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Essays on population and space in India

 | 
Christophe Z. Guilmoto
, 
Alain Vaguet

Part IV. Health and epidemics in Cities

10. Emergence of New Health Care Networks in India

Hyderabad, a Centre of Innovation

Florence Rihouey

Texte intégral

  • 1 See also Véron in this volume.

1In matters of health, India in general seems to be in a very bad situation. The infant mortality rate is still very high (92 per thousand compared with 29 and 27 per thousand in China and Thailand respectively), and significant nutritional deficiencies persist.1 Tuberculosis, tetanus and intestinal problems remain endemic (and sometimes epidemic), while other infectious diseases suddenly appear or reappear on a large scale.

2In this context, the health services seem to be inadequate. Based mainly on a curative system, they are under-equipped : materials, staff and investment are often lacking. Problems of supplies, overloading and hygiene reinforce the poor image of these health care centres—a “morgue” image, which is sometimes very real, especially in the case of government hospitals.

3But India is and remains a land of contrasts. Over the last few years, a new type of facility has been making its appearance. Alongside the health care networks maintained by governmental agencies, charities, nursing homes or practitioners of siddha, ayurveda, unani and homeopathy, a network of hospitals is presently growing up that offers “all specialities under one roof.” Accommodating the best specialists in cardiovascular or ocular surgery, these centres have a direct or implicit connection with the Gulf countries, Europe or the United States, and are comparable to hospitals in the rich countries. With glass, marble, indoor fountains and air-conditioning, their surroundings, services and fees make them real “five-star hospitals.”

4These new facilities reflect the growing importance of the middle classes, whose demand for health care is increasing, the economic significance of a few Indian entrepreneurs who are investing in this sector, and a political context which affects the whole system, since health is a governmental concern (1946, Bhore Committee Report).

5The trend towards a luxury private sector has accelerated since 1991. In order to redress the balance of payments (when the country was more than 75,000 million dollars in debt) the then Prime Minister, Narasimha Rao, got help from the International Monetary Fund and the World Bank, and initiated a liberalization of foreign trade. In this context of structural adjustment, there has been an increasing attempt to attract private investment from abroad (5 000 million dollars in 1994, an estimated 40,000 million up to the year 2000), at a time when public spending continues to decrease.

6As an area for the governmental intervention and the application of political choice, health has not remained untouched by these new measures. Gradually the Welfare State is giving way to multinational corporations.

Growth of the private sector

  • 2 In order to map this specific phenomenon (particularly striking in the urban and hospital landscape (...)

7Hyderabad, the sixth largest Indian city with almost 5 million inhabitants, will serve us as an illustration of this emergence of a new type of service.2 Capital of the state of Andhra Pradesh, and formerly centre of a Muslim princely state, Hyderabad lies on both banks of the river Musi. In the south is the historic centre, now known as “old city”, where most of the inhabitants are Muslim ; to the north are the Hindu areas that form the present dynamic centre of the city.

8This representation of numbers of beds by circles of proportionate size gives a good idea of the scale of the buildings (Figures 10.1 and 10.2). The government hospitals were set up between 1846 to 1980, but most of them date from before the 1960s. They form a significant element in the urban structure, which has not changed (no new hospital or additional beds since 1980). This lack of growth reflects a deterioration of premises and equipment, reduced budgets and a loss of doctors. The private hospitals in existence before 1986 were created by Catholic and Muslim organizations. One of Hyderabad’s special features is that it is home to a large Muslim minority (almost 40 per cent of its population), living almost exclusively in the southern part of the city. The three private health centres located in the south were indeed set up by Muslim trusts in a Muslim area.

  • 3 Apparatuses of European or American origin, used in the domains of imagery, diagnosis and surgery. (...)

9In a period of less than 10 years (the first such hospital dates from 1987), 14 special hospitals were inaugurated in Hyderabad. They offer specific types of health care, which in this area were previously available only in the public sector (such as oncology, nephrology, cardiology, ophthalmology, etc.), but under-utilized due to the lack of adequate equipment and qualified staff. The new centres are equipped with the latest medical technology like MRI, CT scanner or Colour Doppler system,3 and most of the doctors have done a part of their training abroad. Here general medicine goes side by side with plastic surgery, psychiatry, neurosurgery and nuclear medicine.

Figures 10.1 and 10.2 : The hospital landscape, 1986 and 1996

Figures 10.1 and 10.2 : The hospital landscape, 1986 and 1996

10These corporate hospitals, which are real business ventures, financed to a large extent by shares, offer their own health insurance schemes and accord medical as much importance to marketing as to medical services.

