Search :   
“Sharing innovative solutions to common health management problems”
»  Information about HS-PROD
»  HS-PROD Report
»  List of Entries
»  Entries by State/UT
»  Entries by Subject Area
»  FAQ

Medicare Relief Societies at Community Health Centres, Rajasthan
Post your Comments
Subject Area="Health financing." Objective="Alternative means of financing public health services."
Details for Reform Option "Medicare Relief Societies at Community Health Centres, Rajasthan"
Summary

Background: In order to make public health care services sustainable, various options such as pay clinics and auto finance schemes have been explored by State governments since the 1980s. However, these schemes became dysfunctional due to a lack of interest among doctors and institutions and a lack of incentive to generate revenue, since all revenue from these schemes went to the State treasury. But dwindling resources in the public sector coupled with a lack of maintenance of infrastructure and equipment necessitated the Rajasthan Health and Family Welfare department to set up autonomous societies in medical colleges and other health facilities from 1995. The initiative aimed to encourage alternative sources of health financing through user-fee schemes and in-hospital pharmacies. This strategy was first started in a tertiary level hospital, SMS hospital, Jaipur and its success led to its replication in other medical colleges, district hospital and sub-divisional hospitals. The success of this initiative has led the Rajasthan State government to support the setting up of such societies Rajasthan Medical Relief Societies (RMRS) at all hospitals having 30 beds or more, including Community Health Centres (CHC) and recently it has also been introduced in all model Primary Health Care Centres (PHCs). Action: Following the drafting of a constitution and rules of the society, seed money of INR. 12 lacs was given to the medical college hospitals; INR 2 laks to district hospitals. Guidelines and orders were issued to ensure effective functioning of these societies. RMRS was allowed to collect the revenue of user fees from patients’ hospitalised and out-patient department and laboratory, as well as from donations, and contracting out of space. Purchase of hospital equipment was permitted and the government contributed half the cost if the other half was obtained through public contributions. In 1998 guidelines were issued for utilization of revenue generated by the societies; 50% could be used for purchase of equipment, while the other half had to be spent on provision of facilities to patients, cleanliness, and purchase of instruments. Detailed guidelines for purchase, maintenance and repair works were also issued. In 1996, the RMRS was scaled up to cover all hospitals with 100 beds. All equipment used under the auto finance scheme was transferred to a society which would be responsible for its maintenance. Amendments were also made to the Rajasthan civil service (Medical Attendance) Rules, 1970, so as to allow re-imbursement of the charges paid by government employees to the RMRS for diagnostic tests and investigations. A regular audit of accounts was also ordered, along with the exemption of donations received from income tax. The management structure of the societies is autonomous and consists of 9 to 11 officials and non-officials at State, Regional and district levels. The Society functions outside the purview of the State, the General Financial Rules (GFR) do not apply and it can purchase equipment according to its own requirements. Mainly, the funds in RMRS are used for maintenance and renovation of buildings, maintenance and repair of equipment, purchase of new equipment, improving sanitation and cleanliness, improving other facilities for patients and attendants, computerization of various systems and provision of free medicines for below poverty line (BPL) families. The source of funds for the Society includes seed money from the State Government and transfer of operational control of diagnostic machines. Free services are provided to certain sections of the population as stipulated in the Government Order. These include, families living below the poverty line, widows, freedom fighters, destitute people, citizens over 70 years and retired government servants. Charges are as follows i) Average OPD charge INR 2 . ii) Inpatient charges INR 5 . iii) In-patient referral by private practitioner INR 10. iv) Bed charges for private rooms, cubicles or cottage wards from INR 50 to 600 depending upon the type of facility. Management training has been organised for RMRS senior managers on guidelines, stock keeping and accounting. The training programme was coordinated by State Institute of Health Family Welfare. Studies have also been carried out to assess the functioning of RMRS by IIHMR, Jaipur and SIHFW, Rajasthan. Accounting software for medical colleges and big hospitals and an operational manual which includes the audit process have been completed. The National Informatics Centre, Rajasthan, is developing the software for CHCs. Results: In 2003 CHC Sadri, Pali