CHAPTER 4 PROBLEMS AND PROSPECTS OF HEALTHCARE INDUSTRY IN GUJARAT

CHAPTER 4 PROBLEMS AND PROSPECTS OF HEALTHCARE 4.1 OVERVIEW INDUSTRY IN GUJARAT Gujarat Population Census Data shows that it has Total Population of 6.04 Crore which is around 4.99% of total Indian Population. Literacy rate in Gujarat has seen rising tendency and is 79.31% as per 2011 population census. Of that, male literacy stands at 87.23% while female literacy is at 70.73%. Urban Population of the State is 42.6%, which used to be at 37.4% in 2001. Rural population in the state in 2011 fell to 57.4% from 62.6% in 2001. At present the state has 33 districts (226 talukas, 18,618 villages, 242 towns) TABLE 4.1 Demographic, Socio-economic and Health Profile as compared to India Indicator Gujarat India Total population (In crore) (Census 2011) 6.04 121.01 Decadal Growth (%) (Census 2011) 19.3 17.64 Infant Mortality Rate (SRS 2013) 38 42 Maternal Mortality Rate (SRS 2010-12) 122 178 Total Fertility Rate (SRS 2012) 2.3 2.4 Crude Birth Rate (SRS 2013) 21.1 21.6 Crude Death Rate (SRS 2013) 6.6 7.0 Natural Growth Rate (SRS 2013) 14.4 14.5 Sex Ratio (Census 2011) 919 943 Schedule Caste population (in crore) (Census 2011) 0.40 20.1 Schedule Tribe population (in crore) (Census 2011) 0.89 10.4 Total Literacy Rate (%) (Census 2011) 78.0 73.0 Male Literacy Rate (%) (Census 2011) 85.8 80.9 Female Literacy Rate (%) (Census 2011) 69.7 64.6 Source: Health Infrastructure, 2015 Page 100

Country has entered a high growth rate route of 9 per cent. This high rate of growth, though, is not accompanied by a high level of societal growth. The social sectors predominantly health and education have been accorded a very low concern in terms of the distribution of resources. For example, public expenditure on health services as a percentage of Gross Domestic Product (GDP) in country is less than 1 per cent possible to be one of the lowest across the world. Table 4.2 Trends in Health Expenditure in India Generally trend in the Plan expenditure incurred vis-a- vis the Budget Estimates during the Two years of the Twelfth Five Year Plan for Department of Health and Family Welfare is given below. ( Rs. in Crore) Plan Period Budgetary Estimates (BE) Expenditure Health NRHM/ RSBY Total Health NRHM/NHM Total NHM 2011-12 75145.29 193405.71 -- 268551.00 -- -- -- 2012-13 6585.00 20542.00 -- 27127.00 4145.40 16762.76 20908.16 2013-14 8166.00 20999.00 -- 29165.00 4202.93 18266.48 22469.41 2014-15 8733.00 21912.00 -- 30645.00 5645.36 18039.30 23684.66 2015-16 6254.00 18295.00 -- 24549.00 3624.90 14786.29 18411.19* 2016-17 10800.00 19000.00 1500.00 31300.00 -- -- -- * Expenditure figures are provisional as on 31st December, 2015 Page 101

The Twelfth Five Year Plan Central Government lay out for Health & Family Welfare Department has been increased by about 113 per cent to Rs. 2,68,551 crore compared to the expend of Rs. 1,25,922.22 crore in the Eleventh Five Year Plan. The 12th Five Year Plan envisages flawless combination of the health services in the Primary, Secondary and Tertiary sectors, with power on intensification the primary health care delivery services. In addition to this, the plan also envisages for achieving universal health reporting for the population and in line with the abovementioned objective of achieving universal health coverage, the Department has launched the National Health Mission with a vision to enabling Universal access to fair, reasonable and quality health care services which is both responsible and approachable to people s needs. The remarkable gains made by NRHM, and other disease control programmes, are currently being built upon to deliver Universal Health Care (UHC) in all urban and rural areas during the 12th Plan period. Gujarat offers holistic medicinal services and cost effective treatment through various district hospitals, sub-district hospitals and private specialty hospitals. Most wanted after Super Specialties in state contain Cardiology, Neuro Surgery, Orthopedics, Infertility treatment, joint replacement and eye surgeries. Share of primary care in total healthcare promote of Gujarat is approximately 75-80%. Market for tertiary care estimated to develop at a earlier speed, due to increase in income levels, increasing implementation of health insurance and increase in difficult in-patient ailments (heart diseases, kidney ailments, cancer) The healthcare setting in Gujarat is shifting speedily. The accessible medical infrastructure and straightforwardly available healthcare services have better the health of the population of the state extremely over the years. Gujarat is connecting in provisions of quantity of hospitals, healthcare centers, beds and is anticipated to carry on a encouraging movement in future. Doctor to patient portion is 1:10 and nurse to patient proportion is 1:5 The state Government is taking Page 102