11Although this conspicuous presence of up-market private sector health care is of recent date, it is nevertheless the result of a process that started at the end of the 1960s. The growth of the private sector became significant first in states and districts that benefited from the Green Revolution. The nexus of hybrid varieties + irrigation + chemical fertilizers enabled some farmers to invest their agricultural surpluses in commerce or agribusiness (hotels, cinemas, the film industry, poultry-farming, fish-farming... and nursing homes). New educational strategies accompanied these transfers of capital into the secondary and tertiary sectors. During the 1970s, alarmed by promises of agrarian reforms, farmers encouraged their children to follow higher studies. In order to diversify their economic activities, they directed their sons into business, agriculture and the professions (doctors or lawyers). To take up the example of Hyderabad again, one family of landowners, who already owned four food businesses and a cigarette factory, set up in 1973 a 40-bedded nursing home (two of the four people involved in this enterprise were newly-qualified doctors).

12On the other hand, since agriculture is sometimes very closely connected with political power (in Andhra Pradesh the dominant Reddys and Kammas are both agricultural castes), health care became a political tool for local leaders, who invested in welfare services in order to consolidate their position.

13Therefore, the private sector developed first because of this economic growth. However, it also benefited from health policies initiated by the central government. From the Second Plan onwards (1956-1961) public spending on health decreases and the committees responsible for elaborating national policies referred to the parallel increase in the number of private practitioners (Mudaliar Committee Report 1961, then the Jungalwalla Committee Report 1967, and the Haathi Committee Report of 1975).

14From the Table above (Table 10.1.) it is possible to trace this gradually budgetary withdrawal on the part of the central government (amounts allotted to national health care programmes), and one of the states, Andhra Pradesh.

15While earlier plans and committees had considered health policy as the sole responsibility of the government, the Sixth Plan (1980-85) for the first time officially encouraged development of the private sector.

16Low public budgets, combined with the high cost of an essentially curative allopathic system, had in fact led to a breakdown situation. The state was unable to mobilize fresh resources, and this recognition of the private sector looks very like a delegation of human and financial responsibilities.

  • 4 Only Mumbai and Delhi passed laws for the registration of nursing homes. The Delhi Nursing Home Reg (...)

17Unfortunately, this decision only legitimized a sector that was already proliferating, and no thought was given to its role and character. Very few states or municipalities attempted to compensate for this absence of regulation in order to fix minimal norms for functioning (hygiene, cost, equipment, qualifications, etc.)4

Tableau 10.1 : Evolution of the expenses for public health (in Rs. Crores)

Tableau 10.1 : Evolution of the expenses for public health (in Rs. Crores)

18In Hyderabad today there are more than 2 500 individual medical practitioners, and almost 500 nursing homes (5 doctors and 1 nursing home per 10,000 inhabitants ; estimates based on personal investigations, 1995). There are no checks or regulations on this private practice.

  • 5 These cards granted by the government (Public Distribution System) guarantee rations of rice, oil o (...)

19Therefore, health policies have contributed considerably to the spread of private health care services (a mainly urban phenomenon) which at first took the form of individual practices, clinics, and nursing homes. However, the Sixth Plan also permitted the establishment of larger scale health care facilities. At the national level, a reduction or even total exemption from import duties was (and is still) granted for the importation of high-tech equipment. Health care as a whole is recognized as an “industry” and people wishing to set up a hospital may take advantage of loans from public financing companies (such as the Industrial Development Bank of India, for example). At the local level, the Municipality of Hyderabad went so far as to grant large plots of land (up to 30 acres) to encourage the establishment of such hospitals, if they would agree to provide free treatment to a certain proportion of “white card” holders (monthly income below. 500)5— which of course they agreed to, but do not fulfil.

  • 6 The Indian market has been open to foreign pharmaceutical companies since 1948 (Industrial Policy D (...)

20These various measure fostered the mobilization of capital from regional business groups and Non-Resident Indians (NRIs). In this context, the recent structural adjustment policy has simply permitted reproduction of a model of development that was already established in the pharmaceutical sector:6 the entry of multinationals into the Indian market.

From Point to Network : Spatial Organization of Private Hospitals

21In the same way as other services, the distribution of health care centres reflects various different social, economic and political plans. To illustrate our case, we shall again refer here mainly to the example of Hyderabad. In order to sum up the strategies involved, we have grouped private hospitals according to their origins (endogenous/exogenous) and their level of spreading.

