4.3
Correlation Matrix of Different Components of IPHA and IPHE
Availability Usage IPHA State Central IPHE
** **
Availability 1 -.034 .727 .600 .796** .762**
Usage -.034 1 .636** .274 -.128 .032
** ** **
Pearson IPHA .727 .636 1 .638 .460* .559**
Correlation State .600** .274 .638** 1 .617** .818**
Central .796** -.128 .460* .617** 1 .936**
** ** **
IPHE .762 .032 .559 .818 .936** 1
Availability 1.000 -.024 .362* .282 .436** .448**
Usage -.024 1.000 .619** .279 -.155 .149
* ** *
Kendall's IPHA .362 .619 1.000 .406 .053 .324*
*
tau_b State .282 .279 .406 1.000 .240 .702**
**
Central .436 -.155 .053 .240 1.000 .542**
** * **
IPHE .448 .149 .324 .702 .542** 1.000
Availability 1.000 -.018 .547* .422 .612** .619**
Usage -.018 1.000 .786** .426 -.217 .238
* ** **
Spearman's IPHA .547 .786 1.000 .602 .116 .487*
**
rho State .422 .426 .602 1.000 .323 .868**
**
Central .612 -.217 .116 .323 1.000 .705**
** * **
IPHE .619 .238 .487 .868 .705** 1.000
Note: *. Correlation is significant at the 0.05 level (2-tailed), **. Correlation is significant at the 0.01 level
(2-tailed).
177
Appendices
Table A4.4
Health Indicators and Spending & Share on Health Financing
Per Capita
Per Capita
Per Non-
Government Private
Capita Government
Country IMR MMR LEB Spends on Expendit
Income Spends on
Healthcare ure (%)
(USD) Healthcare
(USD)
(USD)
India 42 200 70 4000 39 132 70.8
USA 5.2 21 79.8 52800 4437 8362 46.9
UK 4.5 12 81 37300 2919 3480 16.1
South 42.15 300 61 11500
412 935 55.9
Africa
China 15.2 37 74.2 9800 203 379 46.4
Brazil 19.83 56 76.2 12100 483 1028 53.0
Nigeria 72.97 630 53 2800 46 121 62.1
Russia 7.19 34 70 18100 620 998 37.9
Source: WHO (2013)
178
Appendices
Diagram A4.1: Index for Public Healthcare Access across the States of India
Index of public Healthcare Access across the

Districts of West Bengal
1
0.8
IPHA
0.6
0.4 IPHA
0.2
Nor i na... na
0
r
Dar edinipu
r ga
r ah
We ooghl y
ia
hum
ba M lda
chim uri
al
Birb lia
How g
Mur hbehar
Jalp ad
Pur a
Utta 24 Pa
dwa
in
kur
Nad
...
Coo in ...
eng
4 ...
u
ig
ab
jeel
M
a
Ban
shid
Bur
th 2
st B
sh
rD
H
c
th
Dak
Pas
Sou
Pur
States
Diagram A4.2: Index for Public Healthcare Access across Districts of West Bengal
179
IPHA Value
0
1
0.2
0.4
0.6
0.8
1.2
BURDWAN-I
JAMURIA
FARIDPUR-
KATWA-I
KALNA-I
RANIGANJ
MEMARI-I
GALSI-I
AUSGRAM-I
BHATAR
MANGOLKOTE
KATUGRAM-I
RAINA-II
BARABANI
MANTESWAR
ONDAL
DISTRICT
KANKSA
Blocks
MEMARI-II
PURBASTHALI-I
RAINA-I
SALANPUR
KATWA-II
JAMALPUR
PURBASTHALI-II
GALSI-II
AUSGRAM-II
IPHA ACROSS THE BLOCKS OF BURDWAN
KETUGRAM-II
KALNA-II
KHANDAGHOSH
Diagram A4.4: Index of Public Healthcare Expenditure across the States of India
BURDWAN-II
PANDABESWAR
Diagram A4.3: Index of Public Healthcare Access across the Blocks of Burdwan district
180
Appendices
Appendices
Appendix 5: Tables and Diagrams related to Efficiency of Healthcare

Institutions
Table A5.1
Land Occupied by Different Category of Hospital
Land Area (Area/Bed)
Hospital Category
(In sq. ft.)
State Government Hospital 4267.34
Other Public Hospital 2733.86
Private Hospital 254.545
Table A5.2
Descriptive Statistics of Input Variables of State Government Hospitals
Maximum
Minimum
Deviation
Skewness
Standard
Kurtosis
Median
Range
Mean
BED_SIZE 79.300 50.000 96.635 1.836 1.723 275.000 15.000 290.00

