HOSPITALS IN FAST GROWING COUNTRIES CHINA, INDIA, TURKEY

1
HOSPITALS IN FAST GROWING COUNTRIESCHINA, INDIA,
TURKEY

• PBIRG
• May 2007
• Savannah

AA Healthcare Marketing Research Pierre Pigeon
p.pigeon_at_aplusaresearch.com 33 478 622 323
2
HOSPITALS IN FAST GROWING COUNTRIES

• INTRODUCTION
• INTERNATIONAL COMPARISON
• CHINA
• INDIA
• TURKEY
• CONCLUSIONS

3
HOSPITALS DEFINITIONS

• OECD DEFINITION
• A place where patients stay overnight to receive
  care (in-patients)
• Excludes purely ambulatory centers
• Includes a great diversity of institutions
• Covers 3 groups
• Long term stay
• Mostly for elderly, nursing homes
• Psychiatric hospitals
• Acute care (short term hospitals)
• Medicine/Surgery/ Obstetrics
• HOSPITALS IN FAST GROWING COUNTRIES
• Same base but mostly acute
• Few/No psychiatric hospitals No Long-Term stay
• Unclear limit with health centers/dispensaries
  (lt10beds)
• Co existence of WTM with traditional medicine
  structures

4
3 DIFFERENT SYSTEMS WITH COMMON TRENDS

• Intricated Primary /Secondary /Tertiary care
• Scattered organization
• Still many small structures (lt20 beds) often lt
  100 beds
• (in US 3 admissions in lt 50 bed structures
  10lt100 beds)
• Evolving towards larger structures
• Switch from proximity to quality/specialization
• Few non-acute hospitals (Long stay and
  Psychiatry)
• Co-existence of Traditional Western medicine
• Integrated public systems (Insurance and Delivery
  of care by MOH)
• Hospital is a pivotal structure in Government
  delivery of healthcare to population

5
3 DIFFERENT SYSTEMS WITH COMMON TRENDS

• Increasing number of acute beds
• While numbers decrease in EU/US Still lower than
  EU/US ratios
• Mostly in large hospitals
• Reduction in length of stay
• Still longer than US/EU in China/India
• Increase in occupancy rates
• Low frequency of hospitalization
• 2 to 8 pop/yr vs 12 18 in EU/US

6
REASONS FOR ADMISSIONS DOMINATED BY INFECTIOUS
DISEASES AND TRAUMA IN CHINA INDIA
7
DIFFERENCES BETWEEN SYSTEMS
8
HOSPITALS AND BEDS
9
LESS ADMISSIONS AND LONGER STAY
10
CHINA
11
HOSPITAL AT THE HEART OF HEALTHCARE SYSTEM

• Healthcare mostly delivered in Hospitals or
  Healthcare Centers
• In patients Out patients
• Physicians 70 in Hospitals
• 20 in Health Centers (HC, Township HC)
• 10 in Local Health Units (Health Posts)
• Drugs 85 via Hospitals and HC
• 15 via Retail

Beds
12
VERY DIFFERENT STRUCTURES

• Hospitals and Health Centers cover a great
  diversity of structures
• Large, up to date, Hospitals increasing
• Many small minimal Health Centers (lt15
  Beds) decreasing
• Hospitals mostly Urban
• HC Rural or Urban
• Coexistence of
• Western Type Medicine (increasing)
• Traditional Chinese Medicine (often combined
  with WTM)
• Both with high level physicians

