The Health Care Delivery SystemProvided by Punjab A Study to Review PHSC Punjab Health Systems Corporation vkjksX;e~ lq[klEink National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi - 110067 A Study to Review The Health Care Delivery System Provided by Punjab Health Systems Corporation (PHSC), Punjab Report 2008 vkjksX;e~ lq[klEink National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi – 110067 Email:
[email protected] Website: www.nihfw.org Study to Review The Health Care Delivery System provided by PHSC, Punjab i List of Abbreviations Preface Acknowledgement Study Team Executive Summary vi vii viii viii ix 1 1 3 4 5 8 8 18 18 35 50 64 64 74 84 91 100 100 100 102 104 106 109 109 110 113 113 114 118 118 121 125 125 127 CONTENTS Introduction Objectives of the Punjab Health Systems Corporation Project Rationale Study Objectives Methodology Study Findings Structural and Operational Framework of Punjab Health Systems Corporation (PHSC) Facility Assessment A. District Hospitals B. Sub-divisional Hospitals (SDHs) C. Community Health Centres (CHCs) Views of the Beneficiaries on Quality of Services 1. In-patient Department 2. Out-patient Department Evaluation of the Training Institutes Community Voice Views of the Stakeholders • At District Level Deputy Commissioners (D.C) MLA/Elected Representative Civil Surgeons SMO in charge – District Hospitals • At Sub-Division Level MLA/Elected Representative SMO – Sub Divisional Hospitals • At CHC Level Elected Representatives at CHC Senior Medical Officers - CHC Observations and Discussion Facility Survey Views of the Beneficiaries Views of the Community (through FGDs’) Views of the Stakeholders Conclusion and Recommendations List of Tables 1 District Hospitals 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 General Profile and Facility Survey Facilities Available Laboratory Facilities Out-patient Department Emergency Services Intensive Care Unit Clinical Laboratories Blood Banking Facilities Radiology and Imaging 132 136 140 141 144 146 147 148 149 150 151 153 155 156 157 160 163 165 167 1.10 Operation Theatre 1.11 In-patient Wards 1.12 Hospital Medical Stores 1.13 Medical Record Department 1.14 Hospital Waste Management 1.15 Support Services 1.16 User Charges 1.17 Performance Report 1.18 Staff Position 1.19 Specialist Position 2 Sub Divisional Hospitals 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 General Profile and Facility Survey Availability of Equipment Laboratory Facilities Out-patient Department Emergency Medical Services Intensive Care Unit Clinical Laboratories Blood Banking Facilities Radiology and Imaging Services 168 171 173 176 178 180 181 182 183 185 188 190 192 iii 2.10 Operation Theatres 2.11 In-patient Department 2.12 Hospital Medical Stores 2.13 Medical Record Department 2.14 Central Supply Department 2.15 Five Year Performance Report 2.16 Utilisation of User Charges 2.17 Medical Officers in Position 2.18 Staff Positions 3 Community Health Centres 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 General Profile and Facility Survey Equipment available at CHCs Laboratory Facilities Referral Facilities Out-patient Department Emergency Medical Services Clinical Laboratories Blood Banking Facilities Special Investigations 194 196 198 201 203 205 208 209 210 212 214 216 217 218 219 220 222 223 224 225 225 226 227 229 231 233 236 238 239 240 242 244 245 245 246 246 3.10 Operation Theatres 3.11 In-patient Department 3.12 Hospital Medical Stores 3.13 Medical Record Department 3.14 Hospital Waste Management 3.15 Central Supply Department, 3.16 Laundry Services 3.17 Dietary Services 3.18 Medical Officers in Position 3.19 Five Year Performance Report 3.20 Staff Positions 3.21 Utilisation of User Charges 4 5 6 7 8 9 10 11 12 13 Distribution of Patients in Wards Admissions in Different Hospitals User Charges for Services in Various Hospitals Experience at Facility and Quality of Care Patient Responses on Quality of Services Patient Responses on Behaviour of Staff Availability of Medicines (patients’ responses) Money Spent (patients’ responses) Rules and Regulations at Facilities (patients’ responses) Satisfaction from the Services 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Suggestions for Further Improvement Distribution of Out-patients User Charges for Services (patients’ responses) Observations on Facility Profile (patients’ responses) Quality of Services (patient responses) Health Manpower (patient responses) Waiting Time (patient responses) Patients’ Experience (Rating) Suggestions for Further Improvement (out patients) Responses of Deputy Commissioners Responses of MLA/Elected Representatives Responses of Civil Surgeons Responses of SMOs of District Hospitals Responses of Elected Representatives at Sub-division Level Responses of SMOs of SDH Responses of Elected Representatives at CHC Areas Responses of SMOs of CHC 247 248 250 251 252 254 255 256 257 260 261 262 263 264 265 266 268 Study to Review The Health Care Delivery System provided by PHSC, Punjab v List of Abbreviations ANC ANM ASHA BOR BTR CHA CHC CSSD DC DD-cum-CS DH DMC ECG FGDs GDMO ICU IPF LP MLA MO NHP OPD OT PHC PHSC PPS RKS SDH SHC SMO SP Hospital VED Ante Natal Care Auxiliary Nurse Midwife Accredited Social Health Activist Bed Occupancy Rate Bed Turnover Rate Community Health Administration Community Health Centre Central Sterile Supply Department Deputy Commissioner Deputy Director-cum-Civil Surgeon District Hospital Deputy Medical Commissioner Electro Cardiogram Focus Group Discussions General Duty Medical Officer Intensive Care Unit In-Patient Facilities Lumbar Puncture Member, Legislative Assembly Medical Officer National Health Programmes Out-patient Department Operation Theatre Primary Health Centre Punjab Health Systems Corporation Population Proportionate to Size Rogi Kalyan Samiti Sub-divisional Hospital Subsidiary Health Centre Senior Medical Officer Special Hospital Vital, Essential, Desirable vi Study to Review The Health Care Delivery System provided by PHSC, Punjab Preface The Punjab Health Systems Corporation (PHSC) was created as a non-commercial statutory corporation in 1996 vide Punjab Act no. 6 of 1996, with the purpose to establish, expand, improve and administer curative and preventive services at secondary level health care institutions in the state of Punjab. The corporation has taken over the District Hospitals, Sub-Divisional Hospitals (SDHs) and Community Health Centres (CHCs) along with some rural and urban Medical Institutions. Training Institutes viz. State Institute of Health and Family Welfare (SIHFW), Mohali, and State Institute of Nursing and Paramedical Sciences (SINPS), Badal, Distt. Muktsar and Institute of Mental Health, Amritsar have also been included under PHSC institutions. The present study was conducted with the aim to review the extent to which the objective of the Health Systems Development Project II focusing on improving the health care delivery at the secondary level of health care has been achieved. It was an exploratory study for situational analysis in order to identify the areas of sub-optimal utilisation and suggest the measures for improvement. The study was conducted through the in-depth review of structural organisational and operational framework of PHSC. The site visits to review at least 50% of the 20 District Hospitals located in the different regions of the state and 26% of 37 SDHs and 10% of the 111 CHCs were made along with two special hospitals (Patiala & Bhatinda) and all the training institutions. Ten teams each comprising of faculty and research staff from National Institute of Health and Family Welfare (NIHFW) visited each of the 10 selected sample districts of Punjab and collected the data from respective district areas comprising of District Hospital, Sub divisional Hospital and Community Health Centre. It is hoped that the report of this study will be of considerable help to the State Government and other stakeholders in improving health care delivery system at secondary level of health care. Prof. Deoki Nandan Director, NIHFW Study to Review The Health Care Delivery System provided by PHSC, Punjab vii Acknowledgement The leadership and guidance provided by Prof. J.S. Bajaj, Vice Chairman, Punjab State Planning Board, Government of Punjab, support extended by Health and Family Welfare Department and various stakeholders towards conduction of this study is greatly acknowledged. Study Team Team Leader Amritsar Prof. Deoki Nandan, Director, NIHFW Dr. U. Datta, Reader and Acting Head, Deptt. of Education and Training Mrs. Rita Dhingra, Research Officer Mr. G.P. Devrani, Asstt. Research Officer Dr. B.S. Diwan, PG (CHA) student and Dr. Yashika, PG (CHA) student Prof. J.K. Das, Head, Deptt. of Epidemiology and MCHA Mrs. Reeta Dhingra, Research Officer Mr. G.P. Devrani, Asstt. Research Officer Dr. Devinder Megha, PG (CHA) student and Dr. Vartika, PG (CHA) student Dr. Vivek Adhish, Reader, Department of CHA Mrs. Vandana Bhattacharya, Research Officer Mr. S.S. Mehra, Asstt. Research Officer Dr. B.S. Diwan, PG (CHA) student and Dr. Jagriti, PG (CHA) student Dr. Sanjay Gupta, Reader, Department of CHA and Sub Dean Dr. Rachna Agarwal, Asstt. Research Officer and Mr. S.P. Singh, Research Assistant Dr. Nishant, PG (CHA) student and Dr. Ashu, PG student Dr. V. Adhish, Reader, Department of CHA Mrs. Vandana Bhattacharya, Research Officer Mr. S.S. Mehra, Asstt. Research Officer Dr. Sonia, PG (CHA) student and Dr. Vijaydeep, PG (CHA) student Dr. Gyan Singh, Chief Medical Officer, Department of CHA Mr. S.S. Mehra, Asstt. Research Officer Mrs. Vaishali, Research Assistant Dr. Vartika, PG (CHA) student and Dr. Devendra Megha, PG (CHA) student Prof. M. Bhattacharya, Head, Department of CHA, and Dean Mr. Parimal Pariya, Research Officer Mr. Ramesh Gandotra, Asstt. Research Officer Dr. Kumud, PG (CHA) student and Dr. Naveen, PG (CHA) student Dr. Sanjay Gupta, Reader, Department of CHA, and Sub Dean Mr. Parimal Pariya, Research Officer Dr. Rachna Agarwal, Asstt. Research Officer Dr. Shailender, PG (CHA) student and Dr. Sudha Goel, PG (CHA) student Prof. J.K. Das, Head, Deptt. of Epidemiology and MCHA Mrs. Reeta Dhingra, Research Officer Mr. G.P. Devrani, Asstt. Research Officer Dr. Rakesh, PG (CHA) student and Dr. Madhu, PG (CHA) student Prof. J.K. Das, Head, Deptt. of Epidemiology and MCHA Mr. J.P. Shivdasani, Research Officer Mrs. Vinod, Asstt. Research Officer Dr. Sunil, PG (CHA) student and Dr. Indu, PG (CHA) student Prof. J.K. Das, Dr. Neera Dhar, Reader, Mr. Jai Shivdasani, RO, Dr. Poonam Khattar, Reader, Department of Education and Training, Dr. Manish Jain, MD, and Ramesh Chand, ARO Bhatinda Firozpur Gurdaspur Hoshiarpur Jallandhar Ludhiana Muktsar Sangrur Tarantaran Editorial Team Executive Summary The Punjab Health Systems Corporation (PHSC), has been enacted through “The Punjab Health Systems Corporation Act, 1996 (Punjab Act No. 6 of 1996)”. The ‘Second State Health Systems Development Project’ was started under PHSC in the year 1996, with financial assistance from World Bank, with an objective to upgrade health services at secondary level. This project ended in the year 2002, and since then the Government of Punjab is supervising it through PHSC. Today, PHSC has 166 health institutions throughout the state of Punjab (86 in rural and 80 in urban areas), including District Hospitals, Sub Divisional Hospitals and Community Health Centres. Three Training Institutions viz. State Institute of Health and Family Welfare (SIHFW), Mohali, State institute of Nursing and Paramedical Sciences (SINPS), Badal, and Institute of Mental Health, Amritsar have also been included under PHSC. The present study is an in-depth review of structural organisation and operational framework of the PHSC, and an assessment of the achievements/success of the Health Systems Development Project in improving health care delivery at secondary health care level. The assessment also meant to bring to light the gaps in delivery of health care services and to provide practical recommendations for further strengthening the system. For the present review, a Review Committee was constituted and it conducted on site visits to 10 District Hospitals, 10 Sub Divisional Hospitals, 11 Community Health Centres, 2 Speciality Hospitals and 3 Training Institutions, which were selected using Population Proportionate Sampling Technique (PPS). Key quantitative information was collected using Facility Survey Checklist, Interview Schedules (for health staff), Exit Interviews of clients, and Interviews with other stakeholders. The information obtained was further triangulated with qualitative observations by conducting Focus Group Discussions with the community. The study was conducted between 15th January 2008 and 5th March 2008. It was revealed following the study that health facilities under PHSC are well accessible and the buildings and other infrastructure are appropriate. But the cleanliness of facility and surroundings, as well as landscape requires more attention. Some health facilities were not having the required equipment and among those which were having them, there were few where these equipment were either not being used or was non-functional. Shortage of manpower was revealed as a generalised observation in almost all the health facilities, particularly the specialists, laboratory technicians and Class IV employees. This issue was of grave concern in Sub Divisional Hospitals (SDHs) and Community Health Centres (CHCs). Another observation was that there is no separate cadre for GDMOs (General Duty Medical Officers) and Specialists, which is leading to poor OPD (Out patient department) services since the specialist doctors have to do emergency duties as well. Availability of medicines, particularly of the essential medicines was lacking in almost all the health facilities, and patients had to buy it from private medical shops, which was a matter of dissatisfaction among majority of patients as well as community. Health facilities were also found purchasing few essential drugs from the user charges and were not being supplied from State Study to Review The Health Care Delivery System provided by PHSC, Punjab ix or district level. Besides this although laboratory facilities were available in all the institutions visited, it was observed that they were not able to provide services most of the time due to lack of reagents and equipment. Radiologists and lab technicians were also not available in majority of these institutions. Emergency services were also found grossly compromised, particularly in the sub divisional hospitals, mainly due to staff vacancy and security reasons. Overall the health facilities visited were found deficient with regard to disaster preparedness, referral linkages, record keeping, store management and in provision of basic facilities like toilets to the visiting clients. It was observed that majority of clients approaching PHSC institutions were females belonging to poor socio-economic strata of the community. It was revealed that well to do families prefer to visit private doctors, because of better quality and prompt services there as compared to Government facilities. Major reasons for this discontentment were more waiting time due to lack of doctors and other staff, lack of medicines and other investigative facilities and poor behaviour of some of the health staff. Overall experience of respondents at OPDs of the various health institutions was not found to be very satisfactory. This observation was in particular for CHCs and District Hospitals, which require prompt attention. The community also opined and favoured the observations obtained at the OPD and inpatient departments of the health facilities. Lack of medicines, specialised doctors particularly gynaecologists, lack of diagnostic equipment, investigation facilities, appropriate emergency services, and referrals including ambulance service were major issues raised by the community, which needs to be addressed for improving the acceptability of these services. In brief, it was revealed from the community, clients and other stakeholders, that the project has succeeded in building the infrastructure. But its further maintenance, its capacity to address the community needs and satisfaction and provision of quality health care services through public health facilities still need to be addressed for better utilisation of the available resources. x Study to Review The Health Care Delivery System provided by PHSC, Punjab 1.0 Introduction Hospital services at secondary level play a vital and complimentary role to the tertiary and primary health care systems and together form a comprehensive district based health care system. It was observed that in the state of Punjab, District Hospitals, Sub-divisional Hospitals and Community Health Centres were having critical gaps in buildings, equipment, manpower, and skills and were unable to provide basic health care services. With an objective to improve efficiency and quality of the health care provided at first referral level hospitals, the State Government took an initiative to prepare a proposal for seeking aid from the World Bank. On the request of the State Government, the World Bank team visited the State in March 1995 to review preparation and pre-appraisal of the proposal for the “Health Systems Development Project-II”. On March 21st, 1996, the International Development Association (IDA) approved credit of SDR 235.5 million (US$350 million equivalent) under the multi-states Health Systems Development Project for implementation in the States of Karnataka, Punjab and West Bengal. The Development Credit Agreement and the Project Agreements were signed on April 18, 1996 on behalf of the Government of India and respective states. Thus, Punjab Health Systems Corporation was incorporated through enactment of Legislative act “The Punjab Health Systems Corporation Act, 1996 (Punjab Act No. 6 of 1996)”. The Corporation was incorporated through measures by the Government of Punjab to bring more administrative flexibility for implementation of the ‘Second State Health Systems Development Project’ with World Bank assistance to upgrade Health Services at secondary level. The Corporation took over 166 Institutions, which included District Hospitals, Sub-Divisional Hospitals and Community Health Centres. 86 Medical Institutions are situated in rural areas and 80 are in urban areas. Two training institutes viz. State Institute of Health and Family Welfare, Mohali and State institute of Nursing and Paramedical Sciences, Badal, Distt. Muktsar have also been constructed and were included under PHSC institutions. The World Bank sanctioned the Second State Health Systems Development Project of US$106.10 million to upgrade the envisaged areas means clinical, diagnostic and other services provided by community/rural, sub-divisional/taluka/state general and District Hospitals in the State of Punjab. 1.1 Objectives of the Punjab Health Systems Corporation Project a) To improve efficiency in the allocation and use of health resources in the Project States Study to Review The Health Care Delivery System provided by PHSC, Punjab 1 through policy and institutional development; and b) To improve the performance of the health care system in the Project States through improvements in the quality, effectiveness and coverage of health services at the first referral level and selective coverage at the primary level, so as to improve the health status of the people, especially the poor, by reducing mortality, morbidity and disability. As per the suggestions, the Project for revamping the Secondary Level Health Care Services was proposed to help in: • Adding and renovating hospital building at the block, sub-divisional and district headquarters; • Supplementation of accommodation for essential staff; • Provision of more ambulances and better machinery and equipment; • Increase in body strength at some places; • Additional hospital linen and accessories; • Maintenance funds for building, vehicles, machinery and equipment; • Cleanliness, repair and up-keep of all buildings. The whole of the State was to be covered through 86 Government Health Centres in the rural areas. 1.2 The Benefits to the General Public a. b. Free consultation for all Free diagnostic analysis, medicines and also treatment like operations, etc. for Yellow Card holders, Punjab Government Employees, Pensioners, past and present Members of Legislative Assembly, Hon’ble Judges, Freedom Fighters, under trial Prisoners, under emergencies and natural calamities and under National Programmes. Full availability of equipment and chemicals, etc. for diagnostic facilities. c. 2 Study to Review The Health Care Delivery System provided by PHSC, Punjab 2.0 Rationale As mentioned above, the Health Systems Development Project started under PHSC in 1996 with financial assistance from World Bank and concluded in the year 2002. Since then Government of Punjab is supervising it through a duly constituted corporation i.e. Punjab Health Systems Corporation (PHSC). The present study was conducted with the aim of reviewing as to how far the objective of this Project (HSDP II) has been achieved in improving health care delivery at the secondary level of health care. Also to bring to light any lacunae or gaps observed in delivering the health care services to the community. The study is an In-depth review of the Punjab Health System by the Review Committee constituted for the purpose. 2.1 Constitution of Committee i) Dr. J.S. Bajaj V.C.Punjab Planning Board Chairman Member ii) Dr. K.K. Talwar Director, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh iii) Dr. P.K. Dave Former Director, All India Institute of Medical Sciences (AIIMS), New Delhi iv) Dr. Deoki Nandan Director, National Institute of Health and Family Welfare (NIHFW), New Delhi v) Dr. Shakti Gupta Medical Superintendent, AIIMS, New Delhi Member Member Member Member Member Convener Member Coordinator Member vi) Dr. Sukhdev Singh Director, Family Welfare, Punjab vi) Dr. Roshan Sunkaria, IAS Managing Director, PHSC viii) Shri Tejveer Singh, IAS Special Secretary to Government of Punjab Department of Planning Study to Review The Health Care Delivery System provided by PHSC, Punjab 3 2.2 Terms of Reference The Committee was to make on site visits and to review at least 50% of the 20 District Hospitals located in different regions of the State, along with a similar inspection of 2 Special Hospitals (Patiala and Bhatinda), as well as of 10% of 37 Sub Divisional Hospitals (SDHs) and 5% of the 111 Community Health Centres (CHCs). 2.3 Study Objectives To conduct an in-depth review of structural organisational and operational framework of Punjab Health System Corporation (PHSC) and to assess the efficiency and effectiveness of management system so far established. ii) To conduct site visits to a specified number of District Hospitals, special hospitals, sub divisional hospitals and community health centres and assess the quality and efficiency of the delivery of health care at each of the health institutions. iii) To visit the three special Training and Teaching Institutions which are under the management control of PHSC and conduct a short academic review of the physical facilities as well as of the process of education. iv) To propose requisite remedial measures aimed at optimising a cost-effective and efficient management of PHSC as well as of hospitals and training institutions under its control and management. The field work, data collection, analysis, interpretation and report writing was done by National Institute of Health and Family Welfare, New Delhi. i) 4 Study to Review The Health Care Delivery System provided by PHSC, Punjab 3.0 Methodology 3.1 Type of Study This was an exploratory study conducted in the state of Punjab with an objective to undertake situational analysis, identify areas of sub optimal functioning and suggest remedial measures. 3.2 Duration of Study 15th January to 5th March 2008. 3.3 Sample Size 1. 2. 3. 4. 5. 50% of 20 District Hospitals (DHs) 26% of 37 Sub Divisional Hospitals (SDHs) 10% of 111 Community Health Centres (CHCs) All the Special Hospitals (SHs) All the Training Centres (TCs) Total 10 DHs 10 SDHs 11 CHCs 02 SHs 03 TCs 36 3.4 Sampling Technique Selection of the Districts was done by using the Population Proportionate to Size (PPS) Technique. These Districts were selected proportionately from the 3 existing geographical regions i.e. Majha, Doaba and Malwa. Hence the region wise sample of the Districts drawn was as follows: Majha 1. 2. 3. Amritsar Gurdaspur Taran Taran Doaba 1. 2. Hoshiarpur Jalandhar Study to Review The Health Care Delivery System provided by PHSC, Punjab 5 Malwa 1. 2. 3. 4. 5. Bhatinda Ferozpur Muktsar Sangrur Ludhiana 3.5 Data Collection Tools and Techniques 1) 2) 3) 4) 5) Interview schedule for health functionaries/service providers Exit interview schedule for patient satisfaction Checklist for Facility Survey Questionnaire for trainers Interview schedule for other stakeholders including community The health functionaries, other stakeholders, sample of beneficiaries (i.e. patients selected randomly) and facility surveys of health institutions for study were as follows: 3.5.1 At district level a) b) c) d) e) f) g) District Collector Civil Surgeon Local MLA/MP SMO/MS at District Hospitals Indoor patients Outdoor patients (OPD) Facility Survey of District Hospitals 1x10 = 10 in no. 1x10 = 10 in no. 1x10 = 10 in no. 1x10 = 10 in no. 10% of the total admitted in hospital or minimum of 10 patients 5% of the OPD attendance or minimum of 20 patients 1x10 = 10 in no. 3.5.2 At sub-divisional level a) b) c) d) e) f) Local elected representatives at sub-divisional level SMOs/MS at Sub-Divisional Hospitals Indoor patients Outdoor patients (OPD) Facility Survey of Sub-Divisional Hospitals FGD (Male Community Members) Study to Review The Health Care Delivery System provided by PHSC, Punjab 1x10 = 10 in no. 1x10 = 10 in no. 10% of the total admitted in hospital or minimum of 6 patients 5% of the OPD attendance or minimum of 20 patients 1x10 = 10 in no. 1x10 = 10 in no. 6 3.5.3 At CHC level a) b) c) d) e) f) Local elected representatives at CHCs SMO/MS at CHC Indoor patients Outdoor patients (OPD) Facility Survey of the CHCs FGD (female community members) 1x11 = 11 in no. 1x11 = 11 in no. 10% of the total admitted in hospital or minimum of 3 patients 5% of the OPD attendance or minimum of 10 patients 1x11 = 11 in no. 1x11 = 11 in no. Due care was taken to select the SDHs and CHCs from the same district from which District Hospital was selected so as to study the referral linkages. 3.5.4 Special hospitals a) b) c) SMO/MS at Special Hospitals Indoor patients Outdoor patients (OPD) 1x2 = 2 in no. 10% of the total admitted in hospital or minimum of 10 patients 5% of the OPD attendance or minimum of 20 patients 3.5.5 Training institutes a) b) Facility Survey Interview of the faculty 1x3 = 3 in no. 3.6 Data Collection Team 10 Teams, each comprising of 1 faculty member, 2 research staff and 2 students from NIHFW visited their respective sample district and collected the above mentioned data from whole of the district area. Training Institutes were also evaluated during these visits. Study to Review The Health Care Delivery System provided by PHSC, Punjab 7 4.0 Study Findings Following are the study findings as per the terms of reference provided: 4.1 Structural and Operational Framework of Punjab Health Systems Corporation (PHSC) A review of structural, organisational and operational framework of Punjab Health Systems Corporation (PHSC) was carried out. The detailed findings are as follows: The World Bank team on the request of the State Government visited the State in March-95 to review preparation and pre-appraisal of the proposal for the “Health Systems Development Project-II”. Thus, Punjab Health Systems Corporation had been incorporated through enactment of Legislative act “The Punjab Health Systems Corporation Act, 1996 (Punjab Act No. 6 of 1996)’. The Corporation has been incorporated through measures by the State Government of Punjab to bring more administrative flexibility for implementation with assistance of World Bank to upgrade Health Services at secondary level. The PHSC was incorporated on October 20, 1995 to establish, expand, improve and administer medical care at secondary level of health care services. The project activities were undertaken by the PHSC and the State Government has ensured that PHSC should function as an autonomous body. For its effective implementation, a Strategic Planning Cell is functioning under the overall supervision of the MD, PHSC-cum-Secretary Health. Under this project, PHSC had taken over 166 Institutions, which includes District Hospitals, Subdivisional Hospitals and Community Health Centres. 86 Medical Institutions are situated in rural areas and 80 are in urban areas. Two training institutes viz. State Institute of Health and Family Welfare, Mohali and State Institute of Nursing and Paramedical Sciences, Badal, Distt. Mukatsar have also been constructed and were included under PHSC institutions. The World Bank sanctioned the Second State Health Systems Development Project of US$106.10 million (approximately Rs. 422 crores) to upgrade the envisaged areas means clinical, diagnostic and other services provided by community/rural, sub-divisional/taluka/state general and District Hospitals in the State of Punjab. 8 Study to Review The Health Care Delivery System provided by PHSC, Punjab Organogram of Department of Health & Family Welfare Health & Family Welfare Minister Parliamentary Secretary Health & Family Welfare Principal Secretary Health & Family Welfare Secretary Health cum Managing Director PHSC Special Secretary Health cum Mission Director NRHM cum PD AIDS Director Health Services Director Family Welfare Director (SI) Secretary Health cum Commissioner AYUSH Head of Department Homeopathy C D E F G PHSC Jt. Secretary Health A Health-I, II & IV Branches Under Secretary Health PSACS PHSC Health - V, VI & VII Branches B SI Punjab Health Systems Corporation Social Insurance (ESI) PSACS Punjab State Aids Control Society Study to Review The Health Care Delivery System provided by PHSC, Punjab 9 The major heads under which the funds were provided were Loan Rs. 252.00 crore, Grant Rs. 127.00 crore and Share of the State Government. Rs.43.00 crore. Break up of the budget was as follows: Head Civil works for renovation, new construction and extension Major/Minor equipment, Surgical Packs and Furniture Vehicles and Ambulances Medicines, Medical Lab, Supplies Information Systems and Computers Training and Workshop Salaries and Office Expenses Price Contingencies Total Rs. in Crore 174.07 66.09 8.49 26.51 11.14 12.45 49.66 73.47 Rs. 421.88 4.2 The Corporation consists of: (a) The Chairman who shall be the Secretary to the Government of Punjab in the Department of Health and Family Welfare or a distinguished and eminent medical person. (b) The Vice Chairman of the Punjab Health Systems Corporation is the Secretary Health and Family Welfare and is the overall in charge of the department. He is the Chairman of the Punjab AIDS Control Society, Chairman of SCOVA (RCH Society), TB society and Leprosy Society. (c) Secretary Health-cum-Managing Director, who shall be an officer of the Indian Administrative Service. He assists the Vice chairman of the PHSC in connection with the administrative issues concerning to the PCMS doctors, which include Recruitment, Posting, Transfers, Disciplinary Actions, Service Rules etc. In addition to this, he has also been designated as Head of Department (HOD) of Government Mental Hospital, Amritsar. He is assisted by Superintendents of Health – I and II Branches of the Department and is supported by the Director, General Manager (F&A), Executive Engineers and other Programme Officers. (d) A Board of Directors; and such other employees, as may be determined by the Board of Directors. 4.3 Constitution of Board of Directors The Board of Directors consisting of the following members namely: (a) The Secretary to the Government of Punjab in the Department of Finance, (b) The Secretary to the Government of Punjab in the Department of Rural Development and Panchayats, (c) The Secretary to the Government of Punjab in the Department of Local Government, (d) Representative of the Government of India in the Ministry of Health, (e) The Director of Health Services, Punjab, (f) Six eminent persons as given below nominated by the Government for a period of three years, (provided that no nominee shall be a member of the Board of Directors for more than 10 Study to Review The Health Care Delivery System provided by PHSC, Punjab Punjab Health Systems Corporation Chairman A Vice Chairman-cum-Principal Secretary, Health & Family Welfare Managing Director Director cum Principal S.I.H.F.W. Mohali Director (Institute of Mental Health Amritsar) General Manager (F&A cum Secy Board) Executive Engineer (Works) DMA Principal State Institute (Badal) Dy Dir. (Admn) Dy Dir. (P&T) Asst. Dir. (Admn) Asst. Dir. (Sur) Asst. Dir. (HS) Asst. Dir. (BB) Asst. Dir (Equip) Accountants AMFA AM Audit EE (C) Mohali EE (C) Patiala EE (C) Jalandhar AAO AMFA AAO Acct Admn BB DMA DMC EE (C) F&A HMIS HS Med Supdt P&T Stat Anyst Sur Assistant Manager (Finance & Accounts) Assistant Accounts Officer Accountant Administration Blood Bank Deputy Manager Accounts Deputy Medical Commissioner Executive Engineer (Civil) Finance and Accounts Health Management Information Systems Hospital Services Medical Superintendent Procurement and Transport Statistical Analyst Surveillance Study to Review The Health Care Delivery System provided by PHSC, Punjab 11 two terms or six years whichever is less): (i) A representative of medical institution of excellence in the country, (ii) Two distinguished experts in professions related to medicine and health, (iii) An experienced professionals in Systems Management or Telecommunication, (iv) The Director of the National Institute of Pharmaceutical Education and Research; and (v) A representative of a reputed industrial house manufacturing pharmaceuticals. 4.4 The Managing Director • The Managing Director is the Executive Officer of the Corporation and he shall implement the decisions of the Board of Directors and shall exercise such other powers and perform such other functions, as may be delegated to him from time by the Broad of Directors. The Managing Director exercise general control and supervision over the dispensaries and hospitals in the effective performance of their functions under this Act or the regulations made there under. Corporate Level Departments 1. Strategic Planning Cell (SPC) 2. Department of Administration 3. Department of Procurement 4. Engineering Wing 5. Department of Finance and Accounts 6. Computer Cell. District Level Management of the Corporation 7. Deputy Medical Commissioner 8. District Health Committee 9. Assistant Medical Commissioner 10. Other medical and Paramedical Staff Hospital Level Staff 11. Senior Medical Officer 12. Medical Officer 13. Other medical and Paramedical Staff • • • • 4.5 Functions of the Corporation In order to ensure the focused approach for management of secondary level health care services, additional programme officers in the field of Quality Assurance, HMIS, Waste Management, Surveillance, Referral, Training, IEC, Hospital Services, Blood Bank have been positioned at headquarters level. Separate offices were set-up for Deputy Medical Commissioners (DMC). Apart from this, in order to enhance the data collection and analysis capabilities, the office of DMCs have been strengthened by providing manpower in the field of accounts and HMIS which support the hospitals in proper record keeping and monitoring. 12 Study to Review The Health Care Delivery System provided by PHSC, Punjab The functions of the Corporation are as follows: a) to formulate and implement the schemes for the comprehensive development of the dispensaries and hospitals; b) to construct and maintain dispensaries and hospitals including cleanliness; c) to implement National Health Programmes as per the directions of the State. The State Government and Central Government shall make funds available for this purpose; d) to purchase, maintain and allocate quality equipment to various dispensaries and hospitals; e) to procure, stock and distribute drugs, diet, linen and other consumable among the dispensaries and hospitals; f) to provide services of specialists and super-specialist in various hospitals g) to enter into collaboration for super specialities with health institutions both within the country and abroad to provide better medical care; h) to receive donations, funds and the like from the general public and institutions from both within and outside India; i) to receive grants or contributions which may be made by the Government on such conditions as it may impose; j) to provide for construction of houses to the employees of the dispensaries and hospitals, and the maintenance thereof by mobilising resources for financing institutions; k) to plan, construct and maintain commercial complexes, paying wards and providing diagnostic services and treatment on payment basis and to utilise the receipts for the improvement of the dispensaries and hospitals; l) to run public utility services and undertake any other activity of commercial nature for the delivery of health care within or without the hospital premises directly or in collaboration with private or voluntary agency on contract basis; m) to engage specialised agencies or individuals in the relevant disciplines, directly or from external sources for the efficient conduct of the functions; and n) to provide immediate treatment in case of emergency and for unaccompanied patients. 4.6 Steps for the betterment of employees 1. 2. 3. Chance of foreign training for all doctors and para-medical staff; Substantial training opportunities and fellowships etc. within the country; No change in the terms and conditions of the services, establishment matters will remain wherever they are. 4.6.1 At district headquarter level There is one Deputy Director cum Civil Surgeon (DD cum CS) in each district and hence a total 20 DD cum CS in Punjab. DD cum CS supports the Directorate of Health Services through taking care of implementation of various National and State Health Programmes, Implementation of Registration of Births and Deaths Act and Prevention of Food Adulteration Act. The Deputy Medical Commissioner (DMC) supports the DD cum CS in the provision of hospital services in the district. The District Health Officer assists the DD cum CS in the implementation of the Disease Control Programmes. S/he also supports the Directorate of Family Welfare (DFW) in enforcement of PNDT Act as District Appropriate Study to Review The Health Care Delivery System provided by PHSC, Punjab 13 Authority and implementation of different schemes in the District under National Family Welfare Programme through District Family Welfare Officer and District Immunisation Officer. 4.6.2 At block level The Civil Surgeon is supported by Senior Medical Officers, I/c of PHCs and Medical Officers I/c of Subsidiary Health Centre (SHC) in implementation of various National and State Health Programmes at grassroot level. 4.6.3 At subsidiary health centre level The Senior Medical Officers are supported by Medical Officer I/c SHC for Implementation of different schemes in the SHC area under National Family Welfare Programme through Multipurpose Health Worker (Male and Female). Medical Officers I/c are supported by Multipurpose Health Worker (Male/Female) in implementation of (i) Universal Immunisation Programme (DPT, Polio, BCG, Measles and TT for Pregnant mothers). (ii) Maternal & Child Health (Antenatal Check Up, Institutional Delivery & Post Natal Check Up). (iii) Family Planning: Counseling/motivation. District Headquarters Deputy Director-cum-Civil Surgeon {1 Post at each district} (Total = 18) X Assistant Civil Surgeon District Health Officer District Immunisation Officer District Family Planning Officer Deputy Medical Commissioner Senior Medical Officers of PHC/SHCs SMO (Hospitals) 1 Primary Health Centre for appropriately (100,000) population Total in the State 118 SMO - 1 MO - 2 at each PHC SHC (Subsidiary Health Centre/Dispensary) For 10,000 population each total in the State: 1200 LHV M+F MPHW PHC SHC SMO (Lady Health Visitor) (Male & Female) (Multipurpose Health Worker) (Primary Health Centres) (Subsidiary Health Centre) (Senior Medical Officer) Sub-centre Total with State: 2858+ (5000 population) LHV, Multi-Purpose Supervisor – For a Population of 30,000 (MPHW – M+F) 14 Study to Review The Health Care Delivery System provided by PHSC, Punjab (iv) Management of diarrhoea especially in infants. (v) Health Education: educating the community about the various available services. (vi) Control of Acute Respiratory Infection especially in infants. (vii) Identify the women requiring help for medical termination of pregnancy and refer them to nearest approved institution (viii) Health Survey. 4.6.4 Deputy Medical Commissioner (DMC) The DMC looks after the hospital services in District Hospitals, Sub Divisional Hospitals, and Block level Community Health Centres, which are headed by Sr. Medical Officer or In-charge of the hospital. In two special hospitals, i.e. MKH Patiala and Civil Hospital Jalandhar, there are Medical Superintendents who directly report to headquarters. Apart from this, Principal, State Institute of Nursing and Paramedical Sciences, Badal reports to MD-PHSC through Director cum Principal, State Institute of Health & Family Welfare, Mohali and Director, Institute of Mental Health i.e. Government Mental Hospital, Amritsar reports directly to the Managing Director. Recently the SINPS, Dadal has been handed over to Baba Faridkot University. 4.7 Review of functioning of PHSC To give more autonomy to the Hospitals, PHSC took the steps like (i) Higher financial powers to hospital in-charge, DMCs and CSs were given; (ii) Full powers were given to hospital incharge for commercial exploitation for support services for revenue raising, outsourcing of sanitation services, maintenance services of equipment and hospital building and condemnation of unserviceable articles; (iii) Clear-cut guidelines were given for the procedures to be adopted for retention and utilisation of user charges; (iv) Direct recommendation for recruitment of critical manpower on contractual terms. This is a very encouraging move. Higher accountability is possible only when more autonomy is given to the institutions. In more than 50 hospitals and 20 districts headquarters, capacity has been developed for computerised record keeping, which covers records of HMIS, Accounts, OPD/IPD, Blood Banks, and Diagnostic Services. For this purpose, the concerned staff has been trained and computer operators have been provided. In-house capabilities have been developed for commercially negotiating with the private partners for outsourcing. Slowly this capacity is being decentralised for effective implementation. Though computer was provided for computerised record keeping in hospitals/health centres at all levels, but in reality these computers were being used only for the registration purposes and these were not being used for record keeping or generation of HMIS. Only at few of the places, the medical records department was being managed by trained persons. Computerised HMIS systems were in position and regular data of the hospital activity and efficiency indicators were supposed to be collected and analysed. This was found to be one of the weakest areas in all most all the hospitals/health centres that were evaluated. There was hardly any well planned and organised Medical Record Department. Most of the centres were not even fully computerised, as the computers were there in the registration areas only. Even in some places untrained clerical staff manned it. The data so generated were not properly analysed to get the right information (like BOR, Average Length of stay, BTR, Death Rates etc.) required for effective management and to take right policy decisions. For an effective and efficient Hospital Administrator these are very important tools. Study to Review The Health Care Delivery System provided by PHSC, Punjab 15 Hence, efforts should be made to strengthen these aspects by planning and organising a good Medical Record Department for hospitals at every level. Also these Medical Record Departments should be Computerised and manned by properly trained and dedicated staff, which will take care of all the required Management Information System used for Hospital Administration. Overall percentage of the total Government expenditure on health sector increased from 3.54% in FY 94-95 to 4.27% in FY 03-04 (BE). In absolute term, the allocations have increased from Rs. 2057 million in FY 94-95 to Rs. 7117.20 million in FY 03-04 (BE) against the projected level of Rs. 2956 million. The per capita expenditure on Health at current price has increased from Rs.101 in FY 94-95 to Rs.292 in FY 03-04. Policy as regard to implementation of user charges was placed right from the very beginning. Reports showed the User Charges collections have increased sharply from Rs. 4 million in FY 9697 to Rs. 125.37 million in FY 03-04. This increase has been established by introducing better collection method and increase in the services offered. Retained user charges are being utilised on defined priorities of essential drugs (45%), patient’s facilities (25%), equipment maintenance (15%) and building maintenance (15%). During the study it was observed that in almost all the hospitals at all level about 40-50% of retained revenue from User Charges were used to procure medicines and 20-30% amount on IFP purpose. But utilisation on building maintenance and equipment maintenance were found to be less utilised than its actual allotment. In the year 1996 & 1998, the State Government recruited 279 & 785 doctors. But since then no new recruitments were made. As a result there were some shortages of doctors in the regular cadre which is having its adverse effect on the overall functioning. Efforts were made to ensure that core team of specialists to be made available in every hospital. But in reality the availability of all the basic specialists in respective hospitals could not be ensured. Some times it was observed that a Medical Officer of one speciality on transfer was replaced by a Medical Officer of another speciality or a general duty medical officer, because in Punjab, there is only one cadre for Medical Officers. 