numerous initiatives to make state a Global Healthcare Destination. Through use of modern technical equipment, improved health insurance, major corporate investments and services of extremely experienced medical personnel, the Gujarat healthcare sector is balanced sound for a continuous explosion. Health Education and Research Medical Colleges in Gujarat 1. MBBS 21 (9 Govt., 5Trust & 7 Grant-in-aid) 2. Homeopathic 17 (4 Grant-in-aid & 13 private) 3. Ayurvedic 10 (4 Govt. 1 University, 2 Grant-inaid & 3 Private) 4. Dental 13 (2 govt. & 11 Private) 5. Physiotherapy 32 (5 Govt. &27 Private) 6. Nursing (from GNM to 66 (24 Govt. & 42 Private) M. Sc.) 7. Pharmacy 115 (6 Govt., 14 Grant-in-aid & Private) Key Education Centres Institute of Kidney Disease and Research Centre (IKDRC) Gujarat Cancer Research Institute (GCRI) Government Medical College, Vadodara U. N. Mehta Cardiology Research Institute B. J. Medical College, Ahmedabad Gujarat Ayurvedic University, Jamnagar Pramukh Swami Medical College, Karamsad, Anand Nathiba Hargovinddas Lalbhai Medical College, Ahmedabad Surat Municipal Institute of Medical Education & Research 4.2 DRIVERS OF THE HEALTH SECTOR: 1. Holistic Wellbeing Page 103

Hospitals and wellness centers now looking at a completely and holistic approach towards treating their patients Naturopathy or nature cure is completely developed and scientific system which utilizes the scientifically planned nutritional standard in arrangement with Yoga and physiotherapy for physical and mental health. Wellness centers- as centers of holistic well-being in Gujarat Kalpa Sidhi Health, Ahmedabad Life Care, Ahmedabad Mind Body Zone, Vadodara Reiki, Grandmaster, Vadodara Gujarat Ayurvedic University, Jamnagar Kudrati Upchar Kendra, Amreli Services offered in wellness centers in Gujarat Diet and nutrition Gym and fitness Yoga Herbal medicine Healing touch therapy Stress Management including relaxation, and meditation Reiki Acupuncture Acupressure Pranic and crystal healing Magneto therapy Aroma Therapy 2. Moving Up The Value Chain The healthcare sector in Gujarat has motivated the importance by imbibing the international best practices to deliver flawless patient care of top quality Most important corporate hospital groups such as Sterling, Apollo, Fortis, Wockhardt have made major investments in set up state-ofthe-art hospitals in major cities of Gujarat Better highlighting on education, research and development Page 104

APOLLO tyres-promoted Artemis Health Science is finalising strategy to set up a INR 500 crore medical education centre on the Surat Baroda- Ahmedabad highway in Gujarat The medicity envisions a research centre, a medical college, nursing college, pharma college, medical administration coll ege and a hospital which will have more than 500 beds Bombay Hospitals has signed an MoU during Vibrant Gujarat 2007 to establish a medical institute with Multi speciality Hospital to recommend under graduate and post graduate courses 3. Health Insurance Health insurance policy not only covers expenses incurred during hospitalization but also through the pre as well as post hospitalization stages like money spend for conducting medical tests and buying medicines. Integrated insurance scheme, Gujarat This Community based Health Insurance Scheme is run by the non - government organisation (NGO) Self-employed Women Association (SEWA), based in Ahmedabad, Gujarat One of its primary performance is provided that financial services for women and this was widened in 1992 to consist of health insurance as part of a wider insurance package with life, accident and asset insurance The scheme covers: (i) (ii) Inpatient care Hospitalization cover, in addition to one-time payment for denture and hearing aid. Members can utilize any type of hospital, public private or trust. Page 105