13
ACUTE BEDS 92 OF TOTAL BEDS
TOTAL ACUTE 63,388 Hospitals 3,090,140 Beds
HEALTH CENTERS 41,694 (66) 689,918 Beds (22) 17
B/H
HOSPITALS 18,673 (30) 2,306 000 Beds (75) 123
B/H
MCH Centers 3,021 (4) 94,105 Beds (3) 31 B/H
General Hosp 12,982 (20) 1,699,189 Beds (55)
141 B/H
Urban HC 787 (1) 11,678 Beds (lt1) 15 B/H
Town Township HC 40,907 (65) 678,240 Beds
(22) 17 B/H
Specialized Hosp 2,682 (14 ) 292,079 Beds
(10) 109 B/H
Township HC 30,882 (49) 396,784 Beds (13) 13 B/H
Town HC 10,025 (16) 281,456 Beds (9) 28 B/H
Ophthalmology, Stomatology, Oncology,
Tuberculosis, Infections, OBGYN, Psychiatry
TCMMinority Hosp 3,009 (5) 314,849 Beds (10)
105 B/H
Level 3 630 Level 2 3 600 Level 1
2 400 Not Class. 6 400
MOH 2005
TCM Traditional Medicine Hospital, MCH Maternal
Children Health Center, WM Western Medicine
14
FROM MAJOR UPTODATE HOSPITALS TO SMALL HEALTH
CENTERS
HOSPITALS
HEALTH CENTERS
MCH Centers
Jiujiang city (Jiangxi) MCH Center
Beijing General Hospital
Yunnan province TCM-WM Hosp
Daping village HC (Fujian)
Tianjin City Specialized Hospital
Mutuo County (Tibet) Minority Hosp
Xiliufang (Liaoning) county HC
Waluo (Sichuan) village HC
TCM Traditional Medicine Hospital, MCH
Maternal Children Health Center, WM Western
Medicine
15
INSIDE GENERAL HOSPITALS
Hangzhou city general hospital (Zhejiang)
Chongqin general hospital
Shanghai general hospital
16
INSIDE TCM WM HOSPITALS
Beijing TCM Hosp.
17
INSIDE HEALTH CENTERS
Township HC (Sichuan)
Town HC (Jiangsu)
18
3 LEVELS CLASSIFICATION (CLOSE TO WESTERN
CLASSIFICATION)

• Official classification updated yearly
• Each level additionally divided in sub-levels A,
  B and C (3A 3B 3C). Even (A, A-)
• 50 are not classified
• LEVEL 3
• Highly specialized care neurosurgery,
  cardiothoracic surgery, transplantation, cancer
  treatment
• Large City Hospitals, Prefecture, Province
  hospitals, MOH, Hospitals
• 500 beds
• Often linked to Medical University Scientific
  Research
• LEVEL 2
• Surgery, Medicine, Pediatrics, GynObs.,
• ICU in surgical and medical departments
• At least one CCU (coronary care unit ) in the
  hospital
• City Hospitals, County Hospitals
• 100 to 499 beds
• Offers Internship for undergraduate and training
  school students

