|Year : 2021 | Volume
| Issue : 1 | Page : 45-50
A study on economic evaluation of an outreach health-care facility in Jhajjar District of Haryana: Service delivery model for increasing access to health care
Mohammad Kausar1, Vijaydeep Siddharth2, Shakti Kumar Gupta3
1 Assistant Professor, Department of Hospital Administration, AIIMS, Bilaspur, Himachal Pradesh, India
2 Associate Professor, Department of Hospital Administration, All India Institute of Medical Sciences, New Delhi, India
3 Medical Superintendent, Dr. RP Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||06-May-2020|
|Date of Decision||28-Nov-2020|
|Date of Acceptance||23-Feb-2021|
|Date of Web Publication||20-Mar-2021|
Associate Professor, Department of Hospital Administration, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: An outreach (OR) health-care facility providing broad specialty outpatient services was started by All India Institute of Medical Sciences (AIIMS), New Delhi, in rural area of district Jhajjar, Haryana. Objectives: This study aimed to ascertain the resource requirement for establishing an OR health-care facility and patient satisfaction with regard to the services being provided. Methods: A cross-sectional study was conducted in 2017 at an OR Outpatient Department (OPD) of AIIMS, New Delhi, at Jhajjar. Service delivery model adopted for health-care delivery was hub and spoke. Traditional method of costing was used for economic evaluation. Feedback pro forma of 400 patients who attended OPD services was analyzed to measure health service accessibility. Results: Capital expenditure to set up the facility was calculated to be approximately INR 17,57,49,074/- ($ 2,703,832) and operational cost per year was approximately INR 8,73,86,370/- ($ 1,344,406). Approximate per-patient cost for single OPD consultation was calculated to be INR 874 ($13.45) which included medicines and investigations. High scores for all domains of accessibility of health care were observed. Conclusion: The study provides a preliminary evidence that OR health-care facilities can be instrumental in increasing access to health-care delivery with lesser capital outlays, however, large-scale multicentric studies are needed to arrive at any conclusion. The services have been very well accepted by the local community members being quality medical care with highly subsidized health-care services.
Keywords: Accessibility, affordability, economic evaluation, health-care services utilization, health policy, health-care delivery system, patient satisfaction
|How to cite this article:|
Kausar M, Siddharth V, Gupta SK. A study on economic evaluation of an outreach health-care facility in Jhajjar District of Haryana: Service delivery model for increasing access to health care. Indian J Public Health 2021;65:45-50
|How to cite this URL:|
Kausar M, Siddharth V, Gupta SK. A study on economic evaluation of an outreach health-care facility in Jhajjar District of Haryana: Service delivery model for increasing access to health care. Indian J Public Health [serial online] 2021 [cited 2021 Apr 16];65:45-50. Available from: https://www.ijph.in/text.asp?2021/65/1/45/311523
| Introduction|| |
Health-care access is a fit between patient and health-care system. Health-care services coverage can be potential and actual health coverage. According to Tanahashi, potential coverage comprises availability (human resource, facilities, drugs, etc.), accessibility (services being available within reasonable reach of people in need), and acceptability (costs and cultural compatibility) of health-care services. The actual coverage is contact accessibility and finally effectiveness coverage in terms of its output, adequacy, and satisfactory service performance on specific criteria. According to Penchansky and Thomas, the specific dimensions of health-care access are availability, accessibility, accommodation, affordability, and acceptability. An effective coverage has three critical components: expected quality, probability of utilization, and perceived need. The various dimensions of access to health care as described by various researchers have been enumerated by Levesque et al.
According to the World Health Organization (WHO), access to health care has three dimensions of accessibility, affordability, and acceptability. Dominant nonfinancial access barriers are culture, physical accessibility, and information and education. Socioeconomic status also has a significant impact on actual utilization of available health facilities. Merely making the health-care services may not improve the accessibility of health-care services, as is empirically evident from the underutilization of health-care facilities in various parts of the country.
An outreach (OR) health-care facility with the mandate of providing broad specialty services on an outpatient basis was started in November 2013 in the rural area of Jhajjar district in Haryana state by All India Institute of Medical Sciences (AIIMS), New Delhi. Comprehensive economic evaluation focusing on various domains will help in evidence-based decision-making and will provide an estimated budgetary outlay for establishing such OR health-care facilities.
