1. DEPRESSURIZATION OF URBAN
MEGA PUBLIC HOSPITAL
Partner Agency:- Seth G.S Medical College and KEM Hospital
Under the Supervision of:-
Dr.T.Sundararaman Dr.R.R.Shindhe
Dean ,S.H.S.S H.O.D(Community Medicine)

2. Background
Source:- Asia Pacific Observatory of Health Policies and Systems

3. Background
Global to Local View on Primary Health Care Approach :-
(Everybody’s Business, WHO’s framework for action)(Alma Ata Declaration,1978)
• Primary/First Contact/Level: backed up by secondary level facilities.
• Driver for health care delivery system(health conditions, levels of care and over lifetime)
Bhore Committee:-“The heads of different sections in the district hospitals dealing with
medicine, surgery and so on ... it will be of advantage if they can occasionally visit the
secondary unit hospitals and a certain number of primary unit hospitals and inspect and guide
the professional work of officers discharging corresponding duties in these hospitals. Such
contacts should help to improve the standard of professional work carried out in the hospitals
of the districts generally.”(1,Page 21)

4. Public Health System in Mumbai
Municipal Corporation of Greater Mumbai
HEALTH POST
DISPENSARY
PERIPHERAL
HOSPITALS
TERTIARY
CARE
Municipal
Maternity
Homes
Maternity
Wards

6. Rationale
What literature says?
Inverse Pyramid Phenomenon
• Ideally, only 5% of care and illness requires tertiary level of care(NUHM
Framework)
• Over 70% of the health services including preventive,promotive and curative
clinical encounters shall occur at primary levels (NUHM Framework)
• But primary care accessed at five different levels- medical colleges, secondary
care hospitals of two levels, primary care facilities and outreach services
(Making the Urban Health Mission Work for the urban poor, Report of TRG NUHM
,Feb 2014,Ch.4,Pg.38-39)

7. Rationale
What literature says?

8. Rationale
Consequence !!
• Overcrowding
• Long waiting time
• Very cursory examination
• Hasty referrals
• Patient disillusionment with the health system
• Discourteous communication by the doctors with patients.

9. What does the study aims to do?
• To study the OPD and patient flow pattern at KEM Hospital.
• To study the morbidity patterns reporting in the OPD of the KEM Hospital and quantify the number of
patients who could have been take care at the peripheral centres.
• To study the factors influencing patient’s preference for KEM Hospital for illnesses that could be managed
at primary level outside the hospital.
• To study the healthcare systems in urban settings and its linkages with the tertiary healthcare system.
• To study the measures that KEM and BMC is taking to address this situation especially with respect to gate-
keeping and referral systems, increases in number of beds and staff and the adequacy of financing.
• To develop recommendations and a policy brief in consultation with the key stakeholders in how best to de-
pressurize the mega hospital and enable it to function as a quality tertiary care centre in the main.

10. Methodology
Methods of data collection:-
• Secondary data collection from the Medical Records Department
• Primary data collection from patients(Questionnaire and In-depth
interviews) at various OPDs.
• Non-Participant Observations
• Time-motion Study

11. Progress Report and Analysis
HOSPITAL MAPPING

12. Progress Report and Analysis
OPD LOAD AND PATIENT DISTRIBUTION
NEW CASES
Medicine Surgery
Opthalmolog
y
Gynae & Obs Skin Psychiatry Diabetes Paediatric GOPD Hypertension
April 1440 2406 1377 1580 3115 589 403 1354 6162 65
May 1310 2806 1558 1891 3428 583 460 1576 6080 52
June 1233 2878 1570 1786 3876 561 381 1945 7058 64
0
1000
2000
3000
4000
5000
6000
7000
8000
April May June

13. Progress Report and Analysis
OPD LOAD AND PATIENT DISTRIBUTION
Old Cases
0
500
1000
1500
2000
2500
3000
3500
4000
Medical Surgery Opthalmol
ogy
Gynae &
Obs
Skin Psychiatry Diabetes Paediatric GOPD Hypertensi
on
April 2107 2019 2100 3222 2918 3680 1683 858 1593 459
May 2272 2117 1978 3478 2963 3403 1723 1071 1916 469
June 2399 1744 1960 3377 3107 3696 1662 1200 2367 488
Chart Title
April May June

14. Progress Report and Analysis
OPD LOAD AND PATIENT DISTRIBUTION
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Medicine
Obs & Gynae
GOPD
Opthal
Diabetes
Medicine Surgery
Obs &
Gynae
Paediatric GOPD Skin Opthal Psychiatry Diabetes
Hypertensio
n
Sample Size 35 46 51 26 94 64 35 42 21 5
Daily Average 119 155 170 88 314 215 117 141 70 17
Monthy Average 3587 4656 5111 2668 9428 6469 3514 4237 2104 532
Chart Title
Sample Size Daily Average Monthy Average

