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A Summer Internship Project Report On

Initiative for Health-Primary Healthcare

Prepared By: Pratik s patel Enrolment number: 107110592135 Batch: MBA 2nd SEM

Under the guidance of:

External Guide Dr. Hemang Shah (IFH Organization)

Internal Guide Dr. Abhijit Chatterjee (Director) Mr. Shantanu Chakravarty(Faculty)

PREFACE In todays hyper-competitive business environment and in era of cut-throat strategic approaches MBAs are sure to have an edge over their counter parts. During Post Graduation in Business Administration program, we being Students are exposed to real corporate world through Industrial Training. An MBA program provides its students with an in-depth study of various managerial activities that are performed in any organization. A detailed research/analysis of managerial activities conducted in various departments like Finance, Marketing, Human Resources, Production etc. gives the student a conceptual idea of what they are expected to manage, how to manage and how to obtain the maximum output through optimum utilization resources available and how to minimize the wastage of resources with better efficiency and effectiveness for bringing people together through inclusive growth, where health is a major issue and challenge before us.

ACKNOWLEDGEMENT

It is a moment of pleasure to present this project report undertaken by us as the fulfillment of our summer training for our course of Master of Business Administration. Having completed this project, we realized the importance of the people who have been a lot support to me. We would like to express our deepest gratitude to INITIATIVE FOR HEALTH, VADODARA for providing us with an opportunity of understanding a highly knowledge based sector i.e. healthcare. We are thankful to a group of medicopreneurs for their great initiative in this highly innovative project. We are thankful to Dr. Hemang Shah, for their boundless guidance and constant encouragement. At the same time we would like to thank our Director Dr. Abhijit Chatterjee and gaculty guide Mr. Shantanu Chakravarty for their support and guidance in SIP training with INITIATIVE FOR HEALTH.

Yours sincerely, Pratik s patel. 3

DECLARATION

I, am pratik s patel student of Dr.J.K.Patel Institute Of Management, hereby, declare that the Summer Project titled, INITIATIVE FOR HEALTH-PRIMARY HEALTH CARE is original to the best of my knowledge and has not been published elsewhere. This is for the purpose of partial fulfillment of Gujarat Technological University requirements for the award of the degree of Master of Business Administration, only.

Date: 27/7/2011 Place:vadodara

Name: pratik s patel

INDEX

1.0 EXECUTIVE SUMMARY

PAGE NO- (6)

2.0 SECTOR OVERVIEW 2.1 Overview of HEALTH CARE Sector 2.2 Overview of state (Gujarat) 2.3 Overview of Vadodara district 2.4 Challenges 2.5 Future Trend 3.0 LITERATURE REVIEW

(7-17)

(18)

5.0 ENTREPRENEURS BACKGROUND 6.0 RESEARCH METHODOLOGY 6.1 Objective 6.2 Sample size 6.3 Data Collection 6.4 Interpretation 7.0 SUGGESTIONS/RECOMMENDATIONS 9.0 BIBLIOGRAPHY 10.0 ANNEXTURE

(28) (34) (34) (35) (36) (37) (39) (40) (42)

EXECUTIVE SUMMARY

Concepts behind current health systems are no longer adequate for dealing with the growing complexity of the health arena, both internationally and nationally. It is now too simplistic to classify world health in bipolar terms, such as East versus West, or North versus South. Conversely, epidemiologic differentiation within each country is now producing internal polarization: diminishing health care budgets may increase competition for scarce resources between two different groups of health problems the left-over ills, caused mainly by common infectious diseases and malnutrition; and the emerging threats of chronic ailments, accidents, mental disorders, and now AIDS. In this situation, the former group is likely to lose out. It is imperative to avoid this pernicious competition by developing new health care models that assume a population-based responsibility. Unless comprehensive and cost-effective solutions to the two groups of health problems are provided simultaneously we risk an unacceptable paradox: instead of being an instrument for equity, health services may serve to increase social inequality. Under this condition while socio-economic structure of India is changing at a pace and state like Gujarat is prospering in terms of economy, healthcare is of paramount importance. Gujarat has seen and experienced many entrepreneural activity in past but present approach is quite unique in nature. Present study could evaluate on the point that a paradigm shift in healthcare management at primary point in rural as well as urban area can be highly beneficial for people and country. Need has been identified as well as project cost could be evaluated in terms of operation, finance as well as marketing