NUDOC 10.400 3.000 13.818 2.472 1.854 40.000 2.000 42.00
DOC 0.154 0.164 0.090 0.441 0.492 0.300 0.033 0.33
NUNURS 27.300 11.000 37.151 2.895 1.943 109.000 5.000 114.00
NURS 0.352 0.345 0.116 2.161 -0.780 0.433 0.100 0.53
PARA 5.000 3.000 5.578 4.624 2.137 18.000 1.000 19.00
NECG 0.700 1.000 0.675 -0.283 0.434 2.000 0.000 2.00
NXRY 1.200 1.000 1.317 0.818 1.008 4.000 0.000 4.00
BED_SIZE: Number of functional bed; NUDOC: Total number of Doctors; DOC: Number of Doctors /
Bed; NUNURS: Total number of nurse; NURS: Nurse/ Bed; PARA: Total number of paramedical staff;
NECG: Total number of ECG Machines; NXRY: Total number of X Ray Machine
181
Appendices
Table A5.3
Descriptive Statistics of Output Variables of State Government Hospitals
Maximum
Minimum
Deviation
Skewness
Standard
Kurtosis
Median
Range
Mean
INPT 10051.00 2756.50 13839.07 0.965 1.594 35387.00 950.00 36337.00

IPBD 0.32 0.33 0.15 -1.440 -0.238 0.44 0.08 0.51
DISGE 2103.00 654.50 2702.73 0.629 1.468 7209.00 212.00 7421.00
DISC 0.08 0.08 0.04 -0.550 -0.120 0.14 0.01 0.15
DELVRY 9403.70 2713.00 12603.54 0.863 1.559 31877.00 926.00 32803.00
DLVY 0.31 0.31 0.15 -1.397 -0.128 0.43 0.07 0.51
ECGCS 1228.50 507.00 1658.55 0.090 1.247 4314.00 0.00 4314.00
XRCS 2952.300 1746.000 3662.005 0.280 1.181 10105.000 0.000 10105.000
INPT: Total Number of in-patient; IPBD: Number of in-patient/Bed /Day; DISGE: Total no of discharge; DISC: Total
no of discharge/Bed /Day; DELVRY: Total Number of Delivery; DLVY: Number of Delivery/Bed /Day; ECGCS:
Number of ECG case; XRCS: Number of X-Ray case;
Table A5.4
Descriptive Statistics of Input Variables of Other Public Hospitals
Maximum
Minimum
Deviation
Skewness
Standard
Kurtosis
Median
Range
Mean
BED_SIZE 114.300 67.000 108.476 1.068 1.247 328.000 22.000 350.000

NUDOC 20.500 13.000 19.004 0.421 1.264 55.000 3.000 58.000
DOC 0.212 0.173 0.122 3.009 1.621 0.400 0.100 0.500
NUNURS 37.000 17.500 35.446 -0.068 1.121 100.000 7.000 107.000
NURS 0.343 0.298 0.119 -0.484 0.936 0.314 0.231 0.545
PARA 17.500 17.000 8.947 2.734 1.160 33.000 5.000 38.000
NECG 4.400 3.000 4.351 0.481 1.289 12.000 1.000 13.000
NXRY 1.600 1.500 0.699 -0.146 0.780 2.000 1.000 3.000
BED_SIZE: Number of functional bed; NUDOC: Total number of Doctors; DOC: Number of Doctors / Bed;
NUNURS: Total number of nurse; NURS: Nurse/ Bed; PARA: Total number of paramedical staff; NECG: Total
number of ECG Machines; NXRY: Total number of X Ray Machine
182
Appendices
Table A5.5
Descriptive Statistics of Output Variables of Other Public Hospitals
Maximum
Minimum
Deviation
Skewness
Standard
Kurtosis
Median
Range
Mean
INPT 3983.900 1863.500 3744.996 -1.952 0.514 9013.000 538.000 9551.000