100% equipment as per the norms was supposed to be in position in all the newly commissioned hospitals along with preventive maintenance of the vital equipment to be undertaken through AMCs. But in reality it was found not to be always in place. Availability of the drugs was to be monitored on monthly basis as a part of the hospital grading exercise. The State Government has continued providing the supplies of the medicines in hospitals. But in practice this was one of the major lacunas on the part of service providers. Most of the places it was told that the hospitals were not getting any regular supply of Drugs from the State, rather, they were told to arrange the same from funds generated through User Charges. Support services i.e. ambulance maintenance services, sanitation services and general maintenance services had been contracted out as a time gap arrangement. Waste disposal activities were also contracted out. This initiative was a very good move and it was reported that there were some visible improvements. But later on due to some policy decision the regular Class IV employees Study to Review The Health Care Delivery System provided by PHSC, Punjab 16 working in the peripheral health centres were deployed and contractual staff was removed. As a result, situation of general maintenance services in the hospitals were not one of the best. Main reasons told were absenteeism and unionism. Comprehensive referral system was to be established by introducing procedures at the primary level, through Out Reach Camps held in the rural and far-flung areas and by providing incentives for the referred cases at the higher level institutions. Referral manual has been prepared containing guidelines that specify ‘what’ ‘when’ and ‘how’ of referral. Colour coded referral cards have been introduced for sub centre level to district level for referring the patients. Training to doctors and paramedics for implementation of referral system was given. Incentive for referred patients (queue jump, exemption of OP/Admission Charges) have been introduced, referral routes have been established and displayed in all the hospitals. Special tie-up has been made at tertiary level facilities for creation of special window for the referred patients. But in practice none of these measures could be observed in exact desired manner. This is a very important aspect for an effective and holistic Health Care delivery system and hence all efforts should be made to further strength it and effectively implement it. A set of core indicators is being used to grade all the 154 hospitals. External lab quality assurance programme has been introduced. This was found to be a very useful and an effective mechanism for better and quality service output. Overall, as per the objectives of the PHSC and its policy implementations it was found to be quite cost effective with management efficient system. All the aspects are properly implemented. Many of these aspects are already mentioned above. For ensuring better availability of drugs and other consumables in hospitals/health centres at every level the Model of Tamil Nadu Medical Corporation may be followed. As this model is followed by many states with some modification as per their needs. Referral System needs to made more effective and extreme care needs to be taken to make it two way system and not one way, which was found to be followed in present situation. This was found to be more of Transfer System of patient than of Referral System. In this process the patients will tend to lose their confidence on the lower centres and as a result these centres will become under utilised. The examples for successful two way Referral Systems which are being followed in India are CGHS, ESIC, Railways, Army, etc. Further, for developing an effective and efficient system the National Health Scheme (NHS) followed at United Kingdom (UK) may be studied for its implementation. Efforts should be made to ensure the availability of all the services required for diagnostic and therapeutic processes by applying the modern scientific management techniques. There should be atleast two separate cadres for doctors. One for General Duty and other for the Specialists as it is followed in Central Health Scheme (CHS), ESIC, Railways, Army, etc. Study to Review The Health Care Delivery System provided by PHSC, Punjab 17 5.0 Facility Assessment A survey was conducted to assess the existing facilities with respect to various indicators at each health set up. 5.1 District Hospitals Facility assessment was done in ten District Hospitals selected as sample, which were Amritsar, Bhatinda, Ferozpur, Gurdaspur, Hoshiarpur, Jalandhar, Ludhiana, Muktsar, Sangrur and Taran Taran. Along with these hospitals, two special hospitals were also studied viz. women and child hospital in Patiala and Bhatinda. The general profile and facility assessment of District Hospitals is given in the Table Section (Refer Table – 1). 5.1.1 Accessibility All District Hospitals and special hospitals were easily accessible from the railway station and bus stand and well connected with the road. Average distance from the railway station and bus station ranged from one to four kilometres respectively. 5.1.2 Bed strength Six District Hospitals were 50 to 100 bedded, three were 100 to 200 bedded and one District Hospital of Jalandhar was found to be 300 bedded hospital. Special hospital at Patiala was 154 bedded and one at Bhatinda was 50 bedded hospital. 5.1.3 Water supply Almost all district and special hospitals were having adequate water supply except Bhatinda and Muktsar. Five District Hospitals and two special hospitals were having bore well water supply and four hospitals were having municipal water supply. District hospital, Muktsar was having canal water supply. Water storage capacity was available for one day at 2 District Hospitals and one special hospital, three days at 6 District Hospitals along with Patiala special hospital and two days at the remaining two District Hospitals. 5.1.4 Electricity supply Electricity supply was found to be regular in most of the district and special hospitals. Only three District Hospitals viz. Amritsar, Muktsar and Taran Taran, were having irregular supplies. However, only one District Hospital was having double phase electric supply, while, rest of the nine District Hospitals and two special hospitals were having three phase electric supply. Back up generator system was available in all the ten District Hospitals and two special hospitals. 18 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.1.5 Lifts and ramps Lifts were available in only four District Hospitals out of ten District Hospitals and two special hospitals included in the study. All hospitals were having ramps. 5.1.6 General impression on cleanliness and maintenance of gardens Six district hospitals (60%) were having good cleanliness and four (40%) were average. Among special hospitals, the cleanliness standard was good in Patiala and average in Bhatinda. Five District Hospitals (50%) were found to be having good upkeep of garden and rest five were having average landscaping. Among special hospitals, Patiala was found to have good while Bhatinda hospital with average upkeep of garden/landscaping. 5.1.7 Status of Buildings The status of the buildings in six District Hospitals was good, while it was average in the remaining four District Hospital buildings. Both the special hospitals included in the study were having a good building status. 5.1.8 Signs, roads and lighting Signage system was poor in Sangrur and average in Ludhiana District Hospitals. Rest of the eight District Hospitals were having good sign post system. Among special hospitals Patiala was having good while Bhatinda was having average sign posting. Roads and lighting of six District Hospitals were good, three were average and only one hospital (Amritsar) was found to be poor. Both the special hospitals under study were having good roads and lighting. 5.1.9 Public utility facilities Among all the District Hospitals covered under the study, six had a chemist shop within the premises; majority of District Hospitals (70%) had a canteen as well. Only two District Hospitals did not have Sulabh Shochalaya (Toilet facility) out of 10 District Hospitals. Five District Hospitals had STD/PCO booth within the premises. Both the special hospitals had a chemist shop, canteen and Sulabh Shochalaya within the hospital premises. Bhatinda Hospital did not have STD/PCO booth in the premises. 5.1.10 Ambulance service Ambulance facility was available among all the district and special hospitals covered under the study, with the District Hospital in Bhatinda having ten ambulances and rest of the district and special hospitals having one to five ambulances each. Study to Review The Health Care Delivery System provided by PHSC, Punjab 19 Majority of these ambulances were found to be partially equipped. Only three District Hospitals had fully equipped ambulances. Out of the two special hospitals assessed, only one had a fully equipped ambulance. 5.1.11 Operation Theatres (OT) Majority of the District Hospitals were having at least one minor OT, except Jalandhar and Muktsar hospitals, which were having four and three minor OTs’ respectively. Regarding major OTs, two District Hospitals were having one major OT, three District Hospitals were having three major OTs, three District Hospitals had two major OTs and two hospitals were having four major OTs. Patiala special hospital had two major OTs while Bhatinda special hospital had only one major OT. 5.1.12 Dental services Only the special hospital at Bhatinda, where no Dental Department exists, was without dental services out of the ten District Hospitals and two special hospitals covered under the study. 5.1.13 Maternity services All the hospitals were having maternity services. Fig 1: Normal deliveries conducted in District Hospitals (Punjab) in the last five years 4000 3500 3000 2500 2000 1500 1000 500 0 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No. of normal deliveries r sa r it Am Fe r pu oz r r pu as d ur G ur rp ia sh Ho r ha nd la Ja a an hi d Lu ar ts uk M Pa H) (S la tia r ru ng Sa r Ta an n ra ta ) SH a( d tin ha B Districts 20 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 2: Caesarians done in District Hospitals (Punjab) in the last five years 1600 1400 1200 No. of caesarians 1000 800 600 400 200 0 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr rit sa r ta ra n Ja la nd ha r Pa tia la (S H ) G ur da sp hi ar p uk ts ar Fe ro z Sa ng dh Ta ra n H os Lu Districts 5.1.14 Mortuary Out of ten, seven of the District Hospitals (70%) were having a Mortuary whereas two of them did not have post mortem facilities. Both the special hospitals were without Mortuary and post mortem facilities. 5.1.15 Various hospital management committees Only three District Hospitals were having a drug formulary and hospital antibiotic committee. None of the two special hospitals had a Hospital antibiotic committee, although Patiala special hospital was having a drug formulary committee. All the ten district and two special hospitals were having a store purchase and store verification committee except special hospital at Patiala. Four District Hospitals were not having a Hospital Infection Control Committee and medical audit/death review committee. Both the special hospitals were without Hospital Infection Control Committee, although Patiala hospital had a medical audit/death review committee. 5.1.16 Drugs and equipment management Almost all District Hospitals and special hospitals were having dual drug supply. They get drugs and equipment supply from the state and they can also purchase these supplies on their own, utilising the user charge money. Study to Review The Health Care Delivery System provided by PHSC, Punjab B ha tin da A m M (S H ) pu r ia n ru r ur ur a 21 Percentage of drug items which were requested and received were found to be 50 % in four District Hospitals, 40% in one, 60% in one District Hospital and one special hospital, 90% in one District Hospital, 100% in another and only 20% in Patiala special hospital. Percentage of patients getting all the prescribed medicines was found to range between 40% to 75% in most of the hospitals, except in Muktsar where it was only 25% and in Hoshiarpur it ranged from 5% to 10% for OPD patients. However, indoor patients in Hoshiarpur District Hospital were found to receive 100% of the prescribed medicines. Only two District Hospitals were having their own drug formulary. Six District Hospitals and both the special hospitals maintained buffer stock. All the hospitals were having annual maintenance contracts for maintenance of costly equipment and all hospitals maintained a logbook and history sheet for the equipment except two District Hospitals at Sangrur and Taran Taran. Current functional status of all the existing equipment was found to be good at the time of assessment. 5.1.17 Major equipment Only two District Hospitals at Amritsar and Bhatinda and special hospital at Patiala were not found to have baby incubators. The same were not functional in two out of the remaining District Hospitals having baby incubators. All the District Hospitals were having functional Boyle’s apparatus with circle absorber. All the hospitals were having a cardiac monitor though it was non functional in two of these District Hospitals. One special hospital did not have dental chairs. Dosimeter was present only in Taran Taran and one special hospital. ECG facility was available at all the hospitals; however, the same was not functional in Ferozpur hospital. Emergency resuscitation kit was available in all District Hospitals, except at Muktsar District Hospital. The emergency resuscitation kit was not found functional in Ferozpur hospital. Endoscope was available only in five District Hospitals, although it was non functional in Gurdaspur District Hospital. Endoscope was not available in any of the special hospitals assessed. All the ten District hospitals were having a functional ophthalmoscope. Out of two special hospitals, it was available only at Bhatinda special hospital. Four District Hospitals and one special hospital were having a perimeter. Only one District Hospital at Muktsar was not having phototherapy unit. Only Sangrur District Hospital and one special hospital were not having retinoscope. Shortwave diathermy was not present in three District Hospitals and it was found to be non functional in two District Hospitals and one special hospital. Sigmoidoscope was available at six District Hospitals out of ten. X-ray facility was present in all the hospitals, but ultrasound facility was not present in Sangrur and special hospital, Bhatinda. Slit lamp was available at all District Hospitals, but nowhere at special hospitals. 22 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.1.18 Referral system Referral facilities were available in almost all hospitals, though referral manual was not present in half of the District Hospitals and both the special hospitals. Guidelines for referring patients were not available in four District Hospitals and in both the special hospitals. Colour coded referral cards were available only in six District Hospitals and one special hospital at Bhatinda. Feedback mechanism existed only in three District Hospitals. Transport facilities were provided by all the hospitals. Only one District Hospital and one special hospital was not maintaining records and registers for the same. Incentives for following referral route for patients were provided only in four District Hospitals and one special hospital; they are mainly providing the vehicle for referral. Five District Hospitals along with special hospital at Bhatinda had a tie-up with other hospitals (both public and private) for diagnostic or referral purposes and most of them were with Government hospitals or Medical colleges except District Hospital at Jalandhar which was having tie-ups with private hospitals also. Statistical Bulletin was available only in four District Hospitals. 5.1.19 Outreach services and residential area Three District Hospitals and one special hospital at Bhatinda were having an outreach area and the services provided were mainly related to maternal and child health. All hospitals were having residential accommodation for the essential staff except at Amritsar and Muktsar. Though residential accommodation was available but still staff members were not getting it. 80% of staff was not getting accommodation in Bhatinda, 70% in Taran Taran, 50% in Hoshiarpur and Ludhiana, 40% in Sangrur and 15 % in Jalandhar. Among special hospitals, 40% of the staff was not getting accommodation in Patiala and 90% in Bhatinda. Ferozpur and Gurdaspur were having full accommodation and all staff members were getting the accommodation. All hospitals were having a security service. Among them three District Hospitals were having contractual security service and rest were having in-house security service. Three District Hospitals and one special hospital were having Dharamshala facility. 5.1.20 Out-patient department (OPD) Reception and registration counter was computerised in nine District Hospitals and in one special hospital at Patiala. It was found to be managed by a clerk in two District Hospitals, staff nurse in one, pharmacist in six and by a computer operator in eight District Hospitals and one special hospital. (See Fig 3) Study to Review The Health Care Delivery System provided by PHSC, Punjab 23 Fig 3: No. of OPD Patients in District Hospital (Punjab) in last five years 300000 1st Yr 250000 2nd Yr 3rd Yr No. of OPD patients 4th Yr 200000 5th Yr 150000 100000 50000 0 sa r ta ra n dh ia na Pa tia la (S H ) Fe ro zp ur Ja la nd ha r M uk ts ar da sp ur ar p ru r da A m rit B at h Sa ng da (S B ha tin in H ) ur H os hi Districts There were separate registration counters for male, female and senior citizens in most of the hospitals, except in three District Hospitals and one special hospital where only one District Hospital and one special hospital were having a separate registration counter for the staff. Registration registers were properly maintained and entries were made neatly in all hospitals except District Hospital at Muktsar. In all the hospitals, OPDs were having proper signage and directional signage in every section except at District Hospital Muktsar. Waiting area and sitting arrangement were found to be adequate in all the ten District Hospitals and two special hospitals. Only one District Hospital at Ludhiana was not having proper drinking water facility and District Hospital at Sangrur was not having separate toilet facility for male and female. Ceiling fans were present in all the hospitals. All doctor’s rooms were having adequate space, proper illumination and the examination tables covered by proper sheets, along with stools for seating the patients. All of them were having examination equipment like BP apparatus, torch, hammer etc. Minor OT dressing room was present in all the hospitals except at Taran Taran District Hospital. Injection room within the OPD was available in eight district and two special hospitals. Five District Hospitals and both the special hospitals were having a dispensary/pharmacy with separate counters for male/female/senior citizens/staff. 24 Study to Review The Health Care Delivery System provided by PHSC, Punjab Ta ra n G ur Lu Laboratory and imaging services were easily accessible from the OPD in all the hospitals. Out of all these hospitals only two District Hospitals were not having central collection centre for laboratory services. 5.1.21 Emergency/casualty services A separate medical officer was found available round the clock for emergency cases at eight District Hospitals out of ten and at one special hospital out of two. Glow sign board display at Emergency service department was observed in seven District Hospitals and one special hospital. Board displaying names of doctors/specialists on call in emergency, was found available in nine District Hospitals and one special hospital. Emergency wards were attached along with emergency in all hospitals. However, two of these District Hospitals and one special hospital was not having any triage area. Maximum number of observation beds were in Bhatinda, i.e 19 beds, followed by Hoshiarpur with 10 beds. In rest of the hospitals, observation beds ranged from three to eight. Trolleys and wheel chairs were present in all hospitals except Muktsar. The number varied between one to five. Fig 4: No. of emergency patients in District Hospitals (Punjab) in the last five years 20000 18000 16000 14000 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No.of patients 12000 10000 8000 6000 4000 2000 0 Batinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Sangrur Taran taran Bhatinda(SH) Districts At least one examination room with all basic equipments was present in emergency departments of seven District Hospitals and both the special hospitals assessed. Out of these, one District Hospital and one special hospital had two examination rooms. All the registers including MLR were available in all district and special hospitals assessed. Call book in the prescribed format was not available at two District Hospitals. Study to Review The Health Care Delivery System provided by PHSC, Punjab 25 Fig 5: Admissions through emergency in District Hospitals (Punjab) in the last five years 8000 No. of admissions through emergency 7000 6000 5000 4000 3000 2000 1000 0 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr ta ra n B ha tin da Ja la nd ha r G ur da sp ur hi ar p uk ts ar Fe ro z Sa ng dh Ta ra n H os Lu Districts Waiting area for the attendants, with basic facilities like sitting arrangement, drinking water, toilets etc. were present in emergency department of all hospitals except Taran Taran District Hospital. Public telephone facility was found in only four District Hospitals and one special hospital. Emergency department of all the hospitals had a retiring room for doctors with toilet facility. All the hospitals were having minor OTs for emergency procedures. Sufficient stock of essential and life saving drugs was observed in all the hospitals and all of them were having oxygen cylinders with attachments too. Separate laboratory services in emergency department was observed in six District Hospitals and both the special hospitals assessed. All the hospitals were having imaging and ambulance services in their emergency departments. Treatment facilities for dog/snake bite and poisoning were available in emergency departments of eight District Hospitals only. Similarly only seven District Hospitals were having plaster room in their emergency departments. Almost all hospitals were having staff trained in basic life support practices/system except in Gurdaspur and Muktsar District Hospitals. 5.1.22 Disaster management Only two District Hospitals were having disaster manual and disaster alert code, recall and deployment arrangements. Eight District Hospitals were maintaining a separate drug store for disaster situations. Study to Review The Health Care Delivery System provided by PHSC, Punjab 26 B ha tin da M (S H ) pu r ia n ru r ur a 5.1.23 Intensive care unit (ICU) Five District Hospitals out of ten were having Intensive Care Unit, while none of the two special hospitals assessed were having this facility. Numbers of beds available in the ICU of these five hospitals were 10 in Jalandhar, 6 each in Bhatinda and Gurdaspur, 5 in Sangrur and 4 in Ludhiana. All of these ICUs were air conditioned with generator support. Regarding separate sanctioned staff in these ICUs, Gurdaspur was having two doctors and three nurses; Ludhiana was having one doctor and two nurses and ICU at other hospitals were without any sanctioned staff. None of these ICUs were having sanctioned technical staff. 5.1.24 Clinical laboratory Pathology laboratories were present in all District Hospitals and special hospitals assessed except Ferozpur District Hospital. Microbiology laboratories did not exist in Gurdaspur District Hospital and the special hospital at Bhatinda. A qualified pathologist was available in nine District Hospitals and both the special hospitals. A qualified biochemist was present in only three District Hospitals and a qualified microbiologist was present only in one i.e. Jalandhar District Hospital. All hospitals were having facility for complete urine examination, stool test, blood urea, blood sugar, liver function test, blood grouping and matching test, semen examination and VDRL (Venereal disease research laboratory) test. Special hospital at Bhatinda was not doing complete blood haemo analysis, while all other District Hospitals and special hospitals were doing it. All hospitals were doing lipid profile and FNAC (Finel Needle Aspiration Cytology Biopsy) except Bhatinda special hospital and Ferozpur District Hospital. Three District Hospitals were not doing Pap smear. Biopsies were done only by three District Hospitals and culture and smear examination by only five District Hospitals. Out of ten districts and two special hospitals under study only District Hospital Sangrur was not doing vaginal discharge examination. Bone marrow examination was done in only three District Hospitals out of ten District Hospitals assessed. All these laboratories were found following universal precaution procedures and were using protective measures like gown, gloves, masks etc. Study to Review The Health Care Delivery System provided by PHSC, Punjab 27 All hospitals were collecting specimens centrally except Gurdaspur District Hospital. All the hospitals were having sufficient chemicals and reagents and were observing all bio safety measures. Laboratories of three District Hospitals were not having regular internal quality and external quality control measures. 5.1.25 Blood banking services Blood banking facility was not available at one District Hospital i.e. Amritsar and both the special hospitals. Among the hospitals with blood bank facility, trained qualified medical officers and other staff were present round the clock. All these blood banks were maintaining proper cold chain and refrigerators and doing proper checking and cross matching of blood. Australia antigen, HCV, VDRL, MP and HIV tests were done for every blood bottle of the donor in all these blood banks and efforts were made to collect blood through organising camps. All these blood banks have been renewing the blood banks and HIV licensing as per the rules. 5.1.26 Radiology and imaging services Round the clock availability of X-ray services/sonography was present in all the District Hospitals assessed during the study. All hospitals were having a dark room with all facilities. Moreover, only two District Hospitals and one special hospital were using a dosimeter. Seven District Hospitals and special hospital at Patiala were conducting special investigations like IVP, contrast media etc. Separate register for MLC records was not found to be maintained in three District Hospitals and both the special hospitals. History book and log book of X-ray machines were maintained in all except in Ludhiana District Hospital and Bhatinda special hospital. 5.1.27 Operation theater (OT) All the hospitals were having major and minor OT. Out of ten, two District Hospitals were having four major OTs each, four were having three major OTs, and one District Hospital and both the special hospitals were having two major OTs each. Rest were having at least one major OT. District hospital Jalandhar was having four minor OTs Muktsar hospital having three and rest of the hospitals having one minor OT each. Zoning concept was strictly followed in seven District Hospitals out of ten and one special hospital out of two. All the hospitals were having emergency light- generator facility for the OT. Regular disinfection and sterilisation were done in the OT of all hospitals assessed in this study. Availability of fire-fighting equipments and knowledge to use them were found to be in all OTs except two District Hospitals and one special hospital. 28 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 6: Surgeries performed in District Hospitals (Punjab) in the last five years 35000 1st Yr 2nd Yr 30000 3rd Yr 4th Yr 25000 5th Yr No. of surgeries 20000 15000 10000 5000 0 rit sa r ta ra n Ja la nd ha r G ur da sp ur H os hi ar pu r Pa tia la (S H ) uk ts ar tin Fe ro z dh ng Ta ra n Lu Districts 5.1.28 In-patient wards Almost all the hospitals were having satisfactory cleanliness of wards with adequate housekeeping services except District Hospital Gurdaspur. Wards of hospitals in Hoshiarpur and Gurdaspur were not having adequate and clean toilets and bathrooms. Only at wards of District Hospital Taran Taran, proper bio medical waste management guidelines for collection and segregation of bio medical waste were not followed, but they were having table top syringe and needle destroyer as in other hospitals. Wards in all hospitals were having adequate water supply and upkeep of sanitary blocks except Hoshiarpur. Adequate linen on bed was found in all district and special hospitals except in Gurdaspur and Sangrur hospitals. Three District Hospitals viz. Ferozpur, Ludhiana and Muktsar were having doubling of beds or floor beds. Eight District Hospitals and one special hospital were having satisfactory upkeep of cots, mattresses, lockers, linen etc. in the wards. Only one District Hospital was using uniform for the patients. Regarding availability of necessary equipments in the wards it was observed that nine District Hospitals and one special hospital had functional suction apparatus while in one District Hospital, although it was available but was non-functional. All hospitals were having functional oxygen cylinders with accessories while only six hospitals including one special hospital were having functional venesection/LP/tracheotomy tray. All hospitals were found having functional Study to Review The Health Care Delivery System provided by PHSC, Punjab B ha tin da A m ha B M Sa (S H ) da pu r a ia n ru r 29 Fig 7: No. of In-patients in District Hospitals (Punjab) in the last five years 18000 16000 1st Yr 14000 2nd Yr 3rd Yr 4th Yr 5th Yr No. of In-patients 12000 10000 8000 6000 4000 2000 0 r da ur ur ar na n r r ) r sa pu ha H ru sp zp ts ra tin (S ng rit nd ar dh uk ta ha m da hi Sa la Fe tia M n Lu os Ja Pa Ta G Districts emergency light, wheel chairs and stretcher trolleys. Only two District Hospitals and one special hospital wards were not having stationery, forms and various updated registers. Two District Hospitals were not found following the concept of progressive patient care. All hospitals were having adequate fans and lights. None of the hospitals assessed were providing diet to the inpatients. 5.1.29 Hospital medical store Medical store, suitably located with adequate space was found available in eight District Hospitals and one special hospital. In six hospitals including both the special hospitals, staff members of the medical stores were found to have knowledge on material management, system of FIFO, bin cards, lead time, buffer stock etc. and CMO (Chief Medical Officer)/MO (Medical Officer) were found regularly inspecting the medical store and verifying stock books in all hospitals except Ludhiana and Sangrur. All hospitals were having restriction on entry of unauthorised personnel in the medical store. Vital and essential drugs were found available in the medical stores of all hospitals under study except Sangrur and Ludhiana. Only five District Hospitals were found up-keeping the expiry date register which was regularly inspected by the Medical officer. 30 Study to Review The Health Care Delivery System provided by PHSC, Punjab B ha H tin ur B ra A da ro la (S ia H ) Eight hospitals including both the special hospitals were found making efforts to redistribute large stocks of slow moving drugs or near expiry drugs for its timely utilisation, while only four District Hospitals were having proper arrangements to keep drugs as per ABC/VED category and storage of rubber goods as per guidelines. Medical stores of all the hospitals, except Taran Taran and Ludhiana, were not taking appropriate steps to prevent pilferage of drugs. All hospitals, except Ludhiana and Amritsar, were found having convenient arrangements of issuing drugs to various wards. Only four District Hospitals were found regularly sending samples to chemical laboratory for checking the standard of drugs. All hospitals except Ludhiana were circulating list of available drugs to all MOs, OPD and wards as per generic name. At five District Hospitals and both the special hospitals, the medical store was submitting certified bills to office for release of payment within three days. Auction to clear the empty material from store was done regularly in six hospitals only, including one special hospital. Availability of fire-fighting equipments and knowledge to use them were found at medical stores of only four hospitals including one special hospital. Standing drug committees were found in only five District Hospitals, and only two District Hospitals were having a regularly updated hospital drug formulary. 5.1.30 Medical record department Seven District Hospitals and one special hospital were having a medical record room with enough number of racks. Medical record room was found to be managed by a trained medical record officer or technician in 50% of District Hospitals and both the special hospitals. Case records were maintained as per WHO classification of disease (ICD-X schedule) in only three District Hospitals and one special hospital. All hospitals were found regularly submitting morbidity and mortality reports except in District Hospital of Taran Taran. None of these hospitals were found maintaining the basic hospital utilisation indices like Bed Occupancy Rate, Average Length of Stay, Bed Turnover Interval, Death Rate etc. on a regular basis and in a proper scientific way. All the records were found to be maintained for ten years in five District Hospitals and special hospital at Patiala, five years in two District Hospitals and one special hospital, seven years in Amritsar and fourteen and fifteen years in Muktsar and Bhatinda District Hospitals respectively. Only three District Hospitals and one special hospital were having back up facility to safe guard these records and only five hospitals including one special hospital were following effective retrieval system. Medical audit was done at regular intervals in seven hospitals including one special hospital and Study to Review The Health Care Delivery System provided by PHSC, Punjab 31 regular death audit meetings were held and corrective action was taken in only three District Hospitals and special hospital at Patiala. 5.1.31 Hospital waste management Adequate number of bins and bags of the required colour codes were available and placed strategically in all patient care areas in all the hospitals except Amritsar District Hospital. Proper segregation and collection of waste was done with proper packaging and record keeping in almost all hospitals except Amritsar District Hospital. Gurdaspur, Amritsar and Jalandhar hospitals were also found lacking in proper storage facilities of waste. All hospitals were found following proper transportation of the collected waste. Waste disposal was outsourced in all hospitals assessed except at Sangrur District Hospital. Six District Hospitals along with both the special hospitals were found following the disposal/ recycling methods appropriately for various categories of waste. 5.1.32 Central sterile supply department (CSSD) Nine District Hospitals and one special hospital at Bhatinda were having CSSD under supervision of trained staff/senior nursing officer. Special hospital at Patiala was not having any CSSD. Eight District Hospitals and one special hospital were also having all the required equipments and autoclaves. Physical and chemical quality control measures were followed in seven District Hospitals and special hospital Bhatinda and biological quality control measures were followed in six District Hospitals along with special hospital at Bhatinda. 5.1.33 Laundry services Out of ten District Hospitals, nine were having in-house laundry services, while this service was found to be outsourced at only one hospital. Both the special hospitals were having mechanised in-house laundry service. At five District Hospitals laundry was of conventional (dhobi) type, while it was mechanised at the remaining five. Quality of wash and linen was good in seven District Hospitals and both the special hospitals. In rest of the District Hospitals it was average. 5.1.34 Kitchen facility Kitchen facility was not found available in any of the studied district and special hospitals. 5.1.35 Utilisation of patient care services Analysis of the last 5 years’ data showed that in all the District Hospital the number of patients 32 Study to Review The Health Care Delivery System provided by PHSC, Punjab utilising various medical care facilities including diagnostic and therapeutic, from in-patient and out-door either marginally or steadily increased almost all the District Hospitals. 5.1.36 Utilisation of user charges Year-wise expenditure of the User Charges made under the following major heads i.e. medicines, improvement of In-patient Facilities (IPF), Building Maintenance and Equipments Maintenance. The expenditure made under the head Medicines was 40% to 50% in most of the District Hospitals except at Ludhiana where it went upto 80% and then came down to 50% over the next 4 years. Fig 8: Percent of expenditure of the user charges on Medicine of different District Hospitals (Punjab) 90.00 80.00 70.00 60.00 Percent cost (Rs) 50.00 40.00 30.00 20.00 10.00 0.00 Bhatinda Ferozpur Gurdaspur 2003-04 2004-05 Hoshiarpur 2005-06 Jalandhar 2006-07 2007-08 Ludhiana Patiala (SH) Fig 9: Percent of expenditure of the user charges in IPF of different District Hospitals (Punjab) 35.00 30.00 25.00 Percent cost (Rs) 20.00 15.00 10.00 5.00 0.00 Bhatinda Ferozpur Gurdaspur 2003-04 2004-05 Hoshiarpur 2005-06 Jalandhar 2006-07 2007-08 Ludhiana Patiala (SH) Study to Review The Health Care Delivery System provided by PHSC, Punjab 33 Regarding expenditure on IPF head, it was found to be to be around 20% in most of the District Hospitals. In maintenance of buildings the expenditure was 5% to 10% over the years except for the Special Hospital of Patiala in the first year, which was recorded around 63%. Fig 10: Percent of expenditure of the user charges on buildings of different District Hospitals (Punjab) 70 60 50 Percent cost (Rs) 40 30 20 10 0 Bhatinda Ferozpur Gurdaspur 2003-04 2004-05 Hoshiarpur 2005-06 Jalandhar 2006-07 2007-08 Ludhiana Patiala (SH) Fig 11: Percent of expenditure of the user charges on equipments of different District Hospitals (Punjab) 18 16 14 Percent cost (Rs) 12 10 8 6 4 2 0 Bhatinda Ferozpur Gurdaspur 2003-04 2004-05 Hoshiarpur 2005-06 Jalandhar 2006-07 2007-08 Ludhiana Patiala (SH) 34 Study to Review The Health Care Delivery System provided by PHSC, Punjab In most of the District Hospitals, expenditure on medical equipments recorded less than 10% over the years, except at Bhatinda, Ferozpur and Ludhiana where in some years it was more than 10%. 5.2 Sub-divisional Hospitals (SDHs) Total ten Sub-Divisional Hospitals (SDH) were assessed and facility survey was done as per the prestructure32d checklist. These Sub-Divisional Hospitals were at Ajnala, Batala, Dasuya, Fazilaka, Jagraon, Maler Kotla, Malout, Nakodar, Patti and Talwandi. The General Profile and facility survey of Sub- Divisional hospitals is given in the Tables Section (Refer Table – 2.) 5.2.1 Accessibility All Sub-Divisional Hospitals (SDHs) were easily accessible from the railway station and bus stand and were well connected with the roads. 5.2.2 Water supply All SDH were having adequate water supply. Seven SDH were having bore well supply, while three of them i.e. Maler Kotla, Malout and Talwandi were having Municipal water supply. One day storage capacity of water was found available at three SDH, while rest seven were having storage capacity of three days. 5.2.3 Electricity supply Electricity supply was found to be regular in six SDHs, while it was irregular in rest of the hospitals. Only one hospital (Fazilaka) was having double phase electric supply, while rest of the nine hospitals were having three phase electric supply. All the hospitals were found having back up generator system except Nakodar Sub-Divisional Hospital. 5.2.4 Availability of lift and ramps Most of the Sub-Divisional Hospital were single storey buildings. Facility of lifts was available only at Malout Sub-Divisional Hospital. Ramp was available at all hospitals except Batala, Fazilaka and Jagraon. 5.2.5 General impression on cleanliness and maintenance of gardens Eight hospitals were having good cleanliness whereas it was found average at two hospitals. Upkeep of garden was found to range from `average to good’ at most of the Sub-Divisional Hospitals except Ajnala and Jagraon. 5.2.6 Signs, roads and lighting Signage was found good in six Sub-Divisional Hospitals. Rest of the four hospitals were having average sign postings. Roads and lighting of eight hospitals were found good and two average. Study to Review The Health Care Delivery System provided by PHSC, Punjab 35 5.2.7 Status of buildings Buildings of eight Sub-Divisional Hospitals were found to be in good condition while at two SubDivisional Hospitals (Patti and Talwandi) it was average. 5.2.8 Public utility facilities Out of all the Sub-Divisional Hospitals studied, three were having chemist shops, two were having STD/PCO booths, and only one was having a grocery shop and a cycle stand within the hospital premises. Fifty percent (five out of ten) of the Sub-Divisional Hospitals studied were having a functional canteen. Five hospitals were also found to have Sulabh Shochalaya. 5.2.9 Ambulance service Although facility of ambulance services was available at all the Sub-Divisional Hospitals but only three of them, namely Batala, Fazilaka and Maler Kotla were fully equipped. Seven SDH were having two ambulances while another two viz Dasuya and Talwandi were having three ambulances. Ajnala hospital had only one ambulance and that too was found to be only partially equipped. 5.2.10 Dental services All the Sub-Divisional Hospitals were found providing dental services except one hospital at Fazilaka. 5.2.11 Maternity services Maternity services were provided at all the Sub-Divisional Hospitals assessed in the present study. 5.2.12 Mortuary services Mortuary services with cold storage and other preservative facilities were found to be present at seven out of ten Sub-Divisional Hospitals, whereas facilities of post mortem were available at eight hospitals. Fazilaka was the only SDH where although the mortuary services were available, facilities for post mortem were absent. 5.2.13 Various hospital management committees Only Nakodar and Patti SDH’s were having a drug formulary committee. Nakodar SDH was found to be the only one with a hospital antibiotic committee. Hospital infection control committee was present at Batala, Nakodar and Patti SDH. Store purchase committee was present at all SDH except at Maler Kotla. Similarly, store inspection committee was present at all SDHs except Maler Kotla and Fazilaka. Five of the ten SDH assessed were found having a Medical Audit/Death Review Committee. 36 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.2.14 Drugs and equipment management Out of the ten Sub-Divisional Hospitals assessed, five were having a drug formulary. Almost all hospitals were found to have dual drug supply. They get drugs and equipment supply directly from the state and they can also purchase on their own through user charges money. Buffer stock was found to be maintained at all the SDHs, except Ajnala and Patti. Reorder levels were found to be maintained only at Ajnala, Dasuya, Jagraon and Nakodar SDH. All the SDHs except Ajnala and Patti were found having annual maintenance procedures for costly equipment. Fazilaka, Maler Kotla and Patti SDH were not maintaining log book and history sheet for the equipment. The present status of the existing equipments was found to be average at seven SDHs and good at Batala, Dasuya and Malout SDH. 5.2.15 Major equipment Six out of the ten Sub-Divisional Hospitals were having baby incubators but the incubator at Fazilaka SDH was not found functional at the time of visit. Boyle’s apparatus was available and functional at all the SDH except Fazilaka, where it was not functional. Cardiac monitor was available in all SDHs except Dasuya and Jagraon. The cardiac monitors at Ajnala and Fazilaka SDH were found to be non-functional. Dental chair was available at all SDHs but it was not functional at Ajnala and Fazilaka. Dosimeter was available only at Maler Kotla and Malout SDH and out of these it was found functional only at Malout SDH. ECG machine was available and functional at all the SDHs except Fazilaka. Emergency resuscitation kit was available and functional at all the SDHs. Fibre-optic Endoscope was not available at any of the SDH assessed. Malout was the only Sub-Divisional Hospital without an ophthalmoscope, while rest of the SDH were having a functional ophthalmoscope. Perimeter was available only at Maler Kotla and it was found to be functional. Five of the ten SDHs assessed were having a Retinoscope, which was functional. Slit lamps, which were also in working condition, were present only at five SDHs. Short wave diathermy (Physiotherapy) unit was available and functional at Fazilaka and Nakodar SDH. Study to Review The Health Care Delivery System provided by PHSC, Punjab 37 Sigmoidoscopes were present only in two Sub-Divisional Hospitals but these were found to be non-functional. X-ray facility was available and functional in all Sub-Divisional Hospitals. Ultrasound was present at all SDH except Talwandi. The ultrasound at Patti SDH was not functional. 