SECTOR OVERVIEW

OVERVIEW OF HEALTH CARE SECTOR

Healthcare in India

As features a universal health care system run by the constituent states and territories of India. The Constitution charges every state with "raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002.However, the government sector is understaffed and underfinanced; poor services at state-run hospitals force many people to visit private medical practitioners. Government hospitals, some of which are among the best hospitals in India, provide treatment at taxpayer expense. Most essential drugs are offered free of charge in these hospitals. Government hospitals provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in India) costs a onetime fee of rupees 10 (around 20 cents US) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually much less than the private sector. For instance, a patient is waived treatment costs if he is below poverty line. Another patient may seek for an airconditioned room if he is willing to pay extra for it. The charges for basic in-hospital treatment and investigations are much less compared to the private sector. The cost for these subsidies comes from annual allocations from the central and state governments. Primary health care is provided by city and district hospitals and rural primary health centers (PHCs). These hospitals provide treatment free of cost. Primary care is focused on 7

immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses. Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals). History The art of healthcare in India can be traced back nearly 3500 years. From the early days of Indian history the Ayurvedic tradition of medicine has been practiced. During the rule of Emperor Ashoka Maurya (third century BCE), schools of learning in the healing arts were created. Many valuable herbs and medicinal combinations were created. Even today many of these continue to be used. During his rein there is evidence that Emperor Ashoka was the first leader in world history to attempt to give health care to all of his citizens, thus it was the India of antiquity which was the first state to give its citizens national health care.

Healthcare Infrastructure

The Indian healthcare market was estimated at US$35 billion in 2007 and is expected to reach over US$70 billion by 2012 and US$145 billion by 2017.According to the Investment Commission of India the healthcare sector has experienced phenomenal growth of 12 percent per annum in the last 4 years..

India faces a huge need gap in terms of availability of number of hospital beds per 1000 population. With a world average of 3.96 hospital beds per 1000 population India stands just a little over 0.7 hospital beds per 1000 population. Moreover, India faces a shortage of doctors, nurses and paramedics that are needed to propel the growing healthcare industry. India is now looking at establishing academic medical centers (AMCs) for the delivery of higher quality care with leading examples of The Manipal Group & All India Institute of Medical Sciences (AIIMS) already in place. As incomes rise and the number of available financing options in terms of health insurance policies increase, consumers become more and more engaged in making 8

informed decisions about their health and are well aware of the costs associated with those decisions. In order to remain competitive, healthcare providers are now not only looking at improving operational efficiency but are also looking at ways of enhancing patient experience overall. India has approximately 600,000 allopathic doctors registered to practice medicine. This number however, is higher than the actual number practicing because it includes doctors who have immigrated to other countries as well as doctors who have died. India licenses 18,000 new doctors a year

Primary services Health care facilities and personnel increased substantially between the early 1950s and early 1980s, but because of fast population growth, the number of licensed medical practitioners per 10,000 individuals had fallen by the late 1980s to three per 10,000 from the 1981 level of four per 10,000. In 1991 there were approximately ten hospital beds per 10,000 individuals. For comparison, in China there are 1.4 doctors per 1000 people.

Primary health centers are the cornerstone of the rural health care system. By 1991, India had about 22,400 primary health centers, 11,200 hospitals, and 27,400 clinics. These facilities are part of a tiered health care system that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast majority in the countryside. Primary health centers and subcenters rely on trained paramedics to meet most of their needs. The main problems affecting the success of primary health centers are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas. In addition, the integration of health services with family planning programs often causes the local population to perceive the primary health centers as hostile to their traditional preference for large families. Therefore, primary health centers often play an adversarial role in local efforts to implement national health policies.

OVERVIEW OF HEALTH CARE SECTOR IN GUJARAT

Introduction

Health is the fundamental human right. State has the responsibility for the health of its citizens. The Department of Health and Family Welfare, Gujarat is striving for the attainment of health of its people through the wide network of the Government Health Care delivery system. Health care is more than mere medical care. It embraces a multitude of services provided to the individual or community by health personnel aiming at promotion, protection and restoration of the health of the people. The Department of the Health & Family Welfare, Gujarat State has made available integrated health services to the people of Gujarat though its Primary Health Care network spread across the state. The current focus is on providing healthcare in rural areas becaus of the large gap in service availability in these areas.

History On 2nd October 1952, a two tier rural health care system came into existence throughout India, and in the state as well to fulfill these objectives. Under this system, one six bedded Primary Health Centre and four Sub Centers attached to it were established in each Community Development Block. Following the World Health Summit at Alma Ata and declaration of the goal of Health for All (HFA) 2000 AD the concept of Three Tier health care system was framed. Being a signatory to HFA-2000, the three tier system was rolled out in India under the rural services with the Fifth Five Year Plan in 1978. This system was based on the concept of primary health care, defined as "essential Health Care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford. 10

Under the Guidance of the Commissioner (Health), the Additional Director Rural Health organizes, implements and monitors rural health care services with the help of Regional Deputy Directors and other Programme officers. CDHOs with the help of other health officers and staff look after all health activities in their respective districts. The three tier system following the Primary Health Care approach coupled with the various national health programmes, including Epidemic, Malaria, Blindness and Tuberculosis Control; Leprosy elimination; Polio and Yaws eradication; Reproductive and Child health & Family welfare; Health education, School Health Programme etc. deliver health services to the remotest areas of the state.