China MOH 2005
19
HOSPITALS BY GRADE IN 2005
50 to 70 of Hospitals are not classified
China MOH 2005
20
18,700 HOSPITALS (Exc. HC) 30 OF UNITS, 75 OF
BEDS (EU Top 5 6,400 /US 5,000)
Heilongjiang
886
Jilin
563
Xinjiang
678
Liangning
915
Beijing
Gansu
516
Inner Mongolia
382
474
Tianjin
271
Shanxi
Shangdong
Ningxia
Hebei
884
Qinghai
817
1,121
134
130
Henan
Tibet
Jiangsu
Shanxi
1,172
97
1,004
833
Shanghai
Anhui
247
683
Hubei
Chongqing
Sichuang
572
358
Zhejiang
1,149
553
Hunan
Jiangxi
486
Fujian
782
Guizhou
357
383
Yunnan
648
Guangdong
Guangxi
960
458
38 in 8 Provinces
Hainan
Note city excl. from province
190
22 provinces, 5 municipalities 4
municipalities directly under the Central
Government
China MOH 2005
21
42,000 HEALTH CENTERS 30 OF UNITS, 75 OF BEDS
Heilongjiang
933
Jilin
817
Xinjiang
831
Liangning
1,077
Gansu
Beijing
Inner Mongolia
152
1,358
1,358
Tianjin
191
Shanxi
Hebei
Ningxia
Shangdong
1,640
1,966
Qinghai
266
1,786
406
Henan
Tibet
Jiangsu
Shanxi
2,088
666
1,769
1,004
Shanghai
Anhui
100
2,001
Hubei
Chongqing
Sichuang
1,176
1,102
Zhejiang
5,176
2,339
Hunan
Jiangxi
2,542
1,520
Fujian
Guizhou
953
1,456
Yunnan
1,483
Guangdong
Guangxi
1,463
1,295
Hainan
Note city excl. from province
312
China MOH 2005
22 provinces, 5 municipalities 4
municipalities directly under the Central
Government
22
3.1M ACUTE BEDS IN HOSPITALS HC 200/25 Years
( EU Top 5 1.28M /US 0.8M )
(x 000)
Heilongjiang
112
Jilin
82
Xinjiang
76
Liangning
161
Gansu
Beijing
Inner Mongolia
76
60
64
Tianjin
39
Shanxi
Hebei
Ningxia
Shangdong
103
154
Qinghai
17
231
15
Henan
Tibet
Jiangsu
Shanxi
202
6
100
184
Shanghai
Anhui
78
120
Hubei
Chongqing
Sichuang
129
61
Zhejiang
184
131
Hunan
Jiangxi
141
79
Fujian
Guizhou
73
58
Yunnan
99
Guangdong
Guangxi
193
87
(x 000) Note city excl. from province
45 in 7 Provinces SB
Hainan
17
China MOH 2005
22 provinces, 5 municipalities 4
municipalities directly under the Central
Government
23
2.3 BEDS/1000 POP. HOMOGENEOUS ( 21 over last
25 years) (EU15 4.8/ US 2.8 )
Heilongjiang
3
Jilin
3.1
Xinjiang
3.9
Liangning
3.9
Gansu
Beijing
Inner Mongolia
6.4
2.3
3.7
Tianjin
4.8
Shanxi
Hebei
Ningxia
Shangdong
3.1
2.2
Qinghai
2.8
2.5
2.9
Henan
Tibet
Jiangsu
Shanxi
2
2.4
2.7
2.5
Shanghai
Anhui
5.8
1.8
Hubei
Chongqing
Sichuang
2.1
1,9
Zhejiang
2.1
2,9
Hunan
Jiangxi
2.1
1.8
Fujian
Guizhou
2.2
1.5
Yunnan
2.3
Guangdong
Guangxi
2.5
1.8
Hainan
Note city excl. from province
2.1
China MOH 2005
22 provinces, 5 municipalities 4
municipalities directly under the Central
Government
24
2 TYPES OF STRUCTURES HOSPITALS (75 OF
ADMISSIONS) HC (25)
CHINA MOH 2005
25

• Hospitals (HC) are managed by Government/Province
  s/Cities
• Various levels of autonomy
• Some external costs are paid by patients
• Mostly no Medical Insurance coverage (30)
• 20 coverage in Rural
• 50 coverage in Urban
• If not covered, patient pays
• If covered, patient pays only part of costs
• depends on city, type of care, type of
  insurance etc.
• Patient is free to go to hospital
• Incentive to follow referral process
• Patient can be followed by multiple physicians
  within hospital
• Day dependent

26
DRUGS REPRESENT AN IMPORTANT SHARE OF
 EXTERNAL  REVENUES

• Hospital
• Self Financing
• Expected to finance 70 to 90 of their
  expenditures
• Revenues
• Government lt 20
• Drug selling 40 to 50
• Diagnosis tests 30 to 40
• Other lt10

• Health Center
• Self Financing
• Expected to finance 70 of their expenditures
• Revenues
• Government 30
• Drug selling 60
• Other 10

Drugs represent 50 of external medical expenses
27
INDIA
28
INDIA THE MOST COMPLEX SYSTEM