IPBD 0.092 0.085 0.038 1.134 1.057 0.123 0.052 0.174
DISGE 100.100 20.000 140.824 1.794 1.504 418.000 0.000 418.000
DISC 0.002 0.001 0.002 5.951 2.283 0.008 0.000 0.008
DELVRY 3577.500 1597.500 3492.395 -1.958 0.515 8242.000 415.000 8657.000
DLVY 0.081 0.078 0.039 0.217 0.585 0.132 0.026 0.158
ECGCS 2232.000 1669.000 1993.585 -1.242 0.604 5419.000 54.000 5473.000
XRCS 5236.000 3326.500 4698.701 0.026 1.211 12385.000 1265.000 13650.000
INPT: Total Number of in-patient; IPBD: Number of in-patient/Bed /Day; DISGE: Total no of discharge; DISC: Total no of
discharge/Bed /Day; DELVRY: Total Number of Delivery; DLVY: Number of Delivery/Bed /Day; ECGCS: Number of ECG
case; XRCS: Number of X-Ray case;
Table A5.6
Descriptive Statistics of Input Variables of Private Hospitals
Standard
Mean Median Deviation Kurtosis Skewness Range Minimum Maximum
BED_SIZE 138.600 128.000 99.851 1.397 0.615 274.000 15.000 289.000
NUDOC 44.800 34.000 44.076 3.478 1.718 115.000 5.000 120.000
DOC 0.304 0.313 0.079 -0.441 0.374 0.203 0.213 0.415
NUNURS 120.800 80.000 124.150 3.107 1.603 326.000 4.000 330.000
NURS 0.732 0.625 0.416 -2.716 0.212 0.921 0.267 1.188
PARA 53.600 30.000 62.668 2.747 1.645 157.000 2.000 159.000
NECG 4.000 4.000 2.550 -2.260 0.000 6.000 1.000 7.000
NXRY 2.000 2.000 1.581 -1.200 0.000 4.000 0.000 4.000
BED_SIZE: Number of functional bed; NUDOC: Total number of Doctors; DOC: Number of Doctors / Bed; NUNURS:
Total number of nurse; NURS: Nurse/ Bed; PARA: Total number of paramedical staff; NECG: Total number of ECG
Machines; NXRY: Total number of X Ray Machine
183
Appendices
Table A5.7
Descriptive Statistics of Output Variables of Private Hospitals
Standard
INPT 138.600 128.000 99.851 1.397 0.615 274.000 15.000 289.000
IPBD 44.800 34.000 44.076 3.478 1.718 115.000 5.000 120.000
DISGE 0.304 0.313 0.079 -0.441 0.374 0.203 0.213 0.415
DISC 120.800 80.000 124.150 3.107 1.603 326.000 4.000 330.000
DELVRY 0.732 0.625 0.416 -2.716 0.212 0.921 0.267 1.188
DLVY 53.600 30.000 62.668 2.747 1.645 157.000 2.000 159.000
ECGCS 4.000 4.000 2.550 -2.260 0.000 6.000 1.000 7.000
XRCS 2.000 2.000 1.581 -1.200 0.000 4.000 0.000 4.000
Table A5.8
Descriptive Statistics of Input Variables of All the Hospitals
Standard
BED_SIZE 105.160 60.000 100.611 0.122 1.091 335.000 15.000 350.000
NUDOC 21.320 11.000 26.375 7.498 2.433 118.000 2.000 120.000
DOC 0.207 0.200 0.113 0.602 0.775 0.467 0.033 0.500
NUNURS 49.880 16.000 69.907 10.591 2.907 326.000 4.000 330.000
NURS 0.424 0.350 0.252 4.826 2.128 1.088 0.100 1.188
PARA 19.720 12.000 32.058 15.840 3.742 158.000 1.000 159.000
NECG 2.840 1.000 3.400 2.984 1.816 13.000 0.000 13.000
NXRY 1.520 1.000 1.159 -0.065 0.558 4.000 0.000 4.000
INPT: Total Number of in-patient; IPBD: Number of in-patient/Bed /Day; DISGE: Total no of discharge; DISC: Total no
of discharge/Bed /Day; DELVRY: Total Number of Delivery; DLVY: Number of Delivery/Bed /Day; ECGCS: Number
of ECG case; XRCS: Number of X-Ray case;
184
Appendices
Table A5.9
Descriptive Statistics of Output Variables of All the Hospitals
Standard
INPT 6941.600 2892.000 9381.230 6.122 2.496 35799.000 538.000 36337.000
IPBD 0.195 0.158 0.147 -0.061 1.086 0.462 0.052 0.514
DISGE 977.640 418.000 1915.955 7.221 2.809 7421.000 0.000 7421.000
DISC 0.034 0.008 0.046 0.205 1.220 0.147 0.000 0.147
DELVRY 6510.440 2848.000 8633.636 5.663 2.396 32388.000 415.000 32803.000
DLVY 0.186 0.156 0.146 0.066 1.091 0.483 0.026 0.510
ECGCS 3664.320 1500.000 9500.487 23.146 4.735 48500.000 0.000 48500.000
XRCS 7312.320 3219.000 16757.167 21.847 4.555 85404.000 0.000 85404.000
185
RSNBD RSNLP RSNPRO
