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CHAP'l'ER V
EVOLUTION OF MEDICAL CARE IN HYDERABAD-SECUNDERABAD
,History of Growth of Medical services Prior to state Formation
During the Kakatiya dynasty medicine was dispensed by
barber surgeons, physicians, hermits, sanyasins and the
practitioners of ayurvedic and siddha medicine. After the fall
of the Kakatiya dynasty, the Qutub Shahis introduced Unani system
of medicine in 1323 A.D. A hospital cum medical school called
"Dar-UI-Shifa" was founded in 1595 and Unani medicine was taught
and practiced here.1/
Allopathic medicine made its advent only in 1839 after the
Nizam entered into a Subsidiary Alliance with the British in
1798. This Alliance gave the forces of the East India Company
permanent residence within the Nizam's state along with a variety
of economic concessions.2/ Between 1798 and 1858 the cantonment
area grew from an area of four square miles and a population of
eight thousand, consisting of' military personnel and civilians,
to a population of fifty thousand and an area of seventeen square
miles. Due to the British presence this area had a different
identity from Hyderabad which was directly under Nizam's rule.
In the former, the official language was English and missionaries
played a prominent role in running schools and hospitals whereas
in Hyderabad most of the schools were run by mosques and Urdu was
the official language.3/
In 1839 two Assistant Surgeons, T .Key and N. Simon of the
Hyderabad contingent of the British Army started a medical school
96
in Secunderabad to train medical subordinates. In 1846 the
Residency Dispensary was established to serve as a centre to
impart clinical training to medical subordinates. During the
same year the earlier school was closed down but almost
immediately the Resident obtained the sanction of the Nizam to
establish a school at the dispensary which was called the
Hyderabad Medical School.4/ The earlier school was established
wi thout the consent of the Nizam while the latter was started
wi th the cooperation of the Hyderabad State. 5/ The residency
surgeon received a salary from the Nizam's government with a view
to train qualified practitioners of medicine and surgery, who
would be capable of assuming independent medical charge in the
service of the Nizam's government or entering into private
practice in different parts of Hyderabad city. No fees were
charged to students and infact stipends were paid to them by the
Nizam's government. 6/ The medical school trained medical
officers and subordinates for the Hyderabad Medical Services and
hospital assistants for Berar. In the beginning, teaching in the
medical school was done in Urdu and ciinical instruction was
imparted at the Residency Dispensa~y but from 1884 onwards
English was introduced. The Hyderabad Medical School trained
three categories of personnel which included the hakeems,
government hospital assistants and Berar hospital assistants.
For the first ten years the medical diploma awarded was called
"Hakeem" and it was not until 1927 that MBBS degree was awarded.
The obj ecti ve behind training of Hakeems in the school was to
enable them to hold charge of the various civil dispensaries in
97
the Nizam's state and offer efficient medical and surgical aid on
European principles to the patients.7/ - -- --
The total strength of the Medical School at the beginning of
the period (1903-1906) was 65, of which only 26 students passed
the final test.8/ In 1881 only 1.18% of the population in
Hyderabad were physicians, surgeons and druggists. In 1911 there
was an increase of 60% and medical practitioners alone increased
by 50.4% as was revealed by the Census.
Growth Of Medical Services:
The establishment of the Residency Dispensary was followed
by the Hospital and Poor House in 1851 both of which were
voluntary bodies under the management and supervision of the
British Resident. In 1866 the Nizam established the Afzalgunj
Hospital as a centre of clinical teaching for the students of the
Hyderabad Medical School. During the turn of century there were
five allopathic hospitals,two managed by the British resident and
the remaining by the Hyderabad State. The three hospitals run by
the latter included the Afzalgunj Hospital, Central Police
Hospital and the Chanchalguda Jail h-ospi tal. Apart from
hospitals, allopathic services were expanded by establishing
dispensaries in different parts of the city. While the emphasis
was mainly on curative services, the early part of this century
saw the beginnings of preventive inputs. In 1912 a Sanitation
Department was created and kept as additional charge of the
Director of Medical department who was also designated as
Sanitary Commissioner. He was assisted by two deputy
commissioners and under him were district sanitary officers. The
Table: 5.1 - Hospitals Bstablished During the Late
19th and Barly 20th century
Sl.No. Name
1. Residency Dispensary
2. King Edward Memorial Hospital
3. Afzalgunj Hospital.
4. Mental Hospital
5. Police Hospital
6. Fever Hospital
7. Nampally Hospital
8. Hospital for T.B. and Chest Diseases
Year of Establishment
1846
1851
1866
1895
1908
1915
1923
1947·
Managed By
British Resident
British Resident
Hyderabad state
**** Hyderabad state
Hyderabad State
Hyderabad State
Hyderabad State
Source Government of Andhra Pradesh, Hyderabad District Gazeteer, Hyderabad, 1987.
99
S1.No.
1.
2.
3.
4.
5.
6.
7.
8.
Table 5.2 - Hospitals Established After state
Name
Golkonda Hospital
Sarojini Devi Eye
Niloufer Hospital
Cancer Hospital
Formation
Hospital
Year Of Establishment
1950
1951
1953
1955
Zenana Maternity Hospital 1957
ENT Hospital 1961
King Koti Hospital 1980
Nizam's Institute of Specialities 1964
Type
General
Special
Special
Special
Special
Special
General
Special
Source : Directorate of Medical Services, Hyderabad, 1990
Note : An Autonomous institution modelled on the lines of All India Institute of Medical Sciences, New Delhi.
100
main impetus for the creation of the sanitary department were
repeated epidemics of plague and malaria which arose due to
unsanitary conditions and overcrowding of poorer residential
areas.9/
In addition a major flood in 1908 highlighted the inadequacy
of drainage, sanitation as well as poor planning of other
infrastructural inputs. These various reasons acted as a
catalyst for the state to introduce public health measures.
During the early and middle part of this century four
hospitals were established. (Table 5.1). These included the
Fever hospital which was established in 1915, Nampally hospital
in 1923 and the hospital for the treatment of Tuberculosis and
Chest Diseases in 1947. Tae Fever hospital was started to treat
infectious diseases like plague, influenza and cholera which had
reached epidemic proportions in this area.
Growth of Medical Care After state Formation
Until 1948 the twin cities were growing under two different
administrations. While the former was under the feudal patronage
of the Nizam, the latter was under British control. It was
Police Action of 1948 which brought the twin cities under a
common administration. After the formation of Andhra Pradesh in
1956, the state played an·active role in the expansion of medical
services. (Table 5.2)
After state formation four hospitals were established and of
these one was general and the remaining three offered specialist
services. The two voluntary hospitals viz. Residency dispensary
and King Edward Memorial Hospital were taken over by the
101
government and renamed as Sultan Bazar Hospital and Gandhi
Hospital respectively. The Afzalgunj Hospital was renamed as
osmania General hospital and expanded with the addition of a
variety of specialities in 1957.
If one studies the expansion of the hospital since the late
fifties the emphasis has been on establishing specialist
departments. During the late fifties specialities like
anaesthesia, gynaecology and neurology were introduced. The
sixties was the per iod when the cardio-thoracic unit was
established and the seventies saw the growth of several
specialities like neuro-surgery, urology, nephrology, gastro-
enterology and Burns unit. The eighties was when the Artificial
Limb Centre was started.
Commenting on the expansion of special i ties a senior
official of the Directorate of Medical Education remarked:
"The Osmania General hospital has been facing a major financial constraint over the last eight years. They are being allocated only Rs.6000 per bed per year and this amount was fixed in 1984. Since then there has been no revision of this amount but at the same time specialities like neurology, nephrology and cardiology are growing. While excellent work is going on in these areas, a good deal of the funds have been diverted to them. Since high technology equipment plays an important role in these specialities, the acquisition of these have eaten into the hospital's budget. All these developments have occurred at the expense of general medical care. The quality of general medical has suffered due to the rise of specialities as a result of which the poor patient is denied. basic care." 10/
The Superintendent of the hospital also expressed similar views:
"Over the last ten years there has been little increase in the budgetary allocations and at the same time several super specialities have been introduced. Alongwith the introduction of special i ties there has been considerable pressure from the specialists to acquire the latest high technology equipment Which has eaten into the hospital's budget. This has had serious implications for general care." 11/
102
The nursing superintendent said "general services have suffered
as result of the rise of super specialities. This has had a
negative effect on the quality of care in the hospital."12/
Thus what. is apparent is that the expansion of medical
services was not only curative but specialist oriented, not only
in the twin cities but the state as a whole. In keeping with the
trend of establishing specialist hospitals, an autonomous
institute of specialities called the Nizam's Institute of Medical
Specialities was established in 1964, with partial assistance
from the government. It had a bed strength of 320 and offered
specialities like orthopaedics, cardiology, gastro-enterolgy and
the like.
Prior to 1986 the administration of these various hospitals
and dispensaries was under the Directorate of Medical and Health
Services. Subsequently, after 1986, the administration of the
state government hospitals was trifurcated as a result of which
there were three centres of administration. The Directorate of
Medical Education has control over all teaching hospitals both
general and specialist.
Andhra Pradesh vaidya
The second centre of administration is
Vidhana Parishad (APVVP) or the
Commissionerate which was established in 1985. This was set up
with the view to create an autonomous body which would have all
non-teaching hospitals at the district and taluk levels with a
bed strength of thirty and above under its jurisdiction.13/. This
body has been empowered to recei ve funds from the s ta te
government, donations from the general public and institutions
both from within and outside India. Apart from receiving funds
the commissionerate can also "plan, construct and maintain
103
Table 5.3 - Hospitals Managed by the Directorate of
Medical Education - 1990
SloNo. Name Type Year of Bed Strength Present Establishment Establishment Bed Strength
I. Osmania Hospital General 1866 30 1168
2. Gandhi Hospital General 1851 20 1012
3. Niloufer Hospital Special 1953 419
4. Cancer Hospital Special 1955 250
5. Diseases of Chest & Tuberculosis Splo 1947 670
6. Zenana Maternity Hospital Splo 1957 452
7. ENT Hospital Splo 1961 75
8. Mental Hospital Splo 1895 600
9. Sarojini Devi Eye Hospital Splo 1951 100 500
10. Fever Hospital Splo 1915 200 330
II. Govt. Maternity Hospital Splo 1846 39 150
Total 5626
Source Directorate of Medical Education, Hyderabad, 1990.
104
Table 5.4 - Hospitals Managed by the Andhra Pradesh
Vaidya Vidhana Parishad, 1990
Sl.No. Name Year of Bed Strength at Present Establishment Establishment Bed Strength
l. King Koti Hospital 1980 100 100
2. Golkonda Hospital 1950 105 105
3. Malakpet Hospital 1908 80 100
4. Narnpally Hospital 1923 24 86
Total 309 391
Source Andhra Pradesh Vaidya Vidhana Parishad, Hyderabad, 1990
Table : 5.5 - Hospitals Managed by the Directorate of
Medical Services
SL.No. Name Bed Strength At Present
1. Dabirpura Hospital 12
2. Ameerpet Hospital 6
3. Seethaphal Mandi Hospital 30
4. Barkas Hospital 8
Total : 56
Source Directorate of Medical Services, Hyderabad, 1990
105
commercial complexes, paying wards, provide diagnostic services
and treatment on payment basis."14/
The APVVP has all hospitals, other than teaching hospitals
with a bed strength of thirty or more under its jurisdiction.
The third centre of administration is the Directorate of Medical
Services which manages all hospitals with less than thirty beds,
dispensaries and Primary Health Centres(PHCs) in the rural areas
of Hyderabad.
Table 5.3 gives us an idea of the hospitals under the
Directorate of Medical Education. As mentioned earlier majority
of the specialist teaching hospitals in the twin cities were
established after state formation and have expanded considerably
in bed strength when compared to the hospitals managed by the
APVVP. The hospitals under APVVP offer mainly general services
and the+e has been little increase over the years in bed strength
as well as numbers. (Table 5.4) When it comes to hospitals under
the control of the Directorate of Medical Education there are
only four hospitals with a .total bed strength of fifty six.
There has been little expansion in this set of hospitals as
well. (Table 5.5)
Thus if one looks at all the three sets of hospitals it is
quite. clear that the emphasis has been on the expansion of ,
teaching hospitals both general and specialist rather than the
medium or smaller hospitals.
Apart from the state government, other agencies like the
municipality, a few public sector undertakings, the Central
Government Health Scheme (CGHS), Employees State Insurance
106
S1.No.
1.
2.
3.
4.
5.
6.
Source
Table • 5.6 - HosRitals Managed by: some Public sector • Undertakings
Managed By Yr. of No. Present Establishment Bed strength
ESI (Erragadda) 1965 1 334
ESI (Ramachandrapuram) NA 1 68
Railway Hospital 1888 1 120
CRPF Hospital NA 1 100
BHEL Hospital NA 1 160
APSRTC Hospital NA 1 120
Total 6 902
Statistical Division, Directorate of Medical Services, Hyderabad, 1990.
107
Scheme (ESIS), voluntary as well as private entrepreneurs also
provide medical care.
Medical Services Provided by Public sector Undertakings and Insurance Schemes
There are six hospitals run by various public sector
undertakings and the ESI scheme. Of the six hospi tals, the
Rail~ay hospital which is the oldest was established in 1888 by
the British in Secunderabad. The remaining hospitals -were
established during the sixties and seventies. (Table 5.6)
The Employees state Insurance Scheme runs two hospitals with
a bed strength of 334 and 68 respectively offering outpatient as
well as a variety of in patient services to workers in the
organised sector. In addition the scheme also runs ten,
dispensaries in various parts of the city.