15. Progress Report and Analysis
• Sample Size for OPD Interviews:- 419 (30% of the average daily OPD of 10
OPDs which caters to primary care services)
• Field notes of every 5th patient or Convenience sampling of patients with
narratives to tell.
• Interviews conducted:-
GOPD- 94 Skin- 64
Surgery - 46

16. Progress Report and Analysis
Process Mapping

17. Progress Report and Analysis
Referred or not?
71
23
GOPD
Not Referred Referred
39%
61%
GOPD
Referral Note Without Referral Note

18. Progress Report and Analysis
Referred from?
53%
23%
18%
6%
GOPD
Private Practitioner
Private Hospitals
Public Hospital
Interdepartmental
Health Post

19. Progress Report and Analysis
Pathways of Referrals and Consultations
• Referrals made after considerable time and investigation(more than 3
visits/month):-60% of the total number of patients referred
• High cost of care in private hospital a reason for visiting KEM:-20.1%
• Did not know about any government hospital nearby: 26.9%
• KEM’s reputation for better care:-59.25%

20. Progress Report and Analysis
Pathways of Referrals and Consultations
1) Referred by a Private
Practitioner/Private Hospital
Referral
Note
No Referral
Note(Orally
Referred)
2)Seen in a government hospital
dissatisfied didn’t go to private,
came directly to KEM
3)Consulted private provider,
dissatisfied didn’t go to other
government facility came to
KEM
4)Patient's Attendant 5)Came directly to KEM
Based on
specific
reputation
Based on
general
reputation
6)Diagnosis made but visits
KEM for follow up and
drugs
7)OTHERS

21. Progress Report and Analysis
Pathways of Referrals and Consultations
12%
7%
23%
11%
33%
5%
9%
GOPD Pathways of referrals and
consultations
1
2
3
4
5
6
7
1) Referred by a Private
Practitioner/Private Hospital
2) Seen in a government hospital
dissatisfied didn’t go to private,
came directly to KEM
3) Consulted private provider,
dissatisfied didn’t go to other
government facility came to KEM
4) Patient's Attendant
5) Came directly to KEM
6) Diagnosis made but visits KEM
for follow up and drug
7) OTHERS

22. Progress Report and Analysis
Should these cases be managed at Peripheral centres?
71%
13%
7%
8%1%
GOPD
Should have been managed at primary care
One consultation to rule out complexity
Diagnosis established,follow up at periphery
Sceondary
Tertiary care

23. Progress Report and Analysis
• “I have been coming here since childhood, I was born here”
• “I delivered both my children here at KEM, so I consult doctors here only.”
• “We don’t go to any other hospitals, we directly come to KEM for all illnesses”
• “We get all the specialists for various illnesses here at KEM, hence we don’t go
anywhere else”
• “The BMC health posts are only to give medicine for cough and fever, those
medicines are of no use.”

24. Possible Recommendations
Disruptive Innovation Incremental Innovation
Recommendations Risks and Assumptions Recommendations Risks and Assumptions
Stop OPDs
(As being considered at
Safdarjung Hospital, Delhi)
 Sudden refusal of
services without ensuring
peripheral centres to be
well equipped.
 Functional and
geographically well
distributed peripheral
centres.
Patients with chronic illness
referred back to peripheries
for investigations, follow up
and drugs
Lab facilities available as per
norms at peripheral centres.
Drug availability
Refusal of services without a
referral card
• Care seeker has
voluntarily by passed
peripheral services
inspite of availability of
services at periphery
Direct access to the patients
with colour coded referral
card
Limiting the number of
patients registered in daily
OPD
No corruption in issuing the
referral card
Increased waiting time ,span
of treatment and multiple
visits.

25. Possible Recommendations
Zoning Units
Zones based on the basis of
roads leading to district hospital
Internal deputation of specialists
Direct Access by patients by
passing the queue.

26. References
• Lawn, J. E., Rohde, J., Rifkin, S., Were, M., Paul, V. K., & Chopra, M. (2008). Alma-
Ata 30 years on: revolutionary, relevant, and time to revitalise.The Lancet, 372(9642),
917-927.
• Van Lerberghe, W. (2008). The world health report 2008: primary health care: now more than
ever. World Health Organization.
• Bajpai, V. (2014). The challenges confronting public hospitals in India, their origins,
and possible solutions. Advances in Public Health, 2014.
• World Health Organization. (2007). Everybody's business--strengthening health
systems to improve health outcomes: WHO's framework for action.

27. References
• Dilip, T. R., & Duggal, R. (2004). Unmet need for public health-care services
in Mumbai, India. Asia-Pacific Population Journal, 19(2), 27-40.
• Yadav, K., Nikhil, S. V., & Pandav, C. S. (2011). Urbanization and health
challenges: need to fast track launch of the national urban health
mission.Indian Journal of Community Medicine, 36(1), 3.
• “Making the Urban Health Mission work for the Urban Poor” Report of the
Technical Resource Group, National Urban Health Mission, Feb 2014

28. THANK YOU!
HAVE A NICE DAY AHEAD!