tau
tau
tau
rho
rho
rho
Pearson
Pearson
Pearson
Kendall's
Kendall's
Kendall's
Spearman's
Spearman's
Spearman's
Correlation
Correlation
Correlation
-.089 -.089 -.089 .375** .375** .375** 1.000 1.000 1 RSNPRO
.053 .053 .053 1.000 1.000 1 .375** .375** .375** RSNLP
1.000 1.000 1 .053 .053 .053 -.089 -.089 -.089 RSNBD
.185** .185** .185** -.033 -.033 -.033 -.148* -.148* -.148* RSNINF
-.085 -.085 -.085 -.174** -.174** -.174** -.115 -.115 -.115 RSNREFF
Table A6.1
-.118 -.118 -.118 -.012 -.012 -.012 -.184** -.184** -.184** RSNPE
Healthcare Service
.093 .093 .093 -.202** -.202** -.202** -.162* -.162* -.162* RSNCOA
.065 .065 .065 -.140* -.140* -.140* -.112 -.112 -.112 RSNCHI
-.209** -.209** -.209** -.257** -.257** -.257** -.170** -.170** -.170** RSNEMG
Correlation Matrix OF Decision Variables
-.063 -.063 -.063 -.443** -.443** -.443** -.082 -.082 -.082 RSNES
-.135* -.135* -.135* -.145* -.145* -.145* -.162* -.162* -.162* RSNSKP
.030 .030 .030 -.179** -.179** -.179** -.127* -.127* -.127* RSNKP
-.060 -.060 -.060 -.151* -.151* -.151* -.069 -.069 -.069 RSNAHS
Appendix 6: Tables and Diagrams related to Patients’ Perception on
186
Appendices
RSNCOA RSNPE RSNREFF RSNINF
tau
tau
tau
tau
rho
rho
rho
Pearson
Pearson
Pearson
Pearson
Kendall's
Kendall's
Kendall's
Kendall's
Spearman's
Spearman's
Spearman's
Correlation
Correlation
Correlation
Correlation
-.162* -.162* -.184** -.184** -.184** -.115 -.115 -.115 -.148* -.148* -.148*
-.202** -.202** -.012 -.012 -.012 -.174** -.174** -.174** -.033 -.033 -.033
.093 .093 -.118 -.118 -.118 -.085 -.085 -.085 .185** .185** .185**
.221** .221** -.050 -.050 -.050 -.038 -.038 -.038 1.000 1.000 1
.024 .024 -.039 -.039 -.039 1.000 1.000 1 -.038 -.038 -.038
-.078 -.078 1.000 1.000 1 -.039 -.039 -.039 -.050 -.050 -.050
1.000 1 -.078 -.078 -.078 .024 .024 .024 .221** .221** .221**
.112 .112 .151* .151* .151* .017 .017 .017 .272** .272** .272**
-.033 -.033 -.077 -.077 -.077 -.129* -.129* -.129* .069 .069 .069
-.191** -.191** .036 .036 .036 .020 .020 .020 -.224** -.224** -.224**
.083 .083 -.147* -.147* -.147* .067 .067 .067 .072 .072 .072
-.038 -.038 -.048 -.048 -.048 .016 .016 .016 .047 .047 .047
-.025 -.025 -.055 -.055 -.055 -.105 -.105 -.105 -.046 -.046 -.046
187
Appendices
RSNSKP RSNES RSNEMG RSNCHI
tau
tau
tau
tau
rho
rho
rho
rho
Pearson
Pearson
Pearson
Pearson
Kendall's
Kendall's
Kendall's
Kendall's
Spearman's
Spearman's
Spearman's
Spearman's
Correlation
Correlation
Correlation
Correlation
-.162* -.162* -.082 -.082 -.082 -.170** -.170** -.170** -.112 -.112 -.112 -.162*
-.145* -.145* -.443** -.443** -.443** -.257** -.257** -.257** -.140* -.140* -.140* -.202**
-.135* -.135* -.063 -.063 -.063 -.209** -.209** -.209** .065 .065 .065 .093
.072 .072 -.224** -.224** -.224** .069 .069 .069 .272** .272** .272** .221**
.067 .067 .020 .020 .020 -.129* -.129* -.129* .017 .017 .017 .024
-.147* -.147* .036 .036 .036 -.077 -.077 -.077 .151* .151* .151* -.078
.083 .083 -.191** -.191** -.191** -.033 -.033 -.033 .112 .112 .112 1.000
.058 .058 -.133* -.133* -.133* .003 .003 .003 1.000 1.000 1 .112
.097 .097 -.152* -.152* -.152* 1.000 1.000 1 .003 .003 .003 -.033
-.206** -.206** 1.000 1.000 1 -.152* -.152* -.152* -.133* -.133* -.133* -.191**
1.000 1 -.206** -.206** -.206** .097 .097 .097 .058 .058 .058 .083
.001 .001 -.049 -.049 -.049 .159* .159* .159* .010 .010 .010 -.038
-.021 -.021 -.107 -.107 -.107 .275** .275** .275** -.057 -.057 -.057 -.025
188
Appendices
RSNAHS RSNKP
tau
tau
rho
rho
rho
Pearson
Pearson
Kendall's
Kendall's
Spearman's
Spearman's
Spearman's
Correlation
Correlation
-.069 -.069 -.069 -.127* -.127* -.127* -.162*