• Beds in multiple types of structures
• Hospitals, Health Centers and Dispensaries
• Public and Private (Profit Non Profit)
• Allopathic or Ayush (Indian System Medicine)
  medicine
• Rural and Urban
• With multiple private structures
• Balanced Public / Private system
• Bed number growing in public and private

29
BALANCED PUBLIC PRIVATE SYSTEM

• Balanced Public /Private
• Public 45 Units 66 beds 50 admissions
• Private 55 Units 33 beds 50
  admissions
• Private
• Smaller units 60 of lt 30 bed H. but only 25
  of gt75 bed H.
• More urban
• More dynamic faster growth transfer from
  Government
• Particular conditions
• 75 of Eye care
• 40 of Deliveries but 60 of CS
• 70 of MI
• 60 of Major Surgery
• 50 of Physicians
• 75 of Specialists
• Most specialists in Hospitals gt 30 beds

30
INDIA BEDS IN MULTIPLE STRUCTURES
15 393 Units 683 000 Beds 44 B/H
31
TOTAL ALLOPATHIC UNITS 15,393 (37)
TOTAL HOSPITALS HEALTH CENTERS 15,393 683,000
Beds
Disp. AYUSH 25,678 138,500 Beds 5 B/H
PUBLIC 7,008 (46) 468,000 Beds (66 ) 67 B/H
PRIVATE HOSPITALS 8,385 (54) 214,000 Beds (34
) 26 B/H
HOSPITALS 3495 (23 ) 361,000 Beds (50 ) 103
B/H
COMMUNITY HEALTH CENTERS 3,513 (23 ) 108,250
Beds (16 ) 31 B/H
URBAN 1,823 (17 ) 272,666 Beds (43 ) 31 B/H
RURAL 884 (6 ) 23,769 Beds (3 ) 27 B/H
URBAN 433 (3 ) 20,147 Beds (3 ) 47 B/H
RURAL 3,080 (20 ) 88,103 Beds (13 ) 29 B/H
32
ALLOPATHIC INSTITUTIONS
PRIVATE
PUBLIC
 Christian Medical College hospital,
Vellore Urban Hospital
Misssion Hospital Rajahmundry (Rural hospital)
Private Allopathic Hospital
ESI Hospital
Bongaigaon Rural Health Center (CHC)
Urban Community Health Center (CHC)
Apollo Speciality Hospitals New Delhi
Specialized Hospital Cardiology Kata
33
TOTAL ALLOPATHIC UNITS 15,393 (37)
TOTAL HOSPITALS HEALTH CENTERS 15,393 683,000
Beds
Disp. AYUSH 25,678 138,500 Beds 5 B/H
PUBLIC 7,008 (46) 468,000 Beds (66 ) 67 B/H
PRIVATE HOSPITALS 8,385 (54) 214,000 Beds (34
) 26 B/H
HOSPITALS 3,495 (23 ) 361,000 Beds (50 ) 103
B/H
COMMUNITY HEALTH CENTERS 3,513 (23 ) 108,250
Beds (16 ) 31 B/H
Level 2/3
Level 3
Level 2
TERTIARY MEDICAL COLLEGES AND HOSP. 117 gt 500
Beds Urban Care / Education/ Research
DISTRICT HOSPITALS 3,200 100 500 Beds Urban
Care/ Point of Entry
MENTAL HOSPITALS 30 Urban Long Term Stay
ESI HOSPITALS 800 100 Beds Non
Profit Employee State Insurance
PRIVATE HOSPITALS 7,200 Urban
PSU HOSPITALS 400 Public Sector Units for
Employees
34
7 008 Public Allopathic 3 495 Hospitals 3 513
CHC 28 States 7 union territories
JammuKashmir
76
Himachal Padesh
141
Punjab
160
Uttaranchal
36
Haryana
133
105
NEW DELHI
Arunachal Pradesh
Sikkim
45
Rajasthan
7
Uttar Pradesh
510
294
Assam
Nagaland
48
100
Bihar
Meghalaya
101
Manipur
30
28
Gujarat
Jharkhand
West Bengal
Tripura
Madhya Pradesh
503
Mizoram
26
47
20
324
642
Chattisqarh
138
KOLKATA
Orissa
Maharashtra
406
1 170
MUMBAY
HYDERABAD
521
Goa
58 in 6 states (36 in 3)
Karnataka
20
Andhra Pradesh
723
BANGALORE
CHENNAI
Tamil Nadu
424
Kerala
189
Sources are DHS of States/UTs, some States/UTs
have either not submitted the information of
source years (only 2004,2005,2006)
35
470 000 Beds in Public Allopathic Units 361 000
in Hospitals 109 000 in CHC 28 States 7
union territories
JammuKashmir
3
Himachal Padesh
8
Punjab
9
Uttaranchal
1
Haryana
7
20
NEW DELHI
Arunachal Pradesh
Sikkim
2
Rajasthan
1
Uttar Pradesh
32
9
Assam
Nagaland
2
3
Bihar
Meghalaya
Manipur
3
2
1
Gujarat
Jharkhand
West Bengal
Mizoram
Tripura
Madhya Pradesh
35
2
1
1
18
58
Chattisqarh
6
KOLKATA
Orissa
Maharashtra
13
76
MUMBAY
HYDERABAD
35
Goa
59 in 6 states (37 in 3)
Karnataka
3
Andhra Pradesh
41
BANGALORE
CHENNAI
Tamil Nadu
44
Kerala
26
Sources are DHS of States/UTs, some States/UTs
have either not submitted the information of
source years (only 2004,2005,2006)
36
ACTIVITY IS EQUALLY SPLITED BETWEEN PUBLIC (53
OF ADMISSIONS) PRIVATE (47)
37
2 OPPOSITE FINANCING SYSTEMS