Therefore, this study attempted to ascertain whether the creation of an OR health-care facility on lines of hub-and-spoke model of service delivery has increased access to health care and patient satisfaction/experience to the health-care services being provided. In addition, it also studied the resource requirement (financial, human, technological, etc.,) for starting and operationalizing such a facility that can be potentially replicable.
| Materials and Methods|| |
A cross-sectional and descriptive study was conducted from July to December 2017 in an OR Outpatient Department (OPD) located 50 km away from AIIMS, New Delhi, premises in a rural setting. Economic evaluation: For utilization and economic evaluation, traditional method of cost analysis was used. Classification of costs was done under capital and operational costs. Capital expenditures included building and equipment. Historical costs were brought to the current year using the Cost Inflation Index (CII 200 in 2012–2013 and 272 in 2017–2018). Operational expenses estimated in the study included human resource (Doctors, Nursing Staff, Technicians, Housekeeping Staff etc.), materials/supplies, support services (laboratory services, radiological services etc.), engineering maintenance costs, etc. Utilization of health-care services was captured from the OPD management information system. Data on utilization of services and operational costs incurred from January to December 2016 were analyzed using Microsoft Excel spreadsheet. Currency conversion to US Dollars was done at the exchange rate of 65 INR in 2017.
Feedback pro forma and its various domains
A structured questionnaire comprising 30 items (16 items were on a five-point Likert scale) measuring socioeconomic status, accessibility, affordability, accessibility, and accommodation was developed by the researcher for gathering feedback from OPD patients to measure the accessibility of health-care services based on the themes gathered from review of literature. It was implemented as a feedback pro forma for patients visiting OR facility.
Accessibility was taken in terms of convenient location,, distances traveled to reach health-care facility,,,,, time to reach health-care facility,, and availability of transportation.,, Availability was measured in terms of adequate supply of medicines,, access to laboratory services, availability of female doctors, choice of the health-care service/specialty provider, availability of human resources at health facilities,, availability of basic amenities, waiting time for consultation and investigations,,,, and facilities for poor patients. Items related to affordability were socioeconomic assessment,,, affordability of drugs and investigations (laboratory and radiodiagnosis),, and travel cost., Acceptability had variables of availability of female health-care staff, sociocultural factors such as gender,,, and cultural preferences for traditional healers., Accommodation (adequacy) was studied in terms of convenient facility working hours, behavior of health facility staff, quality of care or service quality,,, and expectations of household.
Demographic details and socioeconomic status as per the Modified Kuppuswamy Scale for January 2017 were also captured. Socioeconomic status was studied to observe the acceptability of health-care delivery services across various socioeconomic strata. Face content validity was done by the faculty of hospital administration and was pilot tested. Cronbach's alpha of the piloted questionnaire was 0.82, and socioeconomic dimensions under study did not contribute to Cronbach's alpha. Only 400 feedback pro formas were studied from patients availing outpatient services. These pro formas were randomly taken out using simple random sampling.
The hub-and-spoke model described in our study is a method of organizing services comprising a huge amount of resources invested at the main campus (hub), which provides resource-intensive medical services, complemented by satellite campuses or spokes, offering more limited basic services at sites distributed across the served area, routing others to hub. It is a highly scalable, efficient design, with satellites being added as needed or desired. It permits stretching of investment and retention of quality, service, and support, despite achieved efficiencies. They have to potential to help eliminate the geographical disparity in availability of health-care services.
Health-care delivery system at outreach health-care facility
The service delivery model which has been adopted for health-care service delivery at OR-OPD is hub-and-spoke model, with tertiary care teaching hospital located 60 km away at Delhi being the hub while OR health facility being the peripheral facility at the other end of the spoke. The OR health-care facility is one among the various OR health-care facilities of AIIMS, New Delhi. Each OR health-care facility provides different health-care services, however, this OR health-care facility has been studied as it has the mandate of providing broad specialty outpatient services in general medicine, general surgery, obstetrics and gynecology, pediatrics, orthopedics, ophthalmology (including availability of an optometrist), otorhinolaryngology, dermatology, and psychiatry, which is relevant from public health point of view. It has an in-house radiology facility (X-ray and ultrasonography) providing services on nominal charges and free for poor patients.
Statistical analysis and ethics statement
Data were analyzed using IBM SPSS Statistics version 20 procured from SPSS Solutions Pvt ltd, Bengaluru. One-way ANOVA with Bonferroni correction was used for tests of significance among various variables. Since the study did not involve any direct interaction/intervention with patients and only feedback forms were analyzed after seeking administrative approval, hence, approval of the institute ethics committee was not required.
| Results|| |
Utilization of services
The OR-OPD is visited by people from the state of Haryana and Delhi. Patients from as far as 180 km visited OR-OPD (range: 1 km–180 km, median of 12 km). More than two-third of the patients belonged to Jhajjar (56%) and Gurugram (22%) districts of Haryana followed by Delhi state (17%). Temporary residents from other nearby states also visited. The staff working at OR-OPD accounted for 1.5% of the visits.