The Railways run a 120 bed hospital, the Central Reserve
Police Force (CRPF) a 100 bed hospital, the Bharat Heavy
Electrical Limited (BHEL) a 160 bed hospital and the Andhra
Pradesh state Road Transport Corporation (APSRTC) a 120 bed
hospital. None of these organisations run dispensaries but the
CGHS manages 11 dispensaries in var'ious parts of the city for
employees in the central government service.
Services provided by the Municipality
The Municipal corporation of Hyderabad (MCH) . provides both
curative and public health services in the twin cities. It runs
three free dispensaries, a maternity hospital and nineteen
Maternal and Child Health Centres in different parts of the city.
There are separate wings dealing with medical and public health.
108 '.:
In the medical wing there is a chief medical officer who is
overall incharge of running the maternity hospital and free
dispensaries. The other duties of the Chief Medical Officer
include registration of births and deaths and the removal of
environmental waste. The public health wing is mainly concerned
with malaria and family welfare and is also in charge of running
the maternal and child health centres. These centres are staffed
with a health visitor, AuxilIary Nurse Midwife ,(ANM), Dai, Ayah
and a chowkidar. Their functions include conducting deliveries,
child health and immunisation programmes.
Health Service Inputs in Slums
Apart from medical care and public health inputs, the MCH
also has outreach programmes in slums. This is being implemented
through the Urban Community Development (UCD) programme which was
initiated during the sixties. This programme initially included
installation of public water taps, latrines, paving roads etc.
Later on the scope of the programme was widened to include socio-
economic, educational and family welfare inputs. The ueD has
been supported by international agencies like the UNICEF, and the
Overseas Development Agency (ODA) which is. a British funding
body. Since 1983-84 the MCH has been implementing the Hyderabad
Slum Improvement Programme (HSIP) which is being funded by the
ODA. The project provides for a variety of physical inputs like
roads, drainage, drinking water pipes, sewers, community halls
and lavatories. In addition to this there are also social inputs
which include improvement of housing, health and nutrition. The
health and nutrition services under HSIP cover a range of
, 109
programmes which include immunization of pre-school
children, ante-natal care, treatment of minor illnesses, vitamin
"A" prophylaxis and distribution of iron and folic acid for women
and children. Under nutrition services there are supplementary
nutrition programmes and subsidised milk distribution for
children. The HSIP covered only 207 slums out of a total of 730
slums in the twin cities in 1987.
Thus medical care in the city is being provided by multiple
agencies like the state government, the municipality and certain
public sector undertakings. The total bed strength in this
sector is 6975.
Non-Government Institutions in Medical Care:
The non-government sector consists of the voluntary or 'non-
profit' institutions which are managed by trusts which are both
religious and non-religious 'as well as institutions which are
'for profit' enterprises. There is great deal of variation in
the management of private enterprises ranging from single
owner/partners to private and public limited concerns.
Voluntary sector:
The British residents founded and managed two hospitals as
voluntary bodies viz. the Residency Dispensary in 1846 and the
King Edward Memorial Hospital in 1851. Both these were taken over
by 'the government after its formation in 1956.
At present there are only eleven hospitals in the twin
cities, -of which, eight offer both general and specialist
services and the remaining offer only a speciality viz. eye and
110
Table 5.7 - Voluntary Hospitals in the Twin Cities
Sl • No • Name
1~ Vijaya Marie Hospital
2. St. Theresa's Hospital
3. Mahavir Hosp. & Research Centre
Type of Managemeot
Sisters of Charity
Society of Jesus,Mary & Joseph
Jain Trust
4. Muslim Maternity Islamic Trust Hospital
5.
6.
7.
Princess Esra Hospital
Durgabai Deshmukh Hospital
Shroff Memorial
Princess Esra Trust
Andhra Mahila Sabha Trust
Hospital Nandini Gandhi Trust
8. Sagarlal Memorial Hospital
9.
10.
Sivananda Rehabilation Home
Lion's Sadhuram
Trust
Trust
Memorial Lion's Club
11.
Hospital
L.V. Prasad Eye Institute
L.V. Prasad Trust
Type of Hospital
General
General
General
General
General
General
General
General
Leprosy
Eye
Eye
Year of Establishment
1957
1974
1974
1970
1967
1964
1974
1982
1958
1978
1986
Source : Handbook of the Andhra Pradesh Voluntary Health Association of India, Hyderabad, 1985.
111
Table 5~8 - Bed Strength and Services Offered by Voluntary Hospitals in the Twin Cities
S.No. Name Bed Strength Present Services Training Outreach at Establishment Bed Strength Offered Progranmes Progranmes
1. Vijaya Marie 29 160 Gen Surgery, Gynaecol ogy Paramedical Health Education Hospital Paediatrics,Family Nursing child & maternal
Plaming ENT. (3 1/2 yrs.) health,Sanitation in slllJlS.
2. St. Theresa's 200 250 Gen. Surgery,Gynaecology Paramedical Family Planning, Hospital Paediatrics,Orthopaedics Nursing Maternal & Child
Dental, Intensive Care Course health,Sanitation Unit, Blood Bank (3 1/2 yrs.)
3. Mahavi r Hospi tal 82 82 Gen. SurgerY,Gynaecology Multipurpose Research Researc~ Centre Paediatrics,Dialysis Health Workers Unit On
(18 Months) Mycology.
4. Musl im Maternity 25 50 Gen. Surgery, Gynaecology Auxillary Nurse Mobile Clinics Hospital Paediatrics Midwi fe (ANM)
(2 yrs), lab Tech. Diploma
5. Princess Esra 50 50 Gen. Gynaecology, Hospital Eye, ENT, Paediatrics
Others
6. Durgabai Deshmukh 75 175 Gen. Gynaecology, Nursing & Outreach Hospital Surgery,Orthopaedics, MPHW Training Progranmes to
Paediatrics, Cardiology villages
7. Shroff Memorial NA 60 Gen. Obs-Gynaecology, Rural Health Hospital Medicine,Surgery Caq:>S
ENT ,Eye,Dental Blood Bank
8. Sagarlal Memorial 18 60 Gen. Gynaecology, Research Hospital Surgery Centre
9. Sivananda leprosy NA 120 Reconstructive Surgery Vocational Home Physiotherapy Training,Health
Education, Screening •
. 10. lion's Sadhuram NA 100 Eye Surgery Eye Caq:>S Eye Hospital
11. l. V. Prasad Eye NA 110 Testing,Surgery Training Institute Rehabi l itation for for
Visually I~ired Opthalmologist
112
leprosy. six of these hospitals are managed by secular bodies
and the remaining by religious trusts consisting of two
christian, two muslim and a Jain. The earliest date of
establishment of these hospitals was during the late fifties
which was after state formation. Subsequently, two hospitals
established during the fifties, two in the sixties, five in the
seventies and two in the eighties. (Table 5.7)
Bed strength and Services Offered
The total bed strength in this sector is 1217 and the
hospi tals offer services ranging from general , maternity,
surgery, paediatrics, Ear Nose and Throat (ENT), cardiology etc.
The specialist hospitals treat only a specif ic problem namely
leprosy and eye. Apart from offering medical care most of these
organisations have outreach programmes into slums in the city and
in some instances to nearby villages as well. These outreach
programmes include mobile clinics, conducting health camps,
health education, regular screening for specific diseases
specially in cases like leprosy and eye, immunisation and family
planning programmes. A few of these organisations run regular
training programmes for nurses, AuxilIary Nurse Midwives (ANM)
and Multi purpose Health Workers (MPHW).
The Private or "for-profit" sector
During the turn of the century the private sector was mainly
restricted to individual practitioners. As far as private
hospitals are concerned the earliest reference available is the
statistical Year Book of 1940-41 for the State of Hyderabad.
According to this source there were twenty two government and
113
non-government hospitals during the first three decades of the
twentieth century. 15/ However, this does not provide us any
details regarding these institutions. In order to get further
insight into the nature of private institutions a special effort
was made to locate private practitioners who were in their
seventies and who could help us construct a picture of the
services as they existed during the early part of th~s centllry.
We found that there were three practitioners who were above
seventy, of whom two were still running a nursing home and formed
a part of our sample. Interviews with these elderly doctors .
revealed that there were hardly a dozen of them during the early
part of this century. As Dr. Vasu who is well into his eighties
recalled:
"One of the oldest qualified was Dr.Kirloskar who set up a clinic in the 1890s. Subsequently around a dozen practitioners, both British and Indian, set up clinics."
Dr. Vasu was one of the first to establish a nursing home
in the twin cities. He was a surgeon who had been trained in
Germany and his wife, a German, was a gynaecologist. They
established a eight bed nursing home in i939 where they offered
gener~l, maternity and surgical services. Oro Desai who is now
in his late seventies recalls that Dr. Vasu's nursing home was
the first of its kind and during the same period there was a
pathological lab cum nursing home in Secunderabad. Neither of
the doctors were able to provide details regarding this
enterprise. Dr. Vasu and Desai recall that:" during the forties
and fifties there were private nursing homes with few beds, run
114
mostly by foreign trained specialists. The remaining were run by
doctors who had only a basic degree in medicine." 16/
Dr. Ramamurthy had established a nursing home in the early
fifties recalls:
"most of us fifties were basic degree There were abroad. "17/
who started nursing homes during the forties and not trained locally. Some of us had qualified ina from Madras or Bombay and set up general practice. few specialists and all of them were trained
What seems to emerge from these various interviews is that
from the turn of the century until 1939 there were few
institutions and the private sector was restricted to individual
practi tioners. It is only from the forties that nursing homes
grew in the twin cities.
The Present Scenario:
According to an estimate by a leading drug manufacturing
company there are 3000 doctors in Hyderabad of whom roughly a
third are in the public sector and the remaining are in the
pr iva te sector. 18/ The latter would include doctors who have
individual practice in the form of clinics, own nursing homes or
hospi tals and those who are employed in these nursing homes or
hospitals.
There is a wide variety in the institutions delivering
medical care in the private sector. These include clinics which
offer only outpatient services, nursing homes and hospitals which
offer both outpatient and inpatient services. In addition there
are institutions which offer pathological and diagnostic testing
facilities. According to information compiled by Dr.B.G. Rao's
doctor's directory there were 387 clinics run by general
115
practitioners during 1986-87, which offer only out-patient
services. There is a wide range among those institutions which
offer both out-patient and inpatient services. The institutions
which offer such services include nursing homes and hospitals
which are managed either by single owners or partners. There are
also hospitals which are run as private and public limited
companies. A private limited company is a "type of business that
permits a limited number of shareholders to enjoy limited
liability and to be taxed as a company. Unlike the public
limited concern a private limited may not offer shares for public
subscription, but unlike a partnership it is obliged to file
accounts. "19/ The public limited concern on the other hand are
like any other industry which float shares in the market and
enjoys all the concessions given to industries.
Nursing Homes and Hospitals in the Twin cities
There are 184 nursing homes and hospitals in the twin cities
of which 177 are managed by single owners or partners, two are
managed as private limited and the remaining five as public
limited enterprises. (Table 5.9) Of the 177 nursing homes managed
by single owners or partners, 166 of them offer general,
maternity, surgical and a few specialities while the remaining
eleven offer only specialist services for ear, eye, orthopaedic
and kidney related problems.
116
Table 5.9 PRIVATE INSTITUTIONS IN BYDERABAD
SloNo. Type Ownership Numbers
1. General Single owner Nursing Homes & partners 166
2. Specialist Single owner Nursing & partner 11
3. Private limited 2
4. Public limited 5 -------------------------------------------------- - ~ - ~ ~ - - . - ",
Total 184
There is considerable variation in the size of operations
among the general nursing homes category and since all of them
offer maternity services it is possible to sift out the larger
ones from the smaller ones based on whether they have been
recognised by the Municipal Corporation for family welfare
activities. This is because the Municipal Corporation recognises
only those nursing homes which have (a) well equipped operation
theatre (b) a post graduate qualified gynaecologist (c) a
doctor who is a member of the Indian Medical Association and (d)
registered with the municipal corporation to conduct family
planning operations.
Based on this criteria the 166 nursing homes were
differentiated into 80 large and 86 small nursing homes. The
estimated bed strength of this category is 2648 while the bed
strength of the specialist nursing homes. category is 168.
Private and Public Limited Enterprises
Since there is no qualitative difference except ownership,
both these categories were clubbed together. The total bed
117
strength of this category is 1245 with the average bed strength
of the corporate sector being 234 while in the private limited
category it is 38. The hospitals in this category offer both
general, specialist and super-specialist services. In addition
they have supportive services like diagnostic facilities which
includes routine testing as well as scanners. All of them also
_l1av~.a phar!llacy on.the premises.
In the· following sections we present data on the general
nursing homes under two broad headings. Firstly we look at the
characteristics of these nursing homes in terms of bed strength,
services offered,infrastructural facilities available and medical
and paramedical staff employed in these enterprises. The second
aspect will include the social background of owners, sources of
capital, size of operations I background of clientele and
inter-relationship with the public sector.