5.2.16 Referral system Referral facilities were available in all SDH but referral manual was present only at six out of ten SDH’s studied. Guidelines for what to refer and when to refer were present at five SDHs whereas guidelines for how to refer were present at six places. Colour coded referral cards were available at five and feedback mechanism existed at four SubDivisional Hospitals. Transport facility was provided by all the SDHs. Maintenance of records and registers was done at all except Talwandi SDH. Incentive for following the referral route in the form of provision of ambulance was available only at Fazilaka SDH. All the SDHs were found to refer their patients to government/District Hospitals/medical colleges except Nakodar and Talwandi SDH. For diagnostic purposes, five SDHs were found to have a tie-up with other hospitals (both public and private). Statistical Bulletin was available only in four SDHs and out of them two were also having monthly bulletin and two fortnightly bulletins. 5.2.17 Outreach services Out-reach area services in the form of MCH camp, Eye camp, Blood donation camp and IEC were found to be available only at Fazilaka, Jagraon, Maler Kotla and Talwandi SDH. 5.2.18 Residential area Residential accommodation for the essential staff members was available at all SDHs except Ajnala and Jagraon. However, only four of these were having in house security services. Non availability of accommodation at four of these places was more than 50%. None of the Sub-Divisional Hospitals were found to have the facility of Dharamshalas. 5.2.19 Out-patient department Reception and registration counters were present in all the Sub-Divisional Hospitals (four were having computerised registration and rest of them manual). These counters were managed by a clerk in one SDH, by MSW in another one, by clerk/MSW in two others and a computer operator in five SDHs. Staff manning these counters was knowledgeable about the OPD procedures. There were separate registration counters for male, female and staff members at three SDHs. Four SDHs were having a separate registration counter for senior citizens as well. Registration registers were properly maintained and entries were made in all SDHs except at Malout. 38 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 12: No. of OPD Patients in Sub-Divisional Hospitals (Punjab) in the last five years 180000 160000 140000 No. of OPD Patients 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 120000 100000 80000 60000 40000 20000 0 a a a ka ar tti n a t uy ao ou al al tk jn at ko as gr zi al od Pa Fa Ja er D ak M Sub-divisional Hospitals In all SDHs, all sections of OPD were having proper signage and directional sign except at Ajnala and Maler Kotla. Waiting area was found to be adequate in six out of ten SDHs and only five SDHs were having proper sitting arrangement. Drinking water facility, Ceiling fans, Toilet facility, doctor’s chamber with adequate space, examination table with proper sheet, stool for patients to sit and examination equipments (like torch, BP apparatus and hammer etc.) were available in almost all the Sub-Divisional Hospitals. However toilet facility was not available at Nakodar. Examination table with proper sheet was not present at Jagraon SDH. All the hospitals were having adequately illuminated OPDs. Injection room along with facilities to deal with emergency situations was not available at Maler Kotla and Patti SDH. Similarly, Talwandi and Patti SDH were not having Minor OT/Dressing room with all the basic equipments. Only five Sub-Divisional Hospitals were having dispensaries/pharmacy with separate counters for male/female/senior citizens/staff. Laboratory and imaging services were easily accessible from the OPD in all the Sub-Divisional Hospitals. All SDHs were having a central collection centre for laboratory services except Maler Kotla SDH. 5.2.20 Emergency/casualty services All the Sub-Divisional Hospitals assessed were found having round the clock emergency services, with almost all the basic facilities. There was a separate medical officer available round the clock for emergency situations in seven Sub-Divisional Hospitals out of ten. Glow sign board displaying emergency service department M al Study to Review The Health Care Delivery System provided by PHSC, Punjab Ta N lw A B an la di 39 Fig 13: Emergency Patients in Sub-Divisional Hospitals (Punjab) in the last five years 6000 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 5000 4000 No. of patients 3000 2000 1000 0 Ajnala Batala Dasuya Jagraon Malerkotka Malout Nakodar Patti Talwandi Sub-divisional Hospitals was seen at five SDHs and board displaying doctors/specialists on call in emergency was seen at eight SDHs. Emergency wards were found attached to the emergency department in all SDHs except Ajnala, with observation bed strengths ranging from 1 to 12. Four of these ten SDHs were not having any triage area. Trolleys and wheel chairs (ranging from 1 to 4 in number) were present in all SDHs. Examination rooms with all basic equipments and all the registers including MLR were available in emergencies of all SDHs. Emergency department at all SDHs also had a retiring room for doctors with toilet facility except at Malout hospital. Call book in the prescribed format was seen only at four SDHs assessed. Waiting area for the attendants of the patients with basic facilities like sitting arrangements, drinking water, toilets etc were available in emergency departments of seven SDHs, but public telephone facility was found at only two places. Five SDHs had Major OT for emergency services whereas treatment room cum minor OT for various emergency procedures was present in emergency departments of all SDHs. All SDHs were having oxygen cylinders with attachments and sufficient stock of essential and life saving drugs was available in almost all the SDHs except at Ajnala. Laboratory, imaging, and ambulance services were available at emergency departments of all the Sub-Divisional Hospitals. All the SDHs were having staff trained in basic life support except at Malout and Talwandi. 40 Study to Review The Health Care Delivery System provided by PHSC, Punjab Treatment facilities for dog/snake bite and poisoning were available at emergency departments of eight SDHs (except Patti and Talwandi). 5.2.21 Disaster management Only three SDHs (viz. Dasuya, Fazilaka and Nakodar) were having Disaster manual and all these three were having disaster alert code, as well as recall and deployment arrangements. Seven SDHs were maintaining a drug store for disaster situation. Plaster room was present at six SDHs. 5.2.22 Intensive care unit (ICU) ICU was available at only four SDHs viz. Ajnala, Batala, Patti and Talwandi, with the bed strength ranging from 2 to 6 beds. None of these ICUs were found to be air-conditioned and were also not having any back up generator support. Staff sanctioned specifically for ICU was present only at Ajnala Sub-Divisional Hospital (Doctor-1, Nurse-1, Technical staff-1 and class IV-1). Similarly record keeping of the patients was found to be done only at Ajnala SDH. Oxygen/suction apparatus/compressed air were available at Ajnala, Batala and Talwandi SDH. Defibrillator and ventilator were not available at any of the SDH, whereas ECG machine was available only at Batala SDH. Only Batala and Talwandi SDH were found to have all the life saving vital drugs. Strict aseptic procedures were found to be followed only at the Batala SDH. 5.2.23 Clinical laboratory A pathology as well as microbiology laboratory was present in half of the Sub-Divisional Hospitals assessed during the study. Qualified pathologists and microbiologists were found present at four of these hospitals respectively. None of the hospitals were having a qualified biochemist. All Sub-Divisional Hospitals were having facility for complete blood haemogram analysis except Batala and Patti SDHs. Complete urine examination was available at all the Sub-Divisional Hospitals. Ajnala SDH was found not conducting stool tests whereas Blood Urea and Blood sugar tests were not conducted by Patti SDH. All of the rest SDHs were providing these laboratory facilities. Facility of liver function test was available at five SDHs, lipid profile at four, FNAC at one, culture and smear examination at one, semen examination at eight, vaginal discharge examination at two, bone marrow examination at one and other routine tests like HIV/pregnancy tests at six SDHs. Blood grouping and matching test and VDRL tests were done at all the SDHs. Pap smear and biopsy were not done at any of the SDH. Study to Review The Health Care Delivery System provided by PHSC, Punjab 41 Six of ten SDHs were found following universal precaution procedures and were using some protective measures like the use of gown, gloves, masks etc. All necessary laboratory chemicals and reagents were available at all SDHs except at Ajnala Sub-Divisional Hospital. Specimens were collected centrally in all the ten SDHs. All of them were observing the biosafety measures except Ajnala and Maler Kotla SDH. Regular internal and external quality control measures were found being undertaken by twelve SDHs respectively. 5.2.24 Blood banking services Batala, Dasuya, Fazilaka, Maler kotla, Nakodar and Patti SDH were having the facility of a blood bank. Trained or qualified medical officer as Blood Transfusion Officer was present at Batala, Dasuya, Fazilaka and Nakodar SDH, while no such officer was available at Maler, Kotla and Patti SDH. Round the clock availability of trained staff and services was a feature of all SDHs except Maler Kotla. All SDHs having blood banks were found following all the procedures like - checking and cross matching of blood by B.T.O; proper maintenance of cold chain and refrigerators; Australia antigen, HCV, VDRL, MP and HIV tests for every blood unit of donor; renewal of blood bank/HIV license as per rules; disposal of HIV positive blood bags and undertaking bio-safety measures and availability of table top syringe and needle destroyer and, colour coded bags. Efforts were made to collect blood through voluntary blood donation camps at five sub divisional hospitals out of the six having a blood bank. Feedback of transfusion and record maintenance of untoward incidences was found being done at Batala, Dasuya, Maler kotla and Nakodar SDH. 5.2.25 Radiology services Round the clock availability of X-ray services/sonography was present at six SDHs. However, radiologists were available only at two out of these. X-ray machines (500/300mA) were available at all the SDHs visited, but they were not found working at Batala and Dasuya SDH. X-ray machines (200/100mA) were available at five SDH and out of these only three were found functional; rest two were pending for condemnation. X-ray machines (moblie/60mA) were available at six SDHs and all of them were in functional status. All SDH were having a dark room with all the required facilities. Dosimeter was used only at Maler Kotla and Malout SDH and they send these dosimeters regularly to BARC for evaluation. Special investigations like IVP; contrast media etc. were available and conducted at four SDHs. Separate register for MLC records was found to be maintained at all the SDHs; and all of them except Patti SDH were found maintaining history sheet and log book of X-ray machines. 5.2.26 Operation theatre Dasuya Sub-Divisional Hospital was having three major operation theatres whereas hospitals at Fazilaka, Malout and Patti were having one major operation theatre each. Rest of the hospitals 42 Study to Review The Health Care Delivery System provided by PHSC, Punjab were found to have two operation theatres. All the hospitals assessed were having at least one minor operation theatre with the exception of Malout and Nakodar hospitals with two minor operation theatres. All SDHs were having major and minor OTs, except Jagraon SDH, which was not having a minor OT. Zoning concept in OT was followed at six SDHs. Fig 13: Normal Deliveries conducted in Sub-Divisional Hospitals (Punjab) in the last five years 900 800 700 No. of Normal Deliveries 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 600 500 400 300 200 100 0 a a N ak od ar ka n a M al ou t al uy ao tk al tti jn at as gr zi ko Pa Fa Ja er D Sub-divisional Hospitals Fig 14: Caesarians done in Sub-Divisional Hospitals (Punjab) in the last five years 600 1st Yr 2nd Yr 500 3rd Yr 4th Yr 5th Yr No. of caesarians 400 300 200 100 0 Ajnala Batala Dasuya Fazilaka Jagraon M al Malerkotka Nakodar Patti Ta Sub-divisional Hospitals Study to Review The Health Care Delivery System provided by PHSC, Punjab lw A B an la Talwandi di a 43 Boyle’s apparatus was available in OT of all the SDHs and the same was found under repair at two of them. Boyle’s apparatus at Ajnala SDH was found pending for condemnation. All the SDH were having hydraulic operation tables. Operation tables at three of these hospitals were found to be under repair and at one for condemnation. Shadowless lamps were available at all the hospitals. One lamp each at Fazilaka and Maler kotla SDHs were under repair. Fumigation apparatus was available at six SDHs. One out of the two available fumigation apparatus at Jagraon SDH was found to be under repair. Suction apparatus was available at all the SDHs, but one of the two suction apparatus at Patti SDH was under repair. All SDHs were having air conditioned OTs. Electrical cautery was available at all the SDHs. However, it was not functional and under repair at Ajnala, Batala and Jagraon SDH. Endoscope in the operation theatre was available at Fazilaka SDH only while laryngoscope was available at Batala, Dasuya, Fazilaka, Maler Kotla and Nakodar SDH. Facility of cardiac monitor was available at six SDHs and that of cardiac defibrillators at two SDHs. Pulse oxymeters were found to be available at all the SDHs except at Batala and Jargaon. All SDHs were found to maintain OT records, but maintenance of OT postponement records were done only at two SDHs. Emergency light or back up generator facilities to the OTs were available in all SDHs. Availability of fire-fighting equipments and knowledge to use them was found in OTs of five SDHs. Regular disinfection and sterilisation procedures were done at OTs of all sub divisional hospitals. 5.2.27 In-patient wards Almost all SDHs were having satisfactory cleanliness of wards, with adequate housekeeping Fig 15: Patients admitted in Sub-divisional Hospitals (Punjab) in the last five years 10000 9000 8000 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No. of Patients 7000 6000 5000 4000 3000 2000 1000 0 a ka ar tti a a n a t uy ao ou al al tk Pa jn at ko as gr zi al od Fa Ja er D ak M Sub-divisional Hospitals 44 Study to Review The Health Care Delivery System provided by PHSC, Punjab M al Ta N lw A B an la di services. All SDHs had adequate and clean toilets and bathrooms and; adequate and proper linen for all the beds except at the Batala SDH. At Batala and Talwandi SDH, the wards were not found to follow proper bio medical waste management guidelines for collection and segregation of bio medical waste; Talwandi SDH, in addition, was not having table top syringe and needle destroyer, whereas at Ajnala and Batala SDH, although the table top syringe and needle destroyer were available, they were not properly utilised. Wards in all SDH except Talwandi were having adequate water supply and upkeep of sanitary blocks. None of the SDH had doubling of beds or floor beds. All SDHs under study were having satisfactory upkeep of cots, mattresses, lockers, linen etc. in the wards except at Batala and Malout. Uniform for the patients was found to be used only at Jagraon SDH. Regarding availability of necessary equipments in the wards, it was observed that all SDHs were having functional suction apparatus except Malout, where it was not available. Oxygen cylinders with accessories were available in functional condition at all SDHs. Functional venesection/LP/ tracheotomy tray were available at all SDHs, except Malout, Patti and Talwandi. Eight SDH were having functional emergency light/wheel chairs/stretcher trolley. All SDHs were found to have adequate stationery, forms and various updated registers, and they were found maintaining various registers and records required in the ward. Concept of progressive patient care was not followed at Ajnala and Jagraon SDH. All SDHs were having adequate and working fans and lights. Only Malout SDH was providing diet to the inpatients. 5.2.28 Hospital medical store Medical stores were found suitably located with adequate space and protection of drugs and non-drug items from pilferage, temperature and humidity at Dasuya, Fazilaka, Jagraon and Nakodar SDH. There was no restriction on entry of unauthorised personnel in the medical store at Maler kotla and Patti SDH. At seven SDHs, staff members of the medical stores had knowledge on material management, system of FIFO, bin cards, lead time, buffer stock etc., while at the remaining three hospitals the staff responsible was not having this knowledge. CMO/MO were found regularly inspecting the medical stores and verifying stock books at all SDHs except Maler Kotla. Availability of vital and essential drugs was found at medical stores of all SDHs except Ajnala. Up-keep of the expiry date register and its regular inspection by the medical officer was observed at six out of the ten SDHs under study. At seven SDHs, efforts were made to redistribute large stocks of slow moving drugs or near expiry drugs for its timely utilisation, while only four SDHs were having proper arrangements Study to Review The Health Care Delivery System provided by PHSC, Punjab 45 to keep drugs as per ABC/VED category and storage of rubber goods as per guidelines. Medical stores of six SDHs were taking appropriate steps to prevent pilferage of drugs, while all SDHs except Ajnala were having convenient arrangements of issuing drugs to various wards. Six out of ten SDHs were regularly sending samples to a chemical laboratory for checking the standard of drugs and to take necessary action thereon. All SDHs except Maler Kotla were circulating list of available drugs to all MOs, OPDs and wards as per their generic names. Medical stores of all SDHs except Jagraon, were submitting certified bills to office for release of payment with in three days. Auction to clear the empty material from store was found to be done regularly at only five SDHs. Availability of fire-fighting equipments and knowledge of staff to use them was found in medical stores of five SDHs. Standing drug committee and availability of regularly updated hospital drug formulary was found at only five SDHs out of ten. 5.2.29 Medical record department Only five SDHs were having medical record room with enough number of racks and cup boards. Record keeping in medical record room was manual in all the SDH assessed, except Jagraon where it was computerised. Trained staff comprising medical record officer or technician was present at all SDHs, except Maler Kotla. However, in spite of this, the condition of the medical records was not found satisfactory. None of these hospitals were found maintaining some of the basic hospital utilisation indices like Bed Occupancy Rate, Average Length of Stay, Bed Turnover Interval, Death Rate etc. on regular basis and in proper scientific way. Case records were maintained as per WHO classification of disease (ICD-X schedule) at only three SDHs. All SDHs except Patti were regularly submitting their morbidity and mortality reports. Duration for which the record was maintained ranged from 5 to 10 years. Back up facility to safe guard these records was present at Ajnala, Dasuya, Fazilaka and Malout SDH. Five SDHs were having effective retrieval system. Six SDHs were found holding regular death and medical audit. 5.2.30 Hospital waste management Adequate number of bins and bags of required colour codes were found available at all SDH except Talwandi; and these were found placed strategically in all patient care areas at seven out of these SDHs. 46 Study to Review The Health Care Delivery System provided by PHSC, Punjab Proper segregation, collection of waste with proper packaging and record keeping, proper transportation and storage of waste was seen in almost all SDHs except Talwandi, where proper segregation and collection were lacking and Ajnala, where proper collection, packaging, labelling and record keeping were lacking. All SDHs were having proper storage facility and transportation for the biomedical waste. Waste disposal was found to be outsourced at all SDHs except Maler Kotla and Malout. Disposal/ recycling methods for various waste categories were done at six SDHs. Autoclaves and shredders were not available at Ajnala, Fazilaka and Malout SDH. 5.2.31 Central sterile supply department (CSSD) All SDHs except Maler kotla and Malout were having CSSD under supervision of trained staff/senior nursing officer, and these SDH were having all the required equipments and autoclaves. Physical and chemical quality control measures were found to be followed at CSSD of seven; whereas biological quality control measures were followed at six SDHs. 5.2.32 Laundry services Among ten SDHs under study, five were having in house laundry service while the remaining five were found to have outsourced laundry services. Laundry was of conventional (dhobi) type in five SDHs and mechanised in rest of the SDH. Laundry staff was found to be adequate only at four SDHs. Quality of linen as well as quality of wash was good at four SDHs only, while in rest SDHs it was found average. 5.2.33 Kitchen facility Kitchen facility was present only at Maler Kotla Sub-Divisional Hospital, with proper and safe arrangement for storage of raw material. 5.2.34 Utilisation of patient care services Analysis of the last 5 years’ data showed that at all SDHs the number of patients utilising various medical care including diagnostic and treatment from in-patient and outdoor came down in first 2-3 years. But after that, it steadily increased (though at a slower rate) during the recent years. However, the figures for the delivery services were not found very encouraging, during the last 5 years and in almost all the districts, these figures fluctuated on either side. Therefore, it is not only very difficult to conclude anything from this data, but it was found very much disturbing, that in some places the numbers have actually come down. One of the reasons may be irregular availability of the gynaecologist and its associated basic facilities in these hospitals. Study to Review The Health Care Delivery System provided by PHSC, Punjab 47 5.2.35 Utilisation of user charges Year-wise expenditure of the user charges made under the following major heads i.e. medicines, improvement in-patient’s facilities (IPF), maintenance of buildings and equipments. The expenditure made under the head medicines was 40% to 45% in most of the Sub-Divisional Hospitals except at Ajnala where maximum expenditure made on first 4 years (2002-06) whereas very low during the year 2006-07. Fig 16: Percent of expenditure of the user charges in medicine of different Sub-Divisional Hospitals (Punjab) 120 100 Percent cost (Rs) 80 60 40 20 0 Dasuya Fazilka Ajnala 2003-04 Batala 2004-05 Jagraon 2005-06 Malar Kotla 2006-07 Malout 2007-08 Patti Talwan-di Saboo Fig 17: Percent of expenditure of the user charges in IPF of different Sub-Divisional Hospitals (Punjab) 70 60 50 Percent cost (Rs) 40 30 20 10 0 Dasuya Fazilka Ajnala 2003-04 Batala 2004-05 Jagraon 2005-06 Malar Kotla 2006-07 Malout 2007-08 Patti Talwan-di Saboo 48 Study to Review The Health Care Delivery System provided by PHSC, Punjab Regarding IPF, most of the Sub-Divisional Hospitals utilised 20% to 25% of the user charges over the years. In maintenance of buildings, majority of the Sub-Divisional Hospitals used less than 15% of the users charges except Fazilka, Batala and Jagraon. In maintenance of equipment majority of the Sub-Divisional Hospitals spent less than 10% of the user charges over the year, except the hospitals at Ajnala, Jagraon and Talwan-di Saboo where it was more than 10% in some years. Fig 18: Percent of expenditure of the User charges in building of different Sub-Divisional Hospitals (Punjab) 25 20 Percent cost (Rs) 15 10 5 0 Dasuya Fazilka Ajnala 2003-04 Batala 2004-05 Jagraon 2005-06 Malar Kotla 2006-07 Malout 2007-08 Patti Talwan-di Saboo Fig 19: Percent of expenditure of the user charges in equipment of different sub-divisional hospitals (Punjab) 35 30 Percent cost(Rs) 25 20 15 10 5 0 Dasuya Fazilka 2003-04 Ajnala Batala 2004-05 Jagraon 2005-06 Malar Kotla 2006-07 Malout Patti 2007-08 Talwan-di Saboo Study to Review The Health Care Delivery System provided by PHSC, Punjab 49 5.3 Community Health Centres (CHCs) Facility survey was done at total of eleven CHCs as per the pre-structured checklist. These CHCs were Badal, Fatehgarh, Ferozshah, Goniana, Kartarpur, Khemkra, Longowal, Machiwar, Mahilpur, Majitha and Manawala. The general profile and facility survey of CHCs is given in the Tables Section (Refer Table – 3). 5.3.1 Accessibility All CHCs assessed were easily accessible from the railway station and bus stand and were well connected with the roads. 5.3.2 Water supply Almost all CHCs were having adequate water supply except CHC Manawala. Nine CHCs were having bore well supply while two CHCs i.e. Badal and Goniana were with Municipal water supply. Water storage capacity was found to be one day at 4 CHCs, three days at another 4 CHCs and for two days at remaining three CHCs. 5.3.3 Electricity supply Electricity supply was found to be irregular in most of the CHCs and only three CHCs at Kartarpur, Mahilpur and Majitha, were having regular supply to some extent. Only one CHC was with double phase electric supply, while rest of the CHCs were having three phase electric supply. Back up generator system was available at all the eleven CHCs. 5.3.4 General impression on cleanliness and up keep of gardens Six CHCs maintained good cleanliness while five were found to be average. Only two CHCs were having good upkeep of the garden and rest were having average landscaping. Only one CHC was found to have poor upkeep of the garden. 5.3.5 Status of Buildings Regarding status of the building, nine CHCs were in good condition and at two CHCs i.e. Khemkara and Mahilpur, buildings were in average condition. 5.3.6 Sign, roads and lighting Signage was found poor in Khemkara CHC whereas, it was good at six CHCs. Rest of the CHCs were having average sign posting. Roads and the lighting system were good at seven CHCs, average at three and found poor at one CHC. 50 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.3.7 Public utility facilities Out of all the CHCs studied, none were having a chemist shop or a grocery shop within the premises and only one CHC was having a canteen. Three out of 11 CHCs were having Sulabh Shochalaya. 5.3.8 Ambulance service Ambulance facility was available in all the CHCs studied. Out of these, six CHCs were having at least one ambulance and rest were having two or more ambulances. These ambulances were found to be partially equipped except at two CHCs, where ambulances were well equipped to some extent. 5.3.9 Intensive care unit None of the CHCs were having intensive care unit; however all the CHCs were found to have round the clock emergency services. 5.3.10 Other services (patient care) Except two CHCs all were having dental services and all eleven CHCs were having delivery services. 5.3.11 Mortuary None of the CHCs were having mortuary or post mortem facilities. 5.3.12 Various hospital management committees Out of eleven, only one CHC was having a drug formulary and hospital antibiotic committee, eight CHCs were having a store purchase and store verification committee, while only three CHCs were having hospital infection control committee and medical audit/death review committee. 5.3.13 Drugs and equipment management Almost all CHCs were having dual drug supply. They receive drugs and equipment supply through the state and also buy on their own utilising user charge money. Only three CHCs were found to have their own drug formulary. Seven CHCs were maintaining buffer stock, while only four CHCs followed reorder level. Five CHCs were having annual maintenance contracts for costly equipment, while six CHCs maintained log book and history sheet for the available equipment. 5.3.14 Major equipments Only one CHC was not having Boyle’s apparatus with circle absorber and two CHCs were lacking the facility of dental chairs. Emergency resuscitation kit was present at all CHCs except Badal CHC. Study to Review The Health Care Delivery System provided by PHSC, Punjab 51 Eight CHCs were having ophthalmoscope, but it was found to be non functional at one of these CHCs. Sigmoidoscope was only present in three CHCs. Other major and minor operation equipment was not found present at CHC Manawala. X-ray facility was available in all CHC except in one CHC i.e Manawala. 5.3.15 Referral system Referral facilities were available in all CHCs except Manawala; however, proper referral manual and guidelines for referring patients were not present in most of the CHCs. Colour coded referral cards were found to be present only at five CHCs and feedback mechanism existed only at CHC Longowal. Transport facilities were provided by almost all the CHCs except CHC Manawala, as referral facilities were not present here. Only one CHC was not maintaining records and registers other than CHC Manawala. Seven CHCs were found to have a tie-up with other hospitals (both public and private) for diagnostic or referral purposes and most of them were with government hospitals or medical colleges except CHC Kartarpur, which had a tie-up only with private hospitals. Statistical bulletins were available only at four CHCs; and out of these three were also having monthly bulletin and one CHC fortnightly bulletin. 52 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.3.16 Outreach services Six CHCs were having an outreach area and services provided were mainly maternal and child health. 5.3.17 Residential area Only one CHC was not having residential accommodation for the essential staff. Besides this, six CHCs mentioned that they were having some sort of security services, which was mainly in house. None of the CHCs had the facility of dharamshala. 5.3.18 Out-patient department Reception and registration counter was maintained by a clerk at one CHC, by a staff nurse at three CHCs, by a pharmacist at six CHCs and remaining one CHC was found to be managed by either staff nurse or pharmacist. Separate registration counters for male, female and freedom fighters were available only at two CHCs, while rest of them were having single registration counters. Only one CHC was having separate registration counters for staff and senior citizens. Registers used for registration were properly maintained and entries were found to be made at all CHCs. At all CHCs, OPDs were having proper signage and directional sign in every section. Waiting area was found to be adequate at ten CHCs, and proper sitting arrangements were available at 9 CHCs. Fig 20: No. of OPD attendance at CHC hospitals (Punjab) in the last five years 80000 1st Yr 70000 Number of OPD Patients 2nd Yr 3rd Yr 4th Yr 5th Yr 60000 50000 40000 30000 20000 10000 0 u r a h ah rh ra n ra al al a r pu n h ah ilp h em ka ro js ta r on te n ac M Community Health Centres K Study to Review The Health Care Delivery System provided by PHSC, Punjab M an Fa Lo ar G Fe M K M aw al ad gw ga oj B h iw ia it a 53 Two CHCs were not having drinking water facility, and three were not having separate toilet facility for male and female. Ceiling fans were present at all eleven CHCs. Doctor’s rooms were having adequate space and proper illumination with examination table covered by proper sheet at all eleven CHCs’. Only one CHC was not having a stool for seating the patient and examination equipments like BP apparatus, torch, hammer etc. Seven CHCs were having an injection room along with OPD facility, to deal with emergency situation; minor OT/dressing room was present at six CHCs. Only five CHCs were having dispensaries/pharmacy with separate counters for male/female/senior citizens/staff. Laboratory and imaging services were easily accessible from OPD at all the CHCs, with only seven CHCs having a central collection centre for laboratory services. 5.3.19 Emergency/casualty services A separate medical officer was found to be available round the clock in emergency departments of eight CHCs. Glow sign board displaying ‘emergency service department’ was found only at four CHCs, while board displaying ‘doctors/specialists on call in emergency’ was found at nine CHCs. Emergency wards were attached along with emergency departments at eight CHCs, with bed strengths ranging from 1 to 6 in number. However, two of these eight CHCs were not having triage area. Observation beds were available at nine CHCs, with beds ranging from one to four in number. Trolleys and wheel chairs were present at all CHCs, mostly ranging from 1 to 3 in number. Only one CHC had five trolleys/wheel chairs. Examination rooms with all basic equipments were available in emergency departments of six CHCs and all the registers including MLR were available at nine CHCs. Call book in prescribed format was not found at any of the eleven CHCs. Waiting area for the attendants of the patients, with basic facilities like sitting arrangement, drinking water, toilets etc. were available at emergency departments of eight CHCs, but public telephone facility was found to be present only at one CHC. Emergency departments of six CHCs were having a retiring room for doctors with toilet facility. Seven CHCs were having minor OT in emergency department for various emergency procedures. Sufficient stock of essential and life saving drugs were available at almost all the CHCs except CHC Khemkar; two CHCs were not having oxygen cylinders with necessary attachments. Separate laboratory service and imaging service in emergency department was available in seven and eight CHCs respectively. All CHCs were having ambulance services. 54 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 21: No. of emergency patients at CHC Hospitals (Punjab) in the last five years 3000 1st Yr 2nd Yr 2500 3rd Yr 4th Yr 5th Yr 2000 No. of patients 1500 1000 500 0 Badal Fategarh Ferojshah Goniana Khemkaran Longowal Community Health Centres Mahilpur Mojitha Manawala Fig 22: Admission through emergency at CHC Hospitals (Punjab) in the last five years 900 1st Yr No. of admissions in the Emergency 800 700 600 500 400 300 200 100 0 2nd Yr 3rd Yr 4th Yr 5th Yr Fatehgarh Ferojshah Goniana Kartarpur Khemkaran Longowal Mahilpur Mojitha Machiwara Community Health Centres Study to Review The Health Care Delivery System provided by PHSC, Punjab 55 Treatment facilities for dog/snake bite and poisoning were available at emergency departments of nine CHCs. Only seven CHCs were having staff trained in basic life support. 5.3.20 Disaster management Only five CHCs were having a disaster manual, and four CHCs out of them were having disaster alert code, recall and deployment arrangements as well. Five CHCs were found to maintain a drug store for disaster situation. 5.3.21 Clinical laboratory All CHCs were having facility for complete blood haemogram analysis and complete urine examination. Two CHCs were not conducting stool test and special tests like blood urea; rest all CHCs’ were providing these services. Blood sugar test and blood grouping and matching tests were available in all CHCs except one. Biochemistry laboratory was present at all CHCs with pathology lab only at three CHCs and microbiology lab at four. However, none of the CHCs were having a qualified pathologist, biochemist or microbiologist. Only three CHCs were not found following universal precaution procedures; laboratories at six CHCs were found having some protective measures like gown, gloves, masks etc. Five CHCs were collecting specimens centrally. Three CHCs’ were not having all the necessary laboratory chemicals and reagents. 5.3.22 Blood banking services None of the CHCs under the study were having blood bank facility. 5.3.23 Radiology services Round the clock availability of X-ray services/sonography were found available at seven CHCs. However, a radiologist was present only at CHC Ferojshah. All CHCs were having a dark room with all the facilities, but none of the CHCs were using dosimeter or conducting special investigations like IVP, contrast media etc. Only CHC Longowal was not found maintaining separate register for MLC records. Five CHCs were found maintaining history book and log book of X-ray machines. 56 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.3.24 Operation theatre (OT) All the CHCs were having major OT except CHC Ferojshah, and out of these two CHCs were having two major OTs. CHC Goniana, Mahilpur and Khemkaran were not having any minor OTs, while rest of the eight CHCs were having one minor OT each. Zoning concept in the OT was found to be followed only at three CHCs. All the CHCs were having emergency light-generator facility for OT. All CHCs were maintaining OT records except CHC Manawala. However, maintenance of OT postponement records was done only at three CHCs. Regular disinfection and sterilisation were found being done in OTs of eight CHCs out of eleven CHCs under this study. Availability of fire-fighting equipments and knowledge to use them were found at OTs of only two CHCs. 5.3.25 In-patient wards All the CHCs, except CHC Badal, were having satisfactory cleanliness of wards with adequate housekeeping services. At nine CHCs wards were found to have adequate and clean toilets and bathrooms. Wards at only two CHCs were not following proper bio medical waste management guidelines for collection and segregation of bio medical waste, and were not having table top syringe and needle destroyer. Fig 23: Nornal deliveries conducted at CHC Hospitals (Punjab) in the last five years 250 1st Yr 2nd Yr 200 3rd Yr 4th Yr 150 5th Yr No. of Normal deliveries 100 50 0 h h na w al ar n ad hg ka ng ilp rp ia ith a ha on B te ta ro ah oj K ar Fa Lo G K he Fe M Community Health Centres Study to Review The Health Care Delivery System provided by PHSC, Punjab M ac m M hi js w ar al ur ra ur a 57 Fig 24: Caesarians done at CHC Hospitals (Punjab) in the last five years 120 1st Yr 2nd Yr 100 3rd Yr 4th Yr 5th Yr 80 No. of caesarians 60 40 20 0 Fatehgarh Goniana Kartarpur Longowal Mahilpur Mojitha Machiwara Community Health Centres Wards in eight CHCs were having adequate water supply and upkeep of sanitary blocks with proper and adequate linen on bed. None of the CHCs were found having doubling of beds or floor beds. Nine CHCs were found having satisfactory upkeep of cots, mattresses, lockers, linen etc. in the wards. Only one of the 11 CHCs was having uniforms for the patients. Regarding availability of necessary equipments in the wards, it was found that six CHCs were having functional suction apparatus, while another CHC which although was having the suction apparatus, but it was non functional. All CHCs were having oxygen cylinders with accessories; however, at two CHCs, they were nonfunctional. Only three CHCs were having functional venesection/LP/tracheotomy tray. Nine CHCs were found having functional emergency light/wheel chairs/stretcher trolley. 58 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 25: No. of patients admitted at CHC Hospitals (PUNJAB) in the last five years 3500 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 3000 2500 Number of Inpatients 2000 1500 1000 500 0 Badal Fatehgarh Ferojshah Goniana Kartarpur Khemkaran Longowal Mahilpur Mojitha Machiwara Community Health Centres Wards at only two CHCs were not having adequate stationery, forms and various updated registers; however, all were found maintaining various registers and records required in the ward. All CHCs were having adequate fans and light. None of the CHCs were providing diet to the inpatients. 5.3.26 Hospital medical store Medical stores suitably located with adequate space were found at eight CHCs. At seven CHCs, the medical store staff had knowledge on material management, system of FIFO, bin cards, lead time, buffer stock etc. CMO/MO were found to regularly inspect the medical store and verify stock books at all CHCs except CHC Manawala. Eight CHCs were having restriction on entry of unauthorised persons in medical store. Availability of vital and essential drugs was found at medical stores of eight CHCs, while only five CHCs were up-keeping the expiry date register, which was regularly inspected by a medical officer. Only five CHCs were making efforts to redistribute large stocks of slow moving drugs or near expiry drugs for its timely utilisation. Three CHCs were having proper arrangements to keep drugs as per ABC/VED category and storage of rubber goods as per the guidelines. Study to Review The Health Care Delivery System provided by PHSC, Punjab 59 Medical stores of three CHCs were not found to take appropriate steps to prevent pilferage of drugs. All CHCs were having convenient arrangements of issuing drugs to various wards. Only CHC Kartarpur was found to send samples regularly to chemical laboratory for checking standards of drugs. Eight CHCs were circulating list of available drugs to all MOs, OPD and wards as per their generic names. Medical store at seven CHCs was submitting certified bills to office for release of payment within three days. Auction to clear the empty material from store was done regularly at only five CHCs. Availability of fire-fighting equipments and knowledge to use them were found to be in the medical stores of only two CHCs. Standing drug committee was found to exist only at three CHCs, and only these CHCs were having regularly updated hospital drug formulary. 5.3.27 Medical record department All eleven CHCs were having medical record room with sufficient numbers of racks. Record keeping in medical record room was manual in all the CHCs assessed, but at only four CHCs, this was managed by medical record officer or technician having some training in medical record keeping. None of these hospitals were found to maintain some of the basic hospital utilisation indices like bed occupancy rate, average length of stay, bed turnover interval, death rate etc. on the regular basis and in proper scientific way. Case records were maintained as per WHO classification of disease (ICD-X schedule) at only two CHCs. However, all eleven CHCs were found regularly submitting morbidity and mortality report except CHC Manawala. Only two CHCs were having back-up facility to safe guard these records and only four CHCs were found following some kind of retrieval system. 5.3.28 Hospital waste management Adequate number of bins and bags of required colour codes were available and placed strategically in all patient care areas in nine out of eleven CHCs included in the study. Proper segregation and collection of waste was found to be done with proper packaging and record keeping at almost all CHCs except Badal. CHC Fatehgarh and Badal were found lacking in proper transportation of waste. Only four CHCs were having proper storage facility for the biomedical waste. 60 Study to Review The Health Care Delivery System provided by PHSC, Punjab 5.3.29 Central sterile supply department Only six CHCs were having CSSD under supervision of trained staff/senior nursing officer, nine CHCs were having all required equipments and autoclaves. Quality control measures were found to be followed at all six CHCs having CSSD. 5.3.30 Laundry services Among eleven CHCs under study, six were having in-house laundry services, while remaining five had outsourced it. At all CHCs, laundry was of conventional (dhobi) type. Quality of wash was found good at four CHCs only, while in rest of the CHCs, it was found to be average. Quality of linen was good at six CHCs and average in the remaining five CHCs. 5.3.31 Kitchen facility Kitchen facility was not available at any of the CHCs assessed. 5.3.32 Utilisation of Patient care services At all the CHC hospitals, analysis of last 5 year data, revealed that the number of patients utilising various medical care services, including diagnostics and treatment, from in-patient and outdoor had came down in first 2-3 years. But after that, it has steadily increased during the recent years, though at a slower rate. However, the figures for service delivery were not found very encouraging. For the last 5 years, the figures had fluctuated on either side in almost all the districts. Therefore, not only it is very difficult to conclude anything, but is very much disturbing, that in some places the numbers have even come down. One of the reasons may be irregular availability of a gynaecologist and its associated basic facilities in these hospitals. 5.3.33 Utilisation of user charges Year-wise expenditure of the user charges made under the following major heads i.e. medicines, improvement of the in-patient’s facilities (IPF), maintenance of buildings and equipments. The expenditure made under the head medicines was 40% to 50% in most of the community health centre (CHC) except the CHC at Badal, Fatehgarh Churian and Manawala. Regarding IFP, most of the CHC spent 20% to 30% of the user charges over the years except at Longowal. (See Fig 26 and 27) The utilisation of User charges in maintenance of buildings at the CHCs under study were observed to be varying very widely in the CHCs, over the years as shown in the graph. 