The department is constantly working to promote and protect the health of the community through expansion of the health infrastructure, increased recruitment of health personnel, and integration of promotive, preventive, curative and rehabilitative health services

VADODARA DISTRICT PROFILE

Historical perspective ( Vadodara )

Many evidences of human population of years ago have been acquired from the area Dhatakri which is at the west border of the river vishwamitri. Approximately around five thousand years back, this human race initially used the stone weapons. Eventually positive changes continued in the same area Akota is located and eventually its area developed and amongst them one of the areas is one of the elements of todays Kothi area. In this area this place had been developed near the banyan tree and therefore this place is known as Vatpatrak. It has been estimated that the word Vadodra has been derived from that. In Marathi language Vadode, In Parsi Badahade in Hindi Badoda and in English Baroda has been evolved. It is believed that the oldest remainings of Baroda are not more than Sixteen hundred years old. 11

Akota located on the river side of the river vishwamitri had to frequently face lots of losses due to the flood waters. There was huge destruction of man and materials ,tool place. Therefore with the notion of safety, people started sifting from Akota to this place and in this way Baroda had marched for success and so in continuation of this areas success, it happened to become the main hub of the district. Baroda district is one of the most important districts of Gujarat. It is located between 21 degree to 23 degree longitude and 73 degree to 74 degree latitude. It is located on the plain region of Madhya Pradesh, from Gujarat Panchmahal district is on the north side of Baroda district, Kheda district at the border of north-west border, Bharuch district in the south and in north-west direction. Zabva district of Madhya Pradesh in the north direction and Dhuliya district of Madhya Pradesh is in the direction of Agni borders. In the north and south direction river Mahi sagar and Narmada are situated. Moreover rivers passing through this district and meeting khambhat are jambova, surya, vishwamitri and Dhadhar rivers. Important religious places like Chanod, Karnali, Nareshwar, Motikoral and many others are located on the river side of river Narmada which passes through the district Baroda. According to 2001 census, total perimeter is 7550 square kilometers. According to 2001 census there is a population of 36.40 lakhs and the population density per square kilometer is of 482 persons which is more than the state density being 258. Land Area Information Majority of the area is the part of the plane of middle Gujarat. Due to the inclusion of Chota Udaipur Jetpurpavi,Kanwat and Naswadi the east area is hilly and therefore the land is unequal, where as the other portion is of fertile soil but sandy. Dense trees at the banks of rivers Mahi and Narmada are spectacular. Total geographical area of the district is 7550 hectares. Rivers and Water Reservoirs Among the District Rivers, Narmada and Mahi are the main rivers. Mahi flows from the north to south-west and the river makes the vegetation fertile by land minerals long bank of Narmada makes the land fertile by its rich alluvium deposits. Religious temples and Maqbaras like ancient monuments make the river bank picturesque. Important religious places like Chanod, Karnali, Nareshwar, Motikoral and many others are located on the river side of river Narmada which passes through the district Baroda. Moreover Jambuva, Surya, Vishwamitri and Dhadhar are the rivers which pass through and meet the Bay of Khambhat. Satpuda and Sahadri range of mountains are at the borders of the district. Mountain Pavagahd of the Jilla Panchmahal is located at the east border.

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Population Statistics : There are total 50 villages having population of more than 5000 people. According to the census, the population rise of a decade in male is 17.47% , in female is 18.30% and the total percentage is 17.87. There are 919 females per 1000 males. Rural population rate is 45.20.

SERIAL NO

MALE

FEMALE

TOTAL

URBAN AREA

1034338

961242

1995580

RURAL AREA

863030

783192

1646222

TOTAL

1897368

1744434

3641802

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DISTRICTS POPULATION INFORMATION:

Vadodara distinct:

SEX MALE

URBAN 863030

RURAL 1034338

TOTAL 1897368

FEMALE

783192

961242

1744434

TOTAL

1646222

1995580

3641802

SCHEDULE CASTES SCHEDULE TRIBES

109989

94296

204285

79108

888285

967393

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POPULATION INFORMATION IN VADODARA POPULATION Rate of Population Rise percentage 17.87

Population density Females per thousand men Citys population percentage

482 919 45.20%

Total Employed And Its percentage Principal Employees And Its percentage General Employees And Its percentage Non-working people And Its percentage Literacy rate details

1518845 41.70% 1202620

33.00% 316225 8.70% 2122957 58.30% 70.80%

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Challenges:

High capital costs: Depending on the region and real estate costs, an average hospital requires capital infusion of Rs 40 lakhs to a crore per bed (& even more). Industry estimates suggest that any hospital with capital costs of more than 50 lakhs per bed has high gestation period and even may be unviable. Land and building together account for almost 40 per cent of the total project cost and affects the viability depending on the resulting per bed cost. Medical equipment: Contributing to almost 40 per cent costs in a tertiary setup, the medical equipment though cutting edge at the time of purchase poses the threat of inevitable obsolescence within five to seven years of setup. This problem is compounded by the fact the most of such equipment is imported and very few local reputed manufacturers exist. This will lead to apportioning to higher treatment costs and will further lead to lesser competitive edges and low utilization rates resulting in an undesired operating margins. Human resources: As Dr Prathap Reddy puts it, "the biggest challenge for him and Apollo is filling the void of human resources". The fast-expanding domestic healthcare industry is the third largest employer, but is severely short of manpower, according to him. As per ministry of health, there is a shortage of approximately half a million doctors, a million nurses and the deficit needs to be filled in the next five years. Such shortage will lead to exponential salary hike demands, and further lead to high patient care costs. With organised sector being the preferred choice now, there will be a huge demand even for the skilled and quailed health administrators to run the show. Considering one skilled and quailed administrator is required for every 50 employees, there would be a requirement of almost 50000 such healthcare professionals in the near future. Highly regulated environment and unrealistic stringent norms and restriction of entry to the private entities in the field of medical education has led to further deficiencies in terms of number of skilled professionals being released for intake by various hospitals.

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FUTURE TREND Dahej to get 50-bed hospital The rapidly developing industrial belt of Dahej will soon have a 50-bed hospital. At present, the region does not have a medical facility of this scale. The nearest mid-scale medical facility is at Bharuch, 45 km away. Dahej Health & Welfare Society, formed by Reliance Industries and the state government, will construct and operate the hospital. It will provide free treatment to families living below the poverty line and patients referred by the public health centres will be subsidized up to 70 per cent. There are more than 10,000 workers in a region and another 8,000 population residing in nearby villages like Lakhigam, Ambheta, Jageshwar, Dahej and Nawa Vadia. The hospital will provide outdoor medical services for nearby communities, outreach mobile services, family planning camps, blood donation drives, vaccination centers, diagnostic multidisciplinary camps, eye camps and HIV/AIDS awareness drives.

(Source : TOI 24/07/2011)

Ten Industry Trends 2010

Trend 1 : Public-private partnership Trend 2 : Single speciality delivery model Trend 3 : Diagnostic centres Trend 4 : Low-cost healthcare delivery models Trend 5 : Healthcare system- staying connected to patients Trend 6 : Integrated medicine Trend 7 : Technology partnership-arresting the rising cost Trend 8 : Operations optimization-rewarding performance Trend 9 : Patient safety-a renewed focus Trend 10: Healthcare design-alternative care settings

Source: Outlook Express 17

LITERATURE REVIEW

Indian Public Health Standards (IPHS) For Primary Health Centers

Directorate General of Health Services Ministry of Health & Family Welfare Government of India

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Indian Public Health Standards for Primary Health Centers

The concept of Primary Health Centre (PHC) is not new to India. The Bhore Committee in 1946 gave the concept of a PHC as a basic health unit to provide as close to the people as possible, an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care.

The health planners in India have visualized the PHC and its Sub-Centers (SCs) as the proper infrastructure to provide health services to the rural population. The Central Council of Health at its first meeting held in January 1953 had recommended the establishment of PHCs in community development blocks to provide comprehensive health care to the rural population. These centers were functioning as peripheral health service institutions with little or no community involvement. Increasingly, these centers came under criticism, as they were not able to provide adequate health coverage, partly, because they were poorly staffed and equipped and lacked basic amenities. The 6th Five year Plan (1983-88) proposed reorganization of PHCs on the basis of one PHC for every 30,000 rural populations in the plains and one PHC for every 20,000 population in hilly, tribal and backward areas for more effective coverage. Since then, 23,109 PHCs have been established in the country (as of September 2004). PHCs are the cornerstone of rural health services- a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who directly report or referred from Sub-centers for curative, preventive and promotive health care.

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Infrastructure

The health care infrastructure in rural areas in India has been developed as a three tier system and is based on the population norms as shown in Table 2.1.

Table 2.1 : Primary Health Structures and their Population Norms Centre Sub-Centre Primary Health Centre Community Health Centre Plain Area 5000 30,000 1,20,000 Tribal/Difficult Area 3000 20,000 80,000

Sub-Centres (SCs) The Sub-centre is the most peripheral health unit and first contact point between the primary health care system and the community. Each sub-centre has one Female Health Worker/ANM (Auxiliary Nurse Midwife) and one Male Health Worker. One Female Health Assistant (Lady Health Visitor LHV) and one male health assistant supervise six sub centers. Sub-centres are assigned to perform tasks related to components of primary health care. They are provided with basic drugs for minor ailments needed for taking care of essential health needs of population. The Government of India is providing 100% central assistance to all sub-centres in the country since April 2002 in the form of salaries of ANMs and LHVs and rent of buildings.