1. Characteristics of General Nursing Homes
1.1 Year of Establishment and Type of OWnership:
Our sample survey reveals that th~ough the fifties and
sixties there were few nursing homes and it is only from the
seventies that there is growth. Nearly 90 percent of the large
nursing homes were established between 1970 and mid eighties,
however, 77 percent of the small nursing homes were established
only during the eighties. (Table 5.10)
118
Table 5.10. Year of Establishment
SloNo. Type 1950-60 1960-70 1970-80 1980-90 Total
1. Small 1 1 3 17 22
2. Large 1 1 9 9 20
2 2 12 26 42
As far as type of ownership is concerned; in the small
nursing home category 68 percent were managed by single owners
and only 32 percent were run as partnerships. In the case. of
large nursing homes 60 percent were managed as partnerships while
only 40 percent were single owners. Partnership in both
categories were essentially husband-wife teams, both of whom were
doctors. (Table 5.11)
Table 5.11. Type of OWnership
Sl.no. Type Single owner Partner Total
1. Small 15 7 22 Nursing Home (68) (32) (100)
2. Large 8 12 20 Nursing Home ( 40) (60) (100)
Total 23 19 • 42
1.2 Bed strength and services Offered
There was variation in the bed strength across the small and
large nursing homes. The former had bed strengths ranging from
less than four to twenty and the average was nine. In the latter
119
category the bed strength ranged from twenty to forty and the
average was thirty three. (Table 5.12)
Table 5.12 Frequency Distribution of Bed strengths in Nursing Homes
Sl. Type No.
1- Small
2.- - Large
4-10 10-15
13 7
Bed strength
15-20 20-25 25-30 30-35 35-40 40+
2
9 1 2 3 5 -----------------------------------------------------------------
Total 13 7 2 9 1 2 3 5
Nearly ninety two per cent of the small nursing homes ·have
bed strengths below fifteen and the remaining eight percent have
between fifteen and twenty beds. In the large nursing homes
forty five per cent have bed strengths ranging between twenty and
thirty while fifty five percent have between thirty and forty
beds.
Bed strengths have not grown uniformly in the two sets of
nursing homes. The beds in the small nursing homes have grown
at a slower pace than the large ones. (Table 5.13)
Table 5a13 Growth of Beds in Small Nursing Homes
SloNo. Year Sample Units Bed Strength Present Bed strength
-------------------------~---------------------------------------1- Before 1960 1 10 10 2. 1960-70 3. 1970-75 4 36 31 4. 1975-80 5. 1980-85 12 84 123 6. 1985-90 5 ·36 43
Total 22 166 207
12(1)
From table 5.13 it is clear that there was little growth of
beds in nursing homes established during the sixties and
seventies and there were also very few of them as well. During
the seventies the bed strength infact showed a negati ve growth
because the owner was forced to reduce the bed strength due to
competition from newer nursing homes in her area. To quote the
owner:
"I started my nursing home during the late sixties and early seventies when there were very few nursing homes in this area. At that time my practice was thriving but through the late seventies and early eighties a number of nursing homes have come up which are better equipped and run by doctors with post graduate degrees. Since I have just a MBBS degree and virtually no consultants I find my clientele shrinking. Besides I am
)- almost sixty and find it difficult to cope with even a minimum ~, number of patients. "20/ . . . y --- While there was little growth during the earlier phase, for
those established during the eighties there is some growth of
beds.
The trends observed in the large nursing homes presents a
contrast to the small ones. (Table 5.14) Across all years one
finds that the bed strengths have doubled. This can be explained
partlyny the fact that nearly fifty percent of these enterprises
were established during the seventies and therefore have been
around for more than a decade. The other reasons could probably
be explored by looking at the social background of the owners and
sources of capital for the expansion of these enterprises.
121
Table 5.14 Growth of Beds in Large Nursing Homes
. Sl No. Year Sample units Bed Strength Present Bed Strength
---------------------------------------------~----------------1- Before 1960 1 12 25 2. 1960-70 1 6 20 3. 1970-75 5 50 132 4. 1975-80 4 65 162 5. 1980-85 5 80 153 6. 1985-90 4 110 170
Total 20 323 662
1.3 Services Offered
All the nursing homes offer out patient services and all of
them provide general and maternity services. The number of them
which offer surgical and other specialities however varies with
the size of the nursing homes. Most of these nursing homes also
offer family planning and immunisation services. (Table 5.15)
Irrespective of size and the fact that it is only the larger
enterprises which are officially recognised to provide family
planning services nearly ninety per cent of the small and large
nursing homes were providing family planning services which
includes spacing methods, conducting abortions and
sterilisations, mostly tUbectomies. Similarly, nearly eighty per
cent of the nursing homes in both categories conduct
immunisations. Recently the Municipal corporation of Hyderabad
has been providing vaccines to nursing homes free of cost to
cover not only the patients who come to them but also as outreach
programmes to nearby slums.
122
Sl. Type No.
1. Small Nursing Homes (Total Sa""le = 22)
2. Large Nursing Homes (Total Sa""le = 20)
Total 44
Table 5.15 - Services Offered
Services Offered Fami l y Planning Inmunisation In-Patient
Out- General Mater- Surgi- Paed- Spacing Abor- Sterili- None OPT Polio MMR Patient nity cal
22 20 21 14
19 20 20 18
41 40 41 32
atrics methods tions satious (Tubectomy)
19 19 19
2 18 17 18
2 37 36 37
123
3 17 17 14
2 16 15 15
5 33 32 29
Nature of Assistance Provided by the state to Private Nursing homes for Family Planning and Immunisation
The incentives provided by the state are of two types viz.
through the supply of material in terms of condoms, intra uterine
devices as well as cash for those who undergo sterilisation. All
nursing homes which are recognised by the Municipal Corporation
of Hyderabad for family planning are provided Copper 'T' free of
cost. For those who undergo sterilisation, both the acceptor and
the doctor are paid. The terms and conditions of this scheme are
as follows:
"As regards incentives the following amounts will be
admissible to the private doctor/acceptor out of the compensation
amount of Rs 170 regardless of whether or not the private doctor
charges his/her own fee from the acceptor."21/
In Hyderabad patients undergoing sterilisations are given Rs
120 for tUbectomies and Rs 100 for vasectomies and the doctor
gets Rs 50 per case.
Apart from this the Municipal Corporation also has a grant-
in-aid scheme for private nursing homes and voluntary hospitals
conducting family planning operations. The recognised nursing
home or hospital can apply for grant-in aid for beds specially
reserved for family welfare. The MCH gives three thousand rupees
per bed per year as recurring grant provided there are at least
seventy five cases per bed year of family planning operations.22/
The various incentives offered by the state is indicative of the
importance given to family planning. Not only are incentives
given but the private practitioner can also charge the patient
for any family planning service that he/she renders.
124
Recently the municipality is supplying these recognised
nursing homes with vaccines free of cost under the Expanded
Programme for Immunisation (EPI). Since the scheme is a new one
the coverage of nursing homes is limited and even in those cases
where the vaccine is being provided the MCH is not bothered if
the private practitioners charge the patients for the services.
Communicable Diseases
Majority of these nursing homes reported treating a variety
of communicable diseases which are an important component of
national vertical programmes.
Table 5.16 Treatment of Communicable Diseases
SloNo. Type Malaria T.B. Cholera Typhoid Filaria Leprosy
1.
2.
Total
Small
Large
44
22 (100) 19
(95 )
41
19 ( 86) 17
(85 )
36
6 (27)
9 (45 )
15
11 ( 50) 12
( 60)
23
Note: Figures in brackets denote percentages.
2 (5)
3 (15)
5
3 (14)
4 (20)
7
Nearly all the nursing homes treated malaria and 85 percent
of them in both categories treated tuberculosis. Around 50-60
percent of them treated typhoid whereas less than 20 percent
treated cholera, leprosy or filaria. (Table 5.16) However none
of these nursing homes maintain any records of the number of
cases treated nor had any government agency approached them to
find out if they treated such cases.
125
2. Facilities Provided
The facilities provided by the nursing homes is directly
related to the size of operations. The small nursing homes in
general have only one operation theatre, no laboratory or
pharmacy attached to it. However in the case of the larger
enterprises they usually have more than one operation theatre, a
few of them have labs and pharmacies attached and some even have
high technology equipment like ECG and ultrasound scanners.
2.1 Operation Theatre:
More than half of the small nursing homes have a major
operation theatre and the remaining only a minor one. In the
case of large enterprises 45 percent had atleast one major
operation theatre, 30 percent had a major and a minor and the
remaining 25 percent had two major theatres. (Table 5.17)
Table 5.17 Facilities provided
SI.No. Type Operation Theatre laboratory
1. 2.
Small Large
1 major major/minor 2major
12 9 5 6
5 10
Pharmacy
2 6
-----------------------------------------------------------------Total 42 21 5 6 15 8
55 percent of the small nursing homes had a major operation
theatre while the remaining had only a minor one which served the
purpose for conducting deliveries and minor surgeries. If they
got cases which required major surgeries, all of them said that
they use the theatre facilities in the larger nursing homes. As
one of the owners who has only a minor theatre described:
. "I conduct all major gynaecological cases in another private hospital. I have an arrangement whereby I pay for the facilities
126
which includes operation theatre, surgeon's assistance and anaethestist. The total charges for these various services comes to Rs 1500. Once the surgery is over I move the patient back to my nursing home." 23/
Only 23 percent of the small nursing homes had a lab
attached and a mere 9 percent had a pharmacy on the same
premises. However in the larger enterprises 50 percent had a lab
and 30 percent had a pharmacy attached. A similar pattern was
observed in the use of medical equipment in these nursing homes.
Commonly used medical equipment in these nursing homes included
X-Ray, ECG and ultra sound equipment. Twenty three percent of
the small nursing homes had ECG equipment while only one nursing
home had an X-ray and none had ultra sound equipment. When it
comes to the larger enterprises 65 percent of them had x-ray
equipment, 20 percent had ECG and 15 percent had ultra sound
equipment.
2.2 Laboratory attached to nursing homes:
Only 23 percent of the small and 50 percent of the large
enterprises had a lab attached . When the owners who did not
have a lab attached were asked whether they referred their
patients to a specific lab 95 percent of them answered in the
affirmative. It is significant to not that such a high
percentage referred patients to a specific lab. An important
reason for this is the nexus between private nursing homes,
pathological and diagnostic centres where commissions offered by
the latter to the former plays an important role.
Our survey revealed that there are 130 pathological labs
and diagnostic centres registered with the MCH in 1990. This is
127
of course not a complete listing however it does give us some
idea of the numbers involved. Except for two enterprises which
are corporately managed, the remaining are managed by single
owners or partners. Our interviews based on personal contacts
with half a dozen owners of these enterprises revealed the role
of commissions in getting doctors to choose a specific lab to
refer patients for testing as well as prescribing the type and
number of tests to be performed.
As one of the owners observed: "Over the last five years there has been a proliferation of labs in the city which has lead to intense competition among them. This has resulted in commissions playing an important role in getting patients. 99 percent of the owners of these labs do pay commissions. The nature of commission varies -sometimes it it is a fixed percentage of the cost of a particular ·test that is paid to the doctor otherwise it is offered in the form of some expensive gift. The point however is that commissions play an extremely important role in ensuring patient supply."24/
A promoter of a corporate diagnostic centre frankly admitted
that concessions are offered to doctors and said:
"In order to entice doctors to prescribe diagnostic tests we offer commissions usually around 10-15 percent of the cost of the test specially in the case of CAT scans. But this is nothing unusual because other diagnostic centres as well as pathological labs also offer commissions. After all we are all essentially a business so we have to find ways to make it viable. "25/
Dr. c. who has recently established a diagnostic centre is
still in the process of discovering how this system functions.
He said:
II Nearly all labs in .this city offer commissions to doctors. So far I have been able to survive without paying commissions but sooner or later I will have to join the rat race for mere survival. In this city several other factors like caste plays an important role in referrals. I find that Reddy specialists do not refer cases to me because I am a Kamma and prefer to refer cases to a diagnostic centre run by Reddys. I wouldn't have thought this would be an important reason but a Reddy doctor friend of mine told me how important caste connections are in this business."26/
128
While majority of the owners do offer commissions there are
few who do not. Dr.R. who is a pathologist runs a well reputed
diagnostic centre. Pr ior to starting this centre he was in
government service for fifteen years. He resigned from service
in 1983 to set up this lab'because:
"the lab facilities in the government hospitals were far from adequate. Reagents and laboratory equipment were not easily available as a result of which a number of patients had to be referred to private labs. Seeing the situation I decided to set up my own lab."27/
Because of his association with the government hospitals
some of the top specialists refer cases to him. He does not
offer any concessions to any doctor and says:
"I run a professional lab and its my competence which makes doctors refer cases to me."28/
Dr.S. who is also a pathologist runs a lab and says that:
"I started my lab six years back when there were very few in this city. At that time I used to get twenty to thirty patients a day. Over the last couple of years a number of labs have labs have come up in the city as well as in this area. As a result of this I get, on an average, only seven or eight patients a day. Since i do not offer concessions like the other labs I do not get as many referrals. The problem in this city is that the smaller labs are mostly run by technicians with no qualified pathologist. There are quite a few instances when pathologists who are in government service run labs on the sly by registering it under someone else's name. They have to do this because there is a rule which prohibits non-clinical staff' inn government service from practising privately. Obviously those who are in government service are at an advantage since they have direct access to patients. "29/
Interviews with owners of nursing homes also revealed the
role of commissions. All of them admitted having been offered
commissions. Dr.J. who runs a six bedded nursing home said:
"Last week a lab in this area which had acquired an ultra sound scanner approached me and said that their charges for abdominal scanning was 150 rupees and for every case I refer they would pay me 25 rupees. I told the lab representative that majority of my patients earn Rs 600-800 per month, if I prescribe an ultra sound test how can they afford it? 'The point is ultra
129
sound has become a part of the routine testing and is being prescr ibed even when it is unnecessary. Because of intense competition among the labs they have even started tapping small nursing homes like mine." /::-
These various interviews just show the mutually supportive
relationships which have been built up within the private sector
raises certain important issues for medical ethics.