• PUBLIC
• (Insurer is Supplier Beveridge type)
• Public 100
• State Government 85
• Healthcare5 of state budget
• Tertiary level 20 (1 of State Budget)
• Secondary level 17 (1 of State Budget)
• MOH Family Welfare 15
• Private 0 5

• PRIVATE
• (Insurer is not Supplier Bismark type)
• Public 2
• Social Insurances
• CGHS 1.6
• ESIS 0.5
• Private 98
• Households 86
• Private Insurance 12

Sourcefinancing and delivery of health care
services in India (ministry of health and family
welfare government of India,2005)
38
SHARE OF DRUGS

• Drugs represent (Public Private)
• 50 of patients out of pocket for in-patients
  
• 75 for out-patients
• Drugs paid by patients (out of pocket) are
• 25 for In-patients
• 75 for Out-patients

39
AYUSH HOSPITALSINDIAN SYSTEMS OF MEDICINE
AYUSH 1,354 Hospitals 22,546 Dispensaries
53,300 Beds 2 B/H
Siddha 2,386 Beds (4.5 ) 3.3 B/H
Ayuveda 35,182 Beds ( 66) 2,22 B/H
Homeopathy 11,205 Beds (21 ) 1,9 B/H
Naturopathy 622 Beds ( 1.2) 8,2 B/H
Yoga 622 Beds ( 1.2) 8,1 B/H
Unani 3,774 Beds ( 7.1) 3,1 B/H
Source AYUSH in India 2005
40
TURKEY
41
TURKEY

• Dominated by Public Sector
• Very important outpatient activity particularly
  for specialists
• Free access to hospital specialists
• Mixed funding from MOH and Insurance/Patient
• Still many small hospitals
• Bed numbers keep increasing (Bed/pop US, lt EU)

42
GREAT DIVERSITY

• 1,200 Hospitals 150,000 beds 50,000 doctors
• Beds increasing 10 / 5yrs
• Mostly public structures 90 of beds
• Private increasing fast
• (8 of admissions, 10 surgeries 9 births)
• Great diversity of institutions