(iii) Delivery profit for fixed deposit members. There is a limit on compensation of Rs. 2,000 per year. At the time of discharge, the member must give for the bill and apply for refund from the scheme The scheme is managed by SEWA which purchases medical insurance from a Government Insurance Company subsidiary National Insurance Company (NIC) and ICICI Lombard. Employees State Insurance Scheme, Gujarat Each individual after joining an insurable employment, after implementation certain rules and regulations, is issued an identity card which has all necessary details i.e. name, insurance no. of the IP, dispensary and local office to which he is attach and names of his/her family members. This card is a very essential document and has to be shown while obtaining medical benefits Beneficiaries can claim treatment at the dispensary/clinic of the IMP to which he/she is allotted on the construction of the certificate Total number of beneficiaries are approximately 5,14,000 Private players in Gujarat Bajaj Allianz Health Insurance Company Limited TATA AIG General Insurance Company Vysya life Insurance Company National Insurance Company Ltd. Page 106

Public Private Participation (PPP) in Gujarat 122 grant in aid Hospitals. Shamlaji Hospital located in tribal area of Sabarkantha 5 CHCs (Malav, shamlaji, Rajsitapur, Mota Phospholiya, Golagandi) and 4 PHCs (Chansad, Dahej, Khoreli Mata no Madh) Centre of Health, Education, Training and Nutrition Awareness (CHETNA) has been actively supporting a total of 23 Mother NGOs and 4 Service NGOs working effectively to implement Reproductive and Child Program (RCH) Out sourcing of MRI services to a CBO in Surat PPP for Maternal and Child Health Services under Chiranjivi Yojna and Bal Sakha Yojna Hyderabad based Emergency Medical Research Institution (EMRI) with the Gujarat Government will take care of road and fire accident victims on a 24-hour basis through the year by just dialing 108 Assisted Reproductive Technology (ART) clinics by private organizations. Sarva Swastha Abhiyan (SSA, an NGO dedicated to taking quality healthcare to inaccessible areas) has opened 10 centres in five predominantly tribal areas of Idar, Prrantij, Bardoli, Hansot and Mundra that will be connected through telemedicine to super speciality hospitals at Ahmedabad, Nadiad, Vadodara and Surat. Surat setting-up of Medical Colleges in PPP mode at Bhuj. The challenges opposite to Health Care Organizations and Health Care Professionals at present are more difficult than at any other time in our Page 107

history mainly contained by the situation of globalization and social, political and economic changes. 4.3 HEALTH INFRASTRUCTURE (GUJARAT) Table 4.3 Number of Sub-Centers, PHCs & CHCs Functioning No. State/ UT Sub Centers Primary Health Centers Community Health Centers 1 Uttar Pradesh 20521 3497 773 2 Rajasthan 14407 2083 568 3 Maharashtra 10580 1811 360 4 West Bengal 10357 909 347 5 Bihar 9729 1883 70 6 Karnataka 9264 2353 206 7 Madhya Pradesh 9192 1171 334 8 Tamil Nadu 8706 1372 385 9 Gujarat 8063 1247 320 10 Andhra Pradesh 7659 1069 179 All India 153655 25308 5396 Source: Rural Health Infrastructure, 2015 All over India, out of 153655, 25308 were primary health centers and 5396 were community health centers. Page 108

Now, when we deliberate in our study area i.e. Gujarat stands 9 th rank among all states with 8063 sub-centers. Gujarat has 1247 and 320 PHCs and CHCs among 25308 and 5396 respectively all over India. Table 4.4 District Wise Availability of Health Centre in Gujarat (As on March 2015) District Sub Centers PHCs CHCs Sub- District Hospital District Hospitals Ahmedabad 214 37 10 1 0 Amreli 247 39 12 3 1 Anand 274 48 11 0 1 Aravali (Modasa) 215 35 10 1 0 Banskantha 468 91 21 1 1 Bharuch 222 38 9 0 1 Bhavnagar 297 43 13 2 0 Botad 87 14 5 0 1 Chootaudepur 310 45 10 1 1 Dahod 637 85 13 1 1 Devbhoomi Dwarka 107 17 4 1 0 Gandhinagar 171 25 9 1 0 Gir Somnatah (Veraval) 158 23 8 1 0 Jamnagar 152 24 6 0 0 Junagadh 232 36 10 0 0 Kutch- Bhuj (Kachchha) 285 44 15 2 0 Page 109