10% to 15% of user charges were found to be used for equipment maintenance in all the CHCs over the years except for Badal, Kartarpur and Mahilpur where it was even less then 5% except in few years. (See Fig 28 and 29) Study to Review The Health Care Delivery System provided by PHSC, Punjab 61 Fig 26: Percent of expenditure of the user charges in medicine of different CHCs of PHSC (Punjab) 70 60 50 Percent cost (Rs) 40 30 20 10 0 Badal Fatehgarh Churian Ferojshah Goniana Kartarpur Khemkaran Longowal Mahilpur Majitha Machiwara Manawala 2003-04 2004 -05 2005-06 2006-07 2007-08 Fig 27: Percent of expenditure of the user charges in IPF of different CHCs of PHSC (Punjab) 70.00 60.00 50.00 Percent cost (Rs) 40.00 30.00 20.00 10.00 0.00 Badal Fatehgarh Churian Ferojshah Goniana Kartarpur Khemkaran Longowal Mahilpur Majitha Machiwara Manawala 2003-04 2004 -05 2005-06 2006-07 2007-08 62 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 28: Percentage of expenditure of the user charges in buildings of different CHCs of PHSC (Punjab) 35 30 25 Percent cost (Rs) 20 15 10 5 0 Badal Fatehgarh Churian Ferojshah Goniana Kartarpur Khemkaran Longowal Mahilpur Majitha Machiwara Manawala 2003-04 2004 -05 2005-06 2006-07 2007-08 Fig 29: Percentage of expenditure of the user charges in equipment of different CHCs of PHSC (Punjab) 30 25 Percent cost (Rs) 20 15 10 5 0 Badal Fatehgarh Ferojshah Churian Goniana Kartarpur Khemkaran Longowal Mahilpur Majitha Machiwara Manawala 2003-04 2004 -05 2005-06 2006-07 2007-08 Study to Review The Health Care Delivery System provided by PHSC, Punjab 63 6.0 Views of the Beneficiaries on Quality of Services 6.1 In-patient Department A total of 224 respondents were interviewed from various health institutions like CHCs, Sub-divisional hospitals, District hospitals and Special Hospitals of Punjab Health Systems Corporation. 6.1.1 Socio-economic profile of respondents • Out of 224 respondents, the services of Punjab Health Systems Corporation were utilised more by females (56.3%) as compared to males (43.8%). When observed separately at the in-patient department of special hospitals, more female patients (90.9%) were found admitted as compared to the males (9.1%). This may be because these hospitals were mainly for women and children. Similarly at Sub-divisional hospitals, more female patients (55.9%) were found admitted as compared to the male patients (44.1%). At District hospitals the service utilisation was found to be 55.2% by females as compared to 44.8% by males. But at CHCs, the service utilisation by males was found to be more (65.5%) as compared to the females (34.5%). Utilisation of services by less than 15 years age group was very little (1.3%). Half of the respondents (50%) were in the age group of 15-30 years, while 20.1% respondents were in 31-45 years age group. Remaining respondents were above 46 years of age. • • Fig 30: Age distribution of in-patients at various health care institutions in Punjab 80 70 68.2 Percentage of Patients 60 50 40 30 20 10 1.9 0 54.4 48.3 43.8 22.9 18.1 13.3 25 13.8 24.1 13.8 4.5 0 22.7 8.8 11.8 4.5 0 0 Dist. Hospital(105) Less than 15 Sub-Divisional(68) 15-30 31-45 CHC(29) 46-60 SP. Hospital(22) Above 60 64 Study to Review The Health Care Delivery System provided by PHSC, Punjab • • Literacy level of respondents was low. 35.7% were illiterate and 24.6% were just educated up to primary level. 26.3% respondents were educated upto senior secondary level and 2.2% were graduate and post graduate. Economic status of the respondents was low, as monthly income of 40.2% respondents was less than Rs.2000 per month; of 39.3% respondents was between Rs.2000-Rs.5000 per month and only that of 1.3% respondents using PHSC health services was more than Rs. 15000 per month. (Refer Table 4) Fig 31: Income distribution of in-patients at various health care institutions in Punjab 60 55.2 Percentage of patients 50 39 44.8 38.2 39.7 31.8 40 31 30 22.7 27.3 20 16.2 11.4 13.6 5.9 1 0 6.9 3.4 3.4 4.5 10 3.8 0 Dist. Hospital (105) Less than 2000 Sub-Divisional (68) 2001-5000 5001-10000 CHC (29) 10001-15000 SP. Hospital (22) Above 15000 6.1.2 Admission procedure • 51.3% of the respondents were found to be admitted through emergency, while 48.2% of the admissions were through regular OPD. This indicates that, nearly half of the respondents came for utilisation of PHSC services only in the case of emergency. This might be because they do not have access to other health facilities due to economic reasons and are left with no other alternative except to seek emergency care in these facilities. When respondents were asked to rate their experience about the admission procedure at these institutions, 77.7% respondents rated it as being poor while another 12.1% stated that the procedure was average. When this poor rating was assessed specifically at different health institutions, it was revealed that 86.2% respondents from CHCs; 80.9% from Subdivisional hospitals and 77.3% from Special Hospitals had rated the admission procedure as poor. At District hospitals percentage rating was slightly less than the other health institutions (73.3%). This is indicative of the fact that the majority of respondents were not satisfied with the admission procedure. (Refer Table 5) • Study to Review The Health Care Delivery System provided by PHSC, Punjab 65 Fig 32: Opinion of in-patients about admission procedure at various health care institutions in Punjab 100 90 86.20 80.90 73.30 77.30 Percentage of Patients 80 70 60 50 40 30 20 10 0 10.50 11.40 4.40 18.20 11.80 3.40 10.30 4.50 Dist. Hospital (105) Sub-Divisional (68) Good Average CHC (29) Poor SP. Hospital (22) 6.1.3 User charges • • More than 3/4th of respondents (87.9%) were found to have paid charges for making slip/ card; 78.6% for admission and 86.2% for investigations as user charges. 69.2% respondents stated that adequacy of information imparted to them by the doctor about their disease and treatment was perceived as adequate; however 24.6% respondents Fig 33: Distribution of in-patients regarding user charges at various health care institutions in Punjab 120 Percentage of Patients 100 80 96.6 87.6 84.8 83.8 85.3 64.7 79.3 96.6 86.4 90.9 86.4 60 40 20 0 18.2 8.6 10.3 10.3 Dist. Hospital (105) Slip/card Sub-Divisional (68) CHC (29) SP. Hospital (22) Consultancy charges Admission charges Investigation charges 66 Study to Review The Health Care Delivery System provided by PHSC, Punjab • said that the information given to them was incomplete. When the issue about the adequacy of information was looked at from the perspective of health-institution, it was found to be highest at CHCs (82.8%), followed by Special Hospitals (77.3%), District Hospital (65.7%) and at last the Sub-Divisional Hospitals (66.2%). 54.5% respondents stated that they were informed about the rules and regulations of health institutions, while 44.2% respondents stated that they did not receive any such information. (Refer Table 6) 6.1.4 Experience of respondents at OPD/Emergency • 17.9% of respondents rated their experience at the emergency/OPD as average for various health care institutions. 1.8% respondents rated their experience as poor and 2.2% respondents preferred not to express their experience regarding services at emergency/OPD. When an analysis was done in terms of health facility, it was found that 90.9% respondents at Special Hospitals, 82.4% respondents at Sub-Divisional Hospitals, 75.2% respondents at District Hospitals and 65.5% respondents at CHCs rated their experience as good. Thus, there is a scope of improving the services at CHCs level. (Refer Table 7) • 6.1.5 Cleanliness and comfort in the wards • Out of all respondents, 66.5% rated general cleanliness of wards and beds as good while 44.2% respondents rated it as average. When percentage rating was done separately for different facilities with respect to the in-patient department for general cleanliness, it was found to be rated as good by 95.5% respondents in Special Hospitals, 79.3% respondents in CHCs, 63.3% respondents in Sub-Divisional Hospitals and 64% in District Hospitals. Fig 34: Opinion of in-patients about general cleanliness of beds/wards at various health care institutions in Punjab 120 100 Percentage of Patients 95.5 79.3 61 60.3 80 60 40 20 2.9 4.4 36.2 35.3 20.7 0 4.5 0 0 Dist. Hospital (105) Good Sub-Divisional (68) Average CHC (29) SP. Hospital (22) Poor Study to Review The Health Care Delivery System provided by PHSC, Punjab 67 • 66.5% respondents perceived the cleanliness of bed linen as good and 30.8% respondents perceived it as average. Facility wise 100% of respondents at CHCs, 86.4% at Special Hospitals, 63.2% at Sub-Divisional Hospitals and 60% at the District Hospitals perceived cleanliness of bed linen as good. Fig 35: Opinion of in-patients about general cleanliness of ward bed-linen at various health care institutions in Punjab 120 100 100 86.4 Percentage of Patients 80 60 60 40 63.2 33.3 27.9 13.6 0 0 0 SP. Hospital (22) Poor 20 6.7 0 Dist. Hospital (105) Good 8.8 Sub-Divisional (68) Average CHC (29) • • • Among the respondents from different health institutions, 74.1% respondents perceived that the degree of comfort in the ward was good while 30% perceived it as average. When different facilities were compared, it was revealed that respondents perceived comfort better in the wards of CHCs (86.7%) and Special Hospitals (86.4%); as compared to District Hospitals (72.4%) and Sub-Divisional Hospitals (66.2%). Overall 79.5% respondents stated that good facilities e.g. lights and fans were available in the wards whereas 18.8% respondents considered these facilities as average. Respondents had perceived these facilities better at the wards of Special Hospitals (90.9%) and CHCs (82.8%), as compared to SDH (77.9%) and District Hospitals (77.1%). (See Fig 25) Regarding toilet facilities, overall 47.3% respondents perceived that toilets were clean. However, when assessed facility wise, 63.6% respondents from Special Hospitals, 55.2% from CHCs, 47.1% from Sub-Divisional Hospitals and 41.9% from District Hospitals perceived that toilets in the wards were clean. (Refer Table 8)(See Fig 26) 6.1.6 Behaviour of doctors, nurses and staff during stay in hospitals • Overall 93.3% respondents stated that the behaviour of the doctors with the patients is good, while 5.8% respondents considered it as average. Remaining 0.9% respondents did not make any comment. When the percentage distribution was seen separately at different 68 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 36: Opinion of in-patients about availability of light & fans in wards at various health care institutions in Punjab 100 90 Percentage of Patients 90.9 77.1 77.9 82.8 80 70 60 50 40 30 20 10 0 19 3.8 Dist. Hospital (105) Good 22.1 0 Sub-Divisional (68) Average 17.2 9.1 0 CHC (29) 0 SP. Hospital (22) Poor Fig 37: Opinion of in-patients about cleanliness of toilets in wards at various health care institutions in Punjab 70 Percentage of Patients 63.6 55.2 47.1 41.9 38.1 27.9 23.5 18.1 6.9 1.9 Dist. Hospital (105) Good 60 50 40 30 20 10 0 Sub-Divisional (68) Average 37.9 31.8 1.5 CHC (29) Poor 4.5 0 0 SP. Hospital (22) Can't say • facilities, it was found that 95.5% respondents from Special Hospitals, 94.1% from SubDivisional Hospitals, 92.4% from District Hospitals and 93.1% patients from CHCs considered the behaviour of doctors as good. This indicates that the overall behaviour of doctors in the health institutions has been good. Regarding the behaviour of nurses in the in-patient departments, 80.4% respondents perceived it as good, 17.4% as average, 1.8% as poor and the remaining 0.4% did not comment on their behaviour. Health facility-wise, 87.6% patients from District Hospitals, Study to Review The Health Care Delivery System provided by PHSC, Punjab 69 Fig 38: Opinion of in-patients about behaviour of nurses at various health care institutions in Punjab 100 90 87.6 82.8 81.8 Percentage of Patients 80 70 60 50 40 30 20 10 0 18.2 11.4 6.9 30.9 67.6 6.9 1 0 1.5 0 3.4 0 0 Dist. Hospital (105) Good Sub-Divisional (68) Average CHC (29) Poor SP. Hospital (22) Can't say • 82.8% from CHCs, 81.8% from Special hospitals and 67% respondents from Sub-divisional hospitals considered the behaviour of nurses as good. Overall, 74.1% respondents stated that the behaviour of staff members was good in the inpatient department of various health institutions. 19.2% patients considered the behaviour as average, 1.8% considered it poor, while remaining 4.9% respondents did not say anything. Fig 39: Opinion of in-patients about behaviour of doctors at various health care institutions in Punjab 90 80 78.1 69.1 69 77.3 Percentage of Patients 70 60 50 40 30 20 10 18.1 20.6 20.7 18.2 10.3 6.9 1 0 2.9 0 3.4 4.5 0 Dist. Hospital (105) Good Sub-Divisional (68) Average CHC (29) Poor SP. Hospital (22) Can't say 70 Study to Review The Health Care Delivery System provided by PHSC, Punjab • • • When the respondents were asked about the attitude of nurses at the time of admission, it was revealed that 77.7% respondents considered it good, 19.6% considered it average, 1.3% considered it poor while remaining 1.3% did not comment on this. Facility-wise it was found that 86.4% respondents from Special Hospitals, 80% respondents from District Hospitals, 75.9% from CHCs and 72.1% from Sub-Divisional Hospitals considered the behaviour of nurses as good. Regarding behaviour of other staff members, health facility-wise assessment revealed that 78.1% respondents from District Hospitals, 77.3% from Special Hospitals, 69.1% from SubDivisional Hospitals and 69% from CHCs stated that the behaviour of other staff members was good. The findings revealed that 99.6 % respondents had not paid any money to staff members of the health facility. It was found that none of the respondents from District Hospitals, CHCs and Special Hospitals had to pay any money to staff members of the hospital. However, at the Sub-Divisional Hospital, 1.5% respondents stated that they had paid to the staff members of the hospital. (Refer Table 9) 6.1.7 Availability of diagnostic services • Out of 224 respondents, 65.6% stated that the facilities e.g. laboratory and radiological investigations were good, 24.1% respondents considered the facilities as average, 1.3% considered them poor and remaining 12.1% respondents did not respond to it. When percentage of laboratory and radiological investigation facilities were seen at different health institutions separately, it was revealed that 86.4% respondents of Special Hospitals considered them as good. But in other health facilities such as District Hospitals (65.7%), Sub-Divisional Hospitals (54.4%) and CHCs (51.7%) these percentages were lower than the Special Hospitals. (Refer Table 10) • Fig 40: Opinion of in-patients about availability of Lab. facilities at various health care Institutions in Punjab 100 90 80 86.4 Percentage of Patients 72.4 65.7 54.4 52.9 63.6 51.4 51.7 70 60 50 40 30 20 10 34.3 25.7 12.4 7.6 22.1 20.6 8.8 36.8 37.9 31.8 13.8 10.3 10.3 3.4 4.5 9.1 1 1.9 2.9 1.5 4.5 0 0 Dist. Hospital (105) Good Average Poor Sub-Divisional (68) Can't say All available Some available 0 0 CHC (29) None available Can't say SP. Hospital (22) Study to Review The Health Care Delivery System provided by PHSC, Punjab 71 6.1.8 Availability of medicines in the In-patient department • Only 13.4% respondents stated that all the medicines were available, 55.8% stated that some medicines were available and 29% respondents stated that no medicine was available in the ward of the concerned health facility. When the percentage was seen separately for the various health institutions, then the comparative availability of medicines was found to be more at Special Hospitals (31.8%) as compared to CHC (13.8%), District hospital (12.4%) and Sub-Divisional Hospitals (8.8%). (Refer Table 10) (See Fig 41) • 6.1.9 Money spent on medicines by the respondents • • Out of the total respondents interviewed, 91.1% respondents spent money on medicines while remaining 8.9% respondents did not have to spend any money. In different health institutions, the percentage of respondents who spent money on medicines was 100% at Sub-Divisional Hospitals, 93.3% at District Hospitals, 81.8% at Special Hospitals and 69% at CHCs. (Refer Table 11) 6.1.10 Food supply to the patients • Since, at most of the institutions, food was not supplied from the hospitals, therefore, majority of respondents (80.4%) did not comment on this aspect of the questionnaire. 6.1.11 Quality of care • 83.0% respondents rated their experience at the reception counter as good, 13.4% rated it as average and 0.4% respondents rated it poor. 2.2% respondents did not comment. Fig 41: Opinion of in-patients about availability of medicines at various health care institutions in Punjab 80 72.4 70 Percentage of Patients 63.6 52.9 60 51.4 50 40 30 20 12.4 13.8 8.8 34.3 36.8 31.8 10.3 10 1.9 0 1.5 3.4 4.5 0 Dist. Hospital (105) All available Sub-Divisional (68) Some available CHC (29) None available SP. Hospital (22) Can't say 72 Study to Review The Health Care Delivery System provided by PHSC, Punjab • Facility-wise experience of respondents revealed that services were rated well by 90.9% respondents at Special Hospitals, 86.8% at Sub-Divisional Hospitals, 82.9% at the District Hospitals and 69% at the CHCs. Out of all, 79.0% respondents stated that the overall quality of treatment was good, 17.0% considered it average, 1.8% stated that the quality of treatment was poor while remaining 2.2% respondents did not comment. When assessed for different facilities, quality of treatment was found to be better at Special Hospitals (95.5%) and District Hospitals (81%) as compared to Sub-Divisional Hospitals (73.5%) and CHCs (72.4%). 6.1.12 Security in the In-patient department • Nearly half (46.4%) of the respondents from all the health institutions perceived that the security at health facilities was good. This was perceived as average by 17.4%, poor by 17% respondents and 2.2% respondents did not made any comment about their perception on security. About half of the respondents at District Hospitals (51.4%) and Special Hospitals (50%) and less than half at CHCs (44.8%) and at Sub-Divisional Hospitals (38.2%) perceived the security as good. The above findings suggest that more than half of the respondents did not feel adequately secure in the in-patient department and there is scope to improve security in the health institutions. • • 6.1.13 Overall satisfaction of the respondents • • Overall, 94.2% respondents of the in-patient department expressed satisfaction and only 5.8% were not satisfied with the services of the health institutions. When their satisfaction percentage was observed separately for the different health facilities, Fig 42: Opinion of in-patients about satisfaction on over all services at various health care institutions in Punjab 120 96.2 86.8 100 100 Percentage of Patients 100 80 60 40 20 3.8 13.2 0 0 0 Dist. Hospital (105) Sub-Divisional (68) Yes No CHC (29) SP. Hospital (22) Study to Review The Health Care Delivery System provided by PHSC, Punjab 73 it was revealed that 100% of the patients from in-patient department of CHCs and Special Hospitals, 96.2% patients from District Hospitals and 86.8% from the Sub-Divisional Hospitals were satisfied with the services provided. (Refer Table 13) 6.1.14 Suggestions given by the respondents The major suggestions given by the respondents were as below: • • • About 25.5% of the patients were of the view that the medicines should be provided free of cost or atleast on subsidised rates. Quality of medicines should be improved; food should be provided, clean toilets, regular visits by the higher authorities to check the facilities of the hospital etc. Only 4.2% of the patients were satisfied with the services being provided by the hospitals. (Refer Table 14) 6.2 Outpatient Department A total of 580 respondents were interviewed in the outpatient department of various health institutions like CHCs, Sub-Divisional Hospitals, District Hospitals and Special Hospitals of Punjab Health System Corporation. The following findings have emerged based on the interview of respondents in the outpatient department. 6.2.1 Socio-economic profile of respondents • Out of 580 respondents interviewed the services of PHSC were more utilised by females (57.9%) as compared to males (42.1%). When analysed for health facilities it was found that in the outpatient department of Special Hospitals more female respondents (87.2%) utilised Fig 43: Age distributon of patients attending OPD at various health care institutions in Punjab 60 55.3 Percentage of Patients 50 38.7 34.1 30.3 40 37.7 30 19.0 26.7 20.7 14.1 19.3 25.4 25.5 20 15.8 12.8 4.3 10 5.3 6.7 4.4 1.8 2.1 0 Dist. Hospital (284) Less than 15 Sub-Divisional (135) 15-30 31-45 CHC (114) 46-60 SP. Hospital (47) Above 60 74 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 44: Educational status of patients attending OPD at various health care institutions in Punjab 60 49.1 Percentage of Patients 50 38.5 40 28.9 22.9 30 28.2 25.2 25.5 27.7 19.3 20 10.6 10 6.7 2.8 0 3.7 1.5 11.9 15.8 16.7 21.3 17 11.4 8.5 4.4 2.6 0 Dist. Hospital (284) Illiterate Primary Sub-Divisional (135) Secondary Senior Secondary CHC (114) Graduate SP. Hospital (47) Above Graduate • • • • the services as compared to the male respondants (12.8%). Similarly in District Hospitals, the service utilisation was 59.2% by females as compared to 40.8% by males. But at SubDivisional Hospitals and CHCs, the utilisation of services by both males and females was almost same. Majority of respondents were in the age group of 15-30 years (35.2%) and 31-45 years (29.5%). The literacy level of majority of the respondents was found to be low, as 34.8% were illiterate and 22.4% were just educated up to primary level. (See Fig 44) Their economic status was also low, as 34.0% respondants’ income was less than Rs.2000 per month and 37.9% respondents’ income was between Rs.2000-Rs.5000. This indicates that majority of respondents utilising PHSC were females having poor education and low income. (Refer Table 15) 6.2.2 User charges • • Majority of the respondents (94.8%) were paying user charges for getting an OPD card and 70% of the respondents were found to have paid for investigation charges. (Refer Table 16) The amount of user charge was found to be a token amount of Re.1, which could be the reason for higher proportion of respondents paying for OPD card. (See Fig 45) 6.2.3 General cleanliness • Out of total 580 respondents, 72.4% rated general cleanliness of OPD as good whereas 25.3% respondents rated it average. When the percentage rating was seen separately at outpatient department of different facilities, the general cleanliness was rated good by 87.2% respondents in Special Hospitals, 73.9% respondents in District Hospitals, 71.1% in Sub-Divisional Hospitals and 64% in CHCs. (See Fig 46) Study to Review The Health Care Delivery System provided by PHSC, Punjab 75 Fig 45: User charges at OPD in various health care institutions in Punjab 120 100 Percentage of Patients 98.5 94.4 93 91.5 80 69 71.9 71.1 68.1 60 40 20 4.6 3.7 3.5 12.8 0 Dist. Hospital (284) Sub-Divisional (135) Investigation charges CHC (114) SP. Hospital (47) OPD card charges Consultancy charges • • Overall 77.8% respondents rated the waiting area of OPD as good and 20.3% respondents rated it average. Facility-wise the waiting area of OPD was perceived as good by 93.6% respondents in the Special hospitals, 82.7% in District Hospitals, 77% in Sub-Divisional Hospitals and 59.6% in CHCs. Thus, overall rating of general cleanliness of the OPD along with basic facilities was found to be better in the Special Hospitals in comparison to CHCs. (Refer Table 17) Fig 46: Views of patients attending OPD about general cleanliness at various health care institutions in Punjab 100 90 87.2 73.9 Percentage of Patients 80 70 60 50 40 30 20 10 0 71.1 64 34.2 27.4 22.9 12.8 2.5 0.7 0 1.5 1.8 0 0 0 Dist. Hospital (284) Good Sub-Divisional (135) Average CHC (114) Poor SP. Hospital (47) Cannot say 76 Study to Review The Health Care Delivery System provided by PHSC, Punjab 6.2.4 Availability of basic facilities • Overall 75.7% respondents stated that facilities such as light and fan were good where as 18.4% respondents considered these facilities as average. These facilities were perceived to be better at the OPD of Special Hospitals (89.4%), Sub-Divisional Hospitals (83.7%) and District Hospitals (79.2%), as compared to CHCs’ where 51.8% respondents were positive. The availability of STD/PCO booth was 43.1% in various health institutions. Health facilitywise, 52.6% Sub-Divisional Hospitals 48.6% District Hospitals, 46.8% Special Hospitals and 16.7% CHCs were having the STD/PCO facility. Separate toilets for women were available in 86% of the health facilities. Facility wise separate toilets for women were available at 97.9% Special Hospitals, 88% District Hospitals, 85.9% Sub-Divisional Hospitals and 76.3% of CHCs. This is indicative of the fact that separate toilet facilities need to be made available to the female respondents when more number of females are utilising the OPD services at various institutions. Availability of drinking water was 89.1% in various health institutions. The same was 100% at Special Hospitals, 97% at Sub-Divisional Hospitals, 88% at District Hospitals and 78.1% at the CHCs. (See Fig 47) Overall availability of screened examination room was found to be 87.2%. However this was 100% at Special Hospitals, while the availability of screened examination room was 88.1% in Sub-Divisional Hospitals, 86.3% in District Hospitals and 83.3% in CHCs. (Refer Table 17) • • • • 6.2.5 Adequacy of information about disease and treatment • Overall 81.4% respondents stated that adequacy of information given to them about their disease and treatment by the doctor was good, while 13.6% respondents stated that the information given was average. Fig 47: Views of patients attending OPD about drinking water facility at various health care institutions in Punjab 120 Percentage of Patients 100 80 60 40 20 0 97 88 78.1 100 10.9 14 7.9 1.1 3 0 0 0 Dist. Hospital (284) Yes Sub-Divisional (135) No CHC (114) Cannot say SP. Hospital (47) Study to Review The Health Care Delivery System provided by PHSC, Punjab 77 Fig 48: Distribution of OPD patients informed about the diseases and treatment by the treating doctor at various health care institutions in Punjab 100 90 85.9 78.5 71.9 85.1 Percentage of Patients 80 70 60 50 40 30 20 10 0 Dist. Hospital (284) Good 0.9 22.8 12.6 10.6 1.1 2.1 5.2 3.7 1.8 3.5 4.3 0 Sub-Divisional (135) Average Poor CHC (114) SP. Hospital (47) Cannot say • When the adequacy of information given to respondents about disease and treatment by doctors was assessed facility-wise, it was found that adequacy of information was maximum in District Hospitals (85.9%), followed by Special Hospitals (85.1%), Sub-Divisional Hospitals (78.5%) and CHCs (71.9%) respectively. (Refer Table 18) (See Fig 48) 6.2.6 Availability of medicines • Out of all the respondents, only 10.3% respondents stated that all medicines were available in the OPD, whereas other respondents (62.8%) stated that not all medicines were available. Rest of the respondents (26.4%) stated that none of the medicines were available in the OPD. (Refer Table 18) When the issue was analysed health facility-wise, it was revealed that the availability of all medicines in Sub-Divisional Hospitals and CHCs was 17% and 14% respectively. At other health facilities such as Special Hospitals (8.5%) and District Hospitals (6%) the availability of all medicines was less. (See Fig 49) • 6.2.7 Availability of diagnostic facilities • Most of the respondents stated that the facilities like laboratory and radiological investigations were good (50.7%), whereas 22.1% respondents stated that they were average and 1.95% stated them as poor. (Refer Table 18) (See Fig 50) 6.2.8 Behaviour of staff members • Overall 56.9% respondents stated that behaviour of staff members was good in the OPD of various institutions. Out of the remaining respondents, 32.4% respondents stated that the Study to Review The Health Care Delivery System provided by PHSC, Punjab 78 Fig 49: Opinion of patients attending OPD about availability of medicines at various health care institutions in Punjab 80 70 68.1 72.8 74.5 Percentage of Patients 60 50 54.2 39.1 40 30 20 10 0 6 17 14.1 14 13.2 8.5 7 0 0.7 0.7 0 Dist. Hospital (284) All available Sub-Divisional (135) Some available CHC (114) None available SP. Hospital (47) No response Fig 50: Opinion of patients attending OPD about Lab. & radiological facilities at various health care institutions in Punjab 70 60 50 40 30 23.2 36 32.5 63.8 Percentage of Patients 53.9 51.9 31.9 28.1 28.9 21.5 17 20 10 1.4 2.2 3.5 4.3 0 0 Dist. Hospital (284) Good Sub-Divisional (135) Average Poor CHC (114) SP. Hospital (47) Cannot say • overall behaviour of the staff was average, 8.8% respondents did not say anything about their behaviour and 1.9% said that the behaviour was poor. (See Fig 51) When the percentage distribution was seen separately for different facilities, it was found that 70.2% respondents of Special Hospitals, 60% respondents of Sub-Divisional Study to Review The Health Care Delivery System provided by PHSC, Punjab 79 Fig 51: Opinion of patients attending OPD about behaviour of staff at various health care institutions in Punjab 80 70.2 70 Percentage of Patients 60 60 50 56 50 40.4 40 30 34.5 30.4 21.3 20 10 1.8 7.7 3 6.7 0.9 8.8 6.4 2.1 0 Dist. Hospital (284) Good Sub-Divisional (135) Average Poor CHC (114) SP. Hospital (47) Cannot say • Hospitals, 56% respondents of District Hospitals and 50% respondents of CHCs stated that the behaviour of staff members was good. Almost all the respondents (97.1%) said that they did not have to pay any money to the staff members of the hospitals, while 2.9% respondents reported to have paid to staff members of the hospitals. When this was looked for at different health institutions, it was found that 3.2% respondents from District Hospitals, 3% from Sub-Divisional Hospitals, 2.6% from CHCs and 1% from Special Hospitals had paid to staff members at the respective hospitals. (Refer Table 19) 2.9 Availability of doctors, nurses and staff in the OPD • Overall availability of doctors as stated by the respondents at the health institutions was 94.8%. When respondents were asked about doctor’s behaviour towards them, 91.4% reported the doctor’s behaviour being good. When availability of doctors was assessed for different facilities, then 97.9% respondents of Special Hospitals, 95.1% of Sub-Divisional Hospitals, 95.1% of District Hospitals and 89.5% respondents of CHCs stated that doctors were available. Overall availability of nurses was confirmed by 79% of the respondents and 64.5% said that the behaviour of nurses was good towards the patients. Facility wise percentages of the availability of nurses and their good behaviour towards patients were found to be 80.6% & 63% at District Hospitals, 78.1% & 68.4% at CHCs, 77% & 62.2% at Sub-Divisional Hospitals and 76.6% & 70.2% at Special Hospitals respectively. (Refer Table 19) (See Fig 52) • • 80 Study to Review The Health Care Delivery System provided by PHSC, Punjab Fig 52: Opinion of patients attending OPD about availabilty of doctors at various health care institutions in Punjab 120 97.8 89.5 97.9 Percentage of Patients 100 95.1 80 60 40 20 4.9 2.2 10.5 2.1 0 Dist. Hospital (284) Sub-Divisional (135) CHC (114) SP. Hospital (47) Available Not available 6.2.10 Waiting time • When respondents were asked about the waiting time at various health facilities, a majority of the respondents (88.7%) stated that they have to wait upto 15 minutes. Rest of the patients stated that they waited longer i.e. 9% for 16-30 minutes and 2.3% for more than 30 minutes. At District Hospital, waiting time for 83.6% respondents was up to 15 minutes where as at rest of the facilities more than 91% respondents reported to have got themselves registered in less than 15 minutes (95.7% at Special Hospitals, 95.6% at CHCs and 91.1% at District Hospitals). Time spent in waiting for specialist consultation in the OPD was less than 15 minutes for 63.4% respondents. 22.7% respondents stated that they had waited between 16–30 minutes for specialist consultation where as 13.9% waited for more than 30 minutes. When it was seen for different institutions, 79.7% respondents at Sub-Divisional Hospitals, 72% respondents at CHCs, 55.6% respondents at District Hospitals and 46.4% respondents at Special Hospitals waited upto 15 minutes. Time spent for getting investigations done at the OPD was found to be less than 15 minutes for 83.6% respondents. Between 9.9% respondents waited for 16–30 minutes for getting the investigations done where as 6.5%% waited for more than 30 minutes. When it was seen for different institutions, 91.1% respondents at Sub-Divisional Hospitals, 86.9% respondents at CHCs, 80.5% respondents at District Hospitals and 78.4% respondents at Special Hospitals waited for up to 15 minutes. Waiting time for getting the medicine in the OPD was up to 10 minutes for 80.8% respondents, between 11-20 minutes for 15% respondents and more than 20 minutes for 4.2% respondents. At different health institutions it was up to 10 minutes for 90.4% respondents at CHCs, 86.5% at Special Hospitals, 81% at Sub-Divisional Hospitals and 74% at District Hospitals. (Refer Table 20) Study to Review The Health Care Delivery System provided by PHSC, Punjab • • • • 81 2.11 Experience of respondents at OPD • Out of 580 respondents, 70% rated their experience at OPD as good and 27.4% rated it as being average at the OPD of various health care settings. 1.4% respondents rated their experience as poor and 1.2% respondents did not respond. (See Fig 53) Fig 53: Views of patients attending OPD about waiting area at various health care institutions in Punjab 100 90 82.7 77 93.6 Percentage of Patients 80 70 59.6 60 50 40 30 20 10 0 15.8 20.7 36.8 0.7 0.7 0 2.2 2.6 6.4 10 0 0.9 Dist. Hospital (284) Good Sub-Divisional (135) Average Poor CHC (114) SP. Hospital (47) Cannot say • For different health facilities, it was found that 85.1% respondents at Special Hospitals, 72.6% at Sub-Divisional Hospitals, 71.5% at District Hospitals and 57% at CHCs rated their experience as good. (Refer Table 21) (See Fig 54) Fig 54: Rating of patient’s experience attending OPD at various health care institutions in Punjab 80 71.5 72.6 70 70 Percentage of Patients 60 50 57 39.5 40 30 20 10 1.1 1.1 0 0.7 0.9 0 1.4 1.2 26.4 27.4 23.7 0 Dist. Hospital (284) Sub-Divisional (135) CHC (114) SP. Hospital (47) Good Average Poor Cannot say 82 Study to Review The Health Care Delivery System provided by PHSC, Punjab 6.2.12 Quality of treatment • Overall 75.9% respondents rated the quality of treatment in the hospitals as good. Whereas 21% respondents rated quality of treatment as average, 1.4% stated it as poor and 1.7% respondents did not respond. When percentage distribution was seen separately at different facilities, it was revealed that 93.6% respondents of Special Hospitals, 78.5% respondents of District Hospitals, 77% respondents of Sub-Divisional Hospitals and 60.5% respondents of CHCs rated their experience as good. Overall 77.9% respondents were satisfied with the services of various health institutions, whereas 22.1% respondents were not satisfied with the services of health institutions. Health facility-wise analysis reveals that 80% respondents of Sub-Divisional Hospitals, 79.8% respondents of CHCs, 78.5% respondents of District Hospitals and 63.8% respondents of Special Hospitals were satisfied with the services. In the overall rating about the level of cooperation at the reception counter at various institutions, 93.6% respondents rated it as good and 6.4% respondents rated it as average. Health facility-wise, 80% respondents of CHCs, 79.2% respondents of District Hospitals, 77% respondents of Sub-Divisional Hospitals and 70.2% respondents of CHCs, rated the level of cooperation as good. (See Fig 55) • • • Fig 55: Opinion of patients attending OPD about quality of treatment received at various health care institutions in Punjab 100 90 93.6 Percentage of Patients 80 70 78.5 77 60.5 60 50 40 30 20 10 0 18.7 18.5 6.4 36 1.8 1.1 2.2 2.2 0 3.5 0 0 Dist. Hospital (284) Good Sub-Divisional (135) Average Poor CHC (114) Cannot say SP. Hospital (47) 6.2.13 Suggestions for improvement of services • • Regarding all facilities, 28.3% respondents did not offer any suggestion. 50.5% respondents suggested for free provision of all medicines to everyone, especially to the poor. Other suggestions from respondents were; provision of more doctors or specialists (6.4%), cleanliness of OPD and toilets (4.9%) and proper care of respondents and emergency care (3.6%). 2.3% respondents were fully satisfied with the services of the out-patient department. (Refer Table 22) Study to Review The Health Care Delivery System provided by PHSC, Punjab 83 7.0 Training Institutes 7.1 Introduction Last two decades have witnessed major shift in the health system and concerns have been expressed regarding health issues, critical to women, children and people in the rural and tribal areas. The health sector being no exception, has very heavily relied upon and included in-built components like systematic training. Training has been used as a planned strategy towards development of human resource for the achievement of total health in the country. The training system helps in continuing the review of current needs of state and national programmes and policies to match with the training personnel at all levels in the health care system. In addition to strengthening the functional performance of human resources, it also caters to aspects like cost containment, quality of care and creation of new categories of health personnel. However, several lacunae have been identified in the existing training programmes such as: i. Training often does not bear directly on an employee’s official duties. ii. Duplication of training programmes and the same participants receiving training frequently. iii. Lack of written course evaluations with an objective to provide feedback after training while one has resumed one’s job. Realising these gaps in the existing health care delivery system it was felt that training institutes would also be evaluated along with the other health service facilities in the state of Punjab during conduction of the study. Training institutes evaluated were: 1. State Institute of Health and Family Welfare, Mohali. 2. State Institute of Nursing and Paramedical Sciences, Badal (in the district of Muktsar). 3. Mental Hospital, Amritsar. 7.2 State Institute of Health and Family Welfare (SIHFW), Mohali The State Institute of Health and Family Welfare (Kharar) was established under a WB aided project in 1992 after upgrading the Health and Family Welfare Training Centre, Kharar. Now, State Institute of Health and Family Welfare, Phase-VI, Mohali, Punjab, has been established under IPP VII (Year 1997-1999), under World Bank aided project as an apex institute to cater to the training needs of the northern states like Punjab, U.P, Chandigarh, J&K and Haryana. The Institute has been declared as Collaborative Training Institute (CTI, Mohali) with NIHFW, New Delhi being the nodal agency. The institute from Kharar has been shifted to a new campus at Mohali and is made operational with effect from 1st April, 2004 as State Institute of Health and Family Welfare, Phase-VI, Mohali. Study to Review The Health Care Delivery System provided by PHSC, Punjab 84 7.2.1 Objectives • • • • • To develop trained health manpower resources for better delivery of health care services and effective health management. To conduct policy relevant and field based research studies on areas relating to population health and family welfare. To monitor, supervise and provide technical guidance to regional training centre/School/DTC and NGOs. To render advisory and consultancy services to government, and other health related organisations for developing programmes and policies on population and health. To provide training to other departments/organisations. 7.2.2 Functions • • • • • • • • To plan, conduct, evaluate and follow up of the training programmes for the health personnel in the region. Develop the urban and rural field practice and demonstration areas for providing practical experience to the trainees and utilise the area as field labs. To develop a training curriculum. Conduct simple studies and research, to improve training techniques and tools. Serve as a technical resource for the region Plan, conduct and evaluate special health and family welfare campaigns Provide consultative services on family planning and training to voluntary and allied agencies. Maintain a close liaison with central training institutions for technical help and guidance. 7.2.3 Major components 1. Training • Professional development course • Basic training for MPHW male • In-service training for medical and para medicals • TOT for key trainers (RCH) trainings Research and evaluation studies in collaboration with medical health and related organisation. Service cum training counseling clinics. Monitoring and evaluation of the trainings under Health and Family Welfare departments in the State. Computer HMIS. 2. 3. 4. 5. 7.2.4 Trainers of the training institute This survey was conducted in SIHFW, Mohali. Questions were asked from trainers, considering them as an important stakeholders in this survey. A total of 7 respondents were interviewed. The trainers were mainly medical officers and the nursing tutors, having an average experience of 1520 years of service. The job responsibilities given to them were teaching, planning for ongoing trainings and different administrative responsibilities. Study to Review The Health Care Delivery System provided by PHSC, Punjab 85 The activities mainly carried out by them were training, administrative, planning, session teaching and sometimes data collection for different research projects. After the inception of PHSC, there have been special training programmes sponsored to nominate specialists like surgeons, physicians etc. to improve the quality of different training programmes. One of the respondents was of the view that there is not much change; everything is as it is as it was before. Another respondent indicated that there is an improvement in the quality of work, but she could not specifically point out the type of quality being referred to. After the inception of PHSC, more emphasis is given to Behaviour Change Communication and on counseling which was not the case earlier. All the respondents have done many training programmes over the years like on disaster management, capacity building, RCH, counseling skills, integrated course for NRHM, adolescent and reproductive health, first aid course, workshop on community participation etc. It indicates that trainers are given relevant training, which is of importance to keep them updated with the new emerging trends. They can apply this while conducting different training sessions. Almost all the respondents were positive about the need of more training in the areas like leadership, management. Skills of Trainers: Faculty of training institute were asked basic information regarding organisation of trainings. • When asked about the concept of systems approach to training, all the seven respondents could not speak about it. Though few responded that it should be based on needs assessment followed by a systematic approach to training. • The response on pre-requisites for preparation of training calendar, the respondents most of them reported as training load, availability of resources (man, money and material) and availability of venue. • According to the respondents the training methods used for skill development are hands on training, demonstrations, powerpoint presentations, group discussion and role-play. The above analysis shows that the trainers have fairly good knowledge about the organisation of training programmes. Common complaints of trainees attending training programmes: When asked about the nature of complaints by the trainees who attended the training programmes, some of the common complaints were: Shortage of faculty members, duration of the lectures being very long, quality of food is not very good, and poor hostel facilities. The quality of training programmes is usually assessed by the trainers from pre and post evaluation, participant’s evaluation report and through informal communication with the participants. 86 Study to Review The Health Care Delivery System provided by PHSC, Punjab The procedure for the preparation of training report includes compiling data and taking feedback from the participants. The impact evaluation is not done in the institute, however, according to one of respondent, reaction feedback (immediate) from the participants is taken on completion of training programme.. Some programmes which are proposed to be started shortly are on NRHM, BCC, HISM, Leadership and Disaster Management. Changes required in the existing training structures: Opinion of the respondents was taken to identify the changes required in the existing training structure for the staff in their district. • • • • Guidelines for organising training programmes should be more clear and freely available More class rooms are required Training calendar should be spread uniformly throughout the year There should be more training programmes for the nursing personnel 7.3 State Institute of Nursing and Paramedical Sciences, Badal (in the district of Muktsar) The State Institute of Nursing and Paramedical Sciences was established in the year 2001 at Badal in the district of Muktsar. The main objective of this training institute was to have a good quality training institute available in the rural area of Punjab which can teach and train the candidates from the rural community. It was till recently under the Punjab Health Systems Corporation and has now been transferred to Baba Faridkot University. 7.3.1 Major courses being offered 1. 2. 3. 4. BSc. (Nursing)- a four year full time course with a capacity of 50 admissions (recently started) General Nursing & Midwifery course- Three and a half years with a capacity of 50 admissions Diploma in Radiography- a two year course with a capacity of 10 admissions Diploma in Medical Laboratory Technology- a two year course with a capacity of 20 admissions. 