3. staffing:
Apart from owners who are doctors the other personnel
employed as hired workers are doctors and nurses who the owners
claim are mdstly trained as AuxilIary Nurse Midwives.
Table 5.18 Doctors Employed in Nursing Homes
SloNo. Type 1. Small 2. Large
Total
Number of Doctors Employed
None 14
1
15
<4 8
15
23
4-6
4
4
Total 22 20
42
Table 5.18 shows that sixty four percent of the small
nursing homes do not employ doctors at all and the remaining 36
percent employ on an average less than four doctors. Therefore
in the smaller enterprises it is the owner/ doctor who provides
routine professional care.
The picture is however very different in the larger
enterprises with 95 percent of them employing doctors and on an
average 75 percent of these employ less than four doctors.
4. Qualifications of Doctors Employed:
Among the small nursing homes which employed doctors, fifty
percent of them 'had a MBBS degree, 25 percent had a post graduate
130
degree and the remaining 25 percent had a degree in Ayurveda.
In the large nursing homes 63 percent had a MBBS degree, 5
percent had a post graduate degree and the remaining 32 percent
had a degree in Ayurveda. (Table 5.19)
Table 5.19 Qualifications of Doctors Employed
SloNo. Type
1. 2.
Small Large
MBBS
4 12
16
MBBS+PG
2 1
3
other Systems
2 6
8
Total
8 19
27
The owners in both categories who employed doctors with a
degree in Ayurveda were asked if they offered ayurvedic
treatment. All of them said that the ayurvedic doctors only
administered allopathic medicine. As one of them said:
"I find that those with a BAMS degree are good enough for. taking care of routine cases. They know how to monitor blood pressure and conduct a regular check up which is quite adequate for ordinary cases. They are also willing to accept a lower salary than the MBBS doctor which is a major reason for employing them."31/
We tried to elicit information on the salary paid to these
doctors but found that in general the owners were evasive in
their replies. Around twenty percent of the owners in both
categories said they paid a MBBS doctor Rs 1000 per month.
However the President of _ the Andhra Pradesh Nursing Homes
Association said that this was an inflated f,igure' and at best
doctors were being paid anywhere between Rs 750-800. This was
mainly because of the high unemployment rates among medical
graduates as a result of which they are willing to work even for
low salaries.
131
5. Paramedical staff:
95 percent of the small and all the large nursing homes
employed paramedical staff. Only twenty percent of the large
nursing homes and one small nursing home employed trained staff
nurses and the remaining paramedical staff in both categories
were either ANM trained or were untrained. As the president of
the Nursing Homes Association observed: In the case of
paramedical staff, ANMs were paid between Rs 400-500 and in most
nursing homes women are trained on the job and paid anything from
Rs150-200 and if you ask the owners about their qualifications
they will say that they are all ANM trained.32/
Table 5.20 Paramedical staff in Nursing Homes
Sl.No. Type None· 1-5
1. 2.
Small 1 Large
1
5
5
6-10 >10 Total
18 9
27
3 6
9
22 20
42
Table 5.21 Qualifications of Paramedical Staff
SloNo. Type Staff ANM Nurse
1. 2.
Small Large
Total
1 4
5
18 15
33
Dai
1
1
untrained
1 1
2
Not Applicable
1
1
Although we tried to interview paramedical staff in the
sample nursing homes we found that either the owners did not like
our talking to them or the staff were never free. However during
one of our visits to the nursing home in the sample we managed to
interview a woman who had come in search of a job and had the
time to talk uninhibitedly.
132
Naseem Bano is thirty years old and has studied upto the
eighth class in an Urdu medium school. She has been working in a
voluntary hospital as a nurse for the last nine months and was
paidRs 150 per month. Her job involved a variety of skilled and
unskilled activities which ranged from giving bed pan, cleaning
and changing patients, preparing patients for surgery,
sterilising equipment, assisting doctors for deliveries and minor
surgeries and administering injections and medicines. She was
essentially trained on the job by doctors and in a matter of a
couple of months she had become proficient. Her working hours
were from nine in the morning to six in the evening and during
this period she was continuously on her feet. She decide to quit
her earlier job because of the poor salary and since she lived in
the old city she had to leave horne by seven in order to reach her
work place by nine. Meanwhile she had heard from a friend that
this nursing horne pays ayahs between Rs200-250 so she had come
looking for a job. She said: "the disadvantage of changing jobs
is that if you are a new staff they will give you all the menial
jobs first. So I have to start from giving bed pans, cleaning
toilets, floors etc. It is not a pleasant job at all but I have
no choice."33/
Although it was not possible to interview paramedical
workers in other nursing homes, those owners who were forthright
did admit that the case of Naseem Bano was not an exception but
in majority of the cases was the rule. Nearly 95 percent of the
both categories of nursing homes had paramedical workers who were
133
women from Kerala and were most often accommodated wi thin the
premises of the nursing home.
6. Growth Patterns and Social Background
6.1 Social Background of owners:
In order to gain some insight into the social background of
the owners we looked at the religious and caste background of the
individual. An effort was made to get information on occupation
of the fathers in order to see if they and links with land ,
business or were a family of professionals. This was to throw
light on social links of the owners in the various categories of
nursing homes.
Table 5.22 Social Background of OWners
Religion SI.No. Type Hindu Muslim Christian others
1. 2.
Small 22 Large 28
51
5. 3
8
1 1
2
1 2
3
Caste F.C. B.C.
20 23
43
2 5
7
s.c.
Note: F. C., B. C. and S. C. denote forward caste, backward ~ caste and schedule caste respectively. Numbers do not add up to total sample be~ause of partners.
Majority of the owners in both categories were forward caste
Hindus. Of the 22 forward castes in the small nursing home
category, 8 (36%) were brahmins, 7(32%) were Marwaris and 5(23%)
were kammas. There were only two owners who belonged to the
backward classes both of whom belonged to Telengana, one came
from a family who had petty business and the other belonged to a
family of goldsmiths who continue to practice their trade. Of the
28 forward caste owners of the larger nursing homes there were
134
6 (21%) Brahmins, 4 (14%) were Reddys, 4 (14%) were Kammas, 5
(18%) were Velamas, 2 (7%) were Naidus and 2 (7%) were Marwaris.
There were five who belonged to backward classes.
Table 5.23 Father's Occupation
SloNo. Type Occupation cultivator
1. 2.
Small Large
8 12
20
Prof-business essional service crafts Total
man
13 7
20
6 10
16
1 3
4
1
1
22 20
42
45 percent of the owners of small nursing homes were from
families who were into petty business viz. owners of shops and
traders. 27 percent were cultivators, 21 percent were
professionals and the remaining 7 percent were in government
service.
In the large nursing homes 38 percent were cultivators
followed closely by professionals, mostly doctors, who
constituted 32 percent. 22 percent were from business families
and the remaining 8 percent were in government service. In both
categories put together it is the cultivator- business combine
which dominated followed by professionals.
In order to gain insight we also elicited information
regarding age, sex, religion, caste, qualifications, family links
of the owners. In addition information regarding the religion,
caste and occupation of the father was elicited to comment on
familial links.
135
6.4 Age: Most of the owners of small nursing homes were in the
age group between thirty and fourty years while in the case of
large nursing homes it was between fourty and fifty years.
There were more women running small nursing homes as compared to
the large nursing homes which 'were mostly run by men. In both
categories the owners were mostly from Hyderabad followed by
coastal Andhra.
6.5 Qualifications of owners:
80 percent of the owners of small nursing homes were
qualified with either a MBBS degree or .had a MBBS with a diploma.
There was only one non-medical person and she was one of the
partners in the small nursing homes. In the large nursing home
category 70 percent of the owners and partners had qualified with
a MBBS degree with a diploma or a postgraduate degree. There was
only one person with a non medical degree and he happened to be a
partner in one of the enterprises.
6.6 Sources of Capital:
In the case of small nursing homes majority of the owners
had mostly invested their own capital. But in the case of the
owners of large nursing homes majority of them had invested only
a small proportion of their own capital and had mobilised the
remaining amount through loans from banks. (Table 5.24)
136
Table 5.24 Sources of capital
Sl.no. Type All own 60-70%own 20-30%own 50% own Total + bank loan +bank loan 50% loan
Small 11 6 5
2. Large 2 5 11 2
•. Total 13 11 16 2
7. Type of Accommodation:
22
20
42
In the case of large nursing homes 63% of them had a
separate building to house the nursing home while the remaining
37% had made additions to their own residences. If one were to
examine the social background of the owners of large nursing
homes who could afford to invest in a building exclusively for a
nursing home, 75% of them were forward caste, mainly the
cultivating castes viz. Reddy, Kamma and Velama. The sole
Brahmin and kammas were from Krishna district while the Reddys
and Velamas were from Medak and Warangal respectively.
The father's occupation was cUltivation usually in
combination with either a government job or business and only one
of the father was a professional. Among the forward castes only
one had gone abroad.
Only 25% of those who could afford a separate building for
the nursing home belonged to the minorities viz. two muslims and
a sikh. None of these owners had any connection with lands ; two
of them belonged to a business and one to a professional family.
The two muslims had worked in the middle east for nearly five
years.
137
However among the small nursing homes nearly 70% of them
were using a part of their residence to house the nursing home.
As an owner of a small enterprise described:
"I started a clinic during the late sixties at my residence. After two or three years I added five beds to the clinic and converted the store room into a minor operation theatre cum delivery room. I used one of the bedrooms as a ward. My husband who is also a doctor managed to get a three year assignment in Saudia. All his saving were invested in the addition of two more floors to our house. We moved our residence to the second floor and made modifications in the ground and first floors to suit the needs of a nursing home."34/
In majority of the nursing homes the residence of the owner
and the nursing home are located on the same premises. Usually
one or two rooms are converted into a consulting room, ward and a
minor operation theatre. A few temporary additions are made to
accommodate more patients but basically the doctor and his/her
family live in a portion of the same building.
7.2 Worked Abroad:
Only 23% of the owners in small and 45% of the large nursing
homes had worked abroad.
Table 5.25 Worked Abroad
SloNo. Type Worked Abroad Yes No
1. Small 5 17
2. Large 9 11
countries Middle East
5
7
U.K. others
1 1 -----------------------------------------------------------------
Total 14 28 12 1 1
As far as the social background of those who had gone abroad
in the small nursing home category was concerned there were two
Brahmins and one Kamma, Marwari and Muslim.
138
Table
Sl.No. Religion
1. Hindu
2. Hindu
3. Hindu
4. Christian
5. Hindu
6. Hindu
7. Hindu
8. Hindu
9. Hindu
10. Hindu
11. Hindu
12. Hindu
13. Jain
14. Hindu
15. Hindu
5.26 - Social links of Owners of Small Nursing Homes
Caste
Brahmin
Brahmin
Kamma
Brahmin
Brahmin
Brahmin
Backward Class
Vaishya
Brahmin
Brahmin
Khatri
Marwari
Kamma
Father's Occupation
Cultivation
Advocate
Cultivator
Sex
F
M
M/F
Govt. Service F
Business F
Business F
Business F/M
Govt.Service F + lands
Agriculture M
Business F
Business F
Doctor F
Business of
Business F/M
Businessl M/F Cultivator
District
Hyderabad
Madras
Krishna
Hyderabad
Hyderabad
Hyderabad
U.P.
Krishna
Ranga Reddy
Hyderabad
Guntur
Hyderabad
Hyderabad
Hyderabad
Krishna
Capital 0 Worked Others loan Abroad Business
Interest
All Own Nigeria No
All Own No No
25 % 75 % Algeria No
25 % 75 % No No
All OWn Mid. East No
All Own No Clinic
30 % OWN 70 % loan No No
All Own No Path. lab.