constituted an RMRS with seed money from the European commission. The money generated through user charges was used for repairing the building, construction of cottage wards, buying furniture, petromax (used during load-shedding) construction of stores, paying honorariums to staff for extra work, providing medicines for BPL families. During the quarterly meeting, besides RMRS members there were also representatives from major political parties in the area and the CHC takes approval for the use of funds (for further details see minutes of the meeting available in the documents and illustration section). Before the presentation of any new proposal is presented, needs assessment is done. Availability of funds and discretion to use them for improving the quality of care is a source of confidence for the CHC staff as they can plan what is required for the functioning of the facility. The funds from the RMRS helped the CHC to make a life line store operational. The training given by SIHFW was found useful by the CHC in-charge and that helped them to handle the issues concerning running the RMRS. The setting up of an RMRS in CHCs and PHCs is a recent phenomenon and therefore little documentation on the impact of this initiative on increasing the access to services is yet available. However, a study done by SIHFW on RMRS does mention the achievements or improvements by RMRS (see documents and illustration section). In order to strengthen RMRS a monitoring cell was set up at the state level in 2004. imbursement of the charges paid by government employees to the RMRS for diagnostic tests and investigations. A regular audit of accounts was also ordered, along with the exemption of donations received from income tax. The management structure of the societies is autonomous and consists of 9 to 11 officials and non-officials at State, Regional and district levels. The Society functions outside the purview of the State, the General Financial Rules (GFR) do not apply and it can purchase equipment according to its own requirements. Mainly, the funds in RMRS are used for maintenance and renovation of buildings, maintenance and repair of equipment, purchase of new equipment, improving sanitation and cleanliness, improving other facilities for patients and attendants, computerization of various systems and provision of free medicines for below poverty line (BPL) families. The source of funds for the Society includes seed money from the State Government and transfer of operational control of diagnostic machines. Free services are provided to certain sections of the population as stipulated in the Government Order. These include, families living below the poverty line, widows, freedom fighters, destitute people, citizens over 70 years and retired government servants. Charges are as follows i) Average OPD charge INR 2 . ii) Inpatient charges INR 5 . iii) In-patient referral by private practitioner INR 10 . iv) Bed charges for private rooms, cubicles or cottage wards from INR 50 to 600 depending upon the type of facility. Management training has been organised for RMRS senior managers on guidelines, stock keeping and accounting. The training programme was coordinated by State Institute of Health Family Welfare. Studies have also been carried out to assess the functioning of RMRS by IIHMR, Jaipur and SIHFW, Rajasthan. Accounting software for medical colleges and big hospitals and an operational manual which includes the audit process have been completed. The National Informatics Centre, Rajasthan, is developing the software for CHCs. Results: In 2003 CHC Sadri, Pali constituted an RMRS with seed money from the European commission. The money generated through user charges was used for repairing the building, construction of cottage wards, buying furniture, petromax (used during load-shedding) construction of stores, paying honorariums to staff for extra work, providing medicines for BPL families. During the quarterly meeting, besides RMRS members there were also representatives from major political parties in the area and the CHC takes approval for the use of funds (for further details see minutes of the meeting available in the documents and illustration section). Before the presentation of any new proposal is presented, needs assessment is done. Availability of funds and discretion to use them for improving the quality of care is a source of confidence for the CHC staff as they can plan what is required for the functioning of the facility. The funds from the RMRS helped the CHC to make a life line store operational. The training given by SIHFW was found useful by the CHC in-charge and that helped them to handle the issues concerning running the RMRS. The setting up of an RMRS in CHCs and PHCs is a recent phenomenon and therefore little documentation on the impact of this initiative on increasing the access to services is yet available. However, a study done by SIHFW on RMRS does mention the achievements or improvements by RMRS (see documents and illustration section). In order to strengthen RMRS a monitoring cell was set up at the state level in 2004.