7.3.2 Practical training of students The practical training of a student is done in a number of hospitals on a rotational basis. The hospitals are: a. Civil hospital Badal- not very suitable as daily attendance is very low b. Civil hospital Bhatinda- good daily attendance c. Women and Children Hospital Bhatinda- around 70-80, attendance d. Civil hospital Malout- daily attendance of around 50 e. Mata Kaushalya hospital Patiala- around 200 daily attendance f. Institute of Mental Health, Amritsar g. Rajindra Hospital and Medical college Patiala Study to Review The Health Care Delivery System provided by PHSC, Punjab 87 h. i. Baba Faridkot (GGS Medical college) for Radiography Sub Centre Singhewala under PHC Lumbi for Community Health Nursing 7.3.3 Fees structure The fee structure is as follows: For BSc Nursing the annual fees is Rs. 43,500/For GNM course the annual fees I Rs. 41,500/For DMRT and DMLT courses, the annual fees is Rs. 17,000/- 7.3.4 Salient features 1. 2. 3. 4. The intake in the BSc (Nursing) and GNM courses is very good and generally the fifty seats allocated are filled up with very few drop outs during the academic year. The Diploma in Radiography has generally 50-60% occupancy. This year there are only two students enrolled against 10 seats. The Diploma in Medical Lab Technology does not attract enough number of students- in this batch there is only one student against 20 seats. There is shortage of faculty. 10 out of the required 18 nursing tutor posts are filled up. Further there are only 2 MSc. qualified nurses (including the Principal) for training the BSc. Nursing students. As there is no hospital within the premises and for all practical purposes the civil hospital Badal has very few patients, it is difficult for the students to go for training to Bhatinda and other places. The students have to commute to and fro to Bhatinda as the hostel facilities are not there. This suggests that there is a need of a hostel for the nursing students which will help in cutting down on the commuting time and promote better learning. The eligibility criteria for DMLT course needs to be re-looked at. Punjab technical University is admitting Arts students too. There is lot of dissatisfaction amongst the staff as regards the pay scales. Further as many of the tutors are on contract, they are not able to deliver their best. There is a need for atleast one staff bus for the employees and one more bus for the students as the public transport system is not functioning well. There is also requirement for a full time student counsellor and one health officer. Upgradation of the library with more books, journal and computers with internet connectivity is a must. Modern AV aids are required- especially LCD projector Funds for repair and maintenance of the hostel are needed as many repairs and renovations are pending The institute was more comfortable under the PHSC as regards funds and sanctions for different tasks. It is facing more problems after being transferred to the Baba Faridkot University. 5. 6. 7. 8. 9. 10. 11. 12. 13. 88 Study to Review The Health Care Delivery System provided by PHSC, Punjab 7.4 Mental Hospital, Amritsar This hospital is catering to services of psychiatric patients from Punjab and other states. All the available staff has the expertise in psychiatric and related areas. Training programme of nurses in care of psychiatric patients is also being organised by the hospital. There is a capacity of 350 students for the training programme with a fee structure of Rs. 1500 per student for 1 month training. This is one of the sources of income for the hospital. By virtue of this training programme being organised for the nursing categories, the institute may be considered as one of the potential training institutes. However, before considering that, the following points may be taken into account. • • The faculty of the institute is tuned to the psychiatric care services and due to shortage of them; it would be very difficult for them to carry out other training activities. The institute does not have any professional trainer or faculty who has been trained in Training Technology. Furthermore, their experiences were not matched with the primary health care service delivery. Hence, in the context of declaring a training institute for primary health care service delivery, Institute will have to depend totally on external resource persons. In lieu of the above context, a major part of the training budget might be utilised in the payment of honorarium to the guest faculty. In addition to this, training programmes would likely be earning source for the institute and it will enhance the training budget more. The institute does not have established hostel with mess facilities. Dharamshala for the attendants of in-patients is being used as hostel for the trainee, nurses and kitchen for the patients was being used for the food for them on adhoc basis. As the ongoing in-service training was limited to the psychiatric ward only, institute has not developed any Field Practice Demonstration Area (FPDA), which is essential for Primary Health Care Skill training. On the other side, the Director of the institute, a retired Principal from Medical College, has vast experience and good networking with the health system in Punjab. Furthermore, all the teaching aids space for the training programme is available in the institute. • • • • • A summarised SWOT analysis is being projected below: 7.5 SWOT analysis of training institutes Variable State Institute of Health and Family Welfare, Mohali Well designed complex spread over 5 Acers of land having • Teaching Block • Hostel Block • Administration Block • Residential Block State Institute of Nursing and Mental Hospital, Amritsar Paramedical Sciences, Badal (in the district of Muktsar) Well designed complex having • A vast Teaching Block • Two Hostel Blocks • Administration Block • Residential Block • Sufficient infrastructure. • Had experiences in the conduction of Nursing training • Availability of training and teaching aids Strength Study to Review The Health Care Delivery System provided by PHSC, Punjab 89 Variable State Institute of Health and Family Welfare, Mohali Well equipped • Auditorium • Lecture Halls • Seminar Room • Committee Room • Computer Lab • Demonstration Room • Library Well Furnished • 64 Hostel Rooms • Guest House • Recreation Room • Common Room • Mess • Gym Operational • Two Buses State Institute of Nursing and Mental Hospital, Amritsar Paramedical Sciences, Badal (in the district of Muktsar) Well equipped • Auditorium • Lecture Halls • Seminar Room • Committee Room • Demonstration Room Modestly Furnished Hostel Rooms • Common Room • Mess (run as a cooperative mess with contractual staff) Operational • Three Buses- one 52 seater, one 32 seater, one an 18 seater, One Tata Sumo • Availability of class rooms. • Availability of transport facilities for field visit. • Availability of library Generating income through hostel charges. Weakness • Very limited faculty. • Consultant posts are vacant • No full time director. • Too much dependence on external funding training programmes • Staff shortage. 1. Only experience of Psychiatric training, no experience of other • Only experience in nursing training methodology. training 2. Very limited faculty and that too psychiatric specialist. • Library has adequate space. It does not have enough books. There 3. No proper hostel or mess are only 797 books and 13 nursing facilities. journals available. Seven types of health related journals are also available. There is no internet connectivity in the library and no facilities for the students to browse the internet. Opportunities • Very good linkages with Punjab Health System Corporation having the facilities in the same premises. • Established linkages with NIHFW and other central training institute Threats • Depends upon Punjab Health System Corporation. No apparent threat • Good political support 1. On going mess facilities for patients, may be used for trainees. 2. Existing dharamshala may be used as hostel. Director of the institute is a very much known personality in the health field and having good network which may help in the mobilisation of trainer. 1. Funds for the training may be used in the hospital services for the psychiatric patients. 90 Study to Review The Health Care Delivery System provided by PHSC, Punjab 8.0 Community Voice For listening to the community voice, focus group discussions (FGDs) were conducted to take care of qualitative dimensions. Ten (10) FGDs among the females were undertaken in nearby villages of community health centres and 10 FGDs among the males were conducted in nearby villages of sub divisional hospitals. Let us read and understand their issues. 8.1 Observations among Male Groups 8.1.1 Accessibility to health care facility: a) Health care facility availed by villagers • • Local people are interested in availing the government facilities. However due to various reasons most of them are not utilising these facilities. People of low socio-economic group are utilising the government facilities due to their very little paying capacities. These are the people who primarily try to avail the services. The people belonging to lower–middle group and above, generally utilise private facilities as per their paying capacities. Few Sub-divisional hospital’s /CHCs attract large number of patients, even from the far off places, only because of the good administration and services offered by the hospital incharge. • b) Reasons for non-utilisation of Government health facilities Varied reasons emerged following the discussions in different districts. Following are the few common reasons from all the districts: • If the distance of the health facility is more, then local people tend to utilise private facility only. “Anay janay may he to sara kharcha ho jana hai, Time waste hoga who alag. Isliye hum to pas ke doctor ke pas he chaley jatey hain”. • People are primarily unhappy with the fact that they have to spend the money for availing health services. “Private mein jayen ya serkari mein, kharcha to dono mein he karna hai, Private vale doctor per to hum jor bhi dal sakte hain”. Study to Review The Health Care Delivery System provided by PHSC, Punjab 91 “Sui se le kar glucose, davaiyan, injection sab bahar se he khareedna padta hai”. • In most of the emergency departments, 24 hour services are not available due to nonavailability of staff. Therefore people prefer to go to the private hospitals/nursing homes only. “aise jaedah hai jadon police case hove, emergency which to koi sahuliat nahin hai”. • Availability of the doctor in the hospital/CHC is not sure. “Asain doron jaidai doctor ravey na ravey, sanu to kuch pata nahin,”. (Once we reach most of the time doctor is on leave or gone for some meeting or other commitment, our whole day is gone and even the money). • Majority mentioned that the government doctors prefer to see the patients in their private settings, charging heavy consultation fees. Besides specific investigations, like ultrasound etc. are required to be done from outside private centres. c) Distance from home and connectivity from the road • Majority pointed out that distance is an important factor, but if all the facilities are available with good doctors, people would prefer to utilise those health facilities, e.g. Dasua SubDivisional Hospital is known to be good so far as deliveries are concerned. People from far off places utilise the services available there. There are places where the hospitals/health centres are near the villages or in the residential area, but people still do not utilise the services and go to private hospitals/nursing homes which are far away. Many of the groups commented - “as the same doctors give good treatment in private nursing homes, so we go there only”. • • d) Transport facilities and cost of travel • Sub-divisional hospitals are generally situated near the main roads, which are well connected with the local transport as well. Travel cost depends on the economic status of the family and for the poor patients it is a cause of concern. ‘Panchayat aur local loki madad kar den dey , chanda ekthda ker key de den de”. (Villagers help their native people by contributing money for the medical expenses etc.) e) Services: • The services in the hospital are on payment basis. One group said that they need to buy everything needed during hospitalisation or otherwise. As outpatient also, majority of them have to purchase the medicines from outside. 92 Study to Review The Health Care Delivery System provided by PHSC, Punjab “We can only save the visiting fees of the doctor otherwise there is no difference in going to either Government or Pvt. Facilities. 8.1.2 Availability of the facilities in the hospital a) Waiting time in OPD • • Majority commented that waiting time in OPD depends on the number of the patients. If the doctor is available and fewer patients are there. It takes 20-25 minutes. Whereas if the number of the patients is more, than it may take even 2-3 hours. As far as timings of the OPD are concerned, all of them feel it is convenient for them. b) Availability of the doctors • • Different opinions emerged. Most of them agreed that availability of the staff is there, but there is a scarcity of the staff. The participants also put forth that the availability of the doctors /staff etc. depends on the administrator of that place. “Bade doctor sakht jadon honge sab changa chalta hey”. c) Availability of the medicines • All emphasised on the non-availability of the medicines. Whatever the patient needs while hospitalisation or in OPD, they are asked to buy. Very few people mentioned that for economically weaker section some medicines are given from the hospital. “sarkari aspatalan bich to asan garib loki e jaedah hai, davaiyan kuch bhi nahi dende” ‘Why should we go to the Government hospitals, as only visiting the doctor is not going to help, we need to buy the medicines also “Local private doctors give the medicines also within the Fees”. d) Availability of the laboratory and radiological services • • All were unhappy with the functioning of the laboratory and radiological services. It was pointed out that in case of emergency, there are great difficulties in availing any of these facilities. They were of the opinion that at few of the places, machines/equipment are either not in working condition or the technician is not available. “If it is only the availability, ‘yes’, it is available but if we talk about the functioning aspect, it is questionable”. Study to Review The Health Care Delivery System provided by PHSC, Punjab 93 “Whole day goes off only for one investigation to be done”. Again they were required to collect the report from the lab and then visit the doctor. 8.1.3 Behaviour of health care providers towards patients • • • • Most expressed happiness with the doctors’ behaviour. Few reflected that doctor’s behaviour is more prompt and appropriate when they visit the same doctors in their clinics. It emerged that the staff does not ask for any money for any reason. They are at times cooperative. 8.1.4 Outreach services offered by Government facility • • • • • • • Most pointed out that though ANMs exists in the area, but they are not conducting group meetings. Home visits were also very less. ANC is not a regular agenda. Women themselves go to the hospital to get registered. Few of the respondents said that ANM is active and take due care of the pregnant women. Visits of the ANM/ASHA are actually restricted to specific areas. These workers are more centred to areas near their residence. The far off villages are not taken care off. As such there is no coverage for family planning services. No medicines have been distributed by the ANM since 4-5 years. Iron and folic acid tablets are also not available with them. Only hospitals provide these medicines for 3-5 days to each pregnant women. 8.1.5 Coverage • • Remote areas are not being served. People are forced to utilise private services, sometimes with the same government doctor of the hospital in their private clinics. Most emphasised that health facilities are not fully equipped. They need to go to the other specialised hospitals/referrals to avail some of the facilities. 8.1.6 Satisfaction with the services provided by the Government health facility • Responses were varied among different groups. In the Sub-divisional hospital areas, which are running fine due to good administration, people are somewhat satisfied with it. Whereas those, where there is bad administration like no doctors on duty or shortage of doctors, people are not at all happy with them. 94 Study to Review The Health Care Delivery System provided by PHSC, Punjab • They feel that government has invested so much in the infrastructure for the betterment of the general public, but the ultimate purpose has not been achieved. 8.2 Observations among the Female Groups 8.2.1 Accessibility to health care facility a) Health care facility availed by villagers • • Women primarily want to avail the government facilities. This is either due to their positive experiences in the past or those of the friends/relatives. Most of the women said that for delivery they primarily feel safe in going to the government hospital but due to various reasons most of them actually are not utilising these facilities. Women from the villages need to travel long distances, as CHCs are not situated in the villages but near the main roads. Various groups with single voice stated that delivery occurs most of time during odd hours or in emergency, and for that, one could not depend on the present health system. They added that doctors are not available and for the reasons not known to them, they refer the patient to either private hospital or to the District Hospital. “Wahan hota hi kon hay”. ‘asan to aes lai privaton e jainda hega” • For this reason they go to either private or to the District Hospital. Few of the women also added that the government doctors, who are practicing privately also provide good treatment in their nursing homes, and so it is better to go to them. Parishad CHCs are more popular in some of the areas as compared to the PHSC’s CHCs. • • b) Reasons for non-utilisation of Government health facilities • • • • Most of the rural women visit the CHCs for their reproductive health problems. Most of the places gynaecologists are not available. If the distance of the health facility is more, the local people utilise private facility only. “For delivery we cannot take any chances” was the version of most of the respondents. People were found unhappy because they have to spend the money for availing health services. They were of the opinion that at least delivery facility should be provided by the Government free of cost. “Madam suin se ley kar glucose, davaina, injection sab bahar se he khareedna padta hai”. “Serkari aspatal witch to sab kokh hi milna chaida hay” Study to Review The Health Care Delivery System provided by PHSC, Punjab 95 • At night time nobody can think of going to the CHC for any emergency as hardly anybody would be available there. People prefer to go the private hospitals /nursing homes only. It was commented that in general, these government health service providers provide no emergency facilities. Availability of the doctor in the hospital/CHC is not very sure. Laboratory testing, ultrasound etc. are required to be done from private centres. At many places, women groups stated that these centres are also in someway or other related to the government hospital doctors. Most commented that the government doctors prefer to see the patient in their private settings charging consultation fees.. • • c) Distance from home and connectivity from the road • • • Although distance is an important factor, but if good doctors are available at health facilities, people will most likely utilise these health facilities. Most of the rural women visit Parishad CHC, as it provides the services. The nearby CHCs under PHSCs with 6 doctors are not being visited. At places, where the CHC are nearby the villages or even in the residential area, people still do not utilise the services and rather go to private hospitals/nursing homes which are situated at distance. “The same doctors give good treatment in private nursing homes, so we go there only’. d) Transport facilities and cost of travel • CHCs are found to be mainly situated near the main roads but away from many villages. These roads are however, well connected with the local transport also. Still the paying capacity for the cost of travel depends on the economic status of the family, which is a matter of concern for the poor patients. Those who cannot afford to bear these costs prefer to call for TBAs for conducting the delivery, irrespective of the fact whether she is trained or untrained. • e) Services • It was stated that they have to purchase everything needed during hospitalisation or otherwise. Even as outpatients, majority of the medicines have to be purchased from outside. 8.2.2 Availability of the facilities in the hospital a) Waiting time at OPD • Waiting time in OPD depends on the number of the patients. If doctor is available and few patients are there it only takes 20-25 minutes. Whereas if the number of the patients is more, than it may take even 5-6 hours. As far as timings of the OPD are concerned, all of them felt it is convenient for them. 96 Study to Review The Health Care Delivery System provided by PHSC, Punjab • Few opined that if a gynaecologist is there, women will feel comfortable in going to them and would not even mind the waiting time. Very few deliveries are being conducted at the CHCs. b) Availability of the doctors • Different members were having different opinions on this issue. Though most of them agreed that availability of the doctors is there but there are also some places where there is scarcity of the staff. Few of the women added that if doctor is from the same area, there are chances that they will be available. c) Availability of the medicines • Almost all mentioned about the non-availability of the medicines. Whatever the patient needed whether as in-patients or as out-patients, they are being asked to buy almost everything. Even for the delivery, everything is to be purchased. No medicines are being provided from the hospitals. Very few people mentioned that for economically weaker sections, some medicines are given from the hospital. c) Availability of the laboratory and radiological investigation • All were not very happy with the functioning of the laboratory and radiological investigations. The respondents pointed out the fact that in emergency, it becomes a great problem in availing any of these facilities. Few respondents opined that it is difficult for a pregnant woman to collect the report from the lab and then visit the doctor. It was revealed that at few of the places, machines/equipments are either not in working condition or else the technician is not available. • “If it is only the availability ‘Yes’, it is available but if we talk about the functioning aspect, it is questionable”. “Whole day goes off only for one test to be done” 8.2.3 Behaviour of health care providers towards patients • • • In general, members experienced happiness with the general doctors. But few commented that gynaecologists are available only sometimes. It was reflected that the doctors’ behaviour is more prompt and appropriate when they go to visit the same doctors in their private clinics as compared to government facility. Behaviour of the nursing staff was reported to be good. It was also mentioned that the staff did not ask for any money for any reason and that they are at times cooperative. Study to Review The Health Care Delivery System provided by PHSC, Punjab 97 8.2.4 Outreach services offered by Government facility • • Though ANM is available but home visits are very less. No health related discussion takes place ever. “ab to sub jante hai kya achha hai kya kharab” • • • • All were happy about the pulse polio. However, ANC is not a regular agenda. Women generally go by themselves to the hospital to get registered. Families were found to be well aware about the institutional deliveries. Few stated that ANM is active and takes due care of the pregnant women. Visits of ANM/ASHA is generally restricted to specific area. It was stated that they are more centred towards their residential area. Far off villages are not taken care of. Some women commented that as such there is hardly any coverage for family planning services. They use contraceptives, based on whatever information they get from various sources. No medicines are distributed by the ANM. Iron and folic acid tablets are also not available with them. CHCs provide these medicines for 3-5 days to each pregnant women. Women who go to the private doctors get prescription for iron and folic acid tablets and they purchase it. The people from poor background only visit the hospitals for delivery and that also was when local dais tell them that about some problem during home delivery. • • 8.2.5 Coverage • Remote areas are not being properly served. People are forced to utilise private services sometimes with the same government doctor of the hospital in their private clinics. The centres are like “ujada chaman, wahan kon jayga”. • Health facilities are not fully equipped. They need to go to the other specialised hospitals/ referrals. 8.2.6 Satisfaction with the services provided by the Government health facility • • Most were not satisfied with the government facilities. Very few of them commented that services are fine to an extent but almost all women were of the opinion that the services need improvement. 98 Study to Review The Health Care Delivery System provided by PHSC, Punjab 8.2.7 Suggestions for improvements • There should be improvement in basic facilities in hospitals including cleanliness, recruitment of the staff, specialised doctors, drinking water arrangement, toilets on all the floors and wards, electricity (lighting arrangement), generator, water tank, timely repair of accessories and machines etc. Medicines should be provided by the hospital. If not possible, at least the BPL families should get the facility. For the other patients, subsidised medicines can also be a good option. In emergency delivery cases, at least hospital should provide everything. Provision for laboratory and ultrasound, especially in emergency, should be in perfect condition. On call doctors should be arranged for emergency departments. Fee for the investigations should be subsidised. Community oriented programmes e.g. Camps, health Melas, health education etc. should be organised especially in far-flung areas. Local community participation should be enhanced for utilisation of health services. Mahila Mandals should be strengthened. Emergency departments, ambulances should be arranged at very minimum rates. For transport of delivery cases, there should be no charge. Doctor on emergency duty should be available for 24 hours. The private practice of the Government doctors should be stopped. Every village should have a trained dai and a lady doctor. • • • • • • • • • • • Study to Review The Health Care Delivery System provided by PHSC, Punjab 99 9. Views of the Stakeholders Interviews were conducted with senior administrators and other stakeholders to get their views on the functioning of the health system. The findings of interviews as per facility are given below: 9.1 At District Level 9.1.1 Deputy Commissioners (DC) Out of the 10 districts visited in Punjab for evaluation of the health System, the Deputy Commissioners (DC) of only 9 districts could be interviewed as the DC of Hoshiarpur district was not available at the time the study team visited the district. All the DCs interviewed had less than 2 years of service as D.C. The revelations from these interviews are as follows: (Refer Table 23) 9.1.1.1 Overall functioning • Out of the total 9 DCs interviewed from the various districts visited, DCs of 50% districts reported that the overall functioning of health facilities in their district is good, while 30% reported average (mainly due to shortage of staff) and 20% reported poor and gave lack of doctors as one reason for poor functioning. Regarding availability of staff, 60% DCs admitted shortage of staff, while 30% of the DCs could not say anything definitely on this matter. DCs of district Muktsar, Sangrur and Gurdaspur felt that the decrease in utilisation of health services by the community is mainly due to the shortage of staff particularly the specialists viz., gynaecologist, orthopedician and eye-specialist. Shortage of O.T staff at most places was reported by DC, Muktsar. He also reported that cancer is a big problem in Muktsar and no focus has been given to that. It was emphasised mostly that the general cleanliness is not good and needs further improvement. Maternity services in most of the District Hospitals also need improvement. Long waiting time was also reported as a big problem in the delivery of services (Sangrur District). Besides this, lack of staff, lack of supervision to ensure punctuality and to check absenteeism, improper monitoring systems as well as negative interference (on non-health issues) were reported as other constraints in the delivery of services. • • • • 9.1.1.2 Extent of fulfilment of community needs • Regarding the extent of fulfilment of health needs of the community, 40% of the DCs stated that it is being partially fulfilled (upto 50%) while 40% DCs stated that large extent of 100 Study to Review The Health Care Delivery System provided by PHSC, Punjab • community needs are being fulfilled (upto 80%). Remaining 10% DCs did not have any conclusive comment on this issue. Regarding the perceived barriers among facilities in utilising public health services, 30% felt that availability and accessibility are a barrier mainly for CHCs. 20% felt that there are some barriers in terms of utilisation and acceptability of services. Remaining 50% DCs felt that there are no barriers for the availability, accessibility, utilisation and acceptability at services at District hospitals, but for Sub-divisional hospitals and CHCs it requires further improvement. 9.1.1.3 Referral services • According to 40% DCs non availability and not fully equipped ambulance are a problem, 30% DCs opined that referral services are satisfactory in their districts and the remaining 20% DCs had no idea about this. 9.1.1.4 Knowledge of RKS (Rogi Kalyan Samiti) • More than 60% of DCs were found to have knowledge of RKS while rest were unaware. 10% DCs told about BPL cards being given to poor patients for free treatment. 9.1.1.5 Fund flow • Regarding the fund flow it was felt by 30% DCs that there is no problem with respect to the fund flow, 20% stated that it is not through DC. Other 10% DCs stated that funds are not adequate and another 10% felt that the funds are not being fully utilised. 20% did not have any comment regarding the funds flow. It was suggested that funds should be given for the purchase of C.T. Scan and MRI. Medical Insurance for poor and economically backward people should be introduced at state level. 9.1.1.6 Manpower management • About 40% DCs reported good levels of motivation amongst their staff, 20% reported low to very low motivation level, over load of work and low salaries being the main reasons for low motivation. 30% DCs did not give any comments. Frequent transfers were also opined as one of the main reasons for low motivation level. 9.1.1.7 Constraints in delivery of services • About 30% of the D.C felt that lack of staff is a major constraint in the delivery of health care services. 10% felt that lack of supervision, absenteeism, lack of punctuality, lack of funds, lack of super specialists, lack of facilities and high load of work are some other constraints in the delivery of quality health care services. 9.1.1.8 Suggestions The following suggestions were given by DCs: • More infrastructure facilities and equipments should be provided. • Salary of doctors should be increased otherwise they will go for private practice. • More contractual employees should be placed – especially class IV and lab technician. Study to Review The Health Care Delivery System provided by PHSC, Punjab 101 • • • • • • • • PPP model need to be introduced. Telemedicine should be promoted. Performance linked appraisal should be there. Number and quality of drugs need to be increased and improved. Paid wards should be started. Transport services should be improved. Health insurance should be done for poor patients. Cleanliness should be emphasised upon. 9.1.2 MLA/Elected Representative A total of 10 districts were visited in Punjab for evaluation of the health system and elected representatives of all these districts were interviewed. Elected representatives of 60% districts had a length of service of more than 2 years and 30% had 1 – 1.5 yrs. of service. (Refer Table 24) 9.1.2.1 Overall functioning • About 50% reported that the overall functioning of health facilities in their district is good, while 10% reported it as average and 20% reported as poor (mainly the CHCs). Remaining 20% did not give any comments. The overall services of hospitals were reported to be satisfactory by 40%, 20% reported as average and 10% reported them bad mainly due to poor gynaecological facility. No comments were received from 30% of the representatives. MLA of Jalandhar opined that for improving the functioning of the hospitals, the SubDivisional Hospitals should be upgraded to 100 beds, since the load of patients is more in these hospitals. • • 9.1.2.2 OPD services • With regard to the availability of staff it was felt by 20% of MLAs that the adequate staff is available in the District Hospitals, however, it was felt by 70% of them that there is shortage of doctors in most of the hospitals. With regard to the availability of medicines in OPD, 60% stated that medicines are available but are not sufficient as per the requirement, 40% felt that the medicines are not at all available. They felt the need and suggested that the costly medicines, which the people purchase from outside should be provided at subsidised rates by the District Hospital. With regard to the waiting time, 60% of the elected representatives felt that the waiting time is not much (<30 minutes), while 30% of them felt that it could range anywhere from 1-3 hours. With regard to cleanliness, 70% felt that the District Hospitals are maintaining good and/or satisfactory level of cleanliness while 20% felt that the cleanliness is not good. • • • 9.1.2.3 Extent of fulfilment of community needs • Regarding the extent of fulfilment of health needs of the community, 40% gave a satisfactory response that the health needs are being fulfilled for >60% of the community. 50% of them 102 Study to Review The Health Care Delivery System provided by PHSC, Punjab reported low levels of community needs fulfilment (30 – 50%) and that mostly poor people are the only ones using it. 9.1.2.4 Behaviour of staff • • 60% of the elected representatives felt that the overall behaviour of health staff is good/ satisfactory while the rest 20% felt that it is not satisfactory. It was stated that the behaviour of nurses and class IV in particular is rude towards the patients. No conclusive comments were given by 20% of the elected representatives. 9.1.2.5 Referral services • Regarding the ambulance services, 40% reported that there are good services while the other 40% said that the ambulance services are either not available or wherever available are not functioning well. 20% did not give any comments. When asked to rate the services in a government hospital as compared to Private/NGO/ Charitable hospital, it was stated that government doctors are better qualified than private, but in odd hours and emergency and due to non-availability of the doctors, they have to go to private facilities. Otherwise government services are better. One of the MLA stated that private facilities are better but one needs to pay for that. They stressed on more number of ambulances to be made available and further increase in IEC activity at government hospitals. • • 9.1.2.6 RKS and poor patients’ treatment • • About 40% of the elected representatives were having the knowledge of RKS while the other 30% had no knowledge and 30% did not give any comments. With regard to free treatment of poor patients, 20% stated that free treatment is being given to poor while 30% said that no free treatment is being provided to the poor. 20% said that treatment for poor is being provided from Red Cross fund or from NGOs. 30% did not give any comments which might be due to lack of knowledge. 9.1.2.7 Perceived barriers • When asked about the perceived barriers, the responses received were as follows: Regarding availability, 20% felt that less availability of medicines and ambulance service is a barrier. One serious issue which was reported from Civil Hospital Firozpur was that anti-rabies vaccine is not available and with an increase in the number of street dogs, it is becoming difficult to tackle the situation. With regard to the accessibility, 80% felt that there is no barrier, rather, health facilities upto CHCs are easily accessible, whereas 20% felt that referral service is a barrier as this requires money. Regarding utilisation, 20% of the elected representatives felt that it is not low, while 40% felt that the scarcity of medicines is a barrier and 20% felt that utilisation is low mainly due to lack of diagnostic equipments and laboratory facilities in CHCs. With regard to the acceptability, 20% felt that it is a barrier in CHCs only and 10% felt that non-availability of equipments is a barrier. • • • Study to Review The Health Care Delivery System provided by PHSC, Punjab 103 9.1.2.8 Suggestions • • • • • • • • • • Most elected representatives suggested that more equipment for diagnostic facility (i.e. C.T. Scan, MRI) should be made available for poor patients. More number of ambulances should be made available. They advocated sanction of vehicle for SMO for field visits. Extra water facility should be provided. Security guards should be recruited at health facilities. They suggested increasing plantation in and around hospital complex. Night and emergency services should be improved and more doctors should be made available. The hospital should be upgraded from 50 to 100 beds to adequately meet the patient load. A Generator with greater capacity and power should be installed to improve functioning. Technicians for ultrasound must be recruited. 9.1.3 Civil Surgeons Civil Surgeons of all 10 districts of Punjab included in the assessment for evaluation of the Health System were interviewed. (Refer Table 25) 9.1.3.1 Overall functioning • CHCs: Civil surgeons of 40% district stated that overall functioning of health facilities in their district is good, while 40% reported poor service condition of CHCs and 20% reported over utilisation of OPD. Problem with indoor facilities was reported by 10%. Main problem reported by civil surgeons was shortage of staff especially at CHCs. Regarding bed occupancy, 60% Civil Surgeons stated bed occupancy in the range of 4060% in their CHCs, 20% reported between 10-20% and 20% were not able to provide any exact figure. Sub-Divisional hospitals: 70% Civil Surgeons stated bed occupancy in their districts in the range of 70-100% in Sub divisional hospitals, 20% Civil Surgeons stated bed occupancy as 50%, while remaining 10% did not give any comments. District hospitals: 70% civil surgeons stated bed occupancy in the range of 70-100% in the District Hospitals and 20% reported bed occupancy of 50%. No comments were given by 10% civil surgeons. • • 9.1.3.2 Extent of fulfilment of community needs • Regarding the extent of fulfilment of the health needs of the community, 50% civil surgeons gave a satisfactory response, while 40% reported average level of fulfillment of community and 10% reported that the needs are not being fulfilled at all. 104 Study to Review The Health Care Delivery System provided by PHSC, Punjab • • • • • • Most of the civil surgeons opined that the health services are not being fully utilised by the community because of the following main reasons: Lack of specialists Shortage of technical staff Non-availability of medicines It was stated by most of the civil surgeons that the patients had to spend money on laboratory and radiological investigations. Some civil surgeons also felt that lack of infrastructure for building is also one of the constraints in utilisation of services by the community. It was also stated that due to the shortage/non-availability of staff, patients had to wait for considerable time for receiving consultation from specialists/doctors, for getting medicines and getting investigations done. Civil surgeons were of the view that patients of well off families are not availing their health care facilities because of poor cleanliness, lack of privacy for admitted patients, inferior quality of nursing care and low client satisfaction level. It was stated by civil surgeons that one of the constraints in delivery of health services is due to non-staying doctors at the health facility, which again is due to lack of good accommodation facility and irregular supply of electricity. Civil surgeon of Taran Taran district felt that there is a need to improve the obstetrics & gynaecology services in these facilities. 9.1.3.3 Availability of medicines • • • Only 20% civil surgeons stated that medicines are available in OPD while 80% of them reported that the medicines are lacking. With regard to the waiting time, 50% civil surgeons felt that it is not much, while another 50% felt that the waiting time is long. About 40% civil surgeons stated that cleanliness is not good in their hospitals, while 50% reported it to range from good to average and only 10% felt that it is of very good standard. 9.1.3.4 Behaviour of staff • • 80% civil surgeons felt that the overall behaviour of health staff is in range of good to satisfactory while the rest 20% felt that it needs improvement. Regarding referral services it was stated by 30% civil surgeons that there is no problem while 50% reported that there is shortage of ambulances and drivers at some places. 9.1.3.5 Funds flow • It was stated by 40% of the Civil Surgeons that there is no problem regarding the fund flow. 30% of them reported that funds are not being provided and they are managing only through the user charges. 10% civil surgeons stated that there is a slight delay in getting the funds and the remaining 10% said that funds are available only under NRHM (National Rural Health Mission). • Study to Review The Health Care Delivery System provided by PHSC, Punjab 105 9.1.3.6 Manpower management • • About 30% of civil surgeons reported low levels of motivation amongst their staff, 40% reported good motivation level and 20% reported average levels of motivation. For improving the motivational level among staff members, they laid importance on increasing the salary of staff, constructing the residential quarters, giving desired place of posting of job, incentives for good workers and reducing mismatch with specialist and GDMO regarding place of posting. 9.1.3.7 Perceived barriers • • • Regarding availability, 20% civil surgeons felt that lack of manpower in SDH and CHC is a barrier while other 70% reported no barriers in availability of services. Regarding accessibility, 10% felt that it is a barrier especially for the CHC while the other 70% did not report any barriers. 30% civil surgeons felt that the utilisation of services at CHCs is low by the community, 10% felt that short supply of medicines is a barrier in effective utilisation, while the rest 40% felt that there are no barriers as such with regard to utilisation. Regarding acceptability, 30% civil surgeons felt that there are barriers with regard to CHC while 50% reported no barriers. No conclusive comments were received from 20% civil surgeons. According to most of the civil surgeons interviewed, the areas which require attention are cleanliness of toilets, proper working condition of certain equipments, IEC activity among community, filling up of vacant posts of Class IV, sweepers, ambulances for the hospital, increase in allotment of funds and staff for O.T and pharmacists. • • 9.1.4 SMO (Senior Medical Officers) In-charge of District Hospitals Senior Medical Officers In-charge of all District Hospitals from 10 districts visited were interviewed. It was observed that out of the 10 District Hospital SMOs interviewed, 50% had their length of service for less than 2 years while other 50% had more than 2 yrs. of service in their respective District Hospitals. (Refer Table 26) 9.1.4.1 OPD services • Regarding the staff strength of OPD, 20% SMOs felt that the staff strength is adequate, while 60% felt that there is shortage of nursing staff, Paramedics, Class IV, and radiologists. 20% felt shortage of specialists especially paediatricians in their OPDs. Staff of OPD is overworked in opinion of some SMOs. SMOs of all districts stated that the OPD timings are adequate and the quality of treatment provided from OPD is also quite good. Bed occupancy was estimated 100% in 30% of the hospitals, more than 70% in 40% of the hospitals and less than 70% in 20% hospitals as stated by the SMOs. 60 % SMOs stated that poor patients are being provided with free medicines. 