All Own Iran Promo-tors of Oiag. Centre
All OWn No
All Own No No
All OWn No No
70 % 30 % No No
70 % 30 % No No
80 % 20 % No Real
Estate
Sl.No. Religion Caste Father's Sex Di strict Capi-tal \lorked Others Occupation Loan Abroad Business
Interest
16. Muslim Business F Hyderabad 60 % No No 40 %
17. Musl im Doctor F Hyderabad All Own No No
25 % 18. Musl im Business F Hyderabad 75 % No No
25 % 19. Hindu Backward Craftsman M Hyderabad 75 % No No
Class (Goldsmith)
80 % 20. Hindu Marwari Business FIM Hyderabad 20 % No No
60 % 21. Musl im Govt. Service FIN Hyderabad 40 % No Clinic
22. Hindu Marwari Business F Hyderabad All Own No Cl inic
140
Table 5.27 . Social Links of Owners of Large Nursing Homes
Sl.No. Religion Caste Father's Sex of District Capital Worked Others O~cupation Owner Abroad Business
Interest
75% 1. Hindu Kallllla Cultivation F Krishna 25 % No Film
Production Distribution
25 % 2. Hindu Brahmin Doctor M/F Hyderabad 75 % No Clinicl
DiagCentre 30 %
3. Hindu Reddy Cultivationl M Hyderabad 70 % No No Business
25 % 4. Hindu Brahmin Cultivation F/M Khalllllan 75% Saudi No
30 % 5. Hindu Naidu Doctor F/M Hyderabad 70 % Saudi No
6. Christian Business F/M Hyderabad Own No No
7. Hindu Aggarwal Business F/M Hyderabad Own No Fan Factory
8. Hindu Yadava Doctor M/F Hyderabad Own No Cl inlel
Path.Lab. Chemist
30 % 9. Hindu Backward Cultivation M/F Hyderabad 70 % Iran NO
Class SO %
10. Hindu Vaishya Business M Hyderabad 50 % No Cl inlel
Matr. Home
11. Musl im Doctor F/M Hyderabad Own Saudi No
25 % 12. Hindu Velema Cultivation M/M Warangal 75 % No No
13. Hindu Brahmin Cultivation M Hyderabad Own W. Indies No
141
Sl.No. Religion Caste Father's Sex of Occupation Owner
14. Hindu Brahmin Cultivation M Govt.Service
15. Hindu Reddy Cultivation M
16. Hindu Velema Mi l i taryl M Contractor Cultivation
17. Sikh Business F
18. Musl im Business M
19. Hindu KalTlJla Cultivation F/M
20. Hindu Reddy Business F/M
District
Krishna
Hyderabad
Hyderabad
Hyderabad
Hyderabad
E.Godavari
****
142
Capital Worked Others Abroad Business
Interest
Own 50 % loan)
30 % 70 %
25 % 75 %
30 % 70 %
30 % 70 %
50 % 50 % 40 % 60 %
No No
No No
No No
No No
Iran No
Iran No
U.K. No
In the large nursing home category there were three
Brahmins, one Kamma, Reddy, Naidu, a backward class and two
Muslims had gone abroad. The average length of their stay abroad
was five years and 90% had worked in the middle east.
8. Membership with Indian Medical Association(IMA)
since the IMA is a professional body one would expect all
doctors to be a part of it. However our survey revealed that
only around half the owners of small nursing homes and three
fourths of large ones were members of IMA. Interviews with
several owners of small nursing homes revealed that many of them
choose not to be members of the IMA for several reasons. Firstly
there is a great deal of infighting within the Hyderabad chapter
of the IMA. The IMA is divided on caste lines and therefore is
not a cohesive group. Secondly, many of them feel that the
leadership of the IMA is dominated by well established private
practitioners who tend to represent only the interests of large
enterprises. Infact many of the owners of the small nursing
homes have become members of the Andhra Pradesh Private Nursing
Homes Association which is the spokesperson for their interests.
Lastly they feel that the IMA has become just a fund collecting
body and does not help in furthering their professional or
business interests.
9. Share in running other ventures:
Our study shows that thirteen owners from both categories
were. managing other commercial ventures apart from the nursing
home. Almost all of them had diversified into related areas like
diagnostic labs, chemist shops, clinics etc.
143
Table 5.28 commercial Ventures
SINo. Type Medical Non Medical None Total
1. Small 5 1 16 22
2. Large 5 13 20
Total 10 3 29 42
In the case of small nursing homes only 27% of the owners
had interests in running other commercial ventures and of these
83% had diversified into related areas viz. clinics, and
pathological labs. There was only one owner who had links with
real estate and were renting out a commercial complex to shops.
In the large nursing home category 35% had interests in
other commercial venture and 70% of these were running
enterprises like pathological labs, medical stores, clinics or
maternity homes. The remaining 30% consisted of a film producer,
and a partne~ in a fan manufacturing concern.
10. Background of Clientele
Since our study did not elicit information on the social
background of the users of these nursing homes we asked the
owners for their assessment of who forms the bulk of the
clientele and what social class they belonged to.
Table 5.29 Social Background of Clientele
Sl.no Type Rich Upper middle Middle lower middle Daily class class class wage
1. Small 8 18 15
2. Large 2 5 16 5 2
Total 2 5 24 23 17
144
The owners of small nursing homes reported that majority
their clientele were lower middle class viz. workers in various
factories, clericai staff in offices; and daily wage labourers
who are essentially construction workers, domestic servants etc.
There were only few clientele from a middle class background. As
far as large nursing homes the bulk of their clientele were from
middle class with 23% each in the upper and the lower categories.
Thus one sees a clear demarcation in size of the nursing horne and
the type of clientele it serves.
social Links and Salient Features of General Nursing Homes
The social links of the owners of the small and large
nursing homes reveals the domination of forward castes with
either cUltivation or business backgrounds. Tables 5.26 and 5.27
reveals the social links of owners, father's occupation, capital
invested, whether they have worked abroad and their interests in
other commercial ventures.
In general one finds that the owners of small nursing homes
are from forward castes, single owners belonging mostly to
business, cultivator and professional families. Majority of
these owners have set up their enterprises with their own capital
as well as bank loans. . A very small proportion of them have
worked abroad only a few of them have other commercial interests.
As discussed earlier majority of these enterprises few beds and
other facilities like labs, pharmacy or high technology
diagnostic equipment. Even in terms of staffing majority of them
145
do not employ doctors but all of them employ ANMs and ayahs for
patient care. In the category of large nursing homes one finds
that it is the forward cultivating castes which dominate and the
links with cUltivation is stronger than the other category.
Cultivation is followed by business and professionals form the
minority. The scales of operation in this category is larger.
The enterprises in this category have higher bed strengths as
well as supportive facilities. These findings reveal the sources
of capital which are being invested in the private sector and
point to the movement of capital from agriculture and business
into medical care.
146
REFERENCES:
1. Government Gazetteers
of Andhra Pradesh, Hyderabad, 1983.
Hyderabad District
2. Raj,S. Medievalism to Modernism: Socio-Economic and Cultural History of Hyderabad 1869-1911 Bombay, Popular
3.
Prakashan, 1987.
Bawa, V.K. Indian Ketropolis New Delhi, Publications, 1987
4. District Gazetteer, op.cit
5. ibid
Inter India
6. Saunders, Administrative Report of Hyderabad on Technical Education cited in Raj,S. op.cit pg.283.
7. Govt. of Hyderabad, Andhra Pradesh state Archives,Report on the Hyderabad Medical school 1879 pp.l-8, cited in Raj,S. p.249
8. Govt. of Hyderabad, Administrative Report for 1903-1906 cited in Raj, S. p.249.
9. Gazetteer, op.cit
10. Interview with a senior official in the Directorate of Medical Education, Hyderabad, June 1991.
11. Interview Hospital,
wi th the Superintendent Hyderabad, June 1991.
of osmania General
12. Interview with the Nursing Superintendent, Osmania General Hospital, June 1991.
13. Govt. of AP, Copy of the Bill to set up the Andhra Pradesh Vaidya Vidhana Parishad, Hyderabad, 1985. PP.3-6.
14. ibid
15. Govt. of Hyderabad, sta.tistical Year Book 1940-41 Hyderabad cited in Rehman,A. The Private Sector in Urban Health care:Sociological Aspects M. Phil. dissertation, Osmania University, Hyderabad,. 198,9.
16. Interview with owner of private nursing home,June 1990.
17. Interview with owner of private nursing home,June 1991.
18. Based on a survey by a leading drug company and the Andhra Pradesh chapter of the Federation of Medical Representatives
·Association of India.
147
19. Penguin Dictionary of Economics, Penguin, 1972.
20. Interview with owner of a nursing home, June 1991.
21. operations Research Group, Role of Private Medical Practi tioners in Family Welfare programme: A Case study Of andhra Pradesh, Maharashtra and Tamilnadu Sponsored by Min. of Health and Family Welfare, Baroda, 1988.
22. Municipal corporation of Hyderabad, Facts on Family Welfare in Hyderabad City City Family Welfare Bureau,Hyderabad,1986
23. Interview with owner of a nursing home, December 1990.
24. Interview with owner of a pathological lab, December 1990.
25. Ibid January 1990.
26. Ibid January 1990.
27. Ibid June 1990.
28. Ibid June 1990.
29. Ibid June 1991.
30. Interview with owner of a nursing home,January 1990.
31. Ibid June ~991.
32. Interview with Secretary, AP Nursing Homes Association, June, 1991.
33. Interview with a paramedical worker in a nursing home, June 1991.
34. Interview with owner of a nursing home, January 1990.
148
INTER RELATIONSHIP WITH THE PUBLIC SECTOR
Our survey reveals that the growth of the private sector is
not independent of the public sector and that the former is inter
related to the latter at four different levels. Firstly, the
owners of nursing homes and hospitals may have worked in the
government for sometime and have resigned, opted for voluntary
retirement or have applied for long leave. Secondly, there are
those owners who have close relatives in government service both
medical and non medical and, thirdly, there are government
doctors who act as consultants in these nursing homes. A fourth
means is when nursing homes are recognised by public sector
undertakings to treat their employees. This also includes those
units cover.ed by the Central Government Health Scheme(CGHS) since
CGHS offers only out patient services through their dispensaries.
In the following section we present these trends in our sample
nursing homes.
1. Linkaqes between the Private and Public sector:
It is well known that doctors in the public sector practice
privately, however the nature of this practice has not been fully
explored. Table 5.30 shows that 45% of the owners of large
nursing homes had served in government and nearly 90% of them
resigned from service wnen the ban on private practice was
imposed during 1968 and 1983.
In the case of small nursing homes only 32% of the owners
had served with the government, of these 70% had resigned during
the ban. Only one of the owners had taken long leave in this
category and was intending to join back in a couple of months.
149
Table 5.3§ owners of Nursing Homes In Government Service
Sl.no. Type Govt. Service Resigned Voluntary on leave Retirement
1. Small 7 5 1 1
2. Large 9 8 1
Total 42 16 13 2 1
Dr.V. who is in her late thirties is a gynaecologist and a faculty in one of the medical qolleges in the city. She joined government service in 1970 and took leave in 1983 to go abroad. After doing a four year stint in the middle east she returned in 1987 and set up a nursing home in a commercial complex,owned by her husband. Under the state government rules she is entitled to take leave upto fives years at a time. She re-joined service in 1988 and hopes to apply for leave after a couple of years. Meanwhile her husband manages the nursing home and she is planning to take voluntary retirement and expand her nursing home.1/
In the specialist category one found that only four out of
the eleven owners had worked in government. In the private and
public limited categories none of the owners/promoters had worked
in government.
When the government imposed the ban in 1983 one of the
complaints they had against the doctors was their taking leave
from government and working abroad. A senior official said:
"A number of government doctors have gone abroad without resigning their posts. They have gone to the U. S., Great Britain, western Europe and the gulf countries for employment and making lots of money there. In 1983 the state government had issued notices to about .300 government doctors who had gone abroad without proper authorisation to either return or resign so that the vacancies could be filled up by fresh recruitment." 2/
2. Relatives in Government service
18% of the owners of small nursing homes and 20% of the
large nursing homes had relatives in government service. (Tables
5.31 & 32).
150
Table 5.31 Relatives in Government service-small nursing homes
Sl.no. caste of owner _ Relationship to owner
1. Khatri a.husband
b. sister
2. Brahmin sister-in-law
3. Brahmin Brother-in-law
4. Kamma Husband of partner
Position in government
Superintendent Nizam's Institute C.A.S.
C.A.S.
e.A.S.
e.A.S.
Table 5.32 Relatives in government service-large nursing homes
Slono caste of owner
1. Kamma
2. Backward classes
3. Aggarwal
4. Brahmin
Relationship to owner
sister brother
wife
father-in law
Brother-in-law
position in government
civil surgeon e.A.S.
C.A.S.
Retired Director of Medical&health
e.A.S.
-----------------------------------------------------------~-----
In both categories of those who had relatives in government
service were doctors and were closely related to the owners.
3. Consultants in General- Nursing Homes
While both small and large nursing homes have consultants,
it is the larger enterprises which have a higher proportion of
doctors in government service acting as consultants. Table 5.33
shows consultancy patterns in the sampled nursing homes.
151
Table S.33 Consultants in Nursing Homes
Slono. Type
1. Small
2. Large
Total=42
Govt. Doctors Private Doctors
8 8
13 5
21 13
50% Govt. 50% pvt.
2
1
3
None
4
1
5
The data shows that both small and large nursing homes have
consultants serving with the government as well as those who are
exclusively in the private sector. The proportion of government
and private practitioners who act as consultants varies across
the two sets. In the small nursing home category there are equal
number of doctors in government service and in the private sector
who act as consultants. However in the case of larger nursing
homes the proportion of government doctors as consultants is
higher. It is significant to note here that while one large
nursing home did not have consultants, four small ones did not
have any consultants.
In the specialist category one found that of the eleven
nursing homes five, had consultants and nearly all of them were
from the private sector. In the private limited category, both
hospitals employed consultants and of these one of them had
mainly government doctors as consultants while in the other they
were all private practitioners. In the public limited category
the general trend seems to be to have consultants who are
exclusively in the private sector however for certain super
specialities they do depend on government doctors. Thus across
all three categories one finds the prominent position of
152
consul tants however it is in the general nursing home category
that one finds the maximum involvement of government doctors
acting as consultants.