22- The first category refers to endogenous hospitals, with a single outlet (type 1). These function as simple units, without medical partners or outside financing. The centres concerned are all recently established (1991, 1993 and 1996) and offer a total of 460 beds. Mainly located on the outskirts of Hyderabad, and with no immediate plans for extension, these have been set up by groups including business persons, doctors and managers, who are natives of the city.

23- Next come local centres that have set up a first inter-city branch (type 2) (6 centres, 1 800 beds, 700 of them in a single hospital). In most of these cases, the branches do not offer the same services as the original centre ; but this complementary relationship remains hierarchical.

24Two of these were formed by Muslim groups and are connected with the political party that is dominant in the state. The founder of the Majlis Ittehadul Muslimeen (the main Muslim party in Andhra) was also the director of one of these hospitals.

25- Then the branches have become more numerous and their distribution becomes centrifugal. The hospitals of this kind form networks radiating outwards from Hyderabad (type 3). This is the case, for example, with CDR Health Care Ltd. This company was founded in 1986 by a doctor from a land-owning family and the first CDR Hospital was built in 1989 (250 beds). Benefiting from strong family political support, the founder then diversified his activities and extended his presence in the domain of health. He has set up a medical equipment manufacture, a multimedia medical school, diagnostic centres and dedicated hospitals in the field of cancer, women and children. Three further extensions are being planned, including a hospital specially designed for businesspersons : private secretary, computer, fax and Internet connections will be provided to patients.

26This polar network is spreading within Andhra Pradesh (4 hospitals), based on nodes which are still urban, and various health care centres now exist also in Bangalore, Pune, Mumbai, Jaipur and Calcutta.

27If we consider these three types of spatial organization no longer separately, but as elements in an overall process of expansion, they could be seen as the various phases leading to the establishment of an infrastructural network. This hypothesis seems to be confirmed when we trace the development of the existing centres. The polar network corresponding to type 3 is in fact the outcome of a spatio-temporal progression that has successively integrated types 1 and 2. Similarly, type 2 centres started out as the first type.

28Naturally, the rhythm of growth has been different for each structure. Looking at centres founded around the same date, we find that some are still in phase 1 while others are already organized into networks.

29The succeeding categories include hospitals whose origin could be described as exogenous or foreign, even when the members of the founder-groups administering the facilities originate from Andhra Pradesh. These are Non-Resident Indians entering the health care market. Indian doctors or administrators living in the United States, they are exporting to their native place an American model of private health-centres. The objective is clear : “to transfer the American work-culture” to India.

30- The first of these exogenous models presents a simple structure (type 4). Only a few nodes are interconnected. In contrast to the preceding diagrams, here the centres involved are on the same level. The services offered are the same, and if they belong to the same health care chain, these hospitals are autonomously administered. Also of recent origin (1990, 1993, 1994, 1996—1150 beds), these centres have benefited considerably from the economic liberalization of 1991. Now, Hyderabad-Delhi represents the outstanding axis of a “network” which is likely to expand.

31- The last type of spatial organization involving our sample-town is exemplified by the Apollo Group chain of hospitals (type 5). Starting from Chennai in 1983, this reached Hyderabad in 1989 and Delhi in 1996. Founded by an NRI who was a native of Andhra Pradesh, this network of facilities is just the hospital branch of a group that is well-established in domain of health (development of computer software for hospital administration, medical equipment, training centres...). The company Apollo Hospitals Ltd. is present at every level : apart from the cities already mentioned, centres for treatment and diagnosis are found in Andhra Pradesh, Nepal and Bangladesh. However, the main organizational nodes remain located in Indian cities of national or even international level.

32Its close connections (maily financial) with the American Hospital Corporation, one of the biggest health multinationals in the United States enables it to plan for unparalleled expansion in India : 1 hospital in each state capital by the year 2000.

33According to whether these health-centres are of endogenous or exogenous origin, we find two distinct patterns of organization and spatial diffusion. The firs, based on vertical relationships between focal hospitals and dependent centres, leads to the development of a polar reticulated structure. Hyderabad remains at the centre of this nation-wide organization. The second is based mainly on horizontal relationships between poles on the same level. The hospital, via the private sector, reinforces national polarization and shares in their integration in the world system. Capital cities are indeed the first to be affected by the development of international relationships.