30% SMOs stated that very few medicines are actually available (mainly the 5 basic medicines i.e. Antibiotics, B-Complex, Paracetamol, Ibuprofen & Metronidazole). • • • 106 Study to Review The Health Care Delivery System provided by PHSC, Punjab 9.1.4.2 Services provided • • In opinion of the SMOs, patients are spending money mainly on the transport, medicines and lab investigations. No dietary service is available in any of the District hospitals but it was revealed that at 10% of the hospitals only one meal is being provided to them free of charge by Voluntary organisations. While most SMOs were of the opinion that their services are up to 80% at par with the private sector, some were of the opinion that private sector is giving better services. However, most of the SMOs felt that they are giving best services and value for money particularly to the poor patients. • 9.1.4.3 National Health Programmes (NHP) • About 80% of the SMOs were having information regarding various National Health Programmes. However, 10% SMOs stated that this information is not available under PHSC. 9.1.4.4 Fund flow and RKS • About 40% SMOs stated no problem in fund flow in their hospitals. But 30% SMOs (viz; Tarantaran, Jalandhar and Hoshiarpur) stated that no funds are being provided and they are managing from User Charges alone; 10% SMOs reported shortage of funds while another 10% (i.e., Sangrur) stated that SMO has got no role in this regard. While 80% SMOs were found to be aware of the Rogi Kalyan Samiti, 20% were not sure about its functioning, since they have been recently constituted. They reported that there are some problems in constitution of the committee and conducting the regular meetings. It was revealed that money is mostly being used for infrastructure development, e.g. building etc. At some places, free dentures, dental check-ups and Cataract Operation are being done for poor patients. All the SMOs stated that efforts are being made to provide medicines to all, but due to nonavailability of medicines, some medicines are to be purchased through user charges (e.g. vital and life saving drugs). • • • • 9.1.4.5 Extent of community needs fulfilment • Regarding the extent of fulfilment of health needs of the community, 50% SMOs felt that they are able to fulfil up to 100% needs; while 30% stated that they are mainly catering to the needs of the poor. The community was found to be utilising OPD facility to its maximum. • 9.1.4.6 In-patient services • It was stated by SMOs that at some places (20%) there is shortage of nursing staff and junior doctors, with nurse to bed ratio ranging from 1:20–1:40. 50% SMOs stated that nurse to bed ratio is adequate, in the range 1:2 to 1:6. Doctor/Bed ratio also showed a lot of variation. • Study to Review The Health Care Delivery System provided by PHSC, Punjab 107 • It was revealed that job of cleanliness is given on contract in more than 50% of health facilities. It was also commented by SMOs that at many places drinking water is not being treated and is supplied for usage as such. 9.1.4.7 Manpower management and other services • 90% SMOs stated that they have a system of performance appraisal in their hospitals. The problem of conflicts between the staff and patients was not found to be a big issue in most of the hospitals. Regarding Emergency services, SMOs stated that they run for 24 hours a day with Specialists and Surgeons available on call. One doctor is always present for night duty. Emergency supply of drugs is ensured and Lab. Technician is also available on call during emergency. • 9.1.4.8 Community participation and manpower management • Regarding community participation, it was revealed that at some places food is being provided by Voluntary Organisations and at others there are NGOs and charitable organisations that are providing medicines and blankets other than food. At most places no barriers/challenges are being faced for effective community participation, whereas at one place (Amritsar) some political interference was found leading to some administrative problems, like transfer of staff etc. SMOs were found to adopt a variety of methods for monitoring and effective supervision e.g. ACRs, Daily rounds, monthly meetings, surprise checks, checking of medicine registers, feed backs etc. Some SMOs also stated that they undertake efforts for reducing the stress levels of the staff by counselling them, appreciating them, motivating, following appraisal system, by directly talking and by obliging the person. To increase motivation level, doctors are also being sent outside to receive trainings. Bio-medical waste management was found to be undertaken in most (90%) of the District Hospitals; however 10% of them reported shortage of bags. • • • • 9.1.4.9 Perceived barriers to avail health facilities • Regarding the perceived barriers for availability of health services, 20% SMOs felt that there is lack of information and shortage of staff which is a barrier while the rest 60% did not felt that any barrier existed. Regarding accessibility, 20% SMOs felt that shortage of medicines and lack of staff is a barrier. 60% the SMOs opined that there is no perceived barrier for ‘Utilisation’, while 20% felt that shortage of facilities and lack of information is a barrier in effective utilisation of health services. Regarding acceptability of health facilities only 10% reported these as barriers. • • • 108 Study to Review The Health Care Delivery System provided by PHSC, Punjab 9.2 At Sub-division Level 9.2.1 MLA/Elected Representative–Sub Divisional Hospital Elected representatives of 9 out of 10 districts were interviewed at SDH level. Elected representative of Amritsar district was not available for interview. Elected representatives of 70% districts had more than 2 years of length of service while 20% had less than 2 yrs. of service. (Refer Table 27) 9.2.1.1 Overall functioning • About 30% of elected representatives reported that the overall functioning of health facilities in their district is good, while 50% reported it as satisfactory and 10% as poor (mainly at CHCs). The overall services of hospitals were reported to be in ranges from good to satisfactory by 70% of them, while 20% reported them as not very good. • 9.2.1.2 OPD services • With regard to the availability of staff, 40% of elected representatives stated that the staff was available at the Sub Divisional hospitals, whereas 50% felt that there is shortage of doctors/specialists in the hospitals. Regarding availability of medicines in the OPD, only 20% stated that medicines are available, while 60% stated that sufficient medicines are not available so as to meet the requirement. 10% stated that most of the time no medicines are available. They opined that, all the medicines which the people purchase from outside should be provided from the hospital itself. Regarding the waiting time, 40% of the representatives stated that the waiting time is not much, while 50% of them stated that it is long and it depends on the number of patients and availability of doctors. Regarding cleanliness in OPD, 30% felt that the Sub Divisional Hospitals are maintaining good level of cleanliness, while 30% stated that it is of average level. Rest 30% representatives felt that the cleanliness is not good. • • • • 9.2.1.3 Extent of fulfilment of community needs: • In response to this question, 50% of them gave a good response, with the health needs being fulfilled for more than 75% of the community. 10% stated that only average level of need fulfilment is being achieved. Remaining 20% reported low levels of community needs fulfilment (20 – 40%) and mentioned that the services are being mostly utilised by poor people. 9.2.1.4 Behaviour of staff • Regarding behaviour of staff in Sub Divisional hospitals, 40% elected representatives felt that the overall behaviour ranges from good to satisfactory. 40% felt that it varies and reported the behaviour of staff as average while 10% reported that the behaviour is not good. It was stated that the behaviour of Nurses and class IV in particular is not good. Study to Review The Health Care Delivery System provided by PHSC, Punjab 109 9.2.1.5 Referral services • Regarding the Ambulance services, 40% stated that the services are available and satisfactory, while another 40% stated that the ambulance services are either not available or wherever available, these are on payment basis. 9.2.1.6 RKS and treatment of poor patients • • About 40% of the elected representatives were having the knowledge of RKS, while another 50% were having no knowledge about it. Regarding free treatment of poor patients, 60% stated that these facilities are providing free treatment to poor, while 20% stated that no free treatment is being given to the poor patients. 9.2.1.7 Perceived barriers to avail health facilities When asked about the perceived barriers the responses were as follows: • • • Regarding the availability, 20% felt that less availability of medicines and equipments is a barrier, while 70% perceived that availability as such is no barrier. With regard to the accessibility, all of them opined that there is no barrier. 70% of the elected representatives also felt that there is no perceived barrier for utilisation, while 20% stated that it is a barrier due to non-availability of USG machine and other diagnostic facilities. Regarding acceptability, 80% elected representatives stated that it is no barrier, while 10% felt that the acceptability of health services by community is low. • 9.2.1.8 Suggestions • • • • • • • Most of the elected representatives suggested that more equipment for diagnostic facility (i.e. C.T.Scan, MRI) should be made available for poor patients. They advocated sanction of vehicle for SMO for field visits. Extra water facility should be provided; and security guards must be recruited to ensure patient security. They even suggested increasing plantation in and around hospital complex. Technician for Ultrasound must be recruited. Medicines should be available in good quantity There should be a Blood bank at these health facilities More staff, medicines, funds and ambulances should be made available. 9.2.2 SMO – Sub Divisional Hospitals Senior Medical Officers of all Sub divisional hospitals included in the study were interviewed. It was found that out of SMOs of 10 Sub divisional hospitals, 80% had their length of service less than 2 yrs. and 10% had more than 2 yrs. of service in their respective Sub divisional hospitals. (Refer Table 28) 110 Study to Review The Health Care Delivery System provided by PHSC, Punjab 9.2.2.1 OPD services • • • Regarding the OPD Services, 50% SMOs felt that the staff strength is adequate, while other 50% stated that it is poor due to shortage of Class IV employees and specialist doctors. Bed occupancy was stated as 85-100% in 50% of the hospitals, while the rest 40% SMOs’ reported 40-70% bed occupancy. Poor patients were being given free medicines in opinion of 60% of the SMOs, while in other 30% hospitals, only some of the medicines are available as free. 9.2.2.2 National Health Programmes (NHP) • Most of the SMOs (70%) were having information regarding various National Health Programmes, but at few facilities (30%) information regarding malaria and STD programmes were not available. 9.2.2.3 Extent of community needs fulfilment • Regarding the extent of fulfilment of health needs of the community, 20% of the SMOs felt that they are able to fulfil 100% of health related needs; while other 30% stated this level of fulfilment upto 75% and rest 30% upto 50%. 10 % of the SMOs opined that health needs of the community are fulfilled to high level by the OPD; however, this is comparatively lower for in patient departments. • 9.2.2.4 In-patient department • • • • • It was found that Nurse to bed ratio in most (80%) hospitals was in the range 1:3 to 1:5, while at 10% of the hospital (Ludhiana) this ratio was 1:12. Doctor/Bed ratio was found to be of range 1:3 to 1:6 at 50% of the hospitals, while it is in the range of 1:7 to 1:10 at 30% hospitals. For the rest 20% the ratio was not specified. Dietary services are not organised in the hospitals and this is mostly managed by patient’s attendants. Level of cleanliness was opined to be good at 20% of the hospitals, average level at 30% and poor at 10% of the hospitals. 20% of the SMOs reported shortage of staff and 10% reported that they had recruited the staff on contract basis. 9.2.2.5 RKS and fund flow • While 60% SMOs were aware of the Rogi Kalyan Samiti, its exact status and functioning was not known to 10% of them and 20% reported that RKS is not functioning in their hospitals. 60% SMOs reported no problem of fund flow in their respective hospitals, while 20% of them (Tarantaran and Jalandhar) reported that no funds are being provided to them. SMO of Amritsar Sub-Divisional Hospital stated that they are managing only from the user charges. • • Study to Review The Health Care Delivery System provided by PHSC, Punjab 111 9.2.2.6 Manpower management and other services • Most of the SMOs (70%) stated that they have a system of performance appraisal in their hospitals, which included benchmarking for doctors and ACRs. 10% stated they do not have any appraisal system, while 10% said that they have their own personal perception. Almost all (90%) hospitals were having Emergency services running 24 hours a day with specialists and surgeons available on call, in the opinion of SMOs. They stated that at least one doctor is always present for night duty. Only major constraint brought out following interview with SMOs was that of the nonavailability of doctors. Bio-medical waste management was found being followed at most (80%) of the Sub divisional hospitals, however, 20% SMOs reported shortage of disposal bags. • • • 9.2.2.7 Perceived barriers to avail health services Responses received regarding the perceived barriers are as follows: • Regarding availability, 30% SMOs stated that there is lack of specialists and doctors, which are barriers at their hospitals, 10% SMOs stated lack of medicines and staff as a barrier. Rest 40% SMOs stated that no barrier exist in terms of availability. Regarding accessibility, 70% SMOs felt that it is no barrier, while the other 30% did not comment on this aspect. 10% of the SMOs felt that lack of infrastructure and behaviour of staff are being perceived as barriers for the utilisation of services, while 70% stated that it is not a perceived barrier. Rest 20% did not give any comment on this. With regard to the acceptability, it was felt by 70% SMOs that it is not a barrier and no comments were received from the rest 30% of the respondents. • • • 9.2.2.8 Suggestions • • • • • • • • • • • • Vacant staff positions should be filled up. Regular training for the staff should be provided. Repair and maintenance of staff quarters should be done. Manpower shortage, especially of gynaecologists, radiologists and Class IV employees should be looked into. Fully equipped ambulance and CT scan service should be provided. Private wards should be created at these health facilities. There should be provision of seminar room in these facilities. SMOs should be given authority to cut down on non-performing staff. Security services should be provided on contract basis to ensure security. Costly equipments should have annual maintenance contracts. More and regular supply of medicines should be ensured. Awareness generation regarding available services should be done through the media. 112 Study to Review The Health Care Delivery System provided by PHSC, Punjab 9.3 At CHC Level 9.3.1 Elected Representatives Elected representatives were interviewed for assessment of the functioning of CHCs in their respective areas, in all districts included in the study.. Out of the total 10 districts visited, elected representatives of 90% districts had more than 2 years of length of service while remaining 10% had less than 2 years of service. (Refer Table 29) 9.3.1.1 Overall functioning • When asked about the functioning of CHCs in their districts, about 50% of them reported that the overall functioning of CHCs in their area is good, while 20% stated that it is getting better now and 20% reported that the functioning of CHCs is not good, mainly because the doctors are not available as they were going for private practice. The overall services of CHCs were opined as good by 30% of them, 60% reported the services as average and 10% reported them as ‘not good’. • 9.3.1.2 OPD services • Regarding the availability of staff it was stated by 70% of the elected representatives that the staff is available in the CHCs, however, 30% of them opined that there is shortage of doctors in most places, especially of the gynaecologist. With regard to the availability of medicines in OPD, 50% felt that medicines are available, however rest 50% stated that the medicines are either less or only partly available. They also stated that, all the medicines should be provided at the CHC. Regarding the waiting time, 70% of the representatives felt that the waiting time is not much (<30 minutes), while 30% of them felt that it is long. With regard to cleanliness, 80% stated that the CHCs are maintaining satisfactory/good level of cleanliness; while 10% felt that the level of cleanliness is bad (Hoshiarpur) and 10% felt that this needs improvement (Muktasar). • • • 9.3.1.3 Extent of fulfilment of community needs • In response to this question, 40% stated that the needs are being fulfilled to a large extent; another 30% felt that only 50% of the health needs are being fulfilled and the rest 30% felt that only 10% of the community health needs are being fulfilled and only medico legal cases generally go to CHCs. 9.3.1.4 Behaviour of staff • • Regarding behaviour of staff in CHCs, 70% elected representatives felt that the overall behaviour is good and the rest 30% felt that it is not good. It was commented upon that the behaviour of nurses in particular is bad. Study to Review The Health Care Delivery System provided by PHSC, Punjab 113 9.3.1.5 Referral services • • Regarding Ambulance services at CHCs, 30% stated that the services are available, while 60% stated that the ambulance services are either not available or only partially available. It was stated by the elected representatives that in the emergency situation they utilise the untied funds available with Panchayats to hire a vehicle. 9.3.1.6 RKS and poor patients’ treatment • • About 40% of the elected representatives were found to have knowledge of RKS, while the other 50% were having no knowledge and 10% did not comment on this issue. Regarding free treatment of poor patients, only 20% said that they are being given free treatment, while majority of them (60%) said that no free treatment is being offered to the poor. 20% were not able to give any conclusive comments. 9.3.1.7 Perceived barriers to avail health facilities Regarding perceived barriers to avail health facilities the views of elected representatives were as follows: • Regarding the availability, 40% of them felt that less availability of medicines and absence of doctors is a perceived barrier, 10% felt that far off location is a barrier, while the rest 50% opined that there are no perceived barriers in terms of availability. Regarding accessibility, 10% felt that referral services are a barrier since these referral facilities are located very far, while 90% stated that there no barriers. 40% felt that scarcity of medicines and less availability of doctors is a barrier in utilisation of services available CHCs, while the other 60% reported no barrier. With regard to the Acceptability, it was felt by 40% that it is a barrier in CHCs due to restricted or lack of quality facilities, no barriers were reported by the other 60%. • • • 9.3.2 Senior Medical Officers – CHC • A total of 11 Senior Medical Officers from 11 CHCs were interviewed in 10 districts visited in Punjab for evaluation of the Health System. One SMO from each of the sampled district CHC and 2 from Amritsar were interviewed. It was found that out of 11 SMOs interviewed, 80% had their length of service as more than 2 yrs. while rest 30% had more than 2 yrs. of service at their respective CHCs’. (Refer Table 30) 9.3.2.1 OPD services • Regarding the OPD Services, only 30% stated that the staff strength is adequate; while the other 70% felt opined there is shortage of staff. 114 Study to Review The Health Care Delivery System provided by PHSC, Punjab • • Bed occupancy rate was found to be between 10-20% in 60% of the CHCs, 30-50% in 20% of the CHC and 100% at only one CHC (Bhatinda). Poor patients were being given free medicines in the opinion of 90% of the SMOs interviewed; while 10% stated that they are providing only few medicines and the remaining 10% SMOs did not comment on this. 9.3.2.2 RKS and National Health Programmes • About 80% SMOs were aware of the Rogi Kalyan Samiti. Though some initiatives had already been taken in other areas, but it found not functioning/not formed in 30% of the CHCs due to various administrative reasons. About 40% of the SMOs were having information regarding various National Health Programmes, while 50% stated that not all information is available to them (i.e., Malaria, T.B and STD). Rest 20% SMOs did not give any comments in this regard. • 9.3.2.3 Extent of community needs fulfilment • 20% SMOs felt that they are able to fulfil upto 90-100% needs of the community; 20% stated they are able to fulfil 70-80% of the health needs, 20% stated satisfactory level of needs fulfilment, 20% reported that the CHCs are under-utilised and no definite comments were obtained from remaining 20% of the SMOs. 9.3.2.4 In-patient department (IPD) • With regard to the IPD Services it was found that Nurse to bed ratio in about 20% CHCs was about 1:10, another 40% CHCs had this ratio between 1:3 –and 1:7, while CHC at Ferozpur reported this ratio as 1:1.2. CHC Jalandhar reported shortage of staff. No conclusive comments were received from 30% of the SMOs on issue of services in in-patient departments. Doctor/Bed ratio at 20% of the CHCs was between 1:2 and 1:4 and at the other 40% CHC sit was in the range of 1:5 to 1:7. Doctor-bed ratio was 1:30 at Manawala CHC in Amritsar. Staff shortage was reported form Jalandhar; Sangrur CHC reported high i.e., 1:15 doctor/bed ratio. Level of cleanliness was opined as good by 30% of the SMOs and as average by 70%. 10% SMOs stated that level of cleanliness is not up to the mark. • • • • • 9.3.2.5 Fund flow • While 50% SMOs reported no problem of fund flow in their respective CHCs, 10% of them reported that no funds are being provided to them. Rest 40% SMOs stated that this is being handled by civil surgeons. Study to Review The Health Care Delivery System provided by PHSC, Punjab 115 9.3.2.6 Manpower management • About 90% of the SMOs stated that they have a system of performance appraisal by means of ACRs in their CHCs, which also includes laying down benchmarking indicators for doctors and medical officers. 20% SMOs stated that they are doing appraisals through records and meetings as well as through appreciation letters, other than ACRs. • 9.3.2.7 Other services • About 90% SMOs stated about availability of emergency services running 24 hours a day, with specialists and surgeons being available on call. Only 10% said that there is shortage of staff but still somehow they are providing services. Doctors were mostly available on call. 10% stated that they take help from mini PHCs. Bio-medical waste management was being followed in opinion of 90% of the SMOs, rest SMOs did not provide any conclusive information regarding this aspect. • • 9.3.2.8 Perceived barriers • • • Regarding the availability of services, 30% SMOs felt that there is lack of doctors and shortage of staff, which is a barrier, while the rest 30% did not feel any barrier existed. With regard to the Accessibility, only 10% stated that difficulties are there as CHC is in a border area while 60% reported no problem. Regarding utilisation of services at CHC, 60% of the SMOs felt that due to lack of funds, nonavailability of specialists, shortage of drugs, poor investigation facilities and poor quality of services, there is low utilisation. With regard to the acceptability, it was felt by 20% SMOs that it is low due to less number of doctors, while 40% did not perceive this as a barrier. • 9.3.2.9 Suggestions The following suggestions were made: • Regular Investigation and X-ray facility should be made available even after 3 p.m., so that patients do not suffer. • Essential drugs should be adequately available. • Bed linen should be provided in adequate quantity. Laundry unit should be made available in CHC. • Services should be made accountable to general public/community. • Assured career plan should be developed for all cadres comparable to bench marks. • Manpower must be provided in places where it is lacking. Vacant posts should be filled. The available services can be improved a lot by providing a gynaecologist, paediatrician and dentists in the CHCs’. • Medicines should be supplied and ‘border area’ allowances also be given where the CHC is located near the border. 116 Study to Review The Health Care Delivery System provided by PHSC, Punjab • • • • • • • Doctors and staff should be provided good accommodation facility at par with their status. CHCs should be provided with uninterrupted supply of electricity. There should be AMC for all equipments. Computer operators should be provided. Junior Engineer should visit CHCs twice a month. Availability of Diesel for generator should be ensured at all times. User charges should be increased according to rising inflation, as patients are ready to pay for quality services. Study to Review The Health Care Delivery System provided by PHSC, Punjab 117 10.0 Observations and Discussion 10.1 Facility Survey Based on the analysis of quantitative and qualitative data, the following observations are drawn forth: 10.1.1 Infrastructure a) b) Almost all the hospitals under study were easily accessible from the Bus Stop and nearest Railway Station and easily approachable by a motorable road. The building and general infrastructure for all the health care facilities were found to be reasonably well constructed. But as most of them are newly constructed, this infrastructure needs proper maintenance so that its life can be prolonged. Most of the hospitals were not found to be equipped with the required equipments. In some hospitals, equipment was there but there was mismatch as some were found to be either not in use and some were reported to be out of order. The surrounding of these health care facilities was not found in good condition. Almost every health facility required paying serious attention towards this aspect. The cleanliness of the hospital premises was not up to the mark. c) d) e) 10.1.2 Human resources a) b) Almost all the hospitals under study have vacant posts including post of Doctors and Support Staff. The doctors posted in these hospitals are from one single cadre. There is no separate cadre for GDMO and Specialists. As a result, particularly in CHCs and Sub Divisional Hospitals, the Specialists were also doing night duties/emergency duties and hence were not available for regular OPDs. Doctors including specialists in the hospitals under study were supposed to perform other duties like, the VIP duties, attend court cases and remain involved in various public health activities and health fairs. If regular GDMO would have been available, these duties could well be undertaken by GDMOs. There is an acute shortage of Radiologist, Anaesthetists, Paediatrician and Gynaecologist in almost all the hospitals, particularly in Sub Divisional Hospitals and CHCs. There is also an acute shortage of the support staff, particularly the Technical staff in Sub Divisional Hospitals and CHCs. Frequent transfers of the doctors has also been reflected as a cause of concern and problems in these hospitals. For example, in case where a doctor of one speciality is transferred, he is most likely to be replaced by doctor of another speciality. This disrupts the services of hospital for that particular speciality and patients suffer on this account. c) d) e) f) 118 Study to Review The Health Care Delivery System provided by PHSC, Punjab 10.1.3 Availability of medicines a) b) c) It was observed in all the hospitals and reported by almost everybody that medicines are not available in adequate quantity. The patients were found to purchase the medicines from outside. Though there is a provision of supply from the State and District level, but in practice most of these centres reported that they are asked to buy the medicines from the User Charges fund. It was also observed that purchasing medicines from User Charges fund have become a routine practice in almost every hospital/health centre under study. d) 10.1.4 Laboratory and diagnostic services a) b) c) d) Though the laboratories and diagnostic services were available in all the hospitals assessed, but functioning of the labs was not reported to be up to the mark. The patients are forced to get the tests done from outside laboratory services due to lack of reagents and equipments.. Regarding the radiological services, X-ray Units were found to be non-functional due to erratic electric supply and non-availability of films. Moreover, Radiologists were also not available in all the hospitals. 10.1.5 Emergency and maternity services a) Emergency and Maternity services found to be worst effected mainly in Sub Divisional Hospitals and CHCs. Main reason for this was non-availability of the doctors for Emergency and Maternity services. Even Nursing staff was not feeling comfortable to do the duty in the night and odd hours due to security reasons, as other staff and people are not available during night hours. It was revealed that due to non-availability of the staff and other facilities, the patients have to return back from the facility. As a result, the community is losing confidence in the hospitals. This is one reason of low utilisation of health facilities and also for this trend to down further. b) c) 10.1.6 Disaster preparedness a) b) None of the hospitals, including District Hospitals were found to be properly prepared to deal with any Disaster situation. None of the hospitals including District Hospitals were having any well-prepared Disaster Action Plan. Nor they are having any disaster drill or any disaster manual. 10.1.7 Referral linkages a) Though on paper all these hospitals are having a well laid down referral system but in practice this is not very meticulously followed. Study to Review The Health Care Delivery System provided by PHSC, Punjab 119 b) c) Mostly the patients are transferred from the lower health centre to the higher centre without any feedback loop. No guidelines are available at the facilities for “whom to refer”, “how to refer” “when to refer” and “where to refer”. 10.1.8 Medical records An analysis of all medical records revealed the following: a) b) c) None of the hospitals were having a properly planned and organised Medical Record Department. All the data and statistics from Medical records were found to be maintained manually. None of the Medical Record Departments were found to be computerised. Most of the case-sheets kept in the Medical Record Departments were found to be incomplete and mostly not maintained as per any definite standard indexing/procedure. 10.1.9 Stores management a) b) c) d) The Medical Store management was not found to be very organised, and following the modern techniques of store management. In almost all the hospitals, only few medicines could be found in the medical stores of health facilities. The record maintenance of the stores was not found to be in proper order and they were not maintaining any “Buffer Stock” or calculating the “Reorder Level”. The scientific ‘Inventory Control Techniques’ were not practiced in any of the stores visited and the staff was also not having much knowledge about these techniques. 10.1.10 Diet services a) b) None of the hospitals were providing regular diet to their in-patients, except in one Subdivisional hospital (Meler Kotla). It has been suggested that if the patients are provided diet from the hospitals, this would be highly appreciated. 10.1.11 Basic facilities a) The relatives of the patients, particularly those who are coming from distant places, were not having any proper place to stay (Dharmshala) and were having no access to other facilities like toilet, kitchen etc. As a result they were found loitering all over the places in and around the hospital. Similarly, the basic facilities like toilets, particularly separate toilets for ladies were not available in every OPD. These facilities must also have other services like STD booths, canteen and subsidised chemist shop. Residential accommodation available was not found to be fully utilised, mostly due to poor maintenance of residential accommodation. Study to Review The Health Care Delivery System provided by PHSC, Punjab b) c) d) 120 10.1.12 Rogi Kalyan Samiti a) Though on papers Rogi Kalyan Samitis existed in all the hospitals, but due to their internal administrative problems and non fulfilment of the required pre-requisites, these Samitis were found to be non functional or yet to be made functional in almost all the hospitals. Funds under these Samitis were found to be un-utilised in all these hospitals. b) 10.2 Views of the Beneficiaries A total of 580 respondents were interviewed in the outpatient department and 224 respondents from inpatient departments of various health institutions like CHCs, Sub-divisional hospitals, District hospitals and two Special Hospitals of Punjab Health System Corporation to obtain their opinion about the available health services. 10.2.1 Socio-economic dimension of the respondents a) Majority of respondents utilising PHSC were females having poor education and low income in age group of 15-30 years. 10.2.2 User charges a) Majority of the respondents were paying user charges for getting OPD card and for getting investigations done. More than 3/4th of respondents were paying the charges for making slip/card required for admission. 10.2.3 Admission procedure a) b) 77.7% of the respondents were not satisfied with the admission procedures and 86.2% of respondents at CHC and 81% at sub divisional hospitals rated it poor. Only half of the respondents were informed about rules and regulation of these health facilities regarding admission procedures. 10.2.4 General cleanliness and comfort in wards a) b) Overall ratings of general cleanliness of the OPD along with basic facilities were found to be better in the Special Hospitals and the same was comparatively lower in the CHCs. According to the findings, 66.5% rated general cleanliness of wards and beds as good whereas 44.2% respondents rated it average. 66.5% respondents had perceived the cleanliness of bed linen as good, while 30.8% respondents perceived it average. There is a need to improve the general cleanliness and cleanliness of linen in Sub-divisional hospitals and District hospitals. Out of various health institutions 74.1% respondents perceived that the level of comfort in the wards was good but 30% perceived comfort as average, with better comfort in CHCs and special hospitals. c) d) Study to Review The Health Care Delivery System provided by PHSC, Punjab 121 e) Only 47.3% respondents perceived that toilets were clean. This was further low in case of District Hospitals and Sub divisional hospitals. 10.2.5 Availability of basic facilities a) Facilities like fan and lights were found to be good according to 75.7% of respondents in OPD and 79.5% for inpatients. These facilities were not up to the mark in OPD of CHCs, although it was good in wards of CHC. District hospitals need improvement for both outpatients and inpatients services. STD/PCO booths were not present in 57% of health institutions and only 16.7% of CHCs were having STD/PCO booths out of these health institutions. 14% of health institutions were not having a separate toilet facility which was 23.7% in case of CHCs. 11% of health institutions were lacking in drinking water facilities and again CHCs were lacking more in context of this facility. Separate toilet facilities need to be made available to the female respondents, particularly when more number of females are utilising the services of the OPD of various institutions. 16.7% of CHCs were not having screens in the examination room. b) c) 10.2.6 Adequacy of information about disease and treatment a) Among OPD patients, 81.4% said that adequacy of information given to them about their disease and treatment by doctor was good. 69.2% inpatients reported the adequacy of information as good. In the case of OPD, information given was least in CHCs as compared to other institutions, but on the contrary, CHCs were found better in case of inpatient services. 10.2.7 Availability of medicines a) Only 10.3% respondents stated that all medicines are available in the OPD and 26.4% stated that none of the medicines are available in the OPD. When the percentage was seen separately in the various health institutions than the availability of medicines was more in Sub-divisional hospitals and least in District hospitals. In case of Inpatient department, only 13.4% respondents stated that all the medicines are available and 29% respondents stated that none of the medicine were available in the wards. When the percentage was seen separately in the various health institutions then availability of medicines was found to be more in Special hospitals and least in Sub-divisional hospitals. Among the in-patients, 91.1% respondents were found to have spent money on medicines and in case of different health institutions, the percentage of respondents who spent money on medicines was as high as 100% at Sub-divisional hospitals and up to 69% at CHCs. b) c) 10.2.8 Availability of diagnostic facilities a) Out of all respondents interviewed at OPD, 50.7% stated that the facilities like laboratory and radiological investigations are good. In case of inpatients, 65.6% stated that the facilities such as laboratory and radiological investigations are good. 122 Study to Review The Health Care Delivery System provided by PHSC, Punjab 10.2.9 Availability and behaviour of doctors, nurses and staff a) Overall availability of doctors as stated by the respondents at the health institutions was 94.8% and when respondents were asked about doctor’s behaviour towards them, 91.4% respondents from OPD and 93.3% from in patient departments stated that doctor’s behaviour is good. Availability and behaviour of staff was found to be similar in case of specialists. When percentage availability of doctors and specialists were seen separately, then it was found lower in case of CHCs and District Hospitals among all the institutions. Availability and behaviour of nurses was not found to be as good as in case of doctors. Availability of nurses was found to be 79% and good behaviour of nurses in OPD as 64.5%. On the other hand 80.4% nurse’s behaviour was good in the in-patient department of various health institutions with lowest in Sub-Divisional Hospitals (67%). Overall 56.9% staff member’s behaviour was perceived as good by the respondents in the OPD of various institutions, which was 74% in case of in-patient services. Behaviour of staff was rated lowest in CHCs as compared to other health institutions. In case of OPD 2.9% respondents had to pay to staff members of the hospitals other than user fees for getting services. b) c) d) e) 10.2.10 Waiting time in OPD a) Time spent in waiting for specialist consultation in the OPD was less than 15 minutes for 63.4% respondents and more than 30 minutes for other 13.9%. In case of investigations, 83.6% respondents were found to have waited for 15 minutes and 6.5%% for more than 30 minutes. Waiting time for getting the medicine in the OPD was up to 10 minutes for 80.8% respondents. Patients at District Hospitals and special hospitals were found to have waited for more time period. b) 10.2.11 Security in the in-patient department a) b) Only 46.4% respondents of all the health institutions perceived that the security at these facilities is good, whereas 17% respondents perceived it poor. It means that more than half of the respondents did not feel adequately secure in the inpatient department. Security in the health institutions needs to be improved with more focus on CHCs and sub divisional hospitals. 10.2.12 Quality of care a) Overall 75.9% of OPD and 79% of in-patient respondents rated the quality of treatment in the hospitals as good. CHCs and Sub-Divisional Hospitals were rated low in quality in comparison to the other institutions. Overall 77.9% respondents in OPD were satisfied with the services of various health institutions. However, only 2.3% respondents were fully satisfied with the services of the out-patient department. 22.1% respondents were not satisfied with the services available at the health institutions. 94.2% respondents of the in-patient department were satisfied and b) Study to Review The Health Care Delivery System provided by PHSC, Punjab 123 c) d) only 5.8% were not satisfied with the services of the health institutions. Overall rating about the cooperation at the reception counter of the various institutions was found to be good, but CHCs need to have improvement in this regard. 70% respondents rated their experience at OPD as good and this proportion is only 57% at CHCs. This indicates that services at CHCs need overall improvement. 10.2.13 To sum up a) b) Majority of respondents utilising PHSC were females having poor education and low income levels. Patients approach mainly PHSC for utilisation of emergency services. This may be because at that time they do not have access to other health facilities and they have no other alternative left due to economic reasons. General cleanliness and cleanliness of linen in Sub-Divisional Hospitals and District Hospitals need to be improved. Overall behaviour of doctors, nurses and other staff members in the health institutions was stated to be good by majority of the respondents. Only a minor proportion of them rated it unsatisfactory. Majority of the respondents stated that the medicines are not available, and that they have to buy it from market, as advised by doctors. More than half of the respondents did not feel adequately secure in the in-patient department. Security in the health institutions needs to be improved. Availability of basic facilities, in general, was not very satisfactory in all type of health institutions and particularly in District Hospitals and CHCs. These include: Availability of STD/PCO booth, Better toilet facilities and mainly separate toilets for women in all types of health institutions, Availability of safe drinking water, Availability of screen in the examination room. Behaviour of staff members in the OPDs was not rated to be satisfactory by majority of the respondents. A good percentage of respondents stated that availability of doctors, nurses and staff in the OPDs is good, except at CHCs. However, the finding on the similar issue in the community was very different. Rather this was reported to be as one of the major issues underlying low utilisation of health services provided by PHSC. The facilities like laboratory and radiological investigations were not rated to be satisfactory by majority of the respondents as most of the time these facilities are not available. Because of this, patients are forced to go to private facilities to get the required investigations done. Overall experience of respondents at OPDs of the various health institutions under study was not found to be very satisfactory. This observation holds true in particular for CHCs and District hospitals and needs further attention. A good percentage of respondents felt that the quality of treatment in the hospitals needs to be improved, mainly in the CHCs, as these are in the rural areas and mostly the community was not having any other alternative option for health care. Study to Review The Health Care Delivery System provided by PHSC, Punjab c) d) e) f) g) h) i) j) k) l) 124 10.3 Views of the Community based on Focus Group Discussions The following observations are noted based on focus group discussion in the community: a) General administration of the hospital needs rectification. This includes cleanliness, recruitment of the staff, doctors with specialties, drinking water arrangement, toilets on all the floors & wards, electricity (lightening arrangement), generator, water tank, timely repair of accessories and machines etc. b) All necessary medicines should be provided by the hospital. If not possible, at least the BPL families should get this facility. For the other patients subsidised medicines can also be a good option. c) At least in the emergency situation hospital should provide every facility like diagnostic services or medicines. d) Provision for laboratory and ultrasound should also be in perfect situation. e) Surgeons can be arranged for emergencies on call. f) Fee for the diagnostic tests should also be subsidised. g) There is a need to organise community campaigns such as camps, health melas, health education etc. especially in far-flung areas. h) Local community participation should be enhanced for utilisation of health services. i) For strengthening emergency services, ambulances need to be arranged at very minimum rates. j) Doctor on emergency duty should be available for 24 hours a day. k) The private practice of the Government doctors should be stopped. l) Every village should have a trained dai and a lady doctor. m) It was desired that at least delivery facility for pregnant women should be provided by the government free of cost. n) If all the facilities with the good doctors were available people would prefer to utilise those health facilities o) It was observed in the discussion that the parishad CHCs were more popular in the areas as compared to the PHSCs/CHCs. 10.4 Views of other Stakeholders The view of the other stakeholders is as given below: i) More infrastructure facilities and equipments need to be provided. ii) Salaries of doctors are not very lucrative as a result they go for private practice. iii) More contractual employees are required – especially class IV and lab technicians. iv) Public Private Partnership model needs to be introduced. v) Telemedicine should be promoted. vi) Performance linked appraisal should be adopted. vii) Number and quality of drugs need to be increased and improved for increasing acceptance of the services. viii) Paid wards should be started. Study to Review The Health Care Delivery System provided by PHSC, Punjab 125 ix) x) xi) xii) Transport services should be improved. Health insurance should be made available for poor patients. Cleanliness should be emphasised. More equipment for diagnostic facility (i.e. CT Scan, MRI) should be made available for poor patients. xiii) More number of ambulances should be made available. xiv) A separate vehicle should be made available for SMO for field visits. xv) Extra water facility and clean, treated water should be provided. xvi) Security guards must be recruited to improve security of in patients. xvii) Plantation in and around hospital complex should be increased. xviii) Night and emergency services should be improved and more doctors should be made available. xix) The 50 bedded hospitals need to be upgraded to 100 beds to meet the community needs. xx) Generators with more power and capacity should be made available to improve functioning, as frequent power failure is a perpetual problem in many areas. xxi) Technician for Ultrasound must be recruited. xxii) Vacant staff positions should be filled up. xxiii) Regular training should be provided to the staff. xxiv) Repair and maintenance of staff quarters should be done. xxv) Manpower shortage especially that of radiologist, anaesthetist, paediatrician and gynaecologist and obstetrician, along with class IV employees, should be seriously looked into. xxvi) Fully equipped ambulance and CT scan should be provided. xxvii) There should be provision of a seminar room. xxviii) Facility in charge should be given authority to cut down on non-performing staff. xxix) Security services should be provided on contract. xxx) Costly equipments should have AMC. xxxi) Awareness of services should be done through media. 