Many times it was noticed that those who had relatives in
government service either acted as conSUltants or had a share in
the running of the nursing home. The following is illustrative
of this phenomenon. An owner of a ten bedded nursing home got
into a partnership with the wife of a civil assistant surgeon
from one of the' teaching hospitals in the city.3/ The latter
associates with the nursing home in the capacity of a consultant.
In another case an owner of a six bedded nursing home has a
brother-in-law, a civil assistant surgeon, who helps her in the
management of the enterprise on a daily basis but is formally
listed as a consultant to it.
The relationship between the nursing homes and government is
important because as an owner of a small nursing home said:
"Since I just have a MBBS degree I have to depend on specialists from government hospitals. This is because these days the common man knows the difference between a MBBS and M.D. The government doctors also has access to patients in his job and can therefore divert patients to my nursing .homes."41
Dr. M. Venkat Rao, former Director of Health and Medical
Services and also the chairman, state Advisory Board on Medicine
from 1986-89, studied the functioning of private nursing homes in
order to enforce regulations. On the role of consultants he
said:
"Most nursing homes in the twin cities as well-as districts are dependent on conSUltants for specialities. This is also because many of the owners of these nursing homes have only a MBBS degree and claim to provide a variety of specialities through conSUltants, most of whom are from government service." 51
153
Many doctors want consultants to offer specialities as well
as to ensure a .steady supply of patients. However the
relationship between these consultants and proprietors is not one
of ease. As one of them articulated:
"until 1980 I used to have a number of government doctors serving as consultants. They did bring in patients but over time I found they were behaving irresponsibly. They used to divert patients from government hospitals for simple things like I.U.D. insertions after having charged them in their clinics. Many times these doctors would not keep their appointments so I had to face the patient's wrath. Since I am a third generation doctor in the family and my husband is well off, I got rid of all the consul tants. But most nursing homes that are coming up are dependent on government doctors and often cannot do without them." 6/
As an owner of a large nursing home said:
"most nursing homes of my kind have government doctors as
consultants because they ensure a steady supply of patients." 7/
4. Panel of Public Sector companies:
Yet another source of patient supply to these nursing homes
is by securing a position on the panel of doctors of various
public sector undertakings.
Table 5.34 Panel of Public Sector Undertakings
Sl.no. Type No. of public sector companies Total Sample
1. Small 6 20
2. Large 19 22
Total 25 42
Table 5.34 makes it clear th~t majority of the large nursing
homes are on the panel of one or more public sector undertakings.
These public sector undertakings recognise a few nursing homes to
154
treat their employees and the cost of treatment is reimbursed by
the company subject to prescribed limits. One of the criteria
for recognition of nursing homes is when a sizeable number of
employees of a particular undertaking reside in the area where
the nursing home is located. However owners of these nursing
homes frankly admitted that all of them had to lobby with the
companies and use personal or social connections to get
recognition. Employees covered by the CGHS scheme have inpatient
treatment in recognised nursing homes since there is no hospital
of theirs in the city.
In the case of specialist nursing homes only three of the
eleven are on panel of public sector companies. In the private
and public limi.;ted categories all the hospitals figure on a
variety of public and private undertakings and institutions like
Indian Airlines, BHEL, National Institute of Rural Development,
Police Academy, Nuclear Fuel Complex, ICRISAT, etc.
PRIVATE PRACTICE BY DOCTORS IN GOVERNMENT SERVICE
As table 5.33 reveals, a high proportion of consultants in
the large nursing homes are in government service. In order to
countercheck this a survey was carried out among Civil Surgeons
(CS) and Civil Assistant Surgeons (CAS) to look at the
prevalence and nature of their private practice. In addition we
also tried to elicit the opinions of these doctors regarding how
private practice affects the quality of care, teaching and
research in government hospitals.
There were a total of 30 civil surgeons and 128 civil
assistant surgeons in the teaching hospital. A questionnaire was
155
given to all the doctors in these two categories of which,
19(63%) of the CS and 64(50%) of the CAS responded. There were
11 non respondents in the C.S. and 64 in the CAS categories. The
non respondents included those who refused to f ill up the
questionnaire, were on long leave, those who had either resigned
or had retired, could not be contacted and those on the non
clinical side.
Table 5.35 Private Practice by civil and civil Assistant surgeons
Sl.no. Category Total .Number
1. C.S 30
2. CAS 128
158
Respondents non Respondents Private Practice
19 11 17
64 64 41
133 75 58
Almost all civil surgeons practises privately while only 64%
of the CAS category did so. Of those who practised privately in
the CS category almost all of them had clinics and three fourths
of them also acted as consultants to nursing homes. Five of the
nineteen civil surgeons said that they were consultants to public
limited hospitals however majority were attached to nursing homes
which corroborates the findings from the survey of private
institutions. In the CAS category almost all of them had clinics
while only a small proportion acted as consultants to nursing
homes. (Table 5.36)
156
Table 5.36 Nature of Private Practice Among c.s. and C.A.S
SI.No. category clinic nursing home voluntary hospital
corporate hospital
1. C.S. 18 Respondents=19
2. CAS 37 Respondents=64
Total 55
Note: Numbers do not combinations i.e.
13 3 5
11 5 2
24 8 7
add upto total sample because of some have clinics are also consultants.
What is important to note in the above table is that the
range in the nature of private practice is wide. It ranges from
having clinics to acting as consultants in nursing homes,
voluntary and corporate hospitals. However in many cases one
finds a combination of practices viz. a CS or CAS may have a
clinic and act as a consultant to a nursing home or hospital. We
found that of the eighteen who practised privately, 5 had only
clinics for their practice, the remaining 13 had clinics as well
as acted as consultants to nursing homes and hospitals. In the
CAS category nearly half of them had only clinics for practice
the remaining had a combination of clinics as well acted as
consultants. (Table 5.36) It is apparent from the above table
that majority of the civil surgeons have both individual private
consultations as well as attached to a nursing home or hospital.
Majority of them are attached to nursing homes while only a few
are consultants to corporate and voluntary hospitals.
The scenario in CAS category is different. In this category
more than half of those who practice privately have a clinic,
very few of them have a combination of clinic and consultancy in
157
nursing homes, corporate and voluntary hospitals. In our
interviews wi th civil assistant surgeons as well as the former
secretary of the CAS Association, one issue that all of them felt
strongly about was the monopoly of Civil surgeons on building up
private practice. They feel that while the civil surgeons were
busy building their private practice, both them and the junior
doctors had bear the burden of patient care.
As one of the off ice bearers of the Junior Doctors
Association said:
"the civil surgeon category have a definite advantage compared to other categories because being senior and specialists they are the ones who act as consultants to nursing homes. The professors have total control over patients and other doctors by virtue of their seniority. While these professors are busy building their practice we have to do all the work. The professor just makes around of the-wards in the morning and the rest of the time we have to attend to the patients requirements. Although the civil assistant surgeons also have a good practice they do not enj oy the the monopoly of the civil surgeons. In most cases patients consult the specialist either at his clinic or in the out patients department, then the doctor refers them to nursing homes where they are consultants." 8/
Four civil surgeons, who were also heads of departments
pointed out that over the last ten years the nature of private
practice has undergone changes. Earlier private practice was
restricted to consultations for a couple hours in the evening at
their residence. With the proliferation of nursing homes and
hospitals doctors have started acting as consultants to them.
Even five years back it was quite a common practice for doctors
to admit private patients in government hospitals but
increasingly now the trend is for the doctor to refer them to a
nursing home where they are a consultant. All of them were of
the opinion that individual private practice was not bad, it is
158
undesirable for government doctors to act as consultants to
private hospitals because firstly, they will be unable to devote
adequate time for patients, or their teaching commitments.
Secondly they will be unable to devote time for research and keep
up with the latest developments in their respective fields and
lastly they will be diverting patients to the private sector as a
result of which even the poor will be pushed to paying for care.
The questionnaire tried to elicit the doctors views
regarding the effect of private practice on patient care,
teaching and research.
Table 5.37 Opinions Regarding Effect of Private Practice
Sl.no. category No effect Patient care Research Teaching
1. C.S. 12 6 6 7 Respondents=19
2. CAS 32 20 32 23 Respondents=64
More than a third of the civil surgeons who practice
privately are of the opinion that "it does affect quality of
patient care, teaching and ,research negatively. In the CAS
~ategory half of those who practice privately felt that it
affects research and less than half of them felt it affects
patient care and teaching negatively. As a CAS remarked:
"research usually gets l~st priority in our routine. Between
patient care, teaching and private practice there is little time
f or research." 9 / Some of them also pointed out that both
infrastructure for and motivation by doctors to do research is
lacking. Majority of those who practice privately were of the
opinion that poor salary structure for doctors is the main reason
159
for doing so. As a CAS remarked: "if government doctors are not
allowed private practice without adequate compensation then I
think most of us will not be in a position to maintain even a two
wheeler." 10/
The Non Respondents:
In the civil surgeon category there were eleven non
respondents, of which five are on the non-clinical side and are
not allowed to practice privately, one had retired and his post
was lying vacant, one was on long leave and four refused to
answer the questionnaire. In the civil assistant surgeon
category there were sixty four non respondents. Of this there
were twenty on the non-clinical side, twelve who were on leave,
ten of them could not be contacted and twenty of them refused to
answer the questionnaire. The State government has a rule that
certain categories of non-clinical staff as well as civil surgeon
administrators will not be allowed private practice.
The four ci vi I surgeons who refused to respond to the
questionnaire were very angry when approached. They said:
"Why are you interested in looking at the question of pr i vate practice by government doctors? It is none of your business to pry into these matters. If a doctor wants to practice privately and the government has no objections why should you administer such a questionnaire?" 11/
All of them also expressed their fears that the information
collected would be used against them. This is partly due to a
secret survey conducted by the. former Director of Medical
Education to find how many government doctors practice privately
and are attached to nursing homes as consultants. Some senior
160
doctors claim that the information was used to victimise certain
doctors. The former DME was not available for comment since he
was abroad and when the present DME was contacted I was informed
that there are no records of this survey in their off ice and
therefore must have been carried out by the former DME in his
personal capacity.
Similarly the twenty CAS refused to answer the questionnaire
on the grounds that it was far too 'sensitive' and another ten of
them could not be contacted s.ince they were too busy with
academic work.
Through interviews with doctors in different categories and
three senior professors who are also civil surgeon administrators
and willing to talk, the picture that seems to emerge is that
almost all civil surgeons practice privately while around seventy
per cent of the CAS do so. The super intendent of the study
hospital estimated that around sixty per cent of the civil
assistant surgeons and eighty per cent of the civil surgeons
practiced privately. A larger proportion of those who practice
privately among the civil surgeons are attached to nursing homes
when compared to CAS. These interviews in fact point to a fairly
widespread prevalence of private practice among government
doctors and supports the findings in private nursing homes.
Studies on the extent of private practice in a teaching and
civil hospital in Hyderabad shows that seventy five per cent of
the doctors practice privately. These doctors prefer a
government job along with private practice because the former
offers security, contacts,status and also helps in gaining good
experi~nce. Majority of the civil assistant surgeons felt that
161
it was the civil surgeons who have a successful practice and this
is because:
"they are at an advantage by virtue of their monopoly in the department and the power they wield over junior doctors." 12/
The civil surgeons on the other hand claim that it is
patients who prefer senior experienced doctors which is why they
have a better practice than the civil assistant surgeons.
A senior professor in our study hospital said:
"those doctors who are on the clinical side have the advantage of building up a lucrative practice. Therefore most doctors want to enter government service to get a fixed pay, status and contacts which is useful in building their practice." 13/
On the nature of private practice he said:
"individual private practice in the form of consultations in the doctors residence has always existed. But in the last ten years wi th the rapidly proliferating private sector, doctors are attaching themselves as consultants to these nursing homes and hospitals." 14/
162
PRIVATE SPECIALIST NURSING HOMES:
This category includes those nursing homes which offer only
a specialist service viz. for the ear, nose and throat, eye,
orthopaedics, cancer, kidney disease and infertility. There are
eleven nursing homes in this category.
Type of ownership:
All these nursing homes are managed by single owners who are
all male and specialists. Nearly all of them (10/11) were Hindus
and belonged to the forward castes. Four of them were brahmins,
three Reddys, two kayasths and one refused to divulge his caste
background. There was a sole muslim owner. Of the eleven
owners, four had worked in government and of these two had
resigned and the remaining two had retired.
Father's occupation:
Four of the owners were from business families, three from
families who derived their income from cultivation and four from
family of professionals viz. doctors and lawyers.
Year of Establishment and Bed strength:
Only one nursing home was established in the sixties, three
in the late seventies, five in the eighties and two in the
nineties. The total bed strength of these nursing homes is 198
and the average strength is 18.
Frequency Distribution of Bed Strengths:
six of the eleven nursing homes seven had a bed strength of
less than fifteen beds, three had between twenty and thirty and
163
only one had above thirty five beds. Thus more than half the
nursing homes had a bed strength of below fifteen.
services Offered: Those nursing homes with below fifteen
beds offer mainly medical services and have facilities to conduct
only minor surgeries.
Table 5.38 Services Offered in specialist Nursing Homes
SloNo. Type Services Offered
1. ENT Medical and minor surgeries
2. ENT medical, minor surgeries, audiology and speech therapy.
3. ENT surgery, audiology
4. Eye routine testing and minor surgeries.
5. Eye testing, minor surgeries.
6. Eye medical, surgical.
7. Ortho- medical, surgical, shortwave, physiotherapy. paedic
8. cancer t~sting facilities, cobalt therapy and X-Ray.