District Sub Centers PHCs CHCs Sub- District Hospital District Hospitals Kheda 279 46 11 1 1 Mehsana 288 55 14 2 1 Mahisagar (Lunavada) 222 32 5 1 1 Morbi 136 19 5 1 0 Narmada 174 24 3 1 1 Navsari 296 44 10 2 1 Panchmahals 279 46 10 0 1 Patan 210 36 15 1 0 Porbandar 84 11 4 0 1 Rajkot 240 34 11 4 1 Sabarkantha 276 42 12 1 1 Surat 394 53 14 0 0 Surendranagar 195 37 11 2 1 Dang 68 9 3 0 1 Vadodara 242 40 10 0 1 Valsad 363 45 11 1 0 Tapi 241 30 5 0 1 Total 8063 1247 320 31 21 Source:Rural Health Infrastructure, 2015 Here, out of 33 districts of Gujarat, there are 8063 sub centers of health are available in which Dahod district has 637 highest sub centers and Dahod district has only 68 which is lowest. In the same way, with 91 PHCs Banaskantha district has highest PHCs and Dang has lowest i.e. only 9 and in case of CHCs Banaskantha has highest 21 and Dang with 3 CHCs lowest. Page 110

Other than this only 31 sub-district hospitals and 21 district hospitals are there. Table 4.5 Shortfall in Health Infrastructure As per 2011 Population in Gujarat (as On 31 st March, 2015) No. Particulars In Gujarat In India 1. 2 Total population in Rural Areas Trible Population in Rural Areas 34694609 833748852 8021848 93819162 3. Sub Centers Required 8008 179240 In Position 8063 153655 Surplus * 35145 % of shortfall * 20 4. Primary Health Centers Required 1290 29337 5. Community Health Centers In Position 1243 25308 Surplus 43 6556 % of shortfall 3 22 Required 322 7322 In Position 320 5396 Surplus 2 2316 % of Shortfall 1 32 Source: Rural Health Infrastructure, 2015 * As on 31 st March, 2015 As per 2011 population in India the total population in rural area is 833748852 in India and 34694609 at Gujarat level and in Trible Page 111

population in rural areas is 93819162 at India level where as 8021848 in Gujarat. According to the population at India level there are 179240 sub centers, 29337 PHCs and 7332 CHCs required, while as compared to Gujarat state 8008 sub centers, 1290 PHCs and 322 CHCs are required. But the actual situation is 153655 sub centers, 25308 PHCs and 5396 CHCs are in position at India level. As compared to Gujarat 8063 sub centers, 1243 PHCs and 320 CHCs are in position. So in Gujarat the sub centers are working more than required so there is no shortfall of sub centers but in PHCs 3% of and in CHCs 1% of shortfall is seen. Whereas 20 % of sub centers, 22% in PHCs and 32 % of CHCs is seen at India level. Table 4.6 Building Position for Sub Centers, Primary Health Centers & Community Health Centers in Gujarat No. Particulars Primary Community Sub Health Health Centers Centers Centers 1 Total No. of Centers 152326 25020 5363 Functioning 2 Government Buildings 102319 20521 5028 3 Rented Buildings 34346 953 90 4 Rent Free Panchayat/ Vol. 15661 1663 245 Society Buildings 5 Buildings Under Construction 10349 1283 314 6 Building Required to be 39658 1509 172 Constructed Source: Rural Health Infrastructure, 2015 Page 112