126 Study to Review The Health Care Delivery System provided by PHSC, Punjab 11.0 Conclusion and Recommen- Based on above quantitative, qualitative and triangulation of data, the following recommendations are proposed: 11.1 Human Resource a) b) c) d) e) An assessment may be done for the State of Punjab to find out the staff position for all categories of health workers including doctors. An exercise to find out the strength of the sanctioned and vacant posts needs to be undertaken. Urgent efforts may be made to fill up the vacant positions. Two separate cadres for the doctors i.e. one for GDMOs and one for specialists instead of having only one single cadre of Medical Officers should be created. Category wise GIS mapping of all types of human resources including Medical officers and various Specialists for all the Health Institutions may be done for the entire state. By this exercise, a clear picture will emerge regarding the exact availability against the requirement of each category of health personnel. It is suggested that PHSC may take policy decisions whereby all the doctors are paid a basic minimum salary so as to motivate them to work at government health facilities. This exercise will help in planning and recruitment of the required specialists and GDMOs. Moreover based on the norms of IPHS, posts for GDMOs and other essential categories of specialists may be created and filled up. Availability of basic specialists in the respective health centres will surely build up the confidence among the community and hence result in increased utilisation of services. Separate administrative cadre may be developed for the administrative posts of district, sub-division and CHCs so that a full time and well qualified/trained doctor can be assigned to these jobs. A specialist may not be given this responsibility by virtue of his/her seniority as this effects his clinical practice in the hospital. As reported, the salaries of the doctors under PHSC were not at par with the private sector and this could be one of the reasons for high attrition rate among the doctors. Performance based incentives may be considered not only for retaining the existing specialists, but also State may explore the possibility of involvement of private practitioners under public private partnership as per market rate. This exercise can be done under human resource innovation which is one of the components in NRHM. A similar performance assessment system was already in practice i.e. ‘Bench Marking’. Also, by this method, it may be easier to retain the specialist category of radiology, anaesthesia, paediatric, gynaecology etc. f) g) h) i) j) k) l) Study to Review The Health Care Delivery System provided by PHSC, Punjab 127 11.2 Availability of Drugs a) At all the health care institutions, the beneficiaries reported to have expectations that the medicines, particularly the vital ones, should be provided by the health centre. Moreover, it becomes a moral obligation for the authorities to provide at least the vital and essential medicines. Hence, the availability of these medicines specially the vital and essential ones should be necessary in all health facilities.. Therefore it is recommended that every health centre should prepare the list of medicines (drug formulary) to be used at that centre and the same to be sent to their concerned authorities for procurement/indent. At the State level, these lists of drugs, coming from various types of health facilities through their respective district headquarters to be compiled and a common list to be prepared. By applying scientific Inventory Control Techniques of ABC and VED analysis, they should find out the list of all the vital and essential drugs and the costlier one (which shall not be more than 20% of the total procured drugs). These medicines should be procured through state level and distributed to the districts for onwards supply. Alternatively the state may fix up the rate contract of each item after following the laid down procurement procedures for drug items and supply this information with the required authority letter to the respective districts so that they can directly procure these medicines from the suppliers at the rate fixed by the state. In this way, the state headquarters need not to worry about their budget and every district health centre and below will be procuring these medicines by using funds of Rogi Kalyan Samitis or user charges. By this partial de-centralised procurement, the availability of the medicines will definitely improve and quality of the medicines can also be ensured. Every hospital/health centre should have proper antibiotic policy and standard treatment guidelines. There should be regular practice of prescription audit. b) c) d) e) f) g) h) i) j) k) 11.3 Community Education and Community Rights Regarding Health Facilities a) Every hospital/health centre should clearly display the citizen charter and the name, designation and telephone numbers of the concerned officers to whom they can approach at the time of any dispute or complaint. The beneficiaries should also be informed about the routine procedures they are expected to follow in that health centre and their rights. b) 11.4 Cleanliness a) Special efforts should be taken to maintain the cleanliness of the hospital. CHCs should focus more on this so that it is at par with basic required standards. 128 Study to Review The Health Care Delivery System provided by PHSC, Punjab b) c) d) e) f) The general up keep of surroundings of the hospital should also be maintained properly. For this reason, special efforts should be taken for regular repair, maintenance and landscaping. The toilets should be kept clean and the drainage system in particular to be flushed routinely at regular intervals. Drainage system should be regularly cleaned and monitored. For the support staff a training capsule having role and responsibilities\ including basics of hygiene and sanitation, preventive and promotive health care, motivation, attitudinal changes, services available in the health facility may be developed and continuing exercise should be regularly undertaken. For house keeping and sanitation, the services may be out sourced and may be given to the professional organisation like sulabh etc. A separate toilet for the females should be there in the OPDs of every hospital/health centre. 11.5 Diagnostic Facilities a) b) c) d) Efforts should be made to ensure that all the required reagents and equipments in the laboratories are available. For those special investigations, which are not carried out in the respective centres, the authorities should tie up with the private laboratories at pre-negotiated fixed rates. With these arrangements, the beneficiaries can be referred to these laboratories and they will not end up paying a higher price. Even for the poor patients, respective health centre may pay their charges from the funds available from user charges/Rogi Kalyan Samitis. 11.6 Medical Record Department a) For any good administration, the correct and timely information is very important. This information can only be made available, if the respective data is generated in outpatient and In-door facilities. Hence, to have proper information, every hospital needs to have a well planned and organised medical record department. The information in medical records, helps hospital administrator to monitor the utilisation pattern of their respective hospital and to help them to take required necessary decision for improvement. The following observations are made in this regard: • All the case sheets and medical records pertaining to patient care is required to be maintained following some standard indexing system so that in future, retrieval becomes easy. • Every hospital should come out with the routine statistical bulletin, which should include some of the important Hospital Utilisation Indices like bed occupancy rate, average length of stay, bed turnover interval, gross and net death rate etc. 11.7 Emergency Services a) Due to paucity of doctors and other support staff in various hospitals, the emergency services are not functioning properly. This creates a problem for the community Study to Review The Health Care Delivery System provided by PHSC, Punjab 129 b) c) (especially for the poor population) who are forced to go to the private sector for availing emergency services. This calls for taking into account, that the emergency services are taken very seriously and action needs to be taken immediately. To start with, doctors may be posted in these hospitals, particularly at sub divisional hospital and CHC, exclusively to run emergency services. 11.8 Maternity Services a) Emergency obstetric services: Non-availability of satisfactory obstetric services is another major drawback in the system. The community is compelled to seek care from the private sector due to the non availability of emergency obstetric services in the public sector. Main reasons found out for this was non-availability of gynaecology and obstetrics specialists. Hence efforts should be made to ensure that every hospital upto CHC level has atleast one gynaecologist with all required facilities. A model of public private partnership like the one followed in Gujarat (Chiranjeevi scheme) may be looked into for strengthening the maternity services. b) c) d) 11.9 Other Aspects a) b) c) d) e) f) Admission procedures need improvement with more focus on CHC and sub divisional hospitals. Rules and regulations of health institutions should be properly informed to the patients. Cleanliness of linen in Sub-Divisional Hospitals and District Hospitals needs to be improved. STD/PCO booth to be installed for convenience of the patients and relatives as per IPHS standards and NRHM. CHCs were lacking in many facilities and PHSC should look into this matter immediately to provide quality service to rural people. Inpatients should also be provided by adequate information regarding disease and treatment. The inclination of community to use private services is due to ensured availability of the services including holidays, at night, clean environment and at a time convenient to the people in the community. Hence to increase the utilisation of the facilities, evening OPDs may be started. On the experimental basis, it may be made as pay clinics, with the choice of the patient to select the doctor. A good share of the earning (say about 60-70%) from these pay clinics may be paid to the doctors. The amount paid to the doctors as honorarium may be in consonance to the number of patients they are attending. Proper and well maintained residential accommodation for doctors and other staff may be provided at all levels of health centres. Security in the health institutions needs to be improved with more focus on CHCs and sub divisional hospitals. g) h) i) j) k) 130 Study to Review The Health Care Delivery System provided by PHSC, Punjab l) Every Hospital should have a hospital infection control committee. m) There should be a regular grand clinical rounds for all the health centres i.e. CHCs and above. This should be attended by all the doctors. Hence, to sum up, the utilisation of health care services will definitely improve if along with the availability of doctors and required specialists, the medicines (at least the vital ones), basic laboratory and radiological investigations are made available. Further, the emergency services and the delivery services could be improved and made available round the clock for the satisfaction of the community. This would result in increased utilisation of the facilities provided by PHSC. Study to Review The Health Care Delivery System provided by PHSC, Punjab 131 Table 1.1. General Profile and Facility Survey of District Hospitals Name of the District Amritsar Yes 2 1 Yes 50 Municipal supply Adequate 1 1 3 3 2 3 2 Inadequate Adequate Adequate Adequate Adequate Adequate Inadequate 3 Bore well Bore well Bore well Bore well Municipal supply Municipal supply Canal water 100 200 60 100 -300 -200 100 164Bore well Adequate 3 Yes Yes Yes Yes Yes Yes Yes Yes 1 2 1 1 3 4 2 1 1 Yes 100 Municipal supply Adequate 3 3 3 2 3 3 2 3 1 1 Yes Yes Yes Yes Yes Yes No Yes Yes Yes 2 3 Yes 50 Bore well Adequate 3 Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda Yes 3 1 Yes 60 Bore well Adequate 1 132 Irregular Phasethree Available Yes Yes Good Good Good Poor Good Good Good Good Average Good Good Good Good Average Good Average Yes Yes Yes Yes Good Good Good Good Yes No No No Available Available Available Available Available Yes Yes Good Good Good Good Phasethree Phasethree Phasethree Phase-three Phasethree Regular Regular Regular Regular Regular Regular Phasethree Available No Yes Average Average Average Average Irregular Phasethree Available No Yes Good Good Good Good Regular Phasethree Available No Yes Good Good Good Good Regular Phasethree Available Yes Yes Average Average poor Average Irregular Phasedouble Available No Yes Average Average Good Average Regular Phasethree No Yes Average Average Average Good Accessibility to Railway/ Bus Station Study to Review Distance from Rail Station km Distance from Bus Station km All Weather Roads Bed Strength Source of Water Supply Water Supply (Quantity) The Health Care Delivery System provided by PHSC, Punjab Water Supply (storage capacity available for no. of days) Electricity (supply) Electricity (phase) Electricity (Backup Generator /UPS Available ) Available If more than one storey building (Lift Available) If more than one storey building (Ramp Available ) General Impression- up keep of garden General Impressioncleanliness General Impression- sign posting General Impression- roads and lighting (Contd...) Name of the District Amritsar Good No Good No No No No No Good No Average Good Good Good Good Average Good Good Average No Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran Average No SH Bhatinda Good Good General Impression- State of Building Any Public Utility Service available in Hospital Premises Yes Yes No Yes No No Yes Yes Yes Any public Utility Service Available in Hospital Premises-Chemist Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Any Public Utility Service available in Hospital Premises-Sulabh Sauchalaya No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Any Public Utility Service Available in Hospital Premises-Canteen No No Yes Yes Yes Yes No Yes Yes No Yes Any Public Utility Service Available in Hospital Premises-STD/PCO booth Yes Partially Equipped 1 1 4 Yes 8 6 Yes No NA 3 1 1 1 1 2 Yes 6 10 5 3 Fully Equipped Fully Equipped Partially Equipped Yes Yes Yes Yes Partially Equipped 4 1 3 No NA Yes No Yes No No No Ambulance Services Yes Partially Equipped 4 4 4 Yes 10 Yes Partially Equipped 3 1 2 Yes 4 Yes Partially Equipped 2 3 3 No NA Yes Fully Equipped 1 1 2 No NA Yes Partially Equipped 3 1 1 Yes 5 Yes Fully Equipped 2 1 2 No NA Yes Partially Equipped 1 1 1 No NA Ambulance Services if available Total Number of Vehicles (Nos.) No. of Operation TheatresMinor (Nos.) No. of Operation TheatresMajor (Nos.) ICU types Study to Review The Health Care Delivery System provided by PHSC, Punjab ICU no. of beds 133 (Contd...) 134 Name of the District Amritsar Round the Clock Yes Yes No No Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Round the Clock Round the Clock Round the Clock Round the Clock Round the Clock Round the Clock Round the Clock Restricted Round the Clock Round the Clock Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran No Yes No No No No Yes Yes Yes Yes Push 50 50 40 50 70 100-indoor 5-10-OPD No Yes Yes Yes No No No No Yes Yes Yes Yes No Yes No No No Yes No No No No No Yes 60 50 90 100 Push Pull Pull Push Pull 40 40 No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Push Yes Yes Yes Yes Yes Yes No No Yes Yes Yes No Yes Yes Yes No Push 50 25 No No Yes Yes No No No No No Yes No Yes No No Yes No No Yes No Yes Pull 20 75 No No No Yes Yes Yes Push 50 50 Yes Yes Yes Yes Yes No Push No No No Yes Yes No Pull 60 70 SH Bhatinda Round the Clock Emergency Services Dental Services Study to Review Delivery Services Facilities for Post-mortem Mortuary services with cold storage & other preservative facilities available. Drug formulary committee Hospital Antibiotic committee Hospital Infection Control Committee. The Health Care Delivery System provided by PHSC, Punjab Store Purchase Committee Store verification Committee Medical Audit/ Death Review Committee System of Supply of Drug items through % of Drug items asked for is supplied % of patients getting all the medicines prescribed Is the drug formulary available Is buffer stock maintained (Contd...) Name of the District Amritsar Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran Yes SH Bhatinda Yes Annual maintenance procedure for costly Equipments Yes Yes Yes Yes Yes Yes Yes Yes Yes Log book/ History sheet maintained for the Equipments Good Good Good Good Good Good Good Good No No Yes Present status/situations of the existing Equipments: Good Good Good Good Study to Review The Health Care Delivery System provided by PHSC, Punjab 135 Table 1.2 Facilities Available at District Hospitals Name of the District Bhatinda No NA Yes Functional Yes Non Yes Non Functional No NA Yes Functional Yes Functional No No Yes Yes Yes Non Functional Functional Functional Yes Yes Yes Yes Yes Functional Yes Non Functional Functional Functional Functional Yes Yes Yes Yes Yes Yes Functional Yes Functional Yes NA NA NA NA NA NA No No No No No No No NA Yes Functional No NA No Functional Functional Functional Functional Functional Functional Yes Yes Yes Yes Yes Yes Yes Functional Functional Functional Functional Functional Functional Functional Yes Yes Yes Yes Yes Yes Yes Yes Functional Yes Functional No NA Yes Functional Yes Functional No Functional Functional Functional Functional Functional Functional Functional Yes Yes Yes Yes Yes Yes Yes Yes Yes Functional Yes Non Functional Yes Functional No NA Yes Functional Yes Functional No NA Non Functional Functional Functional Functional Non Functional Functional NA Functional No Yes Yes Yes Yes Yes Yes No Yes Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional No Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda Yes Functional Yes Functional Yes Functional No N Yes Functional Yes Functional Yes Functional No 136 NA Yes Functional Functional Yes Yes Yes Functional NA Functional Non Functional Functional Yes Functional Functional Yes Functional Functional Yes Functional NA Yes Functional NA Yes Functional NA Yes Functional NA Yes Functional NA No NA Baby Incubators Study to Review Baby Incubators Boyles Apparatus Boyles Apparatus Cardiac Monitor Cardiac Monitor Dental Chair Dental Chair Dosimeter The Health Care Delivery System provided by PHSC, Punjab Dosimeter ECG ECG Emergency Resuscitation Kit Emergency Resuscitation Kit Endoscope (fiber optic) Endoscope(fiber optic) Ophthalmo-scopes Ophthalmo-scopes (Contd...) Name of the District Bhatinda No NA Yes Functional Yes Functional No NA No NA Yes Yes Yes Yes Yes Functional Functional Functional Functional Yes Yes Yes Yes Yes Non Functional Non Functional Functional Functional Functional Functional Yes Functional Yes Yes Yes Yes Yes Yes Yes Non Functional Functional Functional Functional Functional Functional No NA No NA Yes Yes Yes Yes Yes Yes Yes Yes Functional Functional Functional Functional Functional NA Yes Yes Yes Yes Yes Yes No Yes Functional Yes Functional Yes Functional No NA No NA NA Functional Functional Functional Functional Functional Functional No No Yes Yes Yes Yes No Yes No NA Yes Functional No NA Yes Functional No NA Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran No NA Yes Functional Yes Functional No NA Yes Functional Yes SH Bhatinda No NA Yes Functional No NA Yes Non Functional No NA No Perimeter Perimeter Photo Therapy Unit Photo Therapy Unit Retinoscope Retinoscope Short Wave Diathermy (Physio therapy) Short Wave Diathermy (Physio therapy) Sigmoidoscopes Sigmoidoscopes Slit lamp Functional Yes Functional Yes Functional Yes Functional Yes Yes Yes Yes Functional Yes Functional Yes Yes Yes Functional Yes Functional Yes Functional Functional Yes Yes Yes Functional Functional Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Yes NA Yes Functional Yes Functional Functional No NA Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes NA No NA Yes Functional Yes Functional Yes Slit lamp Ultra sound Ultra sound X ray X ray Other Major and Minor Operation equipments Study to Review The Health Care Delivery System provided by PHSC, Punjab Other Major and Minor Operation equipments Any Referral System in place 137 (Contd...) 138 Name of the District Bhatinda No No No No No No Yes Yes No NA Higher Centre Vehicle provide to Medical College No Yes Vehicle with colour card No Medical College Colour coded card-Medical college No NA Vehicle provided NA NA Vehicle provided No proper Answer Higher Centre No Yes No No Yes Yes No NA With referral card Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No NA PGI Chandigarh No No No Yes Yes Yes No No Yes Yes Yes No Yes Yes Yes No No Yes Yes Yes Yes Yes Yes No Yes No No Yes Yes No NA Refer to Patiala No Yes Yes No Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes No Yes No No No No No Yes Yes Yes No proper Answer Refer to Medical College No No Yes No Yes Yes Yes Yes Yes No No No No Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran No No No No Yes No Yes No Yes No Yes Yes Yes None Other Government Hospitals Medical College Medical College & Other Government Hospitals No None Private Hospitals Pvt. Hospitals None None None 1 2 No Yes Yes No No Yes No No No No Yes SH Bhatinda Referral manual available Guidelines for- What to refer Study to Review Guidelines-When to refer Guidelines- How to refer Colour coded referral cards available Feed-back Mechanism existing: Transport facility provided: Maintenance of records/ registers Incentive for following referral route The Health Care Delivery System provided by PHSC, Punjab If Yes, what No Answer Not Serve Procedure followed for referral: Tie-up with other hospital (both public and pvt) for diagnostic Hospital has a tie-up with: (Medical College/ other government/ pvt. institutions) Does the Hospital have any Outreach Area (Contd...) Name of the District Bhatinda Available No No Yes Yes Yes Yes Yes Yes No Yes Yes No No No Yes No No No Not Available Not Available Not Available Available Not Available Not Available Not Available Available Yes Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran Not Available No Yes SH Bhatinda Not Available Yes Yes Statistical Bulletin: Availability of dharamshala Availability of residential accommodation for the essential NA 80 0 0 50 15 50 NA if available, what % is not getting accommodation (In % ) Contractual In house In house In house In house Contractual Contractual NA 40 40 70 90 Security arrangement: In house In house In house In house Study to Review The Health Care Delivery System provided by PHSC, Punjab 139 Table 1.3 Laboratory Tests Name of the District Bhatinda Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda No 140 Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes No Yes No Yes Yes Yes Yes Yes No Yes No Yes No No Yes Yes No Yes Yes Amritsar Study to Review Complete Blood Haemogram Analysis Yes Complete Urine Examination Yes stool test Yes Blood urea Yes Blood sugar Yes Liver function test Yes Lipid profile Yes PAP smear Yes FNAC Yes The Health Care Delivery System provided by PHSC, Punjab Blood Grouping and Matching test Yes Biopsy test No Culture and smear examination Yes Semen Examination Yes Vaginal discharge examination Yes Bone Marrow Examination No VDRL test Yes Other routine tests. Yes Table 1.4 Out Patient Department Name of the District Bhatinda Computerised Computerised Computerised Computerised Computerised Manual Computerised Computerised Computerised Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran Computerised SH Bhatinda Manual 3 Total Out Patient Department Amritsar Reception & Registration Counter (manual/ computerised) No No No Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No No No No No No No No No No No No No No Yes Yes Yes No No No No No Yes No Yes No Yes Yes Yes Yes Manual Managed by clerk No No No No Yes Yes Yes No No No No Yes No 2 10 1 9 12 8 Managed by MSW No Managed by staff nurse No Managed by computer operator No Knowledgeable about the OPD Yes Separate registration for male Yes Yes Yes No Yes Yes Separate registration for female Yes Yes No Yes Yes Yes No No Yes Yes Yes No 8 Separate registration for senior citizens No Yes No No Yes Yes No Yes Yes No No 8 Separate registration for staff Yes Yes Yes Yes No No No No Yes No No No 2 Registration registers are properly maintained and Yes Yes Yes No Yes Yes Yes Yes 11 Study to Review The Health Care Delivery System provided by PHSC, Punjab (Contd...) 141 142 Name of the District Bhatinda Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda 10 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 12 12 11 12 11 12 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 12 12 12 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes 12 10 Total Out Patient Department Amritsar All sections of the OPD having proper signage and directional sign Yes Study to Review Waiting area is adequate Yes Proper sitting arrangement Yes Drinking water facility Yes Ceiling Fans Yes Toilet facility Yes Doctor’s Chambers are having adequate space Yes Examination table with proper sheet Yes The Health Care Delivery System provided by PHSC, Punjab Stool for the patient to sit Yes Examination equipments (like BP apparatus Torch, hammer, etc.) Yes Adequate illumination Yes Injection Room along with facilities and to deal with Emergency situation Yes (Contd...) Name of the District Bhatinda Yes Yes Yes Yes Yes Yes Yes Yes Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran No SH Bhatinda Yes Total Out Patient Department Amritsar Minor OT / Dressing Room with all the basic Equipments Yes Yes Yes No No Yes No Yes Yes Yes 11 Dispensaries / Pharmacy with separate counters for male/female/ senior citizen Yes Yes Yes Yes Yes Yes Yes Yes No No Yes 8 Laboratory & Imaging Services easily accessible No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 12 Central Collection Centre for Laboratory Services Yes Yes No Yes Yes 10 Study to Review The Health Care Delivery System provided by PHSC, Punjab 143 Table 1.5 Emergency Medical Services (Casualty) Name of the District Bhatinda Yes Yes No Yes Yes Yes Yes Yes No Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda No 144 Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 3 4 2 0 Yes Yes Yes Yes Yes 0 1 1 2 1 Yes 2 1 1 4 5 3 3 3 5 5 2 2 1 Yes 19 3 7 10 8 4 Yes Yes Yes Yes Yes No Yes 3 0 0 0 Yes No 4 2 1 1 Yes Yes 5 2 2 1 Yes No 3 3 2 1 Yes Yes 6 2 1 2 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Study to Review Amritsar EMERGENCY MEDICAL SERVICES (CASUALTY) Separate Medical Officer(s) available round the clock Board displaying on call doctors/specialist and other staff on duty Glow sign board indicating ‘Emergency Services Department’ Emergency Ward attached to Emergency Department The Health Care Delivery System provided by PHSC, Punjab Triage area Observation Beds (fill number, for No fill 00) Trolleys (fill number, for No fill 00) Wheel chairs (fill number, for No fill 00) Examination rooms (fill number, for No fill 00) All the registers including MLR available for proper reg. Retiring room with toilets for the doctors Call book in prescribed format available (Contd...) Name of the District Bhatinda Yes Yes Yes Yes Yes Yes Yes Yes Yes Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran No SH Bhatinda Yes Amritsar Yes Waiting area for the attendants of the patients with the basic Facilities like sitting arrangements, drinking water, toilet etc. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes No No Yes Yes Yes No No No Yes Yes Yes Public telephone available No Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Treatment room-cumminor OT Major OT Sufficient stock of essential and life saving drugs Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Oxygen cylinders with attachments Yes No Yes Yes Yes Yes Yes No Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Laboratory services Radiology Services Ambulance services Staff trained in BLS Treatment facilities for Dog/ snake bite & Poisoning No No Yes Yes Yes No No No No No No No Availability of Disaster manual Yes Yes Yes Yes Yes Yes No No Yes No No Yes No No No No No Yes No No No No No No Study to Review Yes Yes Yes The Health Care Delivery System provided by PHSC, Punjab Disaster Alert Code, recall & deployment Maintenance of dedicated Drug store for disaster situation Plaster Room Yes No Yes No Yes No Yes No No 145 Table 1.6 Intensive Care Unit (ICU) Name of the District Amritsar No NA NA NA NA NA 0 NA 0 NA 0 0 NA 0 NA 3 NA 0 2 NA NA NA 0 NA 2 NA 0 1 NA NA Yes NA Yes NA Yes Yes NA NA Yes 0 0 0 6 NA 6 NA 10 4 NA NA 5 Yes No Yes No Yes Yes No No Yes No NA NA NA NA NA Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda No NA NA NA NA NA 146 Intensive Care Unit (ICU) Study to Review Total number of beds available: Air-conditioned ICU with generator support Staff sanctioned for the ICUno. of doctors Staff sanctioned for the ICUno. of nurses The Health Care Delivery System provided by PHSC, Punjab Staff sanctioned for the ICUno. of technical staff Table 1.7 Clinical Laboratories Name of the District Amritsar Yes Yes Yes No No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No No No Yes No No No No Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Taran Taran Yes Yes Yes No No Yes Yes Yes Yes Yes No No SH Bhatinda Yes No Yes No No Yes Yes Yes Yes Yes Yes Yes Type of laboratoriespathology Type of laboratoriesmicrobiology Qualified-Pathologist Qualified-Biochemist Qualified-Micro biologist Following the Universal Precaution Procedures Using Protective Measures i.e. gloves/gowns/masks Specimen Collection done Centrally Availability of all the Chemicals and Reagents Observing all the Biosafety measures Accuracy of the Reports Regular Internal Quality Control Measures Undertaken Yes Yes Yes Yes Study to Review The Health Care Delivery System provided by PHSC, Punjab Regular External Quality Control Measures Undertaken No Yes Yes No Yes Yes No Yes 147 Table 1.8 Blood Banking Facilities Name of the District Amritsar No NA Yes Yes Yes Yes Yes Yes Yes NA Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda No NA 148 NA Yes Yes Yes Yes Yes Yes Yes NA Yes Yes NA NA NA NA Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes NA NA NA Yes Yes Yes Yes Yes Yes NA NA NA NA Yes Yes Yes Yes Yes Yes Yes NA Yes Yes NA NA Yes Yes Yes Yes Yes Yes Yes NA Yes Yes NA Amritsar Study to Review BLOOD BANK (If No blood bank fill “8” for section E) Trained or Qualified Medical Officer Posted as B.T.O. Round the Clock Availability of Trained Staff and Services Checking & Cross Matching by B.T.O. Proper Maintenance of Cold Chain and Refrigerators The Health Care Delivery System provided by PHSC, Punjab Australia antigen, HCV, VDRL, M.P. and HIV tests done for Every Blood Bottle of donor. Efforts made to Collect Blood through Voluntary Organisation Camps Renewal of Blood Bank/ HIV License as per Rules Table 1.9 Radiology & Imaging Name of the District Amritsar Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes No No No No No No Yes No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Bhatinda Ferozpur Gurdas pur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Yes No Yes Yes No Yes Taran Taran Yes Yes Yes Yes Yes Yes SH Bhatinda Yes Yes No No No No Availability of the Dark Room with all Facilities Use of Dosimeter and they Regularly sent to BARC Special Investigation like IVP, Contrast Media etc. Round the clock availability of X-ray services/ Sonography Separate Register for MLC Records Maintenance of History Book and Log book of X-ray Machines Study to Review The Health Care Delivery System provided by PHSC, Punjab 149 Table 1.10 Operation Theatre Name of the District Amritsar 4 1 No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No No Yes 1 1 1 1 4 1 3 1 1 3 1 2 3 4 3 3 2 1 1 1 Yes Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda 2 1 Yes Yes 150 No No Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Study to Review No. of Operations Theatres- major No. of Operations Theatres- minor Zoning concepts strictly followed Emergency light or generator facilities provided to O.T. Availability of fire fighting equipments and knowledge to use them The Health Care Delivery System provided by PHSC, Punjab Regular disinfections & sterilisation procedures done at O.T. Table 1.11 In-patients Ward Name of the District Amritsar Yes Yes Yes No Yes Yes Yes Yes Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Yes Taran Taran Yes SH Bhatinda Yes Satisfactory cleanliness of the wards with adequate house keeping Yes Yes Yes Yes Yes Yes Yes Yes Yes Colour codes of Yellow, Blue, Red, White bin & Blue transparent PPF for waste collection Yes Yes Yes Yes Yes No NA NA Rare cases of Gastro & Pead. Yes No NA No Yes No No NA Yes Yes No Yes Yes No NA Yes Yes No No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Table top syringe & needle destroyer Yes Yes Yes Yes Yes No NA Yes Yes Yes Yes No No NA Yes Yes Yes Yes Yes No NA Yes Yes Yes Yes Yes No NA Proper Utilisation Adequate water supply and up keep of sanitary blocks. Adequate & Clean Toilets and Bathrooms All the beds are having proper & adequate linen Floor beds/doubling of beds in the wards if Yes, Analyse the Reason Satisfactory up Keep of cots, mattresses, bedside lockers, linen Yes Yes No Available Not Available No No Available Yes Yes Yes Yes Yes No Yes No Use of Hospital Uniforms by all Patients No Available No Available No Available No Available Yes Available No Available No Available No Available No Not Available Study to Review The Health Care Delivery System provided by PHSC, Punjab Availability and Functioning of Suction apparatus (Electric & Foot Operated) (Contd...) 151 152 Name of the District Amritsar Functional Available Available Available Available Available Available Available Available Available Available Available NA Functional Functional Functional Functional Functional Functional Functional Functional Not Functional Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran NA available Functional Available Not Available NA Available Available Available Available Available Available Available Functional NA NA Functional NA Functional Functional Available Available Not Available Not Available Available Not Available Available Available Functional Functional Functional Functional Functional Functional Functional Functional Functional Available Functional Not Available Functional Available NA Available Not Available NA Available Functional Available Functional Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No Own arrangement No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Functional Functional Functional Functional Functional Functional Functional Yes Yes Yes No Yes Yes Functional No Yes Yes No Yes Yes Functional No Yes Yes No Yes Yes Functional No No Yes No No No Yes Yes Yes Yes Yes Yes SH Bhatinda If available (Functional/ Not) Study to Review Availability and functioning of oxygen cylinder with accessories If available (functional) Functional Availability and functioning of venesection tray, LP, tracheotomy tray. If available (functional) Availability and functioning of emergency light, wheel chair, trolley If available (functional) Functional The Health Care Delivery System provided by PHSC, Punjab Stationeries, forms, upto date various registers etc. Concept of progressive patient care Adequacy and working of fans and lights Satisfactory availability of diet, Quality of care Maintenance of various registers, records, etc. Table 1.12 Hospital Medical Stores Name of the District Amritsar Yes Yes Yes Yes Yes Yes No Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Yes Taran Taran Yes SH Bhatinda No Medical store suitably located with adequate space and protection of drugs and nondrugs items from pilferage, temperature, humidity Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Restriction on entry for unauthorised personnel’s Yes No No Yes No Yes Yes Yes Yes Staff knowledgeable in materials management Inspection of stores by the Civil Surgeon / M.O. I/c at regular interval to verify stock books Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Availability of Vital, essential drugs in sufficient Quantity Yes No Yes No No No Yes No Yes No Upkeep of expiry date register and its regular inspection by MO I/c No Yes Yes No Yes Efforts made to redistribute large stock of slow moving drugs or near expiry for its utilisation. Yes No Yes No Yes Yes Yes No Yes Yes Proper arrangements to keep the drugs as per ABC/VED category and storage of rubber goods as per guidelines Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No No No No Appropriate steps taken to prevent pilferage of Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Study to Review The Health Care Delivery System provided by PHSC, Punjab A convenient arrangement of issuing drugs to various (Contd...) 153 154 Name of the District Amritsar No Yes No Yes Yes Yes No No No No Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No No Yes No Yes No No Yes Yes Yes No Yes No Yes No No No No Yes Yes No Yes No Yes No No Yes Yes No No Yes Yes Yes No No No Yes No No No No No No No Yes No No SH Bhatinda Study to Review Regular sending of samples to No chemical laboratory to check it as per specification and standard & action taken thereon Circulation of lists of available drugs to all the MOs, OPD& wards as per generic names Submission of certified bills to office for release of payments within three days. Auction to clear the empty material from store done regularly. The Health Care Delivery System provided by PHSC, Punjab Availability of Fire Fighting equipments and knowledge of staff to operate it Availability of regularly updated Hospital Drug Formulary Existence of standing Drug Committee Table 1.13 Medical Record Department Name of the District Amritsar pur No Yes Yes Yes Yes Yes No Yes No Yes No Yes Bhatinda Ferozpur Gurdas pur Hoshiar Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda Availability of Medical Record Room with enough number of racks No No Yes Yes No Yes No No No No No Yes No No No Yes Medical record No Yes No No No Yes No Yes Is it managed by a trained medical record officer / technician or No No No No Yes Yes Yes Case record is maintained as per WHO classification of diseases (ICD-X) Yes 7 No No new & old crno., alpha index No Yes Yes Yes No No As per admission No. & year wise Admission No., bundle of 100 No Yes No Yes Computer 15 10 10 5 5 No backup No Yes Yes Yes Yes Yes No No No Yes Regular submission of the morbidity, mortality reports Yes 10 No Yes 14 Manual No Yes 10 Yes Yes Yes 10 Yes No No 10 No No Yes 5 No No For what duration all the records being maintained (In years) Is the backup facility available to safeguard these records What is the effective retrieval system followed by this hospital Regular death audit meetings held & minutes of meeting Yes Yes Yes Yes No Yes No No No Yes Yes Yes No No No No No No Study to Review The Health Care Delivery System provided by PHSC, Punjab Medical audit done at regular interval 155 Table 1.14 Hospital Waste Management Name of the District Amritsar No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda Yes Yes Yes 156 No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Study to Review Are the adequate number of bins and the bags of required Are these placed strategically in all patient care areas Segregation of different categories of wastes done at the Collection of waste, packaging, labelling, record keeping done in scientific Proper transportation of the waste so collected Storage facilities and duration The Health Care Delivery System provided by PHSC, Punjab Disposal/ recycling methods for various categories of Whether waste disposal is outsourced Table 1.15 SUPPORT SERVICES Central Sterile Supply Department Name of the District Amritsar Yes Yes Yes Yes Yes Yes Yes Yes NA Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Yes Taran Taran No SH Bhatinda Yes Under the Supervision of a Trained Technical Staff/ Senior Nursing Officer Yes Yes Yes Yes No Yes No Yes Yes Yes Yes No Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No Having all the required equipments & Autoclaves NA NA NA NA Yes Yes Yes Yes No No NA NA Yes Yes Yes Yes Quality control measures are strictly followed -physical Quality control measures are strictly followed- chemical Quality control measures are strictly followed- biological Study to Review The Health Care Delivery System provided by PHSC, Punjab 157 Laundry Services Name of the District Bhatinda Conventional Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda Mechanised 158 Adequate Adequate Adequate Adequate Adequate Not Adequate Average Average Good Good Good Good Not Adequate Adequate Not Adequate Average Average Adequate Average Good Good Average Good Good Good Good Good Good Good Good Good Good Amritsar Study to Review Laundry Services (Mechanised/ conventional) Conventional Mechanised Conventional Mechanised Mechanised Mechanised Mechanised conventional Mechanised Conventional Laundry Services-staff (Adequate) Adequate Adequate Quality of wash Good The Health Care Delivery System provided by PHSC, Punjab Quality of linen Good Dietary Services Name of the District Amritsar No No No NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur NA NA NA Taran Taran NA NA NA SH Bhatinda NA NA NA Proper & safe arrangement for storage of raw materials Measures for Pest & Rodent control Sanitation and hygiene of the cooking area properly maintained No No No NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Regular health check-up for food handlers NA NA NA NA NA NA NA NA NA NA NA NA Availability of modern cooking equipments Availability of properly maintained records & registers No NA NA NA NA NA Diet service under the supervision of a qualified Dietician NA NA NA NA NA NA Study to Review The Health Care Delivery System provided by PHSC, Punjab 159 Table 1.16 User Charges in Different District Hospitals Total Income (Collection) Medicine I.F.P. Buildings Equipment ERF A/c Salary to Contractual Staff Total Expenditure Detailed Expenditure Rogi Kalyan Samiti 160 1900185 2374199 2741536 3050132 3301463 13367515 5138784 5045995 6313724 6162264 5290741 27951508 2179219 2840423 2908548 3074681 3275538 14278409 3875328 4889763 5213162 6519411 NA 20497664 17546397 3882273 4482801 3365249 1610770 2061622 1712314 8155221 3229772 1480509 2586302 1290006 14278409 7444013 3275538 1312560 729201 3104053 754828 820269 659437 866236 761250 3862220 3074681 1186566 659203 4673865 2908548 634350 2840423 1162196 645664 2129219 874143 435635 27480701 11427634 6336837 3353758 291381 387398 380910 395522 437521 1892732 208792 440287 433148 666745 365905 2114877 4718401 1653431 943988 469782 6209016 2193207 1485296 345977 5711847 2386983 1310739 537007 4323803 2249330 984908 241353 241353 471309 1045958 790272 2868198 291381 387398 380910 395522 437521 1892732 175548 297101 145677 275882 261018 1155226 6517634 2944683 1611906 319306 319306 538604 636396 512474 1687474 0000 0000 279392 364511 446126 1090029 488959 467205 502182 348454 1806800 236679 257767 369147 437868 358735 1660196 157128 191606 236625 247805 235660 1068824 Name of District Hospital Years 2003-04 Study to Review 2004-05 Amritsar 2005-06 2006-07 2007-08 Total 2003-04 0000 0000 0000 0000 100000 100000 2004-05 Batinda 2005-06 2006-07 2007-08 The Health Care Delivery System provided by PHSC, Punjab Total 2003-04 2004-05 Ferozpur 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Gurdaspur 2005-06 2006-07 2007-08 Total (Contd...) Years Medicine I.F.P. Buildings Equipment ERF A/c Name of District Hospital Total Income (Collection) Total Expenditure Detailed Expenditure Salary to Contractual Staff Rogi Kalyan Samiti 2003-04 2004-05 Hoshiarpur 5826166 5826166 6027980 2404437 1399160 611882 6027980 2404437 1399160 611882 527801 527801 2005-06 2006-07 619475 619475 465225 465225 - 2007-08 Total 2003-04 2004-05 9419098 13499437 15416929 383355464 3101683 3803090 4544871 4811096 5024987 21285727 19006370 3864421 2007813 12903927 3183321 1976830 4573092 3326884 3607862 2948549 3777674 2643851 521440 334737 524630 349661 770511 2700979 36213372 16762858 7633236 15858716 6393457 3189803 10724214 5622143 2127532 9630442 4747258 2315901 967000 755944 1056121 2779065 335221 58076 189417 237645 796861 1617220 335006 460244 1355608 2150858 129908 205813 167830 419185 289236 1211972 512714 1194458 3234468 4941640 115586 599608 33138 748332 752563 563893 629259 1945715 147254 60687 248745 72068 4580 533254 - Jalandhar 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Ludhiana 2005-06 2006-07 2007-08 Total 2003-04 2004-05 2005-06 Muktsar 2006-07 Study to Review The Health Care Delivery System provided by PHSC, Punjab 2007-08 Total (Contd...) 