9. Kidney medical, surgery.
10. Fertility gynaecological testing for infertility and minor corrective surgeries.
11. Ortho- surgeries, physiotherapy. paedic
Sources of capital:
Nearly half the nursing homes were established with their
own capital, the remaining head invested a small proportion of
their own capital and the rest was mobilised through bank loans.
164
Table 5.39 social Background and Source of capital ----------------------------------------------------------------Slono. Religion Father's Source of
& Caste Occupation Capital ----------------------------------~------------------------------1. Marwari business 75% own
25% loan
2. Reddy CUltivation all own
3. Brahmin business all own
4. Kayasth professional all own
5. Brahmin CUltivation 30% own 70% loan
a 6. Reddy CUltivation all own
7. Brahmin professional 25% own 75% loan
8. Reddy CUltivation 30% own 70% loan
9. Brahmin professional all own
10. N.A. business 40% own 60% loan.
11. Muslim business 30% own 70% loan.
The social background of owners reveals that it is the
cultivation/business combine which dominates.
staffing and Consultants:
On the question of staffing and consultants we were able to
get information for only nine of the eleven nursing homes. This
is because the nursing home for the treatment kidney diseases and
infertility were established only at the end of 1990. The owners
said that they were still in the process of recruiting personnel
and offering mainly out patient services.
Of the remaining nine, only seven had employed MBBS doctors
working on part time basis.
165
Paramedical staff: Four nursing homes had employed between five
to ten ANM trained personnel, two of them had employed between
two to four ANMs and the remaining two had trained unqualified
persons 'on the job.'
As far as consultants were concerned, of the nine nursing
homes only five had consultants and nearly all of them were
exclusively in the private sector.
If we compare the trends observed in this category of
nursing homes with the general category, one finds that it pretty
much corresponds to the pattern observed in the small enterprises
in the general category in terms of size of operations, range of
facilities and services offered.
PRIVATE AND PUBLIC LIMITED e«mPO.RATE.ENTERPRISES:
There are totally seven enterprises in this category of
which two are private limited concerns while the remaining five
are public limited enterprises. The public limited concerns are
essentially a mid to late eighties phenomenon and these hospitals
are at different stages of completion. Of the five, two have
been functioning for more than two years, two more are still in
the process of being fully commissioned and one has not yet
started functioning.
166
Table 5.40 Private and Public Limited Enterprises in Hyderabad
Slono. Name Promoters Bed strength ------------------~--------------------------------------------1.
2 .
3.
4.
5.
6.
7.
Apollo
CDR hospitals
Medwin Hospitals
Sus ruth Hospitals
Medicity
Banjara Hospital Pvt. Ltd
Hyderabad Nursing Home
·Dr. P.Reddy
Dr.C.Dayakar Reddy
Dr.N Reddy Dr.R.Rao Dr.Ramesh Babu
Dr. Ganerival Dr. Bhargava & 2 NRI doctors
Dr. Reddy (NRI)
Mr & Mrs Chenna Reddy & 2 NRI doctors
Mr.Kishen Rao Mr. Raghuveer Dr. Rajeswar Dr. Rajnikanth
Total Bed strength
300
150 (Only 91 beds have been commissioned)
250
300
300
35
39
1374
The promoters of all the enterprises are from upper castes,
mostly Reddys and nearly all of them belong to families of
cultivators and all of them have a variety of other business
interests apart from the hospital. (Table 5.41)
Private Limited Enterprises
I. Hyderabad Nursing Home: This is the first and oldest private
limited hospital in Hyderabad. It was established in 1973 and
promoted by a business family belonging to the backward classes
167
Sl. No.
1.
2.
3.
4.
5.
6.
7.
Table 5.41 - Social Background of Owners of Private and Public
Limited Enterprises
Name
Apollo Hospital
CDR Hospital
Religion/ Caste
Reddy
Reddy
Medwin Hospital 'Reddy/ 'Velama/ Kamma
Susruth Hospital Marwari Brahmin
Medi City Reddy (NRI)
Banjara Hospital Reddy NRI Reddy Doctor
Hyderabad Nursing Home
Backward Class
Father's Occupation
Cultivation
Forest Service & Cultivation
Cultivation Cult/Business Cult/Business
Cultivation Business
N.A
Cultivation Business
Other Business Interest
NRI has established similar hospitals in Madras, Delhi and has entered into collaboration with United Breweries Bangalore.
55 bedded Nursing home, two restaurants, medical equipment manufacture.
Nursing Home in warangal Donation College (Engineering) at Nagpur
Lands ; Business
N.A.
Printing Press, Producer of Telugu Films
Business Doctor
Advocate
Owner of Ampro Biscuits, Ganta Chutta (Tobacco)
Rice mills and Bambino Vermicelli
168
from Hyderabad. The enterprise is promoted by the father and his
three sons,two of whom are doctors.
Bed strength and services offered: The bed strength of the
hospital is 39 and it offers a variety of general and specialist
services except cardiac cases. The hospital has a pathological
lab, pharmacy, blood bank and an ambulance service. There are
two operation theatres, one major and one minor. The hospital
has two X-ray equipment one portable and one stationery and three
ECG equipment all of which is domestically purchased.
staffing: There are eight full time doctors of which six MBBS
and two with post graduate qualifications. In the paramedical
category there are five staff nurses, fifteen ANMs and three male
nurses. Majority of their nurses are from Kerala. The staff
nurse is paid around RS600 per month, the ANMs are paid Rs 500.
In addition they have fifteen helpers The radiologist, lab
technician and physiotherapists are on a part time basis.
There are th+ee different categories of rooms. There is an
air-conditioned suite with an attached bath which costs Rs 200
per day. The second is a -non air-conditioned single room which
costs Rs 100 per day and third is a general ward which costs Rs
50 per day.
Consul tants: They have a number of specialists who act as
consultants to the nursing home and all of them are private
practitioners.
social Background of Clientele: Majority of their clientele are
from Hyderabad and a very small proportion are from districts.
169
It is the rich and middle classes which form the bulk of their
clientele.
Sources of capital: The promoters invested around a third of
their own capital, another third was raised through selling
shares and the remaining third was mobilised through bank loans.
The nursing home, is housed in a four storey building built
exclusively for the purpose.
other Business Interests: The promoters of this enterprise are
businessmen who earlier owned AMPRO biscuits but they later sold
it and are now producers of Bambino Vermicelli. In addition they
own a couple of rice mills and a factory that makes qantta chutta
(a type of beedi).
Banjara Hospital Private Limited
The second pr i va te I imi ted hosp ita I was promoted in 1989 .
The share holders belong to a landed Reddy family from
Rayalaseema.. Mr and Mrs Reddy manage the enterprise while the
other two share holders are doctors based in the us. The family
owns substantial amount of land in Rayalaseema and apart from
cUltivation they have a variety of other business interests like
printing press and film production. While setting up this
hospital they invested mostly their own capital and a small
proportion was mobilised through loans from banks. When asked if
their NRI relatives had invested money, they said that they had
made some investment but were reluctant to disclose the amount or
form. Their NRI relatives use this hospital as a base for
practice whenever they visit India.
170
Bed strength and Facilities: The hospital is housed in a
specially constructed four storey building in Banjara Hills. It
has a bed strength of thirty five two air-conditioned operation
theatres- one major and the other a minor one. In addition they
also have a full fledged labour room, x-ray unit, pharmacy and a
pathological lab. They have an ECG equipment which is
domestically produced and are in the process of acquiring an
abdominal scanner.
staffing: They have employed six full time doctors, four
qualified with a MBBS degree and two specialists with a post
graduate diploma in ENT and the other in gynaecology. On an
average this category of staff· is paid between RslOOO-2000 per
month. They have four nurses with a BSC in nursing and
specialised as theatre nurses from Kerala. They are paid between
Rs. 500-800 with accommodation. Then there are ten ANMs who are
paid between Rs. 350 and 500 per month. In addition they also
employ twelve ayahs and ten attenders. For the lab there is a
consultant pathologist and two technicians. Most of the
consultants to this are doctors who are in government service or
were in government service at some point in their careers. These
consultants are the major source of referral to this hospital.
171
Profiles of Corporate Hospitals in Hyderabad-Secunderabad
Apollo Hospital Ltd.
The chief promoter of this project is Dr Pratap Reddy who
belongs to Andhra and practised as a cardiologist for sixteen
years in the united states. Inspired by the large
multispeciality hospitals there, he consulted the American
Hospital Corporation which is one of the largest multinationals'
in the provision of medical care in the u.s. Apollo Hospitals
was not only the first corporate venture in the country but it
was also the first to have ~ strong NRI involvement. Soon after
the establishment of the hospital at Madras in 1983, the company
has expanded its operations to Hyderabad and subsequently entered
into collaborations with other companies in Delhi and Bangalore.
Now he has gone in for tie ups with several companies, both
public and private, across the country.
In Hyderabad the company built a 300 bed hospital on thirty
three acres of land at a subsidised cost from the government in
an exclusive residential area. The initial investment in this
project was Rs 12 million which was to cover construction and
equipment costs. Of the 300 beds, 10 are in the out patients, 9
in the intensive care,10 in the intensive coronary care unit, 15
beds in post cardiac care, 7 beds for emergency, 18 beds each in
the general ward and semi-private rooms. The remaining 213 beds
are distributed among the single, deluxe and super deluxe rooms.
The hospital offers a variety of specialist services
provided by specialists who act as consultants. In this hospital,
172
any doctor who aspires to be a consultant has to make an initial
investment of Rs 50, 000. He then gets an interest on his
investment which is essentially a share of the company's profits.
Majority of their consultants are private practitioners except a
specialist for treating kidney diseases who is a professor in one
of the teaching hospitals. The public relations officer said
that while they prefer not to have doctors in government service
as consultants for a few super specialities they have to depend
on government doctors because they are the ones who extensive
clinical experience and have established their competence in the
field.
organisational structure and Facilities Offered
The hospital is run like an industry with different
departments. Broadly there are two major departments-medical and
non medical. The medical department is in-charge of out-patient
and inpatient services while the non-medical department is in
charge of diet, public relations, marketing, laundry and other
services.
The layout of the hospital is like any five star hotel with
marble floors, chandeliers and sofas There is
bookshop, library, pharmacy and conference hall.
a florist,
They have
different categories of rooms, ranging from the general ward and
semi-private to private and deluxe rooms. The deluxe room is
like a regular suite and is provided with air conditioners,
television, channel music, close circuit television and telephone
facilities. Most of the patients who get admitted in this
hospital belong to the middle and upper middle classes and
173
according to one of the administrative officers 'the really rich
still prefer to go abroad for treatment. The company also runs a
diagnostic centre and a round the clock pharmacy in the city
centre. The diagnostic centre offers facilities for routine
testing as well as ultrasound and CAT scans.
social Background of Users
An attempt was made to find out if the hospital maintains
records on income level of patients but the public relations
off icer said that they were not interested in that kind of
information. They were only concerned with whether the patient
could pay for the services used or not. According to the
marketing Executive
"the maximum turn over of beds is in the general ward which costs Rs 100 per day which is inclusive of diet and nursing charges. Basically it is is lower middle and working classes which occupy the general ward. The middle class which is mainly constituted by salaried employees prefer semi-private or single rooms. It is mainly businessmen who can afford the deluxe and super deluxe rooms and for them it is a status symbol to be in these rooms." 15/
The following two interviews with patients from the lower
income group reveals how the corporate sector does not conf ine
itself to the middle and upper income groups. During my repeated
visits to collect information I identified two cases from low
income backgrounds who had come for treatment to this hospital.
Case I: S is a thirty year- old woman from Guntur who has been
suffering from kidney problems for the last three years. Her
husband works as a clerk in a private firm and has a monthly
income of Rs 800. Since she was suffering from sever pain in her
back and side she consulted several doctors1both government and
174-
private. One of the specialists she consulted told her that she
had a kidney stone and advised her to go to Hyderabad to have it
surgically removed. Meanwhile a specialist in Hyderabad referred
her to Apollo and told her that instead of going through a
surgery if she goes to this "big" hospital they will be able to
remove the stone with the help of a 'big machine'. She
immediately came to Apollo but here she has to undergo all the
tests again. So far they have spent Rs10,000 on just the tests
alone and have raised the money by pawning her jewellery and
raising loans. Both she and her husband said: "our hope is that
atleast by paying money we will get the best. We can always make
money but we cannot get life." 16/
Case II: N. is a agricultural labourer in her early thirties
from Nalgonda district. She belongs to the Vaderra caste and
does construction work, road building etc. Their extended family
together own ten acres of land of which N and her husband own
three. Their four year old nephew has been suffering from a
heart problem ever since his birth. They have taken him to
several government hospitals in Nalgonda and Hyderabad. The
Nalgonda district, hospital referred their case to Nizam's
Institute of Specialities at Hyderabad where they did a number
of tests and told them that the child's case was hopeless. Since
this child is the only son of her brother-in-law, they decided to
try somewhere else. A government doctor told them that Apollo is
a 'big hospital' and will definit.ely be able to cure the boy.
They came to Apollo and the specialist prescribed a variety of
tests to be performed. So far they have spent Rs 6000 on tests
175
alone. It is only after the test results come they will decide
on the surgery. N. and her family were told by the hospital that
the cost of the surgery will be anywhere between Rs 10,000-15,000
and this would not include room rent and other incident.al
expenses. Her father-in-law has already sold one third of their
lands which has been just enough to pay the cost of the tests.