As per the Rural Health Infrastructure total 152326 sub centers, 25020 PHCs and 5363 CHCs functioning in India out of which 102319 sub centers, 20521 PHCs and 5028 CHCs are government buildings. Also 34346 sub centers, 953 PHCs and 90 CHCs are taken as rents while 15661 sub centers, 1663 PHCs and 245 CHCs are taken as rent from panchayat or society. Besides all this remaining buildings are under construction or required to be constructed. Other than buildings some more basic infrastructure facilities for their smooth functioning requires amenities like elec tric supply, water supply, computers, operation theaters, labour rooms, beds, machineries, transportation, pharmacy, etc. Table 4.7 Facilities Available at Sub Centers in Gujarat No. Facilities Gujarat India 1 No. Of sub centers functioning 8063 153655 2 No. of sub centers with ANM Quarter 5212 84078 3 No. of Sub centers with ANM living in sub centers Quarter 4 No. of sub centers functioning as per IPHS norms 5 No. of sub centers without regular water supply 6 No. of sub centers without electric supply 7 Without all-weather motorable approach road Source: Rural Health Infrastructure, 2015 65212 54939 7274 31742 0 43695 0 39295 0 17250 Page 113

There are 8063 sub centers functioning in which 5212 with the facilities of ANM Quarter in Gujarat65212 sub centers with ANM living in sub centers Quarter and 7274 functioning as per IPHS norms. As compared to India level Gujarat have regular water supply, electric supply and motorway road. Table 4.8 Facilities Available at PHCs in Gujarat No. Facilities Gujarat India 1 No. of PHCs functioning 1247 25308 2 With Labour Room 1123 17815 3 With Operation Theater 1158 9875 4 Without least 4 beds 1123 17796 5 Without Electric supply 0 1107 6 Without Regular water supply 0 1773 7 Without all-weather motorable 0 1756 approach road 8 With telephone 1158 13276 9 With computer 1158 14293 Source: Rural Health Infrastructure, 2015 PHCs require some basic infrastructure facilities for their smooth functioning. It requires building with necessary facilities like electricity supply, water supply, communication, computers, OT, labour rooms beds etc. In India 2508 PHCs are functioning, in which 1247 are from Gujarat. At India level there are 1107 PHCs having without electrical supply and 1773 without water supply centers. In Gujarat there are 1153 PHCs having telephone and computer facilities. Page 114

In Gujarat there are 1123 PHCs having less than 4 beds as against 177796 at India level. This shows that PHCs in Gujarat are in better working condition with sufficient facilities. Table 4.9 Facilities Available at CHCs in Gujarat No. Facilities Gujarat India 1 No. of CHCs functioning 320 5396 2 With all four specialties 86 751 3 With Computer/ Statistical assistant for 3018 4224 MIS/ Accountant 4 With functional laboratory 318 5024 5 With functional Operation Theater 305 4473 6 With functional Labour Room 305 4913 7 With functionally stabilization units for 135 1862 new born 8 With new born care corm 144 4244 9 With least 30 beds 318 3933 10 With functional X ray machine 253 2707 11 With quarter for specialist Doctors 65 2613 12 With specialist doctors living in quarter 28 1721 13 With referral transport available 318 5022 14 With registered RKS 297 4925 15 Functioning as per IPHS norms 100 1420 16 Allopathic drugs for common ailments 318 5158 17 AYUSH drugs for Common ailment 305 3590 Source:Rural Health Infrastructure, 2015 In Gujarat level 3018 Community Health Centers available with computer/ statistical assistant for MIS/ Accountant, 318 with Page 115

functional laboratory, 305 with functional operation theater, 305 with functional labour room, 135 with functioning stabilization units for new born baby and 144 with new born care corm. Also there are 318 centers with at least 30 beds where 253 with functional X -ray machines. 65 centers are available with quarter for specialist doctors and 28 specialist doctors living in quarters. Medical appointment transportation is available in 318 centers. As per the RKS registered there are 297 centers at Gujarat level also 100 centers are functioning as per IPHS norms. If we talk about the pharmacy or drugs available at Gujarat level there are 318 centers of Allopathic drugs and 305 centers for AYUSH drugs for common illness. Gujarat has directed all its hard work towards productive development in every possible structure. Be it infrastructure or economic capacities, this state is a good example of progress for al l states to follow. So, how has the land of colour, romance and heritage performed in terms of developing healthcare inside the state? Well, the progress made by the state of Gujarat in the healthcare sector is highly praised by all. From governance of small nursing homes 25 years ago to state-of-the-art tertiary care corporate hospitals, today state has made a quick development. It is gradually but progressively transforming into a warm stain for investment in terms of the healthcare sector. At present, the Gujarat's healthcare sector is witnessing an exponential growth, as evidenced by the increasing number of hospitals and healthcare institutes, improving emergency medical services with the assist of 108 ambulance services, and growing medical tourism, flourishing public private partnership (PPP) models and improved Page 116