-.151* -.151* -.151* -.179** -.179** -.179** -.145*
-.060 -.060 -.060 .030 .030 .030 -.135*
-.046 -.046 -.046 .047 .047 .047 .072
-.105 -.105 -.105 .016 .016 .016 .067
-.055 -.055 -.055 -.048 -.048 -.048 -.147*
-.025 -.025 -.025 -.038 -.038 -.038 .083
-.057 -.057 -.057 .010 .010 .010 .058
.275** .275** .275** .159* .159* .159* .097
*. Correlation is significant at the 0.05 level (2-tailed).

**. Correlation is significant at the 0.01 level (2-tailed).
-.107 -.107 -.107 -.049 -.049 -.049 -.206**
-.021 -.021 -.021 .001 .001 .001 1.000
.004 .004 .004 1.000 1.000 1 .001
1.000 1.000 1 .004 .004 .004 -.021
189
Appendices
Appendices
Table A6.2
Total Variance Explained by the Principal Components
Extraction Sums of Rotation Sums of
Component Initial Eigenvalues
Squared Loadings Squared Loadings
% of Cumul % of Cumul % of Cumulat
Total Varian ative Total Varian ative Total Varian ive
ce % ce % ce %
1 1.953 15.026 15.026 1.953 15.026 15.026 1.735 13.348 13.348
2 1.684 12.956 27.983 1.684 12.956 27.983 1.732 13.327 26.675
3 1.486 11.427 39.410 1.486 11.427 39.410 1.436 11.046 37.721
4 1.219 9.377 48.787 1.219 9.377 48.787 1.318 10.137 47.858
5 1.165 8.959 57.745 1.165 8.959 57.745 1.209 9.298 57.157
6 1.014 7.797 65.542 1.014 7.797 65.542 1.090 8.385 65.542
7 0.876 6.735 72.277
8 0.842 6.479 78.756
9 0.805 6.193 84.948
10 0.705 5.424 90.373
11 0.590 4.537 94.910
12 0.462 3.552 98.462
13 0.200 1.538 100.00
Extraction Method: Principal Component Analysis.
Table A6.3
Component Matrix of Decision Variables
Component
Variables
1 2 3 4 5 6
RSNLP -.716 .480
RSNPRO -.684
RSNCHI .366 .345 .359
RSNES -.734 .425
RSNINF .388 .591
RSNEMG .467 -.639
RSNAHS -.558 -.354
RSNREFF .314 -.575
RSNSKP .367 -.570
RSNPE .302 .518 .624
RSNBD .404 .353 -.597
RSNKP .312 .791
RSNCOA .402 .386 -.421
Extraction Method: Principal Component Analysis.
190
Appendices
Table A6.4
Measurement of Differences among
Patients’ Perception about Hospitals (with ANOVA Framework)
ANOVA Table
Perception Sum of Mean
Comparison df F Sig.
About Squares Square
Between Groups 9.624 2 4.812 13.439 .000
Doctor Within Groups 88.440 247 .358
Total 98.064 249
Between Groups 27.150 2 13.575 28.573 .000
Nurse Within Groups 117.350 247 .475
Total 144.500 249
Between Groups 18.936 2 9.468 29.269 .000
Staff Within Groups 79.900 247 .323
Total 98.836 249
Between Groups 155.416 2 77.708 74.847 .000
Hygiene Within Groups 256.440 247 1.038
Total 411.856 249
Between Groups 23.380 2 11.690 29.609 .000
Overall
Within Groups 97.520 247 .395
Perception
Total 120.90 249
Note: df implies degree of freedom
191
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STUDY OF HEALTHCARE