If the child has to be operated they will have to sell away all
their lands as well as pawn whatever jewellery or vessels they
possess.
They are willing to do this because as N. said:
"land and money can be earned but a life cannot be earned. If we lose him we have nothing left so we will .spend money as we feel that there is a chance for him to survive. We will continue to work and somehow carryon as we have always done." 17/
commenting on the scope for ventures like Apollo in an
interview Dr. P.Reddy is of the opinion that there is a lot of
scope for the further growth of corporate hospitals in this
country. He is also of the opinion that since the government
does not have enough resources, it should collaborate with the
private sector to ensure good quality of services. Dr Reddy has
played an important· role in pushing corporate medicine in India.
According to him there are many Indian doctors in the U.S. who
want to serve their country and therefore we should be able to
provide the facilities in~rder to utilise their talents.
INSURANCE SCHEMES
The role of insurance is important in making corporate
hospitals a viable proposition. Apollo Hospitals has tied up
with major insurance companies like New India Assurance and
176
Uni ted India Insurance has resulted in the Apollo Health
Insurance Scheme which has a total membership of 30,000. The
Apollo scheme is characterised by exhaustive hospital benefits
but very little of out-patient cover. Further the benefits under
the Apollo scheme are broken into several heads like room
charges, diagnostic materials and X-ray, so that if the patient
exceeds undel;" any particular head they will have to pay the
excess amount in full even if the other heads have not been
utilised. Thus the main target of this insurance package seems
to be for hospitalisation rather than out patient care.
177
CDR (C.Dayakar Re~dy) Health Care Ltd
The chief promoter of this project is Dr.C. Dayakar Reddy who. . ' ,
is in his mid thirties is a graduate of Kakatiya Medical college, I
Warangal. and did I his postgraduation from Gandhi medical college
in Hyderabad. Hei belongs to a landed family from Warangal. His
father retired fr.om the state Forest Service a couple of yea!s
back and now takes care of their lands. Dr Reddy is married to a I ,
gynaecologist who' belongs to a politically influential family
from Nellore. Wh.i.le he was still a student he set up a sixty bed
nursing home in Hyderabad. At that time there were very few
large nursing hoIttes in the ci ty and most people advised him
against this ven-yure which was considered as an unprofitable
proposition. How.ever his 1{enture proved to be a success. As
Dayakar Reddy pointed out, "my nursing home became a profitable
venture because I 'managed to get top specialists from government
hospitals to serve as consultants. That helped me build up the
reputation for my 'nursing home." 18/ Apart from owning a nursing
home he also started three. restaurants and a unit for the
manufacture of medical equipment in the twin cities. In 1986 he
floated the CDR He~lth Care Ltd as a corporate enterprise and has
taken the nursingihome under this company. In addition to the
hospital he manages a lithotripsy centre at Batra Hospital in
Delhi and is planning to' establish similar diagnostic cum
treatment centres in several cities in the country. Apart from
these hospitals he also owns three restaurants, and a unit for
the manufacture of medical equipment.
178
Bed strength and Facilities Offered
The hospital that he has promoted in Hyderabad will have 150
beds but only 91 beds have been commissioned so far. They offer
both out patient, inpatient and emergency services. The out
patient services are in the form of a poly clinic where general
practitioners and specialists run their clinics. Patients can
consul t any doctor of their choice and at present a number of
specialist services are offered except cardiology.
In the inpatient side both general and specialist services
are offered but the main specialities offered by this hospital
are gastro-enterology and kidney diseases.
The hospital houses a round the clock pharmacy, diagnostic
centre, emergency services and plans are being made to establish
a blood bank and ambulance service. The hospital is furnished
like a five star hotel with a florist, bookshop and pharmacy in
the lobby and the entire building is centrally air conditioned.
At present there are only two categories of rooms available, one
is a single room with an attached bathroom and the other is a
sharing arrangement where two or three persons share it. The
charges for a single room is Rs250 and the sharing one is Rs135
per day and this is inclusive of nursing charges.
staffing
The hospital employs. forty to fifty duty doctors who are
medical graduates. All specialist services are provided through
consul tants . Dr. Reddy who is the promoter has managed to
attract some well qualified doctors and nurses by offering higher
salaries and perks from the government. When asked whether he
has government doctors as consultants he said:
179
"I prefer not to have them as consultants because in general doctors ,in government service do not have a stake in either the private or public sectors. They tend to use both for expanding their interests. I prefer having full time private practitioners as consultants or I ask government doctors to join my hospital on a full time basis. Some have taken long leave from their jobs to work for me." 19/
There are fifty specialist, staff and ANM trained paramedical
personnel. One of the specialist nurses is on long leave from' a
teaching hospital because this hospital offers twice the amount
she earned in government. She has not yet decided if she will
resign her government job since she has almost two years leave.
Insurance Schemes
Recently he has linked up with the United Insurance Company
to introduce a Medicare card Scheme which covers hospitalisation
and out-patient care based on the amount of premium a patient
pays. According to Dr Reddy "the high cost of sophisticated
medical care, insurance schemes play a very important role in
making it a viable proposition both for the seller and the buyer.
In fact insurance schemes mak.e sophisticated care available to
both middle as well as lower middle classeS." 20/
The CDR insurance scheme offers very specialised packages
for specific diseases like diabetes, pregnancy, hypertension and
heart diseases and like th.e Apollo insurance package the accent
is on hospitalisation rather·than out patient services. Recently
the CDR group has also introduced a privilege card for a mere Rs
500 and there's 25 percent off on all tests and consultancies.
When asked to comment on the quick growth of his enterprises
Dr Reddy said:
180
"given my background I had access to some initial capital to start these various projects but it is my entrepreneurial talent coupled with the demand for services that has helped grow to this extent. Another important factor has been my varied social and political contacts. I have political contacts across parties, so whenever I need anything moved my contacts help. In this country you need such connections to move ahead. What others have to wait for months to get done just takes me a couple of days." 21/
social Background of Clientele
When the registry was asked if they had any records on the
socio-economic background of patients they said that they only
ask for the occupation of the patients. They get patients from
different backgrounds but majority of them are from middle and
lower middle classes .. A significant proportion of the patients
come from districts. On an average there are hundred out
patients a days. Al though they refused to give me access to
their patients records, their personnel relations off icer
randomly selected three days to give me a break up of their
patients according to their occupation. The break up is as
follows:
1. Agriculture 2 2. Business 18 3. Government
Employees 13 4. Students 23 5. Police 2 6. Housewife 18 7. Professionals 7 8. Attender 1 9. Daily wage
labourer 1
When asked why such a large number of students the personnel
officer replied saying that a lot of young people come to this
hospital.
181
Views on the Private sector: Dr Oayakar Reddy was of the opinion
that· the growth of private nursing homes has essentially' been a
phenomenon of the seventies and eighties. While the smaller
nursing homes catered only to the lower middle and working
classes, there was clearly a need for well equipped nursing homes
and hospitals. This was partly related to the decline in the
quality of public .hospitals as well as the growth of these
private hospitals. There are two major problems as far as he is
concerned with the growth of the private sector. Firstly, the
lack of any controls on nursing homes and hospitals and secondly
government doctors being allowed private practice.
"The lack of controls or standards in the private sector is peculiar to India because if you look at other countries like the US, they have strict controls. There is so much di versi ty in institutions that provide services that it becomes difficult to prescribe minimum standards. I also feel that private practice by government doctors should be banned so that do not get the best of both worlds without having a commitment to either. I think their salaries should be improved but they should not be allowed private practice. They should make the choice of either being full-time with the government or the private sector." 22/
SUSRUTH HOSPITALS LTD
This enterprise was established in 1983 and managed by a
single owner 0 In 1986 it was converted to a private limited
company and in 1987 it was registered as a public limited
concern. The promoters of this enterprise are a group of
businessmen and doctors who have made an initial investment of Rs
2.2 crores and in addition have mobilised a loan of 6.7 crores of
rupees from the lOBI and the remaining amount of 4.1 crores is to
be mobilised through the issue of shares. Thus the total cost of
the project is Rs' 13 crores. The chief promoter of this
enterprise is Dr. Ganerival who belongs to an old Marwari family
1Q?
who were the first bankers in the Nizam's court. The Ganerivals
were a landed family from Rajasthan and three generations back
they moved'to Hyderabad when the Nizam appointed one of them as
treasurer in his court. Eversince they have been the bankers cum
treasurer in the Nizam's court. During this period they amassed
a great deal of land as gifts from the Nizam in the Vidarbha and
Telengana regions. Even today they hold 1200 acres of lands in
these areas. Apart from owning large amounts of lands in the
districts the family are trustees to an old Rama temple which was
built in 1840 by Dr.G's great grandfather in what is now a part
of the old city of Hyderabad. This temple is built on 22 acres
of land which was gifted by the Nizam to the Ganerival family.
It is on 12 acres of this land that the hospital stands today.
This hospital will concentrate on providing maternity,
paediatric and family planning services. In addition they will
also have acute medical as well as emergency services. They
propose to start a nursing training college and plan to run short
term training courses for technicians . This hospital was
formally launched only in June this yea~ and therefore details
regarding staffing, social background of clientele was not
available.
As far as consultants. were concerned the promoters were very
clear that they will have consultants who are exclusively in the
private sector. The 300 bedded hospital is located on the
premises of the old temple whose land has been leased for the
purpose by the government. It is proposed that organisationally
the hospital will be a separate body where both consultants and
183
patients will be shareholders. Consultant fees will not be paid
in full to them but 60%' will be paid to the consultant and the
<>remaining 40% will be retained by the organisation for running
costs. The consultants will be given shares from time to time
instead of cash or be given admission to continuing education
programmes as this would help in avoiding tax problems for them.
This way the promoters feel that consultants will also develop"an
interest in. the functioning of the hospital rather than just
treat it as another job.
Views on the Private sector
The promoters had very definite views on the private sector
and as one of them explained:
"The recent growth of the private sector is related to increase in the city's population as well as inability of the public sector to cope with the demand. Prior to this the government hospitals were being used as nursing homes by doctors who used to charge patients for admitting them. As the number of private nursing homes increased government doctors started diverting patients to the private sector. Earlier there were very few enterprises which were established without the collaboration of government doctors but increasingly the trend is for doctors in the private sector to promote nursing homes and hospitals. In fact th~ banning of private practice was a water shed because
several specialists resigned from government service and entered
the private sector. However even-now many of the nursing homes
are dependent on government doctors as consultants in order to
get a steady supply of clients." 23/
On the issue of introducing controls, they were of the
opinion that while it was necessary it would have to be done in a
manner which does not affect the interests of the smaller
enterprises.
184
Hedwin Hospitals
Medwin Hospitals a 180 bedded project was promoted by three
doctors in 1989. Of the three, two of them have a MBBS degree
and the third one is a cardiologist The former belong to
forward cultivating. castes from Warangal while the latter is a
Kamma from coastal Andhra. All three of them come from landed
families with other business interests. One of them runs a
eighty bedded nursing home in Warangal and another of the
partners runs two private (donation) colleges. This hospital
offers a variety of services with special emphasis on cardiology.
Commenting on the recent spurt in private hospitals the promoters
said:
" The bed strength in government hospitals has not kept pace with the increase in population. Even ten years back government hospitals were good but due to resource constraints and increase in the demand for services has placed a strain on existing services and this has definitely provided an impetus to the private sector. The increase in the income of ~iddle and upper middle classes has created a demand for better services specially in light of poor quality of care in government hospitals. An important factor for the growth of corporate hospitals is however related to the liberalisation of the import of medical equipment thus making medical care a profitable venture. There is a lot of industrial activity in the state and people are investing in a variety of areas. Medical care with high technology is very profitable which is why there "is a boom in this area." 24/
References
1. Interview with owner of private nursing home, June 1990.
2. Interview with Senior Official, Directorate of Medical Education, Hyderabad, March, 1990.
3. Interview with owner of private nursing home, August, 1989.
4. ibid March, 1990.
5. Interview with Dr. M. Venkat Rao, former Director of Medical and Health Services, Hyderabad, March, 1990.
185
6. Interview with owner of private nursing home, July,1989. <"
7. ibid, March, 1990.
8. Interview with an Off ice Bearer of the Junior Doctors' Association, Osmania General Hospital, Hyderabad, June, 1990.
9. Interview with Civil Assistant Surgeon, Osmania General Hospital, Hyderabad, June, 1990.
10. ibid
11. Interview with a Civil Assistant Surgeon, Osmania General Hospital, Hyderabad, June, 1990.
12. Interview with civil Assistant Surgeon, Osmania General Hospital, Hyderabad, June, 1990.
13. Interview with a senior civil Surgeon, Osmania General Hospital, Hyderabad, June, 1990.
14. ibid
15. Interview with the Marketing Executive, Apollo Hospitals Limited, Hyderabad, March, 1990.
16. Interview with patient undergoing treatment at Apollo Hospital, Hyderabad, March, 1990.
17. ibid
18. Interview with Dr. C. Dayakar Reddy, promoter of CDR Hospital, Hyderabad, March, 1990.
19. ibid
20. ibid
21. ibid
22. ibid
23. Interview with Dr. Ganerival, chief promoter of Susruth Hospital, Hyderabad, March, 1991.
24. Interview with one of the promoters of Medwin Hospital, Hyderabad, June, 1990.
186