medical education. This development is a result of a concentrated attempt by government and the private sector such as corporate hospital groups, research organisations, educational institute s, pharmacies, medical device manufacturing companies and other healthcare delivery systems which support substitute medicines. Dr Ashutosh Raghuvanshi, MD, Vice Chairman & Group CEO, Narayan Hrudayalaya Hospitals, attributes this success to three importan t mechanism that the state has paying attention on technology advancement, quality oriented healthcare service and government initiatives taken to boost convenience. The traditional challenges of managing cost, access and quality are still on the front position of today s health care leaders. Up till now health care organizations, professionals and practitioners look at existing challenges as well as: federal and state legislation Advanced technology Information systems Patient demographics Skilled labour shortage Growing awareness of public opinion Today s Health Care Manager not only has to be knowledgeable in the traditional practices of management and leadership but in addition they have to skilled, educated and strategic in his/her approach to adapting their organization to the changing and frequently perplexing challenges confronting today s Health Care environment. 4.4 PROBLEMS OF HEALTHCARE IN GUJARAT Management is all about planning, monitoring and cont rol. Effective and well-organized management relies on schedule data collection, collection, analysis and opinion of performance indicators at regular Page 117

intervals, and not on adhoc and un -thoughtful data collected works for constitutional reporting requirements. 1. Financial Challenges Healthcare is the second most energy-intensive buildings after restaurants, and internationally, healthcare costs are on the rise. These financial challenges in calculation to an aging world population and rising energy expenditure are putting pressure on healthcare organizations to do extra with less lacking compromising quality of care. 2. Health Reform Implementation Table 4.10 Areas of Concern and Relevant Reform Levers Area of Causes amenable to Concern Reforms Relevant Reform Levers Nonavailability of Staff Outdated policies & incentives Structure Role of Paramedics Limited Remote Decision Organisational Change and Policy Reforms Empowerment of Nurses and Paramedical Staff Decentralisation Making Weak Referral System Lack of Integration Ignorance of Referral System Strengthen Communication and Transport Infrastructure Behavioural Change Health Awareness Poor Service Delivery Weak logistic Management Underutilisation of Data based management Planning, Monitoring and Granting Autonomy Resources Funding Absolute Shortfall Public-Private Partnerships Page 118

Area of Concern Shortfalls Lack of Accountability for Quality Care Causes amenable to Reforms Systemise Inefficiencies Obsession with FP Targets Low Staff Motivation Lack of Transparency Relevant Reform Levers Increasing Government Health Budgets Organisational Change Overall Performance of the Health System e-governance Managerial solutions may lie in the areas on organisational changes to take action to user requirements, delegation, compromise independence, logistics management, resource mobilization through public-private partnership, management information system and so on. Many of these solutions are attempted during Health Sector Reforms in developing countries. Health sector is difficult relating some stakeholders, multiple goals, multiple products and different beneficiaries. Health sector reforms have to be with awareness intended and implemented. Health System change is political and calls for behavioural changes. Below table is the list of essential areas of management concerns, causes willing to health sector reforms and relevant reform levers. To tackle the managerial challenges in delivering quality health services at reasonable cost. 3. Patients Satisfaction The well-being of patients is a key to dropping duration of stay and preventing readmissions. According to the American Society for Healthcare Engineering (ASHE), in green hospitals, patients are discharged an average of 2.5 days before compared to traditional hospitals. Moreover, patient satisfaction can also concern with a Page 119