43
IMPORTANT OUTPATIENT ACTIVITY

• Important outpatient activity in Hospitals
• Primary and Secondary Care
• Represents 60 of all Visits (incl. Primary) in
  Public Sector
• Growing (40/5yrs)
• Hospitals even deliver Primary Care
• 40 outside Hospitals Public or Private
• 60 in Hospitals (Outpatients)
• Specialist Care
• Hospitals mostly
• Or Private Practices

44
HOSPITAL ACTIVITY IS MAINLY PUBLIC
Turkish MOH 2004
45
MAINLY PUBLIC HOSPITALS - BEDS
TOTAL ACUTE HOSPITALS 1,226 150,855 Beds
PSYCHIATRY 5 5,500 Beds
PRIVATE 261Hosp (21) 12,162 Beds (8) 46 B/H
PUBLIC 965 Hosp (79) 138,693 Beds (92) 144 B/H
Private Hosp 234 (19) 10,074 Beds (7) 43 B/H
Foundation Hosp 18 (2) 1,112Beds (1) 62 B/H
MOH Hosp 744 (61) 69,089 Beds (46 ) 93 B/H
University Hosp 42 (3) 23,838 Beds (16 ) 568 B/H
SSK Hosp 118 (10) 27,245 Beds (18 ) 230 B/H
Minority and Foreign Hosp 9 (lt1) 976 Beds
(1) 108 B/H
Municipal 19 (2 ) 2,621 Beds (2 ) 132 B/H
Ministry of Defense 42 (3) 15,900 Beds (11) 379
B/H
MOH 2004
46
HC ARE SMALL STRUCTURES (lt 10 BEDS) AND COEXIST
WITH WESTERN TYPE HOSPITALS
PUBLIC
PRIVATE
MOH
American Hospital Foreign Hosp
Ankara Gülhane Askeri Tip Akademisi (Ministry
of Defense Hosp)
Sanliurfa Blikligol State Hospital
Devlet County Hospital
Baskent University Ankara Hospital
Adapazari SSK Hospital
Istanbul Avrupa Hospital Private hospital
Kayser SSK Hospital
SSK
MOH 2004
47
1,226 HOSPITALS IN 2004 (EU Top 5 6,389 US
4,936 )
2003 1,130
Istanbul
Black Sea
191
174
Marmara
AGRI
7
129
Eastern Anatolia
ANKARA
Central Anatolia
96
207
Aegean
158
Southeastern Anatolia
53
Mediterranean
115
Turkish Public Health Association 2005 (date2003)
48
150,855 ACUTE BEDS IN HOSPITAL ( EU Top 5 1.28
M US 0.8 M )
Istanbul
21
Black Sea
13.8
Marmara
9.1
ANKARA
Eastern Anatolia
8.4
Central Anatolia
20
Aegean
13.2
Southeastern Anatolia
3.6
Mediterranean
10.7
Turkish Public Health Association 2005 (date2003)
49
2.4 BEDS PER 1000 POPULATION(EU 15 4.8 US
2.8)
Istanbul
Black Sea
3.2
2.7
Marmara
2.7
Eastern Anatolia
ANKARA
1.8
Central Anatolia
2.7
Aegean
2.3
Southeastern Anatolia
1.1
Mediterranean
1.9
Turkish Public Health Association 2005 (date2003)
50
FUNDING COMBINES INTERNAL AND EXTERNAL FINANCING

• MOH and University
• Funded by MOH for Personnel and Maintenance
• Revolving Funds (from social insurance or
  patients) for other expenses
• SSK system (18 of beds 15 of hospital Drs)
• Like an HMO treats for free patients belonging
  to SSK
• Public
• Fee for Service paid per patient (set nationally)
• Drugs purchased by each hospital (centrally for
  SSK)
• Drug cost included in fee
• Private
• Hospital Fee set regionally Treatment Fee is
  free but sticks to national tariff
• Drug cost included in fee

51

• THANK YOU