There are 1, 45,272 sub-centres functioning in the country as on March 2007. The progress in number of existing sub-centres is shown in Figure 2.1. NRHM has proposed strengthening of sub-centres in the form of provision of untied fund of Rs10,000 per annum. This fund to be utilized for local needs and maintenance of subcentres. The units will also be provided with essential drugs, both

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allopathic and AYUSH. Up gradation of subcenters is planned with provision of additional manpower in vacant positions

Primary Health Centers (PHCs)

PHCs remain the first contact between village community and Medical Officer. They are manned by a Medical officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 sub-centers. It has 4-6 beds for patients. There are 22,370 PHCs functioning as on March 2007 in the country NRHM aims at strengthening of PHCs for quality preventive, promotive, curative, supervisory and outreach services, through: Adequate and regular supply of essential quality drugs and equipment to PHCs Provision of 24 hour service in at least 50% PHCs by addressing mainstreaming shortage of doctors, especially in high focus states, through manpower. Observance of standard treatment guidelines and protocols. Intensification of ongoing communicable disease control programmes, new programmes for control of non-communicable diseases, up gradation of 100% PHCs for 24 hour referral service, and provision of second doctor at PHC level (1 male, 1 female) to be undertaken on the basis of felt need. Community Health Centers (CHCs) CHCs are manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, labour room and laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March 2007, there are 4,045 CHCs functioning in the country.

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NRHM aims to strengthen services at CHCs by operationalising 100% CHCs as 24 hour First Referral Units (FRUs), including posting of anesthetists. New Public Health standards have been formulated for all cadres of primary health care functioning units including CHCs. The objectives of these public health standards are essentially to provide optimal expert care to the community; to achieve and maintain an acceptable standard of quality of care; to make the services more responsive and sensitive to the needs of the community. A set of assured service package is provided to population. An additional public health programme manager posting is recommended on contractual basis at all CHCs for supervising surveillance operations; coordination of national health programmes; management of ASHAs etc. A standard set of essential drugs and equipment is enlisted at CHCs level. Quality assurance is envisaged in delivery of health care and is recommended that every CHC to have the charter of patient rights prominently displayed at entrance of CHCs.

Manpower

The existing manpower is an important prerequisite for the efficient functioning of the Rural Health Infrastructure. Despite significant progress made in terms of creating manpower over the years, there remains a huge gap in terms of human resources at primary care level, which is realized by the government of India, and the process is underway to bridge the gap. The graphs beneath represent the shortfall in these primary care manpower resources.

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Out Sourcing of Primary Health Care to NGOs

24 X 7 PHCs Availability of essential drugs throughout the year.

Taking total responsibility of the PHC population: No duplication Effective implementation of Reproductive Child Health New Born care.

Good Referral System: Transport for emergencies - One of the staff accompa nies the patient Mainstreaming of HIV/AIDS in PHC Addressing Specific problems: Sickle Cell Anemia & Hot Water Epilepsy . PHC Waste Management Male Health worker, Staff Nurse, Pharmacist, Lab Technician stay in PHC headquarter.

Specialist services at PHC: Obstretician & Gynaecologist, Ophthalmologist,Physician, Pediatrician 23

Financial resources for Primary Health Care India's estimated health expenditure for the year 2001-02 was 4.8% of the GDP. Out of this, central, state, and local governments spent one fourth of the total expenditure Share in Healthcare Spending shown below:

government Expenses

Public/private 25% Enterprise 3% insurance 2% NGO House hold 70%

Households (out of pocket expenditure) contribute maximum share in health spending. In per capita terms, household expenditure measured in nominal prices has almost tripled from Rs 364 in 1995-96 to Rs 905 in 2003-04, while real per capita household expenditure is expected to only marginally increase from Rs 265 to Rs 367 respectively.

Public spending on health in India has increased from 0.22% of GDP in 1950-51 to 1.05% of GDP during the mid-1980s, and stagnated at around 0.9% of the GDP during the later years. In terms of per capita expenditure, it increased significantly from less than Re 1/- in 1950-51 to about Rs 215 in 2003-04. However in real terms, for 2003-04 this is around Rs 120. This is considered far below what is recommended for low-income countries

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BASIC REQUIREMENT FOR PRIMARY HEALTH CARE

Medical care: OPD services: 4 hours in the morning and 2 hours in the afternoon / evening. Time schedule will vary from state to state. Minimum OPD attendance should be 40 patients per doctor per day. 24 hours emergency services: appropriate management of injuries and accident, First Aid, Stabilisation of the condition of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions Referral services In-patient services (6 beds)

Maternal and Child Health Care including family planning Nutrition and health counseling Identification of high-risk pregnancies/ appropriate management Intra-natal care: (24-hour delivery services both normal and assisted) Promotion of institutional deliveries Conducting of normal deliveries Assisted vaginal deliveries including forceps / vacuum delivery

Nutrition Services (coordinated with ICDS) Diagnosis of and nutrition advice to malnourished children, pregnant 25

women and others. Diagnosis and management of anemia, and vitamin A deficiency. Coordination with ICDS.