34The presence of these groups is certainly not confined to the Hyderabad area. Many people have invested in health through Trusts or companies : Tatas, Nandas (Escorts), Hindujas... However, none of these has developed a network comparable to the ones which have started or passed through Hyderabad. Economic wealth, the great mobility of a rising business class, and caste connections should be looked into more closely : 6 of the 10 biggest hospitals in Hyderabad have been founded by Reddys (the dominant agricultural caste in Andhra).

Tableau 10.2 : Cardiology packages

Tableau 10.2 : Cardiology packages

Use of Private Hospital Services

35The development of the health care system towards higher standards of technical and medical performance naturally has an effect on health-expenditure.

  • 7 For a comparison between the hospital fees given and local living standards, upper class incomes av (...)

36The creation of these hospitals in itself represents considerable amounts, from 1 to 150 crores. The cost of treatment is in proportion to the initial investment. To cite an example, Table 10.2 shows the charges current in The Heart Institute (Apollo Hospital, Hyderabad).7 These packages include treatment, room, medicines and meals. Some other billing department (MediCiti hospitals) notice that numerous items are charged extra : imported medicines, sutures, valves (Rs. 27,000 to 45,000), pacemakers, balloons (Rs. 30,000 to 45,000). In Medwin hospital, the patient also has to supply the blood required for transfusion and has to deposit the entire cost of package before any surgery is undertaken.

37In spite of the amounts involved, within three years Apollo has carried out more than 2,000 open heart operations. In 1995, it admitted 9,491 inpatients (all specialities) and 32,165 out-patients (minimum fee : Rs. 130). Since a similar number of admissions were made to the other corporate hospitals, we can estimate the number of patients treated in 1995 by all these private structures together at 420,000 (out-patients) and 120,000 (inpatients).

  • 8 Our analysis focuses on big private hospitals. But it should be noted that regardless of income, mo (...)

38Proportionally, this is still far from the figures given by the two big government hospitals in the city (1,500,000 consultations—78,800 inpatients) which together total more than 70 per cent of the consultations and 50 per cent of the in-patient admissions observed in the public sector (study covering ten government hospitals). Still the number of patients is large, considering the fees charged, and the increasing number of these private centres is evidence of the success they have met with the citizens.8

39On the other hand, since these types of treatment are available only in certain places and sometimes only in the state capital, the area served by these hospitals extends far beyond the city of Hyderabad itself. Taking the example of Apollo again, as representative of all the private hospitals in Hyderabad, figures 10.3 and 10.4 emphasize the extent of its influence upon the spatial and medical behaviour of the population.

40The largest number of patients naturally centres on Hyderabad (8,907 ; represented by an empty circle on the first figure). In Andhra Pradesh, Apollo’s area of influence is greater in the northern districts. People in the south (economically underprivileged areas) either use this type of service less, or turn towards Nellore and Chennai. The fact that the other centres in this group are more recently established probably explains why they have less influence at the regional and national level. At the all-India level, patients come mainly from neighbouring states, except for Tamil Nadu, where the Apollo hospital in Chennai, which is older than the Hyderabad one, has developed its own area of attraction.

Figure 10.3 : Different types of spatial organization of the private health care sector

Figure 10.3 : Different types of spatial organization of the private health care sector

41The present state of hospital data unfortunately does not allow us to quantify the use of this type of service on the international scale. This phenomenon is however very much in the course of development. Some Muslims from the United Arab Emirates or Saudi Arabia, as well as some NRIs from the United States, nowadays come for treatment to the private hospitals of Hyderabad. These members of the Indian Diaspora have adapted their health strategies to the new health care facilities available in India. Living in countries where social welfare is not available for everyone, they can now find in Hyderabad a very high quality service at a low cost. For such people distance is not a limiting factor, since the expenses involved (travel and treatment) are still far lower than the fees charged in the Gulf countries or the United States.

42Above all, it must be emphasized that these services do not affect only the wealthiest class of the population. Employees under the Central Government Health Scheme, or the Employee state Insurance programme are sometimes referred to these hospitals, when the government centres cannot fulfil the patients’ specific needs. These are the only governmental systems of medical insurance in existence in India. They cover employees of the central government and of some firms against a monthly contribution deducted from their wages. Expenditures are of course restricted and each case scrutinized, but again, the state is partially financing the private sector.