hospital s revenue. If the systems are working inadequately or not at all, quality metrics such as Hospital Consumer Assessment of Healthcare Providers and Systems can be adversely affected. As a result, how can healthcare organizations treat with these challenges though controlling costs, reducing waste and implementing a sustainability policy? By utilizing an release and incorporated resolution that provides the right information to the right user at t he right time such as Schneider Electric s Structure War for Healthcare healthcare organizations can make more informed decisions regarding their facilities to get together these challenges head on. 4. Physician Hospital Relations As a rising amount of Americans expand insurance coverage, the demand for primary care increases. It is the building block of healthcare restructuring. Until now is not sufficient medical students are available into primary care, as an alternative choosing more rewarding subspecialties. About $13 billion federal dollars are given to 759 medical institutions with residency programs, but 158 of them do not make any primary care physicians, according to an Atlantic article from July 2013. More than 6,000 regions across the U.S. are selected Health Professional Shortage Areas for their lack of primary care, according to the U.S. Department of Health and Human Services. Each physician in a Health Professional Shortage Area sees 3,500 or more patients. Yet in spite of the increasing need for primary care, the health industry may still be able to fend off a developed emergency. Newly, there has been more discussion dedicated to whether the physician shortage may spread out as predicted. Page 120

"The outdated shortage modeling is the assumption of how much an individual physician can treat. As we look at creating a more effective care model, we have seen a substantial in crease in the number of patients that a primary care physician can see because they are working in conjunction with primary care coaches," says Rob Lazerow, practice manager of research and insights at the Advisory Board Company. The shortage model may in detail be out-of-date HHS shortage area modeling doesn't report for primary care provided by nurse practitioners or physician assistants in their projections. "There is absolutely a move toward team-based care. In some cases it is nurse practitioners or community-based providers, [and] even paramedics are conducting in-home visits as part of their weekly shifts," says Mr. Lazerow. "Some have projected shortages there as well. It would not surprise me if supply does not keep up." If he is correct, the break in primary care physicians is due to over specialization can only be to some extent abated by other healthcare providers. "One way around a shortage, if you can't increase supply, is to figure out how you can restrict demand. ACO-style models are all about preventing care in the first place. That absolutely could be a strategy. The reality, though, is that it takes time to do that," says Mr. Lazerow. "It's not an overnight solution. The amount of time it takes to prevent someone from needing a surgery is a matter of years." In anticipation of medical schools are incentivized to graduate more primary care physicians and ACOs catch up, healthcare improvement may need to depend on interchange primary care providers. 5. Population Health Management Page 121

Population health was one of the biggest ideas in healthcare this earlier period, and it will probable continue or increase momentum in the next few years to approach. But in spite of regular use of the term in the healthcare bubble, population health is a multidisciplinary concept to be common between public health agencies, social institutions and policymakers. Hospitals fit in there anywhere. Defining that responsibility is one of the continuing challenges they will look in 2015. Hospitals' require for population health expertise overwhelms the supply. Nearly 60 percent of health system and hospital CEOs ranked population health as the hardest talent to get within the broader healthcare area. Further, almost half of executives polled recognized community and population health management as a talent gap within their organizations. Some health systems are filling this space by creating new C-suite positions: 10 percent of executives indicated their health system had a chief population health manager. Quantifying population health is second challenge. While healthcare leaders need to think innovatively about how to get better health of a geographic population, in addition they should maintain a healthy sense of doubt about population health efforts. What strength seems like a much-needed involvement on document, such as a grocery store in a food desert, may be one small piece of a multipronged resolution. There is no silver ammunition, after all. In the middle of excitement for population health, systems may simplify problems and overinvest in solutions only to see the same health outcomes. To find achievement, hospital leaders may require diminishing their traditional reliance on programs and as an alternative focusing more on partnerships with community organizations and nonprofits. Still some health systems act as separately as they can, ignoring a assets of expertise and resources. Page 122

"When we talk to other population health managers, they have unearthed a number of unique challenges inside their populati ons, such as domestic violence, elder abuse and other public health crises," says Jason Dinger, PhD, CEO of Mission Point Health Partners in Nashville, the accountable care organization affiliated with Saint Thomas Health. "Unfortunately, most respond by trying to implement their own unique program to respond to the issue. We usually encourage them to first speak with the experts in their community who work on these issues every day. In many cases these are nonprofit organizations that can add great value to the population health effort but often have trouble engaging and integrating with a health system's efforts." 6. Lack of Advancement Opportunities Lack of advancement creates confidence trouble when employees understand they re caught in a dead-end position. Poor confidence manifests itself in a variety of ways, such as neglect of leave policies, loss in job positions and a lack of enthusiasm to hold changes in the workplace. Since small workforces create fewer open positions, it can be complicated for small business owners to inside support their workers at a speed fast enough to work against issues that take place because of lack of promotion. Improvement opportunities don t need to be to senior positions within the company. Developing a plan for employee improvement, from planned raises to increases in responsibility levels and training for new skills, can help employees believe as if they re advancing within their positions even without complete promotions. 7. Poor Salary There are main two avenues of employment for these considerate yet strong professional women: Public sector hospitals or the huge number of private outfits that have mushroomed across cities and small towns. Page 123