School Health

Regular checkups, appropriate treatment including deworming, referral and followups

Adolescent Health Care:

Life style education, counseling, appropriate treatment.

Promotion of Safe Drinking Water and Basic Sanitati

Prevention and control of locally endemic diseases like malaria, Kala-azar, Japanese Encephalitis, etc.

1. Alertness to detect unusual health events and take appropriate remedial measures 2. Disinfection of water sources 3. Testing of water quality using H2S- Strip Test (Bacteriological) 4. Promotion of sanitation including use of toilets and appropriate garbage Disosel.

Referral Services:

1. Appropriate and prompt referral of cases needing specialist care including: 2. Stabilization of patient 26

3. Appropriate support for patient during transport 4. Providing transport facilities either by PHC vehicle or other available referral transport

Training: Health workers and traditional birth attendants Initial and periodic Training of paramedics in treatment . Periodic training of Doctors through Continuing Medical Education.

Basic Laboratory Services:

Essential Laboratory services including: i. Routine urine, stool and blood tests ii. iii. Bleeding time, clotting time, Diagnosis of RTI/ STDs with wet mounting, Grams stain, etc.

iv. Sputum testing for tuberculosis v. Blood smear examination for malarial parasite

Monitoring and Supervision: Monitoring and supervision of activities of sub-centre through regular Meetings / periodic visits, etc. Monitoring of all National Health Programmes Monitoring activities .

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ENTREPRENEURS BACKGROUND

INITIATIVE FOR HEALTH

The project shall involve making standardized, affordable, primary care available to people in Tier 2/ 3 cities at block level as well as urban centres across India. The clinics shall serve as first point of contact for the population of that area. These clinics shall have all the basic facilities and shall use new technological solutions in accordance with the settings in order to ensure the speedy and quality care.

These clinics shall have MBBS doctors working as part/ full time along with trained staff for X-Ray, Lab, Nursing, Pharmacy & Manager for the Centre. First 30 Clinics shall be owned by IFH; thereafter it shall go in for franchising opportunity. In its later phases IFH shall convert some of these centres into centres for excellence in particular specialities depending upon the needs of the place and availability of resources over there. Care would be taken in this regard to take up Gynae and Obs as preferred speciality.

IFH shall also venture into training of their as well as other doctors in the updated medical technologies and methods of practices. IFH intends to use technical solutions for telemedicine, tele-radiology, and smart equipments in Lab and quality drugs. IFH owned community backed centres would also venture in the preventive and promotive aspects of healthcare. This would be initially start in the urban centres by way of 28

permanent memberships for the customers. Immunization and ante natal - post natal care would form a very important aspect of day to day operations.

NEED:

It is a well known fact that there is great mismatch in terms of available resources and demand as far as delivery of healthcare is concerned in the rural areas as well as urban outskirts in India. Even in fast developing states like Gujarat the average population served by government doctors is 25,000 (the overall doctor population ratio is below 500 in most developed countries) which is alarmingly high by all standards. Hence most population out of compulsion and choice go to private settings for their curative needs. The population in these areas rely heavily on the quacks and other non allopathic doctors who even though are not trained to practice allopathic medicine, do so and the patient either pays for under quality treatment or ends up paying more for the disease at the higher centre that could have been treated correctly in the first place. The choice of drugs by these doctors is mostly governed by presentations made by Medical representatives of pharmaceutical companies. This leads to prescription of unnecessary high priced combination of drugs. The consultation charge of the doctor is moderate but overall cost to the patient is more and to the society its huge. Moreover in the smaller towns and cities there is common practice of referring the patients to higher centre for referral from where these doctors get kickback SUBSTAINED COMETITIVE ADVANTAGES:

IFH shall create a mix of modern day practice of medicine with the age old reassurance of personalized care that has simply disappeared from medical science. Community's trust would be of paramount importance which would be gradually built by way honest and effective treatments. At IFH we intend to bring back the concept of neighbourhood physician who provides patients with the best possible primary treatment, diagnoses patients ailments at very early stage sparing the patient of unnecessary agony, provide true referral to the patients wherein the advice is based on the need of the patients rather the monetary gain. Prescriptions shall be generic and based on the need of the patient. Few of the distinct advantages for the patients as against existing health care providers would be: 29

1. Optimal care: It means that the care provided at these clinic shall be what is actually needed, neither low nor more. (neither misdirected under treatment by quacks nor overpriced services by specialists for primary care) 2. One stop treatment: Here not only doctor shall see the patient but the diagnostics( X-Ray & Lab)would also be done under one roof and thus proper diagnosis shall be made with minimum hardship. In house pharmacy would also be available. 3. Referral advice & guidance and connections: Patient coming to IFH shall have added advantage even in those cases where illness is beyond the scope of the treatment of the clinic. IFH shall provide the patient with the information about where to go, and liaison with the referral unit would be made in the benefit of the patient. This would be achieved because of privileged position of IFH as first touch for a wide patient base. 4. Telemedicine: Weekly visits by specialists would be arranged according to the local needs. In those cases where the specialist doctors are not available in the nearby areas IFH shall bring in technology solutions wherein the details (History, Clinical Details, Radio graphs) of the patient shall be sent to the referring doctor who shall then suggest the treatment thus saving both time and money of the patient. 5. Home based diagnostic tests for old age patients: Service of home based diagnostic tests at the existing market rates would be provided for the chronic diseases like Diabetes, Hypertension etc