43Apart from the upper class, these facilities are most commonly used by middle class people, who, whatever their income, must very often take loans in order to access to this kind of health care. Let us take as an example a family of government employees with a higher than average income (Rs. 10,000 per month). For treatment related to the removal of a kidney, the head of the family spent Rs. 120,000. To raise this amount he took loans of Rs. 35,000 from his employer and Rs. 40,000 from private sources, as well as using the scholarship of his eldest son (Rs. 30,000). But all this amounted to only Rs. 105,000, and after payment of the monthly interest, he was left with only Rs. 2,000 per month to cover the needs of his four children as well as treatment for his wife who has asthma. What about the people with monthly incomes of less than Rs. 3,000 who still use these hospitals ? These are very often cases who have been refused admission to government hospitals (because assessed as too serious or not susceptible to treatment with the equipment available), involving key individuals in the family structure such as the head of the household or the only son. The loans taken represent extremely heavy burdens for families who have already sold all their valuable possessions (land if they had any, television, etc.). According to the National Statistical Health Survey, medical care represents the second most common reason for family borrowing, after dowries. Nevertheless, subscription to a private health insurance policy remains exceptional. “Why spend Rs. 1,500 per year, if we get no refund when we do not use medical services?”

Figure 10.4 : Attraction area of a hospital in Hyderabad : Andhra Pradesh

Figure 10.4 : Attraction area of a hospital in Hyderabad : Andhra Pradesh
  • 9 The concessions on location and functioning granted by the government were given on this condition, (...)

44As for poorer people, they have no access to these facilities, and the economic gap is such that it is additionally perceived as social and cultural. In Andhra Pradesh, the Legislative Assembly has ordered an enquiry into the private health centres, for non-fulfilment of the initial contract. In fact, these hospitals were supposed to reserve 10 per cent of their beds and 40 per cent of consultations for the treatment of people earning less than Rs. 500 per month.9 Nevertheless, the medical lobby has always been very active and the present economic and political influence of these hospitals will probably lead to the matter being dropped.

Figure 10.5 : Attraction area of a hospital in Hyderabad : India

Figure 10.5 : Attraction area of a hospital in Hyderabad : India

45The very presence of these hospitals seems to have led to a change in the demand for care. Of course, the phenomenon of epidemiological transition also explains this development. Nowadays infectious diseases are being matched by chronic and degenerative ones. Widening of the pathological field therefore has some effect on the new patterns of use that are being observed. However, orientation of the health care system towards a predominance of technology has modified some health practices. The richest classes nowadays get regular medical check-ups, and turning to high-quality private centres constitutes one of their first reactions to an illness, as much as home remedies.

Conclusion

46The development of the private health care sector, and the recent opening up of the Indian market to foreign companies has considerably altered the supply and type of medical care available. In addition, this developement is very clearly identifiable in the urban laudscape

47Health is not the only sphere to be affected, and the well-publicized entry of the Coca-Cola company also emphasizes this policy of liberalization. This example is not without significance. The visual impact created by this company (with its bill-boards, street stalls...), like the hospitals with their monumental architecture, has become a very strong spatial marker. The American Dream is within reach. The groups that have established themselves in the medical field are fully aware of the spatial and cultural significance of their presence in India. Everything possible is done to stress this American image, including the naming of the hospitals. Earlier we identified two patterns of expansion, according to the local or non-local origin of the centres. The hospital chain, which demonstrates the ultimate form of the endogenous type, bears the name of its founder (C. Dayakar Reddy). The “horizontal” network illustrative of the exogenous model bears the evocative name “Apollo.”

48Therefore, it seems as if Hyderabad today is a medically privileged area. For part of its population, this is certainly true. The upper classes, who formerly had to go to Mumbai or to Vellore (Christian Medical College), now have very high quality care facilities at their disposal. However, the middle classes, whose demand for medical care is increasing, often need to borrow in order to take advantage of them. And most of the population has only two possibilities, apart from traditional or informal facilities : individual practitioners and nursing homes where the quality of treatment varies widely, or the public sector. Because there is a total absence of any “culture of public service”, this sector is currently suffering from a loss of medical staff. The government health centres in towns are not growing, and doctors refuse to work in rural areas : nowadays this is affecting even fresh graduates. Moreover, doctors in service are turning towards the private sector. Despite governmental ban of this kind of multiple practice (Non Private Practise Allowance), many of them do set up their own nursing homes or act as consultants in the private hospitals. Consultations in the government centres are perfunctory, and patients are invited to follow the doctor to his private centre where the equipment is better.