The OR-OPD catered to approximately one lakh patients in the year 2016 with an average of approximately 330 patients visiting per day going up to 1000 patients per day. Utilization of OPD services by females was more (54%) compared to males (46%). Of the total patients who attended OR-OPD, 39% visited the OR-OPD for the first time while 61% were revisit patients. Medicine (31.20%), orthopedics (17.30%), and surgery (13.70%) accounted for more than 60% of consultations, while others were ear, nose, and throat (9.80%), ophthalmology (9.40%), pediatrics (8.50%), gynecology (7.80%), and psychiatry (2.30%).
It was observed that 12,707 (approximately 13%) patients visiting the OR-OPD had utilized the radiodiagnostic services, of which 8771 (9%) had undergone an X-ray and 3889 (4%) underwent ultrasonography, while a Doppler study was carried out in only 47 patients (0.05%). Laboratory services were utilized by 37,006 (37%) patients visiting the OPD. A total of 94,838 laboratory investigations and 6181 (6%) electrocardiograms were performed.
The OR-OPD project was developed on a turnkey basis which included all engineering works, namely landscaping, civil construction, tube wells, electrical substation, DG sets, heating, ventilation, and air conditioning. The total cost incurred on constructing and commissioning this OPD in the year 2012–2013 was 12 crores (CII 200), and considering CII of 272 for the year 2017–2018, the replacement cost was calculated to be INR 16, 32, 00,000/- ($ 2,510,769). Equipment costs (digital ultrasound color Doppler machine, digital mobile X-ray unit with accessories, digitizer, printer and accessories, and defibrillator) were calculated to be INR 1, 25, 49,074 ($ 193,063). Costs of other low-value equipment were not factored in. Thus, the total capital expenditure to set up the facility was calculated to be INR 17,57,49,074/- ($ 2,703,832) approximately.
The operational cost was calculated using the data for the year 2016 and was calculated to be INR 8,73,86,370/- ($ 1,344,406) per year and approximately cost of providing outpatient services was calculated to be INR 874 ($ 13.45) per patient for single consultation (for approximately 1,00,000 patients per year) [Table 1].
Human resource (60%) was a major expenditure followed by support services (28%) (laboratory services [19.82%], pharmacy services [8.11%], and biomedical waste management [0.12%]). Expenditures incurred on medicines and investigations were INR 76/- ($ 1.17) and INR 173/- ($ 2.66) per patient, respectively.
Access to health care
The mean age of the respondents was 40 years ± 16 (mean ± standard deviation), with male respondents being 56% while females being 44%. Most of the respondents used their own vehicle (71.6%) while others used either taxi (2.7%), bus (8.8%), auto rickshaw (9.8%), rail (0.5%), or either only walked (6.1%) or also used a bus (0.5%). The average distance traveled by a patient was 17 km, and the average travel time to reach OR-OPD was 32 min. Those who came walking traveled an average distance of 1.63 km, and it took 11 min to reach the OR-OPD.
OR-OPD was the nearest health facility for 42% of respondents, while for others, it was a subcenter, primary health center (PHC), community health center, or a district hospital for 4%, 26%, 11%, and 15% of respondents, respectively. There was no nearby health facility for 2% of the respondents. The average waiting time for consultation was 70 min while it was 17 min for laboratory investigations, 18 min for X-ray, and 46 min for ultrasonography. Most of the patients (81%) were aware about free services available in OR-OPD to patients below poverty line.
Majority of the patients belonged to middle class (57%) followed by lower class (39%) and very few belonged to upper class (4%). Approximately 30% of patients have made out-of-pocket expenditure (OOPE) for medicines, 8% for investigations, and 75% on traveling. The total OOPE was calculated to be INR 253/- ($ 3.89) per patient with one-third each on medicines, traveling, and investigations.
A third of the patients preferred to visit the OR-OPD, being nearby health-care facility, providing good medical care with provision for free medicines and investigations. Visit to private doctors is preferred by almost a fifth of the patients because of proximity, availability of emergency care, and less waiting time. Almost half of the respondents preferred visiting government hospital (47%) or dispensary (5%). Traditional healer was preferred by only one patient.
High scores of dimensions related to health-care accessibility were achieved (mean scores: 3.7–4.7), and a percentage of patients satisfied ranged from 95% to 100% (scoring 3 or above) [Table 2].
Analysis using one-way ANOVA with Bonferroni correction showed that scores of expectations being met increased with age, decrease in waiting times for consultation, and decrease in OOPEs (for medicines and diagnostic services).
| Discussion|| |
The study explores a good model of health-care delivery, especially in terms of the availability of human resource, facilities and drugs, accessibility of costs, cultural compatibility, contact accessibility, and effectiveness. The themes used in this study appropriately cover all measures of accessibility of health care and are the strength of the study. High levels of satisfaction to all themes reflect greater access to health care meeting expectations of households. Hub and spoke for health-care delivery have been implemented in certain parts of India and is expected to improve cost-effectiveness in terms of travel time and money spent. OR health-care/OPD facilities on similar lines have been created by certain tertiary care institutions in various parts of the country, for example, PGIMER, Chandigarh; AIIMS, Raebareli; and AIIMS, Bathinda, to name a few.