MANAGEMENT SYSTEM IN WEST

THESIS SUBMITTED TO THE UNIVERSITY OF BURDWAN

Under the joint supervision of

I wish Sri Chatterjee all success in his endeavor.

TO WHOM IT MAY CONCERN

the Ph.D. degree in Arts (Commerce) of the University of Burdwan.

regulations of the University of Burdwan.

Date: ……………………… ………………………………………

In the framework of human development, health is considered as an individual right, which is

population stabilization. In view of this backdrop, accessibility to suitable and significant

especially in the developing and under-developed countries.

create health infrastructure in both qualitative and quantitative deliberation to provide

health status and successive better standard of living.

accomplishing the objective of upgraded healthcare status, receptiveness and equality in

Hospital efficiency, a particular measure of hospital performance, is considered for the

fundamental to the collective thought of wellbeing and infirmity.

Improved efficiency in healthcare domain can definitely minimize inter-regional variation of

satisfaction procedures should be utilized to observe the execution of health services

management of healthcare services across healthcare institutions (i.e., State Government

Hospitals, Other Public Hospitals and Private Hospitals).

considered for active discussion in this study.

acknowledge my profound indebtedness to my supervisors Prof. Jaydeb Sarkhel and Dr.

always been extraordinary. I owe my gratitude to Prof. Biswanath Ghosh, Prof. A. C.

Date: ………………… …………………………………………..

List of Tables and Charts ix-xii

Chapter 1 Introduction 1–6

3.3.4 Methodology Regarding Patients’ Perception on 40

3.4 Data Sources of the Study 42

Chapter 4 Public Healthcare Access and Its Linkages to 48 – 74

4.4.2 Index of Public Healthcare Access: An Inter- 60

6.3.1 Patients Access to Healthcare Institutions 109

List of Tables and Charts

Chapter 3: Objectives, Methodology and Data Sources 34 – 47

Table 3.1 Type of Hospitals in the District of Burdwan 36

Chapter 4: Public Healthcare Access and Its Linkages to Healthcare 48 – 74

Table 4.1 Description of the indicators and their data sources 55

Chapter 5: Measurement of Efficiency of Healthcare Institutions & Its 75 - 100

Table 5.7 Estimates of Efficiency Scores and Returns to Scale (Model 4) 90

Chapter 6: Patients’ Perception on Healthcare Services 101 - 133

Appendices 145 - 191

Table A1.1 List of Hospitals in the District of Burdwan 145

Chapter 4: Public Healthcare Access and Its Linkages to Healthcare 48 – 74

Figure 4.1 Relationship Between Public and Private Healthcare 52

Chapter 5: Measurement of Efficiency of Healthcare Institutions & Its 75 - 100

Figure 5.1 Distributions of Hospitals by their Scale of Operation 94

Chapter 6: Patients’ Perception on Healthcare Services from Alternative 101 - 133

Figure 6.1 Bar Diagram Showing Patients’ Perception on Doctor, 117

Appendices 145 -191

number is focused on healthcare of the population. Thus, immense importance is there to

construct healthcare infrastructure in both quantitative and qualitative consideration to offer

outcome and subsequent superior living standard.

The Constitution of India identifies it as a responsibility of the government to provide

play a significant role in the delivery of healthcare service. In fact, Public-private

considered as a permanent answer, especially in underdeveloped or developing democratic

development index observed that there is a considerable difference in infrastructure as well

and this necessitates individual attention. (Sheet et al, 2013).

tertiary-level healthcare service is delivered by medical college hospitals and apex

equality in healthcare financing.