49The state is no longer able to administer the health system, or to exercise any control over the private sector. It is even considering introducing fees for treatment in its own government services. The government’s financial problems are to be transferred to the patients. This measure cannot but increase the indirect costs already paid by those who use the public sector (loss of time...)

50The state is increasingly delegating its powers, and by including medicine under the Consumer Protection Act (1995), it seems to be passing the responsibility on to the consumer groups. Patients now have legal methods of recourse, to sue centres for compensation in cases of negligence or medical error. The inevitable consequences have followed : doctors are increasing the number of tests and diagnostic procedures, so as not, to miss any possibility. This type of “defensive” medicine only raises the patients bills.

51In this context, we may well wonder what will become of the “Health for all in the year 2000” project. India is still far from this goal—is it going to continue only along the same lines ?

Notes

1 See also Véron in this volume.

2 In order to map this specific phenomenon (particularly striking in the urban and hospital landscape) only hospitals with a capacity of more than 50 beds have been taken into account. Nursing homes, clinics and individual practitioners are therefore not shown in Figures 10.1 and 10.2.

3 Apparatuses of European or American origin, used in the domains of imagery, diagnosis and surgery. In cardiology, for example, operation theatres are geared to perform angiography, coronary by-pass, valvuloplasty or pacemaker implantation.

4 Only Mumbai and Delhi passed laws for the registration of nursing homes. The Delhi Nursing Home Registration Act of 1953 was extended in 1992 by an amendment instituting precise criteria for location (only in commercial areas like other business concerns), minimum size of buildings, rooms. However, nothing is said about the quality of services and care. Moreover, this exclusive criterion of location has led to registrations being given up. Private practitioners, who see themselves as providing a welfare service, wish to be located in residential areas. Therefore, out of an estimated number of 5,000 doctors in Delhi, only 200 are registered at present.

5 These cards granted by the government (Public Distribution System) guarantee rations of rice, oil or sugar at fixed prices to the most underprivileged groups. The type of card and the rations vary according to income : white cards and pink ones for incomes below Rs. 500 and Rs. 1,500 respectively.

6 The Indian market has been open to foreign pharmaceutical companies since 1948 (Industrial Policy Document, Delhi). Despite the establishment of governmental pioducuon units during the 1950s and 60s (Hindustan Antibiotics Ltd., Indian Drugs and Pharmaceuticals Ltd...), Indian companies have not been able to compete with the marketing techniques of the multinationals.

7 For a comparison between the hospital fees given and local living standards, upper class incomes averages around Rs. 6,50 per month and lower class ones around 600 per month (Hyderabad 1995).

8 Our analysis focuses on big private hospitals. But it should be noted that regardless of income, more than 70 per cent of all patients prefer to use the private sector (individual practitioners and nursing homes). Only the need for hospitalization, if perceived as necessary, will drive the poorer ones to the public sector. In this connection compare the investigations in Mumbai slums (Yesudian, 1990), in Jalgaon district in Maharashtra (Duggal and Amin, 1989) and in Delhi (Baru, 1998).

9 The concessions on location and functioning granted by the government were given on this condition, but nothing was done to inform the people eligible : “Corporate hospitals not working for poor”, Indian Express, April 7 1995.

Table des illustrations

Titre Figures 10.1 and 10.2 : The hospital landscape, 1986 and 1996
URL http://books.openedition.org/ifp/docannexe/image/9888/img-1.jpg
Fichier image/jpeg, 131k
Titre Tableau 10.1 : Evolution of the expenses for public health (in Rs. Crores)
URL http://books.openedition.org/ifp/docannexe/image/9888/img-2.jpg
Fichier image/jpeg, 63k
Titre Tableau 10.2 : Cardiology packages
URL http://books.openedition.org/ifp/docannexe/image/9888/img-3.jpg
Fichier image/jpeg, 49k
Titre Figure 10.3 : Different types of spatial organization of the private health care sector
URL http://books.openedition.org/ifp/docannexe/image/9888/img-4.jpg
Fichier image/jpeg, 102k
Titre Figure 10.4 : Attraction area of a hospital in Hyderabad : Andhra Pradesh
URL http://books.openedition.org/ifp/docannexe/image/9888/img-5.jpg
Fichier image/jpeg, 73k
Titre Figure 10.5 : Attraction area of a hospital in Hyderabad : India
URL http://books.openedition.org/ifp/docannexe/image/9888/img-6.jpg
Fichier image/jpeg, 69k

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Universite de Rouen, France.

© Institut Français de Pondichéry, 2000

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