A evaluation of the working conditions in these two sectors can easily be prepared on the double scales of compensation and necessary employment situation. While in the private sector is a different story. Utilization marks the experiences of nurses here. Dangerous areas of ignore and mismanagement exist and rules are frequently flouted to make higher profits. Here, the lower level staff and nurses who mostly tolerate the burden of this because it is their salaries that get compromised and not only that of the specialist physicians only, but whose authority and mobility can t be restricted by hospital managements. In addition to, the contractual agreement that nurses come into includes signing a "bond" that requires them to work in the hospital for two to three years and today even confiscating nursing certificates has be come an established practice to control their professional mobility. This kind of arrangements, prevent nurses from in search of other placements without the understanding of their current employers. Such unfairness is mostly possible because of a tolerant, and fundamentally bad, health sector. 8. Shortages in Staff and Resources Attached with shortages in staff and resources, exceed of the central hospitals has caused the previously inadequate resources to be expanded thin and has been responsible as the main 11 constriction towards extending healthcare convenience to the majority of the population. This has unenthusiastically impacted on the quality of the patient care existing mainly in the following: (1) Inpatient wards are overloaded, with patients who sleep on the floor accounting for approximately one-third of the total patient population, Page 124

(2) Patients repeatedly wait for hours outside the outpatient clinics to observe a supplier, (3) The amount of time used up with clinicians has been increasingly reduced in order to accommodate all patients, (4) The medicine provide is usually running very low, and the medical equipment is repeatedly not in function. These fundamental factors have prepared it particularly complicated for hospital managers at all levels to manage. The managers recognize with their sense of weakness and exposure to deal with the problems and also identify the need for extreme actions. In observation of the above reasons, primary health care provided at central hospitals has become a very expensive work out for government. Table 4.11 Health Manpower in Rural Areas in Gujarat Required Surplus In Position Vacant Shortfall Health Worker (Female) Sub 9310 7274 6932 336 2372 Center & PHCs Doctors PHCs 1247 1504 889 615 358 Total Specialists CHCs 1280 NA 74 NA 1206 Radiographer CHCs 320 330 175 155 145 Pharmacists PHCs & CHCs 1567 1550 879 671 688 Lab Technicians PHCs & CHCs 1567 1556 1401 155 166 Nursing Staff 3487 4058 2705 1353 782 Source:Rural Health Infrastructure, 2015 Page 125

As per the table given above, there is 9310 Health Worker (Female) for sub centers and PHCs required in which 7274 are surplus, 6932 are in positions, 336 places are vacant and 2372 are shortfall of staff. In the same way 1247 Doctors of PHCs required, 889 in position which is surplus by 1504, 615 are vacant and 358 are shortfall. Out of total required 1280 specialties of CHCs only 74 are in position and 1206 are shortfall of total specialist. 320 radiographers of CHCs, 1567 Pharmacists of PHCs & CHCs, 1567 Lab technicians of PHCs & CHCs and 3487 Nursing Staff are required where 155, 671, 155 and 1353 are vacant respectively. Table 4.12 Training of Medical and Paramedical Personnel in Gujarat Training Gujarat India ANM/ HW (Female) training school fund by Govt. of India LHV/ HA (Female) promotional school established by Govt. of India 26 355 4 30 HFWTC training center 1 54 MPW (Male) training schools 0 54 Source: Rural Health Infrastructure, 2015 Training is necessary for general health staff like medical and paramedical personnel are conducted to develop skills in diagnosis and management cases. Here for ANM or Health Worker (Female) out of 355, 26 training school funded by Government of India. 4 LHV/ Hea lth Assistant (Female) promotional schools established by Govt. of India and only one HF WTC training centers are available, no MPW (male) training schools in Gujarat. *********** Page 126