Possible setbacks:

The availability of trained staff would be one of the major challenges for this project. To get MBBS doctors who would be willing to go at block level would be a major task. This is one of the main reasons to start the venture from Vadodara city of Gujarat state. There are 330 MBBS seats in the district. 80 more are soon going to be approved. With around 80 Post graduation seats there is good enough possibility of getting MBBS doctors. 30

Some of the differentiating factors for them to choose IHF as against joining as medical officers would be: 1. Compensation: the package would be lucrative both as salary and incentives on work which shall be better than satisfactory. Special incentives for those who will maintain the standard of care and on reaching particular level of revenue there would be profit sharing. 2. Professional growth: IFH is aiming to become the largest chain in terms of primary health care providers. The growth that has been estimated for IFH shall also bear fruits for everyone who shall be involved with it. 3. Security: Working with "Branded Healthcare Providers" and flexi - hours shall provide you with a security and assured growth. 4. Better trained staff and facilities and good working environment: We shall ensure that the working environment is healthy and conducive to good work. The doctor would only be treating patients and would not be bothered with unnecessary paper work. The promoters with their personal experience as providers of care and managerial roles in private and public health facilities have in mind the HR policy (which is virtually nonexistent in health care field) which would be conducive to attract and retain best of talent. The initial set up would be created in districts with easy availability of MBBS doctors. With brand properly established the fully operational model would help overcome the migration threshold of young doctors.

Scalability The target patient base for the services would be those who can afford up to Rs. 50 as consultation charge for first visit. (Drugs and diagnostics would be extra). This range is not markedly different from what is currently charged in most places where these clinics are going to be operational. (Based on initial results of market survey being conducted in prospective locations).With 62.5 % middle class population (CRIS infac, 2005) and 6163% people reportedly using some kind of OPD services (61st NSS survey) in a 30 day period the sustainability would not be an issue and scalability of the model would be immense if it strikes the right chord with the community to which the clinic is serving. Currently there are no schemes of government of Gujarat promoting private players in the field of primary care. But successful operations of these clinics would pave path for fruitful dialogue with the government which would ultimately result in quality primary care for those who cannot afford Rs. 50 as the consultation charge

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Project Phasing: Phase 1 (July 2011Feb 2012) The time from June 2011 to December 2011 shall be utilized to understand the places where the pilots are going to be run and thereafter the rest of the time shall be used to finalize the details of the individual clinics along with raising funds. Once the funds are raised the cluster of 6 clinics shall be made and furnished. (Jan 2012-Feb 2012-60 Days)

Phase 2 August)

(March -

Phase 3 (September December 2012)

This phase shall be the consolidation phase wherein the clinics shall be operated and fine tuning would be done with regards to the operations. Both operational as well as clinical protocols shall be field tested. This phase shall also involve actively finding and developing relations for tie ups with for the secondary and tertiary healthcare providers. They shall be labelled and identified as IFH Referral centres. Phase three would see addition of 12 more clinics based on learning of earlier 6 clinics. So by December 2012 there would be 18 functional IFH clinics.

Phase 4 ( till June 2013) Phase 5 (till October 2013) Phase 6

Considering that the previous cluster has achieved breakeven there would be a re consolidation phase, similar to phase 2. Active looking for adding 12 more functional units. Same time IFH shall also actively seek partners for franchising. Revamping the 1/5 clinics into speciality clinic as per requirements.

Phase 7

Repeat of the above cycle in different geography / Relook At that time.

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PROMOTERS BACKGROUND This project is being promoted by Dr. Hemang Shah (MBBS, MHA), Dr. Hitesh Bhasker (BDS, MHA) and Dr. Tapan Shah (MBBS, DNB). With expertise in the field of clinical medicine, public health and hospital management the promoters wish to create a self sustaining model in the field of Primary Health care.

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RESEARCH AND METHODOLOGY

Entire project will be executed as well as evaluated in seven steps, present study is conducted for first phase with a detail guideline and brief of project provider. To draw a possible conclusion on this study at every step primary data with the help of a structured questionnaire has been collected along with some interview also because of nature of the project. With the help of excel sheet wherever possible qualitative data has been represented in quantitative form to draw a conclusion while presented in terms of chart as well as matrix.