In the present study, the cost of providing outpatient services was estimated to be INR 874/- ($ 13.45) per patient. The cost of providing ambulatory curative services was INR 118.16/patient in a study resettlement colony in South Delhi in 2008–2009. An increase in outpatient care expenditures produces a decrease in inpatient care expenditures. In addition, an increase in number of outpatient visits decreases the number of inpatient stays and readmissions.
Approximately 90% of respondents in our study belonged to “middle class.” People belonging to the lower socioeconomic groups (Grade III, IV, and V) have been found to be more reluctant to get treatment due to cultural beliefs, myths, and lack of knowledge. A very large percentage of the Indian population finds it difficult to access comprehensive care and extension of essential medical coverage to unaided upper-lower, lower-middle, and upper-middle groups.
Higher utilization of health-care services by females (54% of visits) indicates the acceptability of the services, especially given the rural setting of the OR health-care facility. Gender equity has a significant influence on the health of women and girls and gender relations of differences in access to health-care resources. Both health seeking and support have strong gender inclination. Set in a rural cultural frame where there is a gender divide, cultural acceptability was tested with the availability of female doctors. More than 95% of respondents were satisfied with it. In some cultures, women will not seek care from male providers.
OR-OPD was a nearby facility for approximately 40% of respondents, and it was evident that acceptability of services has influenced people to travel from far-off locations. Traveling time has a bearing on accessibility of the services. A study conducted in Hungary had demonstrated that a 1-min reduction of travel time to the nearest outpatient unit increases case numbers. Travel time also plays an important role in rationing health care.
Access to essential medicines is a major determinant of health outcomes. In a recent study, the median availability of essential medicines in public sector outlets was found to be 0%–30%. Basic medicines such as paracetamol and common antibiotics were unavailable in 13% of PHCs, while their stock was insufficient in 75% of PHCs. WHO-promoted essential medicines policies in different countries have improved the quality use of medicine in terms of accessibility and affordability, predominantly in developing countries. Availability of medicines in the OR-OPD setting wherein 99% of respondents (mean score of 4.2) are satisfied is expected to contribute to improved access to health care. Approximately 37% of patients visiting the OPD accessed the laboratory services. Laboratory support facility is an important determinant of utilization of health services. It aids in proper diagnosis, improving treatment modalities, and bring down costs by minimizing syndromic approach to treat ailments.
Almost all services, medicines, and investigations as per the scope of the services of OR-OPD were provided free of cost and 99.5% of respondents were satisfied with the availability of medicines and investigations (mean scores of 4.2 and 4.7, respectively). A fraction of patients had to make OOPE for medications (per person INR 93/- or $ 1.43) and investigations (per person INR 80/- or $ 1.23). Up to 90% of the population in developing countries purchase medicines through out-of-pocket payments. In our study, about 30% of patients paid out of pocket for medicines which are comparable to OOPE in 27.6% of cases who utilized outpatient curative services in another study. In a study conducted in Haryana, the OOPE was INR 521/- ($ 8.02) for outpatient consultation in public sector of which drugs constituted the largest category of spending (49.2%). In our study, the OOPE was lower at INR 253/- or $ 3.89 per patient with 37% on medicines while 32% each on traveling and investigations. In another study, 63.4% of OOPEs were on medicines and 22.7% on laboratory investigation for ambulatory curative services. OOPEs for medicines and diagnostic services in our study had a bearing on patient satisfaction/expectations being met.
This study yields a good model of health-care service delivery providing quality medical care with free provisioning of various services leading to an increase in access to health care, however, the presence of a perceived need is necessary for utilization to occur.
The study did not examine perceived needs given the rural context of the settings which could have an impact on access to health care. Dimensionality and reliability analysis of the study tool used for measuring access to health care has not been carried out, however, the same has been designed after review of literature (Cronbach's alpha = 0.82). The study partially covers the indirect and opportunity costs in terms of the costs of transportation. It does not capture the cost of time taken away from work and the psychosocial aspects which are generally difficult to capture. The results of this study also suffer from the disadvantages associated with traditional or average costing methodology. However, in a developing country like India, it is difficult to carry out activity-based costing due to lack of awareness and poor record keeping and accounting methods.,, Acceptability of costs, although not directly measured, is well exemplified in the study by high satisfaction levels and patients traveling large distances to avail the services.
| Conclusion|| |
The services provided by the OR health-care facility have been very well accepted by the local community members being quality medical care with highly subsidized/free of cost health-care services. The same model and cost analysis information can be utilized by the policymakers/health authorities to increase the access of health-care services, which can be instrumental in achieving universal health coverage. In addition, the per capita cost can also be utilized for devising various insurance packages.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]