Cost In the tribal and semi-desert districts (Jaisalmer, Barmer, Jalore, Nagaur, Bikaner, Jodhpur, Sirohi, Banswara, Dungarpur and Pali), the CHCs have received seed funding from European commission supported Sector Investment Programme of INR 1 lakh each. For the study and for training of EC-SIP CHC in-charge and senior officers INR 2.5 lakhs was transferred to SIHFW, Jaipur.
Place All public health facilities above Sub-centre level in Rajasthan.
Time Frame One year.
Advantages

Revenue generation: Increased availability of financial resources to hospitals from renting of parking areas, auditoriums, contracting out the administration of canteens. Financial Autonomy: Each society is authorised to purchase items ranging from INR 1000 to10,000 though the State’s guidelines suggest that institutional heads have authority to make decisions regarding expenses less than INR 5000. Improved efficiency in the system: The society can follow the State’s established government financial and accounting rules or their own purchasing procedures. Cost recovery: Multiple sources of supplementary financing are available and user charges are levied for a full range of services. Exemptions are judicious.

Challanges

Management skills: Continuous enhancement of the management capabilities of hospital administrators, systems and procedures of procurement, maintenance of equipment and hospital buildings as well as contracting and outsourcing is necessary for smooth functioning of RMRS. Maintenance: A lack of clear policy regarding with whom rests the decision-making authority for repair and maintenance. A study found 53% societies report difficulty in repairing and maintaining equipment. User charges: Procedures for exemption of user charges to vulnerable groups are usually informal and discretionary. Increase in proportion of patients visiting the health facility will make it difficult for RMRS to spend money on upgrading services. Utilization of RMRS funds: Hospital managers fail to spend the generated revenue efficiently, as most of spending is on equipment in absence of trained personnel to operate the machines. So there is under-utilization of machines. Subsidy: The government subsidies to hospitals have not declined because of the transfer of matching grants to participating hospitals. So, it has not relieved the state’s burden. Monitoring: Regular systemic monitoring of the RMRS has to be undertaken at all levels.

Prerequisites

Training of society officials regarding objectives of the society, guidelines governing the societies, budgeting, accounting, management information systems, pricing and needs assessment. Managerial guidelines should be in place. Facilitation of purchase of equipment, rationalising pricing schemes. Expert committee to resolve issues and problems. Continuous monitoring of the functioning of RMRS.

Who needs to be consulted

Dr. N.K. Mathur, Retired Medical Superintendent SMS Hospital. Dr. Ajit Bapna, Retired HOD E& NT, SMS Hospital. Dr. S.C. Mathur, Director SIHFW, Rajasthan. Dr. O.P. Gupta, Director Public Health. Dr. S.D. Gupta, Indian Institute for Health Management and Research, Jaipur.

Risks

Sustainability

The programme is sustainable. Under NRHM, each year now INR 1 lakhs will be transferred to these societies as untied funds.

Chances of Replication

The innovative scheme was started in Rajasthan in one government hospital and later replicated in other facilities up to CHC level. (By March 2003, the number of RMRS in Rajasthan has reached to 301 which includes 16 RMRS in the Medical College Hospitals, 58 in the District Hospitals and 217 at the level of CHCs).Now government is going to start such societies in Model PHC across Rajasthan.

Comments

The success of Rogi Kalyan Samiti (RKS) in Madhya Pradesh was a basis to initiate RMRS in Rajasthan. As per a study undertaken in 1999-2000 by the Indian Institute for Health Management Research (IIHMR), 36% of the societies use only their own purchasing procedures; 44% follow the States’ procedure and about 20% use both. The majority of the societies find purchase procedures comfortable. Cost recovery is 10 to15% of the hospital budget although it varies between 4 and 25%. 26% report selling pharmaceuticals. Private organisations and individuals have adopted wards in 36% of the societies. The proportion of clients receiving free care was lower before the introduction of user charges. Later in 2003 a study was undertaken by SIHFW, on the basis of which guidelines were developed for effective management of RMRS. A training module was developed. A series of trainings have been organised by SIHFW, Jaipur as per the demands of RMRS managers and the training cost per participant is kept at INR 500 per participant, financed by RMRS itself. There has been very high attendance at these training programmes and participants consider them useful.

Contact

Submitted By

Dr. Nandini Roy, HS-PROD Research Consultant, National Institute of Medical Statistics, October, 2005. Last Updated: Prabha Sati, Research Consultant, ECTA, December 2006.

Status Active
Reference Files
scan.pdf
GO1977.pdf
GO1996.pdf
User Charges and Expenditure Statement.doc
RMRS.doc
Reference Links
 
No Record Updated
Read More
 
 
 
» Comparable Databases
» State/UTs Government
» UN Organisations
» Bilateral Organisations
» NGO's
» Miscellaneous
Read More