Objectives of study:

To understand the perception of doctors, patients as well as society on the concept of primary healthcare. To estimate the cost involved in establishing the primary healthcare units at rural as well as urban areas of Vadodara. To understand the associated problems in terms of human resource and technology that is medical equipment to setup PHCs. To decide on the locations to execute pilot project.

In the resesch the main objective of Initiative for Health to establish the primary health care in rural area and the urban block in india. In this research the survey has be taken regards in vadodara for urban area and rural area including all the talukas of vadodara distinctict. There will be 8 block in the rural area including all talukas Savli,sankheda,Dabhoi,waghodia,karjan, nadiad,annd padra,

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The research based non by knowing to local public about Consultation, facilities, Pharmacy, waiting time,cost,cleanness.

Also knowing by quality of consultants, diagnostics services, cost of services , avibility of medicines, cleanness.

Sample size Sample data of raopura(vadodara) block by knowing no of doctors including M.B.B.S,B.A.M.S,B.H.M.S by taking the current health care facilities

NO OF CONSUMERS COVER IN RAOPURA BLOCK:

47 consumer should be cover by knowing name, age, gender, salary, education, And also taking information about Doctor reputation Closer to home Consultant fees Diagnostics facility Pharmacy Services in raopura block.

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Data collection:

As the project is confidential in nature so a structured questionnaire had been provided for data collection. 1st phase of this project is exploratory in nature while review of literature has been conducted. Interpretation of data with the help of excel sheet.

Consumer information in raopura

In raopura the consumer information taken by NAME, AGE, GENDER, EDUCATIONAL,OCCUATION, SALARY

By takes some information about asking question as follows 1. How many times visited physician in last 1 year 2. Where did you last visit physician. a. 1.clinic b. 2.nursing home c. 3.out side city

3. How many year associated with physician. a. 1-2 year 2-5 year 5+ year Criteria for choosing health care Doctor reputation Closer to home 36

Consultant fees Diagnostics facility Pharmac

Salary survey for PHC in raopura

Nurse -2000 to 3000 Comounder-2000 to 3000 X ray technician -3000 to 4000

Good area for establishing PHC in raopura accordance to people of raopura they want the primary health centre should be require near the Near tower choak.

Interpretation

By Taking information from consumer from differ rural and urban the selection made of any health care they give reference given below:

PARTICULAR

URBAN AREA (raopura)(percentage)

DOCTORS REPUTATION CLOSER TO HOME CONSULTATION FEES DIAGNOSTIC FACILITIES PHARMACY

42% 12% 20% 22% 4%

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RAOPURA

Doctor reputation 42% Consultation fees 22% Diagnostics facilities 20% Closer to home 12% Pharmacy 4%

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SUGGESTIONS/RECOMMENDATIONS

Growth rate of Indian economy is now comparable with BRIC ( Brazil, Russia, India and China ) while developed countries are considering this as an opportunity so a business model can be planned to tackle this challenge by adding insurance as major component of the model. Small and medium enterprises ( SMEs) are backbone of any economy and as part of their corporate social responsibility (CSR) possibility of developing a model can be planned.

Gujarat being a state where we have highest number of non-residentIndian (NRI) population so medical tourism can be explored with the model. There are quite a good numbers of qualified medical practitioners available in the blocks and talukas operating in their own clinic with poor infrastructure so a model can be evaluated as partnership model or cooperation model.

Indian pharmaceutical industry is taking a paradigm shift because of product patent regime and looking for a model where they can come closer to the customer as well as consumer so some model can be developed by bringing them close to present model. Healthcare is considered to be in priority sector under planning commission of India apart from education and agriculture so a model with government in terms of private, public, partnership (PPP) can be explored.

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BIBLIOGRAPHY

1. National Rural Health Mission 2005-2012 - Reference Material (2005), Ministry of Health & Family Welfare, Government of India. 2. Bulletin on Rural Health Statistics in India (2005), Infrastructure Division, Department of Family Welfare; Ministry of Health & Family Welfare, Government of India. 3. Guidelines for Operationalising 24x7 PHC (2005) (unpublished), Maternal Health Division, Department of Family Welfare, Ministry of Health & Family Welfare, Government of India. 4. Guidelines for Ante-Natal Care and Skilled Attendance at Birth by ANMs and LHVs (2005), Maternal Health Division, Department of Family Welfare, Ministry of Health & Family Welfare, Government of India. 5. RCH Phase II, National Program Implementation Plan (PIP) (2005), Ministry of Health & Family Welfare, Government of India. 6. Guidelines for Setting up of Rogi Kalyan Samiti / Hospital Management Committee (2005) (unpublished), Ministry of Health & Family Welfare, Government of India. 40

7. Indian Standard: Basic Requirements for Hospital Planning , Part-1 up to 30 Bedded Hospital, IS: 12433 (Part 1)-1988, Bureau of Indian Standards, New Delhi 8. Indian Public Health Standards (IPHS) for Community Health Centre (April 2005), Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India.

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ANNEXTURE

1. Google map

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