161 162 Total Income (Collection) Medicine I.F.P. Buildings Equipment ERF A/c Salary to Contractual Staff 342852 477461 325171 320948 427897 248684 Total Expenditure Detailed Expenditure 6030396 457581 5476548 6887658 3027748 1499017 371009 137009 115355 2529041 1201486 489679 88679 85397 1513687 796653 301086 42819 47958 4212300 804050 433198 2674019 52349 18852183 3188235 4054724 4687936 4454628 4745583 21131106 15773245 4782224 3777499 3129318 2072265 2011939 11282776 4301206 1594972 2942526 301059 820313 1322700 Not Available Due to Formation of New District 951796 1133336 1431652 1541913 1223898 6282595 4735382 2226184 967836 500471 139788 1130925 1160399 581205 199501 1062972 423376 338376 561907 216541 230419 982268 504591 57573 156962 87269 70660 445485 57374 43467 162740 119039 564435 100791 118959 122744 342494 10725 15134 25859 Name of District Hospital Years Rogi Kalyan Samiti - 2003-04 2004-05 Study to Review 2005-06 2006-07 Patiala (Sp. Hospital) 2007-08 - Total 2003-04 2004-05 Sangrur 2005-06 2006-07 2007-08 Total The Health Care Delivery System provided by PHSC, Punjab Taran Taran 2003-08 2003-04 - 2004-05 Sp. Hospital Bhatinda 2005-06 2006-07 2007-08 Total Table 1.17 Performance Report of District Hospital Name of the District Amritsar 68726 104203 109836 125668 139137 2041 3370 4371 5271 7853 1330 2930 9438 9885 10819 3461 4229 3631 3328 3580 1317 1610 2171 1525 1495 6496 4735 7370 3626 4689 2735 5396 5570 5973 4687 4822 4919 4925 5594 4983 3167 4715 4543 2596 4621 6965 9095 6272 10973 13022 13438 15083 15490 6905 6708 6989 6523 6089 8234 6325 11494 7109 8516 6596 12217 3665 10113 4177 9214 25081 29301 27245 13385 18073 2541 4596 6647 1891 3567 11103 3925 10657 6340 12004 12731 5106 9808 6146 11564 13219 16054 10241 8366 13607 13304 13596 3275 4295 3039 9045 6072 10713 13170 12538 10249 7053 6314 9467 12476 6293 6805 9184 10188 3149 3149 4069 3881 3956 1708 3071 4403 4201 2944 1043 1514 1814 1902 1912 220217 104298 176432 231386 156827 156942 93713 221187 95306 183196 242693 222669 182811 134335 193687 88901 160954 235353 169891 176891 106841 162196 188125 162518 6093 6093 8802 10495 11522 3355 3977 4201 8652 10619 0 $ Performance (Annual) Bhatinda 170936 178083 100355 13404 215921 95591 148476 112815 115247 189243 96961 123171 Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur 143949 151743 158268 201481 174259 10165 10165 11492 12323 13051 5751 9072 8590 8223 8642 5353 0 $ Taran Taran 88942 112667 120134 126646 121578 4491 4491 4804 4868 4728 2114 2490 3845 5056 5181 2147 6241 2579 SH Bhatinda 47753 54733 61725 62565 67955 2361 2361 4518 4906 5958 859 2197 2554 2033 3442 345 941 OPD attendance 1st Yr last 5 years 2nd Yr 3rd Yr 4th Yr 5th Yr 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No. of Surgeries 1st Yr done 2nd Yr 3rd Yr 4th Yr 5 Yr th No. of Emergencies 1 Yr st 2 Yr nd 3 Yr rd 0 $ 5802 0 $ 2590 6422 0 $ 977 2614 7140 0 $ 4 Yr th 1176 3059 2817 0 $ 5 Yr th 1792 2016 3419 0 $ 1 Yr st 345 2204 3288 0 $ 2 Yr nd 941 2015 3924 0 $ Study to Review The Health Care Delivery System provided by PHSC, Punjab No. of admissions through emergency 3 Yr rd 977 2017 5055 1922 1176 1792 4 Yr th 5 Yr th 163 (Contd...) 164 Name of the District Amritsar 1350 2737 752 580 909 815 123 104 85 0$ 0$ 1966 76 185 265 301 164 379 362 147 196 30 21 49 40 31 2452 2802 3268 3671 571 852 1123 1241 1409 110 192 1058 1457 1477 1177 1557 530 714 531 519 470 2363 2593 2733 158 0* 0* 0* 0* 0* 0* 0* 0* 0* 0* 367 653 376 291 463 387 269 483 460 308 514 350 314 255 414 317 615 554 738 296 577 742 737 298 196 520 567 781 476 222 310 595 577 237 272 409 457 114 221 312 392 324 268 578 60 610 184 270 375 790 1703 580 158 279 293 827 1731 524 180 223 258 644 1492 0$ 460 233 203 294 1435 0$ 392 173 186 1439 0$ 1167 1344 701 896 1605 14049 908 0$ 1575 1343 741 951 1570 12168 903 0$ 962 1085 721 670 1998 10116 666 0$ 1282 1010 654 612 9734 701 0$ 192 421 535 509 186 190 201 91 95 258 259 234 152 92 205 162 230 137 101 1181 544 9542 561 0$ 1016 Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran SH Bhatinda 0$ 0$ 0$ 0$ 0$ 0$ 0$ 0$ 0$ 0$ 331 610 558 811 1014 124 305 378 333 281 Performance (Annual) No. of medicolegal cases 1st Yr 2nd Yr 3rd Yr Study to Review 4th Yr 5th Yr 1st Yr No. of post-mortum done 2nd Yr 3rd Yr 4th Yr 5th Yr 1st Yr No. of normal deliveries conducted 2nd Yr The Health Care Delivery System provided by PHSC, Punjab 3rd Yr 4th Yr 5th Yr No of Caesarean 1st Yr done 2nd Yr 3rd Yr 4th Yr 5th Yr * All deliveries were conducted at Special hospital Bhatinda $ There was no regular emergency department. There were special hospitals for women and child. Table 1.18 Staff Position of District Hospital Name of the District Hospital Amritsar 2 1 1 27 2 25 40 4 36 35 9 12 13 9 1 4 1 16 14 16 16 7 26 24 28 7 3 8 40 10 10 13 33 27 28 40 15 7 8 18 4 2 34 110 10 100 44 4 40 20 2 12 11 8 20 34 5 8 8 8 42 1 1 3 2 4 4 25 5 26 45 7 38+11(*) 9 3 con. 9 10 2 6 9 11 8 44 8 1 1 1 2 4 1 13 3 10 (Adhoc-1) 11 3 8 3 2 1 2 1 1 1 2 4 1 1 1 2 2 4 4 29 2 27 54 8 46 4 4 1 1 1 Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur 2 1 1 5 1 4 19 4 15 27 1 26 4 1 3 10 Taran Taran 13 13 12 12 7 7 2 SH Bhatinda 1 1 17 1 16 38 18 20 2 1 1 9 2 Name of Post Position of Post M.S. Sanctioned Vacant S.M.O. In-position Sanctioned Vacant Doctors In-position Sanctioned G.D.M.O. Vacant Doctors Specialist In-position Sanctioned Vacant Nursing Staff In-position Sanctioned Vacant Adhoc Technician In-position Sanctioned Vacant Adhoc/con Administrative In-position Staff Sanctioned Study to Review The Health Care Delivery System provided by PHSC, Punjab Vacant (Contd...) 165 166 Name of the District Hospital Amritsar 2 9 6 6 67 10+4(*). 5 27 3 6 18 2 2 11 9 6 6 85 8 7 38 69 64 48 80 110 36+38($) 32 79 70 2 2 19 22 1 71 66 67 80 110 74 32 101 71 26 26 9 8 7 13 18 4+1 (*) +5($) 2 1 10 2 Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur Taran Taran 7 28 1 7 3 4 Name of Post Position of Post SH Bhatinda Class-IV In-position Sanctioned Vacant Study to Review Others In-position 29+6(*) Sanctioned Vacant In-position The Health Care Delivery System provided by PHSC, Punjab * Placed on Deputation $ Gone on deputation to other districts/places Table 1.19 Position of Specialist in District Hospital Name of the District Hospital Amritsar 2 2 2 1 1 2 2 4 3 1 2 1 3 5 3 1 1 3 1 1 2 5 2 1 1 1 Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar SH Patiala Sangrur 2 2 1 Taran Taran 1 1 1 SH Bhatinda 1 1 3 Name of Speciality Degree Medicine M.D. Surgery M.S M.D. Gynaecologist & Obstetrician 2 1 1 1 1 1 1 1 1 1 1 2 3 1 1 2 1 1 2 2 2 2 5 1 2 1 1 2 2 2 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 1 2 3 2 1 1 2 3 3 1 1 1 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 1 1 - Paediatric MBBS M.D. Diploma Opthamology M.D. ENT M.D. Ortho. M.S Dermatology M.D. Psychiatric M.D. M.D. Anaesthesia Blood Bank Diploma M.D. MBBS Pathology M.D. Biochemistry M.D. Micro-Biology M.D. Radiology M.D. Study to Review The Health Care Delivery System provided by PHSC, Punjab B.D.S. Dental MBBS 167 Table 2.1 General Profile & Facility Survey of Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Bore well Adequate 1 day Regular Three Available Available Available Available Available Available Available Three Three Double Three Three Three Irregular supply Regular Irregular supply Irregular supply Regular Regular 1 day 1 day 3 days 3 days 3 days 3 days 3 days Regular Three Adequate Adequate Adequate Adequate Adequate Adequate Adequate Bore well Bore well Bore well Bore well Municipal supply Municipal supply Bore well Yes Yes Yes Yes Yes Yes Yes Yes Bore well Adequate 3 days Regular Three Not Available Available Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi Yes Municipal supply Adequate 3 days Irregular supply Three Available General Impression Any public utility service available in hospital premises 168 Not Available Available Poor Good Average Average Good No Yes No No No Yes No No Yes No Yes No Yes Yes Yes No Yes Yes No Yes No No No Yes Good Good Good Good Good Good Good Good Good Good Good Good Yes No Yes No No No Good Good Good Good Average Good Good Poor Not Available Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Available Good Good Average Good Good No Yes No No No No Available Available NA Good Good Good Good No Yes No No No No Not Available Not Available Not Available Not Available Available Good Good Good Good Good Yes No No No No No Average Average Average Average Average No No Yes No No No Available Average Average Average Good Average No No No No No No General Profile of Hospitals Accessibility to Railway/Bus Station Study to Review Water Supply Water Supply Water Supply Electricity Electricity-Phase Electricity-Back up (Generator/UPS) The Health Care Delivery System provided by PHSC, Punjab Availability of lift Availability of ramp • Up keep of garden • Cleanliness • Sign posting • Roads and light • State of building • Chemist • Sulabh sauchalaya • Canteen • Grocery shops • STD/PCO booth • Other -cycle stand (Contd...) General Profile of Hospitals Ajnala Available Partially Equipped 1 1 2 General 2 Round the clock Yes Yes Yes No Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No Yes Round the clock Round the clock Round the clock Round the clock 5 NA NIL NA NA Round the clock Yes Yes Yes Yes General No General No No No NA Round the clock Yes Yes Yes Yes 2 3 1 2 2 1 No NA Round the clock Yes Yes Yes Yes 1 1 1 1 1 2 2 3 2 2 2 2 Fully Equipped Partially Equipped Fully Equipped Partially Equipped Fully Equipped Partially Equipped Available Available Available Available Available Available Available Partially Equipped 2 2 2 Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Name of the Sub-Divisional Hospitals Patti Available Partially Equipped 2 1 1 General 4 Round the clock Yes Yes Yes Yes Talwandi Available Partially Equipped 3 1 2 General 6 Round the clock Yes Yes No No Ambulance Services Total number of vehicles Minor No. of operation theatres Major ICU types ICU no. of beds Emergency Services Dental Services Delivery Services Facilities for Post-mortem Mortuary services with cold storage & other preservative facilities available. No No No Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No No No No No Yes No No No No No No Drug formulary committee No No No Yes Yes No Yes No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No No No No Yes Yes No No Hospital Antibiotic committee Hospital Infection Control Committee. Store Purchase Committee Store verification Committee Medical Audit/ Death Review Committee Study to Review The Health Care Delivery System provided by PHSC, Punjab Is the drug formulary available (Contd...) 169 170 Name of the Sub-Divisional Hospitals Ajnala Malout Pull & Push Yes No Yes Yes Yes No No Yes No Pull Push Push Yes No Yes Nakodar Patti Push No Yes No Yes Yes Yes Yes Yes No Yes No Yes No Yes Yes Yes Yes Yes Pull Push Pull Push Push Batala Dasuya Fazilka Jagraon Maler Kotla Talwandi Yes Average Good Good Average Average Average Good Yes Yes No Yes No Yes Yes Average No Average Yes Average General Profile of Hospitals System of supply of drug items through Is buffer stock maintained Study to Review Reorder level maintained Annual maintenance procedure for costly Equipments Log book/ History sheet maintained for the Equipments The Health Care Delivery System provided by PHSC, Punjab Present status/situations of the existing Equipments: Table 2.2 Availability of equipment Name of the Sub-Divisional Hospitals Batala Yes Functional Yes Functional Yes Functional Yes Functional No NA Yes Functional Yes Functional No NA Yes Functional No NA Yes Functional No NA Yes Functional Functional Yes NA No No NA Yes Functional No NA Yes Functional Functional Functional Yes Yes Functional NA Yes No Yes Functional Yes Functional No NA Yes Functional No NA No NA NA NA NA No No No Yes Non Functional Yes Functional Yes Functional No NA Yes Functional Yes Functional No NA Functional Non Functional Functional Functional Yes Yes Yes Yes Functional Non Functional NA Functional No Yes No Yes Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional No NA No NA No NA No NA Functional Non Functional Functional Functional Functional Yes Yes Yes Yes Yes Functional Non Functional NA Functional NA Yes Yes No Yes No Yes Functional Yes Functional Yes Functional Yes Functional No NA Yes Functional Yes Functional No NA Yes Functional No NA Yes Functional Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti No NA Yes Functional Yes Functional Yes Functional No NA Yes Functional Yes Functional No NA Yes Functional No NA No NA Talwandi No NA Yes Functional Yes Functional Yes Functional No NA Yes Functional Yes Functional No NA Yes Functional No NA No NA Ajnala Yes Baby Incubators Yes Functional Boyles Apparatus Yes Functional Cardiac Monitor Yes Non Functional Dental Chair No NA Yes Non Functional Dosimeter ECG Yes Functional Emergency Resuscitation Kit No NA Yes Functional Endoscope (fiber optic) Ophthalmoscopes No NA Yes Functional Perimeter Study to Review The Health Care Delivery System provided by PHSC, Punjab Photo Therapy Unit Functional (Contd...) 171 172 Name of the Sub-Divisional Hospitals Batala Yes Functional No NA Yes Non Functional Yes Functional Yes Functional Yes Functional Yes Functional Functional Functional Functional Functional Yes Yes Yes Yes Functional Functional Functional Functional Yes Yes Yes Yes Yes Functional Yes Functional Functional Functional Functional Functional Functional Yes Yes Yes Yes Yes NA Functional NA Functional Non Functional No Yes No Yes No Yes Functional Yes Functional Yes Functional Yes Functional NA NA NA NA Non Functional NA No No No No Yes No NA Functional NA NA NA Functional NA No NA Yes Functional Yes Non Functional Yes Functional Yes Functional No Yes No No No Yes No Functional Functional NA Functional NA NA Functional Yes Functional No Yes No No Yes Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi No NA No NA No NA No NA No NA Yes No NA No NA No NA No NA Yes Yes Yes Yes Ajnala Retinoscope Study to Review Short Wave Diathermy (Physio therapy) Sigmoidoscopes Slit lamp Ultra sound Functional X ray Functional Functional The Health Care Delivery System provided by PHSC, Punjab Other Major and Minor Operation equipments Functional Functional Table 2.3 Laboratory Facilities Available at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Yes No Yes Yes No No No No Yes No No Yes No No Yes Yes Yes No Yes Yes Yes No No No No No Yes Yes Yes Yes Yes No No No No No No No No Yes No No Yes Yes Yes Yes Yes Yes No No Yes No No No No No No No Yes No No Yes Yes No Yes No No Yes Yes No No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No No No No Yes No No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes No Yes Yes Yes No Yes No No Yes Yes Yes Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti No Yes Yes No No No No No No Yes No No No No No Yes No Talwandi Yes Yes Yes Yes Yes Yes Yes No No Yes No No No No No Yes Yes Laboratory Tests Complete Blood Haemogram Analysis Complete Urine Examination Stool test Blood urea Blood sugar Liver function test Lipid profile PAP smear FNAC Blood Grouping and Matching test Biopsy test Culture and smear examination Semen Examination Vaginal discharge examination Bone Marrow Examination VDRL test Other routine tests. HIV/Pregnancy Test Study to Review The Health Care Delivery System provided by PHSC, Punjab (Contd...) 173 174 Name of the Sub-Divisional Hospitals Ajnala Yes Yes Yes Yes Yes No No Yes Yes No NA Government. Hospitals No No No Yes Yes No Government. Hospitals Distt. Hospitals Medical College Government. Hospitals NA NA Ambulance Provided NA NA Government. Hospitals No No Yes No No No NA Distt. Hospitals No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Waiting For Patient None Yes Yes No Yes No Yes No Yes Yes No Yes No No No Yes Yes Yes Yes Yes No NA Yes NA Yes No Yes Yes No NA Government. Hospitals Yes Yes No Yes Yes No NA Yes NA Yes No Yes Yes No NA Yes NA Yes Yes Yes Yes No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No Yes No Yes No No NA None Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi None None None None Medical College No NA NA No Yes Eye camp, IEC Medical College Medical College Yes MCH, Eye camp Eye camp Other Government. Hospitals Yes Blood Coll. Camp, Medical College No NA No NA No NA No NA Yes MCH Laboratory Tests Any Referral System in place Referral manual available Guidelines for- What to refer Guidelines-When to refer Study to Review Guidelines- How to refer Colour coded referral cards available Feed-back Mechanism existing: Transport facility provided: Maintenance of records/ registers Incentive for following referral route The Health Care Delivery System provided by PHSC, Punjab if Yes what Procedure followed for referral: Tie-up with other hospital (both public and private) for diagnostic Hospital has a tie-up with: Other Government. Hospitals Does the Hospital have any Outreach Area If Yes, what services are provided (Contd...) Laboratory Tests Ajnala Yes Monthly No No Yes Yes Yes No Yes Yes Yes No No No No No No No NA NA Fortnightly NA Fortnightly NA Monthly No No Yes No Yes No Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar No NA No Yes Name of the Sub-Divisional Hospitals Patti Talwandi No NA No Yes Statistical Bulletin Availability of Dharamshala Availability of residential accommodation for the essential staff NA No NA In house In house No In house No 00 90% 25% NA 70% 25% If available, What % is not Getting Accommodation `25% No 50% In house 65% No Security Arrangement: Study to Review The Health Care Delivery System provided by PHSC, Punjab 175 Table 2.4 Out Patient Department at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Manual No Yes No No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes No No Yes No No No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No No No Yes No Yes No No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes No No No No Yes Yes No No Yes Yes No Yes Yes Yes Yes No No No No No No No No No Yes Yes No No No No No Yes Yes Yes No No Yes No No No Yes No No No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Computerised Computerised Manual Manual Computerised Computerised Manual Manual Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi Manual No No No No Yes No No No No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes 176 Out Patient Department Reception & Registration Counter Managed by clerk Study to Review Managed by MSW Managed by staff nurse Managed by computer operator Knowledgeable about the OPD Separate registration for male Separate registration for female Separate registration for senior citizens Separate registration for staff registration registers are properly maintained The Health Care Delivery System provided by PHSC, Punjab All sections of the OPD having proper signage and directional sign Waiting area is adequate Proper sitting arrangement Drinking water facility Ceiling Fans Toilet facility Doctor’s Chambers are having adequate space Examination table with proper sheet Stool for the patient to sit Examination equipments (like BP apparatus Torch, hammer, etc.) (Contd...) Out Patient Department Ajnala Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Name of the Sub-Divisional Hospitals Patti Yes No No No Yes Yes Talwandi Yes Yes No Yes Yes Yes Adequate Illumination Injection Room along with facilities and to deal with Emergency situation Minor OT/ Dressing Room with all the basic Equipments Dispensaries/ Pharmacy with separate counters for male/female/senior citizen Laboratory & Imaging Services easily accessible Central Collection Centre for Laboratory Services Study to Review The Health Care Delivery System provided by PHSC, Punjab 177 Table 2.5 Emergency Medical Services (Casualty) at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Yes No No Yes 02 4 04 01 Yes Yes No Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 01 01 02 01 01 Yes Yes No Yes 01 02 03 01 03 2 2 4 1 2 04 12 04 03 04 07 4 02 01 Yes No No Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes 05 2 02 01 Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No 01 1 00 01 Yes Yes No No No Yes Yes Yes Yes No Yes No Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi Yes No No Yes No 06 1 01 02 Yes Yes No No 178 No Yes Yes Yes No Yes Yes Yes No Yes No Yes No Yes No Yes No Yes No Yes Separate Medical Officer(s) available round the clock Study to Review Board displaying on call doctors/ specialist and other staff on duty Glow sign board indicating ‘Emergency Services Department’ Emergency Ward attached to Emergency Department Triage area Observation Beds (fill number, for No fill 00) Trolleys (fill number, for No fill 00) The Health Care Delivery System provided by PHSC, Punjab Wheel chairs (fill number, for No fill 00) Examination rooms (fill number, for No fill 00) All the Registers including MLR available for Proper Reg. Retiring room with toilets for the doctors Call book in prescribed format available Waiting area for the attendants of the patients with the basic Facilities like sitting arrangements, drinking water, toilet etc. Public telephone available Treatment room-cum-minor OT (Contd...) Name of the Sub-Divisional Hospitals Ajnala Yes No Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No No Yes Yes No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes No Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti No Yes Yes Yes Yes Yes Yes No No No No No Talwandi No Yes Yes Yes Yes Yes No No No No Yes No Major OT Sufficient stock of Essential and Life Saving Drugs Oxygen Cylinders with Attachments Laboratory Services Radiology Services Ambulance Services Staff Trained in BLS Treatment Facilities for Dog/Snake Bite & Poisoning Availability of Disaster Manual Disaster Alert Code, Recall & Deployment Maintenance of Dedicated Drug store for Disaster Situation Plaster Room Study to Review The Health Care Delivery System provided by PHSC, Punjab 179 Table 2.6 Intensive Care Unit at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes 02 No 01 01 01 01 Yes Yes No No No No No Yes NA NA Yes NA NA No NA NA NA NA NA Yes NA NA NA No NA NA NA Yes NA NA NA NA NA NA NA NA NA No NA NA NA NA 00 NA NA NA NA NA NA NA NA NA NA NA NA 00 NA NA NA NA NA 00 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 00 NA NA NA NA NA NA No NA NA NA NA NA NA 05 NA NA NA NA NA NA 04 No 00 00 00 00 No No No No No No No Yes No No No No No No Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi Yes 06 No 00 00 00 00 00 Yes No No No Yes No 180 Availability of ICU Total number of beds available: Study to Review Air-conditioned ICU with Generator Support Staff sanctioned for the ICU- no. of Doctors Staff sanctioned for the ICU- no. of Nurses Staff Sanctioned for the ICU- no. of Technical Staff Staff sanctioned for the ICU- no. of Class IV Record Keeping of the Patients The Health Care Delivery System provided by PHSC, Punjab Availability of oxygen/ suction apparatus/ compressed air Defibrillator ECG machine Ventilator All the life saving Vital drugs Strict aseptic procedures are followed Table 2.7 Clinical Laboratories at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Yes No No No No Yes Yes No No Yes No No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes No No No No No No No No No No No No No No Yes Yes Yes Yes No Yes Yes No Yes No No No No No No Yes Yes No Yes No Yes No No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti No No No No No Yes Yes Yes Yes Yes No No No Talwandi Yes Yes No No No No No Yes Yes Yes Yes No Yes Clinical Laboratories Type of Laboratories- Pathology Type of Laboratories- Microbiology Qualified- Pathologist Qualified- Biochemist Qualified- Micro Biologist Following the Universal Precaution Procedures Using Protective Measures i.e. gloves/ gowns/masks Specimen Collection done Centrally Availability of all the Chemicals and Reagents Observing all the bio-safety measures Accuracy of Reports Regular Internal Quality Control Measures Undertaken Regular External Quality Control Measures Undertaken Study to Review The Health Care Delivery System provided by PHSC, Punjab 181 Table 2.8 Blood Banking Facilities Name of the Sub-Divisional Hospitals Ajnala No NA NA NA NA NA Yes Yes Yes NA Yes NA Yes Yes Yes NA Yes NA Yes Yes Yes NA Yes NA Yes Yes Yes Yes Yes Yes NA No NA Yes Yes Yes Yes NA No NA Yes No Yes Yes Yes Yes Yes Yes Yes NA Yes NA Yes Yes NA NA NA NA NA Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi 182 NA NA NA NA NA Yes Yes No Yes Yes Yes NA NA Yes Yes Yes NA Yes Yes Yes NA Yes Yes Yes Yes Yes Yes Yes NA No NA NA NA NA NA Yes Yes Yes Yes Yes Yes Yes Yes Yes No NA NA NA NA NA BLOOD BANK (If No blood bank fill “8” for section E) Study to Review Trained or qualified medical officer posted as B.T.O. Round the clock availability of trained staff and services Checking & cross matching by B.T.O. Proper maintenance of cold chain and refrigerators Australia antigen, HCV, VDRL, M.P. and HIV tests done for Every blood bottle of donor. Efforts made to collect blood through Voluntary Organisation Camps The Health Care Delivery System provided by PHSC, Punjab Renewal of blood bank/HIV License as per Rules Disposal of HIV Positive Blood Bags & bio-safety measures undertaken Availability of Table Top Syringe & needle destroyer and Colour Coded Bags Feedback of Transfusion, and Record maintenance of untoward incidences Table 2.9 Radiology and Imaging Services at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala No 0 0 0 0 1 1 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 2 1 1 2 2 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 1 1 1 0 0 1 1 0 0 0 1 1 1 0 0 No No No Yes No No Yes 1 1 0 0 1 1 0 0 0 0 0 0 0 0 Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti No 1 1 0 0 0 0 0 0 1 0 0 1 0 0 Talwandi No 0 0 0 0 1 1 0 0 2 2 0 0 0 0 Radiologist available X-ray Machines Mobile C-arm- Total No. Available X-ray Machines Mobile C-arm Working Condition X-ray Machines Mobile C-arm Under Repairs X-ray Machines Mobile C-arm Pending for Condemnation X-ray Machines 500/300 mA Total No. Available X-ray Machines 500/300 mA Working X-ray Machines 500/300 mA Under Repairs X-ray Machines 500/300 mA Pending for Condemnation X-ray Machines 200/100 mA Total No. Available X-ray Machines 200/100 mA Working Condition X-ray Machines 200/100 mA Under Repairs X-ray Machines 200 / 100 mA Pending for Condemnation X-ray Machines Mobile / 60 mA Total No. Available Study to Review The Health Care Delivery System provided by PHSC, Punjab X-ray Machines Mobile / 60 mA Working Condition (Contd...) 183 184 Name of the Sub-Divisional Hospitals Ajnala 0 0 Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No Yes Yes Yes Yes No No Yes Yes No No No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No No Yes 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi 0 0 Yes No No Yes Yes X-ray Machines Mobile / 60 mA Under Repairs X-ray Machines Mobile / 60 mA Pending for Condemnation Study to Review Availability of the dark room with all facilities Use of dosimeter and they regularly sent to BARC Special investigations like IVP, contrast media etc. Round the clock availability of X-ray services/Sonography The Health Care Delivery System provided by PHSC, Punjab Separate register for MLC records Table 2.10 Operation Theatres At Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala 2 1 No 1 0 1 2 0 0 1 0 0 1 0 0 3 0 0 2 0 0 0 2 0 0 0 2 NA 0 2 0 0 6 0 0 NA 0 0 1 0 0 0 1 0 0 2 0 0 1 0 0 0 0 1 2 3 2 2 0 0 2 1 0 3 0 0 3 0 0 0 0 0 0 2 0 0 0 4 2 1 2 2 1 0 2 1 0 1 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 2 3 2 1 1 1 1 0 2 2 1 1 0 0 0 0 0 1 0 0 2 0 0 No Yes Yes Yes No Yes 1 1 1 0 1 1 2 3 1 2 2 1 2 2 Yes 2 0 0 2 0 0 4 0 0 0 0 0 6 0 0 3 0 0 Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti 1 1 No 1 0 0 2 0 0 2 0 0 0 0 0 2 1 0 2 0 0 Talwandi 2 1 Yes 1 0 0 3 0 0 2 0 0 1 0 0 3 0 0 3 0 0 No. of Operation Theatres Major Minor Zoning concepts strictly followed Total No. Available Boyles Apparatus Under Repair Pending for Condemnation Total No. Available Hydraulic Operation Table Under Repairs Pending for Condemnation Total No. Available Shadow less lamp Under Repairs Pending for Condemnation Total No. Available Fumigation apparatus Under Repairs Pending for Condemnation Total No. Available Suction Apparatus Under Repairs Pending for Condemnation Study to Review Air conditioner The Health Care Delivery System provided by PHSC, Punjab Total No. Available Under Repairs Pending for Condemnation 185 (Contd...) Electric cautery Endoscope Laparoscope Cardiac monitor Cardiac defibrillators Pulse oxymeter Portable mobile x ray machine 186 Name of the Sub-Divisional Hospitals Ajnala 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 2 2 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 1 1 2 1 1 1 1 Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 Total No. Available Under Repairs Pending for Condemnation Study to Review Total No. Available Under Repairs Pending for Condemnation Total No. Available Under Repairs Pending for Condemnation Total No. Available Under Repairs The Health Care Delivery System provided by PHSC, Punjab Pending for Condemnation Total No. Available Under Repairs Pending for Condemnation Total No. Available Under Repairs Pending for Condemnation Total No. Available Under Repairs Pending for Condemnation (Contd...) Name of the Sub-Divisional Hospitals Ajnala Yes Yes Yes Yes Yes Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Yes Talwandi Yes Up-to-date maintenance of O.T. records like O.T. registers, emergency O.T., Monthly abstract discipline wise, major/minor etc No Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No No No No Yes No Yes Maintenance of operation postponement register No Yes Yes Yes No Yes No Yes Emergency light or generator facilities provided to O.T. Availability of fire fighting equipments and knowledge to use them Regular disinfections & sterilisation procedures done at O.T. Study to Review The Health Care Delivery System provided by PHSC, Punjab 187 Table 2.11 In Patient Wards at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi Yes No 188 Yes No Yes Yes Yes No NA Yes No Available Functional Available Functional Available Functional Functional Available Functional Functional Available Functional Available Available Functional Functional Functional Available Functional Available Functional Available Available Available No No No Yes Available Functional Available Functional Available Functional No Yes Yes Yes NA NA NA NA NA Yes No Available Functional Available Functional Available Functional No No No No No No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No NA No No Not Available Not Functional Available Functional Not Available NA Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No NA Yes No Available Functional Available Functional Available Functional Yes Yes Yes Yes Yes No NA Yes No Available Functional Available Functional Not Available NA No Yes No No Yes No NA Yes No Available Available Not Available NA Study to Review Satisfactory cleanliness of the wards with adequate house keeping Colour codes of Yellow, Blue, Red, White bin & Blue transparent PPF for waste collection Table top syringe & needle destroyer Proper utilisation Adequate water supply and up keep of sanitary blocks. Adequate & clean Toilets and Bathrooms All the beds are having proper & adequate linen Floor beds/doubling of beds in the wards The Health Care Delivery System provided by PHSC, Punjab if Yes, analyse the reason Satisfactory up keep of cots, mattresses, bedside lockers, linen Use of hospital uniforms by all patients Availability and functioning of suction apparatus ( electric & foot operated) If Available Functional Availability and functioning of oygen cylinder with accessories If available Functional Availability and functioning of venesection tray, LP, tracheostomy tray. If available (Contd...) Name of the Sub-Divisional Hospitals Ajnala Available Functional Yes No Yes NA Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes NA No No No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes NA Functional Functional Functional Functional Functional Not Available Available Available Available Available Available Available Functional Yes Yes Yes No Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Not Available NA Yes Yes Yes No No Yes Talwandi Available Functional Yes Yes Yes No Yes Yes Availability and functioning of emergency light, wheel chair, trolley If available Stationeries, forms, upto date various registers etc. Concept of progressive patient care Adequacy and working of fans and lights Satisfactory availability of diet, Quality of care Maintenance of various registers, records, etc. Study to Review The Health Care Delivery System provided by PHSC, Punjab 189 Table 2.12 Hospital Medical Stores at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala No No Yes Yes Yes No No Yes No Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi No 190 Yes No Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes No Yes No No No Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No No Yes Yes Yes No No Yes No No No No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes No Study to Review Medical store suitably located with adequate space and protection of drugs and non-drugs items from pilferage, temperature, humidity Restriction on entry for unauthorised personnel’s Staff knowledgeable in materials management Inspection of stores by the Civil Surgeon/ M.O. I/c at regular interval to verify stock books Availability of Vital, essential drugs in sufficient Quantity The Health Care Delivery System provided by PHSC, Punjab Upkeep of expiry date register and its regular inspection by MO I/c Efforts made to redistribute large stock of slow moving drugs or near expiry for its utilisation. Proper arrangements to keep the drugs as per ABC/VED category and storage of rubber goods as per guidelines Appropriate steps taken to prevent pilferage of A convenient arrangement of issuing drugs to various Regular sending of samples to chemical laboratory to check it as per specification and standard & action taken thereon (Contd...) Name of the Sub-Divisional Hospitals Ajnala Yes Yes Yes Yes Yes No Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Yes Talwandi Yes Circulation of lists of available drugs to all the MOs, OPD& wards as per generic names Yes No No No No Yes Yes No Yes No Yes Yes Yes No No No Yes No Yes Yes No Yes Yes No Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Submission of certified bills to office for release of payments within three days. Yes Yes Yes No Yes Yes No No No No Auction to clear the empty material from store done regularly. Availability of Fire Fighting equipments and knowledge of staff to operate it Availability of regularly updated Hospital Drug Formulary Existence of standing Drug Committee Study to Review The Health Care Delivery System provided by PHSC, Punjab 191 Table 2.13 Medical Records Department at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Yes Yes Yes Yes No No No No Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi No 192 Manual Yes Yes Yes Yes Yes No Yes Yes Manual Manual Manual Computerised Manual Manual Manual Manual Yes Manual Yes No Yes Yes Yes No No No No No No Yes 5 yrs. Yes No No Computerised Yes No BLS No Yes Yes No No 9 yrs. 5 yrs. 10 yrs. Not Available 6 yrs. Yes Yes Yes Yes Yes Yes 10 yrs. Yes In-patient no. No Yes Yes Yes Yes Yes Yes No Yes Yes Yes 5 yrs. No No No Not Available No No Yes 8 yrs No Yes Yes Yes No No Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No No No No Availability of medical room with enough no. of racks and cup-board etc. Study to Review Medical record Is it managed by a trained medical record officer/ technician or Case record is maintained as per WHO classification of diseases (ICD-X) Regular submission of the morbidity, mortality reports Duration for all the records being maintained (In years) The Health Care Delivery System provided by PHSC, Punjab Is the backup facility available to safeguard these records Is the effective retrieval system followed by this hospital Correspondence Regular death audit meetings held & minutes of meeting Medical audit done at regular interval Are the adequate number of bins and the bags of required Are these placed strategically in all patient care areas (Contd...) Name of the Sub-Divisional Hospitals Ajnala Yes Yes Yes Yes Yes Yes Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Yes Talwandi No Segregation of different categories of wastes done at the No Yes Yes Yes Yes Yes Yes Yes Collection of waste, packaging, labelling, record keeping done in scientific Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes No Proper transportation of the waste so collected Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Storage facilities and duration Disposal/ recycling methods for various categories of Waste Availability of autoclaves, shredders Whether waste disposal is outsourced Study to Review The Health Care Delivery System provided by PHSC, Punjab 193 Table 2.14 Central Supply Department at Sub-Divisional Hospitals Name of the Sub-Divisional Hospitals Ajnala Yes Yes Yes Yes Yes No No Yes Yes Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti Talwandi Yes 194 Yes No No No In house Conventional Mechanised Not adequate Average Average NA NA NA NA NA Average Good Good Good Average Good Good Good Not adequate Adequate Adequate Not adequate Mechanised Conventional Mechanised Conventional Not adequate Average Average Yes In house In house Out sourced In house Out sourced Yes Yes No Yes Yes No Out sourced Mechanised Not adequate Good Good NA Yes Yes Yes Yes Yes No Yes Yes In house Mechanised Not adequate Average Average NA Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Out sourced Yes No No No Adequate Average Average NA Adequate Average Average NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Yes NA No NA NA NA NA NA NA NA NA NA NA NA NA Study to Review Under the supervision of a trained technical staff/ senior nursing officer Having all the required equipments & Autoclaves Quality control measures are strictly followed -physical Quality control measures are strictly followed- chemical Quality control measures are strictly followed- biological Laundry Services Out sourced Conventional Conventional Laundry Services The Health Care Delivery System provided by PHSC, Punjab Laundry Services- staff Quality of wash Quality of linen Dietary Services (If no dietary services fill “8”) Adequate space for kitchen Proper & safe arrangement for storage of raw materials Measures for Pest & Rodent control Sanitation and hygiene of the cooking area properly maintained (Contd...) Name of the Sub-Divisional Hospitals Ajnala NA NA NA NA NA NA NA NA No NA NA NA NA NA No NA NA NA NA NA No NA NA NA NA NA NA NA NA No NA NA Batala Dasuya Fazilka Jagraon Maler Kotla Malout Nakodar Patti NA NA NA NA Talwandi NA NA NA NA Regular health check-up for food handlers Availability of modern cooking equipments Availability of properly maintained records & registers Diet service under the supervision of a qualified Dietician Study to Review The Health Care Delivery System provided by PHSC, Punjab 195 Table 2.15 Five Years Performance Report of Sub-divisional Hospitals Name of the Sub-Division hospital Ajnala 80500 79500 78300 81000 72000 2810 2729 2915 2670 2750 3419 3335 3840 3853 3524 1470 1390 1220 1410 1524 1470 1390 1220 1410 1524 2599 2607 2384 2938 2280 2452 2696 3545 3384 1990 3777 4522 4086 3512 2139 2380 2796 3984 3072 4189 2863 4257 2581 4011 9416 2926 6179 2956 2305 3432 4111 4144 1271 1540 1690 1925 2046 4176 7442 2404 6002 4803 8233 777 6208 4521 5212 5847 4647 6519 10474 8456 3991 4264 4610 4260 4984 2915 3582 3758 3549 3596 2573 1890 3045 1925 6348 7653 4867 5240 9242 5723 6265 4221 5012 8631 6025 5610 3997 4680 8477 2480 2808 2882 931 649 1087 1567 4141 1627 1997 2104 2039 2351 1013 1271 1395 1203 1484 6066 5123 4340 7370 2022 5932 4297 3593 6062 1882 110633 93716 83576 140825 165133 80273 153877 3697 5315 4513 4196 5891 5977 2083 2352 2463 1230 1618 1872 94889 92177 76734 114972 156622 82641 107246 118951 90957 71851 91738 145816 88343 NA 123853 87245 83174 139954 89208 NA 129245 125296 124884 122326 4525 3871 3620 3001 2771 1939 3432 5220 4832 4115 1303 1405 1248 2267 1479 1303 1410 1486 1349 1525 87877 83843 74417 132144 93452 107846 132857 Batala Dasuya Fazilka Jagraon Malar kotla Malout Nakodar Patti Talwandi 55896 57762 43878 55667 57050 1554 1563 985 1728 1911 853 766 508 1282 1418 617 531 392 745 943 405 479 392 739 795 196 Performance (Annual) 1 Yr st 2 Yr nd OPD Attendance last 5 years 3 Yr rd Study to Review 4 Yr th 5 Yr th 1st Yr 2nd Yr In-patient Admitted 3rd Yr 4 Yr th 5 Yr th 1 Yr st 2 Yr nd The Health Care Delivery System provided by PHSC, Punjab No. of Surgeries done 3 Yr rd 4 Yr th 5 Yr th 1 Yr st 2 Yr nd No. of Emergencies 3 Yr rd 4 Yr th 5 Yr th 1 Yr st 2 Yr nd No. of admissions through emergency 3 Yr rd 4 Yr th 5 Yr th (Contd...) Performance (Annual) Ajnala New Hospitals NA NA NA NA NA NA NA NA NA 91 85 77 82 45 120 125 152 137 36 230 286 461 356 413 556 321 282 261 152 214 724 138 76 64 93 270 677 90 313 574 198 333 516 244 427 17 14 27 44 141 62 99 96 62 105 56 116 147 207 159 160 129 169 586 706 798 848 178 149 151 129 136 148 137 119 90 118 126 150 101 98 118 150 125 126 900 318 1711 838 417 76 89 91 110 103 9 10 39 88 902 229 1445 934 790 321 880 180 1120 740 635 445 870 154 883 609 444 NA NA NA 262 85 210 223 11 140 192 27 50 73 850 150 625 390 NA Batala Dasuya Fazilka Jagraon Malar kotla Malout Nakodar Name of the Sub-Division hospital Patti 502 484 489 471 467 137 141 121 151 108 104 133 239 374 365 52 100 265 269 344 Talwandi NA 234 237 417 363 0 0 0 0 0 9 7 25 93 117 0 0 0 3 4 1st Yr 2nd Yr No. of Medico-legal cases 3 Yr rd 4 Yr th 5th Yr 1st Yr 2nd Yr No. of post-mortem Done 3rd Yr 4th Yr 5th Yr 1st Yr 2nd Yr No. of normal deliveries conducted 3rd Yr 4th Yr 5th Yr 1st Yr 2nd Yr No. of Caesarian done 3rd Yr 4th Yr Study to Review The Health Care Delivery System provided by PHSC, Punjab 5th Yr 197 Table 2.16 Utilisation of user Charges in different Sub-divisional Hospitals Total Income (Collection) Medicine I.F.P. Buildings Equipment ERF A/c Salary to Contractual Staff 201324 57869 307953 6,81,896 204455 136185 256041 246270 361026 12,21,036 NA 511424 368495 323291 628269 33,76,602 423310 16,26,520 NA 168746 318647 220125 227657 9,35,175 210429 400142 262757 12,13,968 NA 97929 132093 48453 126620 4,05,095 2,59,193 _ _ 140035 219412 524273 8,83,720 _ _ _ _ _ 5353 5.353 213389 129108 120710 115393 115724 6,94,324 152880 226370 184104 201772 176177 9,41,303 _ _ _ _ _ Total Expenditure Detailed Expenditure Rogi Kalyan Samiti 198 62785 68831 128887 64310 67140 4,42,345 2856930 2501043 2564636 2591846 2781007 1,32,95,462 1937123 2569442 2724788 3236033 3555379 1,40,22,765 NA 1498695 1526801 1417432 1713121 61,56,049 63,43,392 1405856 1184084 1643986 824751 592215 2109466 1331367 NA NA 1,33,54,148 51,15,010 2944546 1007892 804628 41,65,300 3824239 1019279 1737364 2560358 1138910 624839 2118990 999299 517145 1906015 949630 481342 117708 239991 62,63,228 36,44,240 17,52,581 1208331 635697 513302 985821 751368 455726 1359199 797979 47256 38168 225669 1254498 749642 323472 44323 1455379 709554 412825 65783 2,95,994 1,04,143 28,470 27,026 31069 765 15450 1825 7676 62204 14087 1610 5050 186126 112365 52071 17340 4350 98998 86210 6593 6195 61842 34450 159042 1500 9950 SDH Years 2002-03 Study to Review 2003 -04 Ajnala 2004-05 2005-06 2006-07 Total 2003-04 2004-05 Batala 2005-06 2006-07 2007-08 The Health Care Delivery System provided by PHSC, Punjab Total 2003 Jan to Dec 2004 Dasuya 2005 2006 2007 Total 2003 2004 Fazilka 2005 2006-07 2007-08 Total (Contd...) SDH Medicine I.F.P. Buildings Equipment ERF A/c Years Total Income (Collection) Total Expenditure Detailed Expenditure Salary to Contractual Staff 112842 163221 178744 4,54,807 92452 233949 214823 187615 97998 5,53,458 74497 59033 84062 519310 296156 246211 14,47,615 63443 159343 26556 59721 4,42,593 269202 9,98,041 29124 32525 68380 146260 64820 97408 4,38,517 _ _ _ _ _ 0 0 0 0 161124 174611 3,35,735 15202 11520 26,722 336599 565234 252212 409806 203184 17,67,035 245619 262633 331809 516636 377071 336386 20,70,154 - Rogi Kalyan Samiti 2003-04 1280104 1526969 1586933 1949779 71,11,169 2401730 2911828 3074958 3843699 3431073 1,56,63,288 883084 1170491 1218956 1485141 1643569 1785796 81,87,037 984319 1088831 1564222 1919253 1178820 1747670 1658387 993277 1217550 748091 67,05,933 1229213 314876 19,71,319 1194926 269199 1543708 202159 1045483 497789 906414 427686 124537 786189 259610 177339 1,37,31,130 69,31,740 34,80,861 3232796 1894129 768283 3096277 1544136 865383 2643327 1290855 650957 234480 89337 2913691 1341339 700184 72985 1845039 861281 496054 58658 54,69,417 20,82,150 18,04,228 7,47,683 1224822 503702 319985 192054 209081 7,07,312 1089631 385255 354189 170995 179192 1166907 464614 318339 125349 130561 1171531 539026 332573 131927 168005 767384 816526 189553 479142 127358 20473 2004-05 Jagraon 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Malar Kotla 2005-06 2006-07 2007-08 Total 2002-03 2003-04 2004-05 Malout 2005-06 2006-07 2007-08 Total 2002-03 2003-04 2004-05 Nakodar 2005-06 Study to Review 67,35,445 63,64,975 The Health Care Delivery System provided by PHSC, Punjab 2006-07 2007-08 Total 199 (Contd...) 200 Total Income (Collection) Medicine I.F.P. Buildings Equipment ERF A/c Salary to Contractual Staff _ _ _ _ _ 9455 17257 7632 34,344 144000 144000 136157 136000 7,27,257 49925 94061 86546 32675 2,63,207 100000 100000 2,00,000 167100 Total Expenditure Detailed Expenditure 1447955 1664189 1941864 1895881 2132756 90,82,645 378461 320439 392751 564122 475974 21,31,747 20,62,243 7,34,351 5,60,559 2,39,610 465776 188931 115123 69741 524283 156613 122462 67410 73995 51674 2,30,172 402239 139355 100269 31148 27951 299001 93472 84821 35112 35671 370944 155980 137884 36199 40881 1,35,73,006 45,54,846 25,54,524 6,72,441 12,26,193 2234989 927108 396859 134275 640747 3840986 1111049 526386 53579 117934 4010536 1020627 600732 221555 81758 1821980 813206 590521 128621 145632 1664515 682856 440026 134411 240122 SDH Years Rogi Kalyan Samiti 2003 2004 Study to Review Patti 2005 2006 2007 Total 2003-04 2004-05 Talwan De Saboo 2005-06 2006-07 2007-08 The Health Care Delivery System provided by PHSC, Punjab Total Table 2.17 Medical Officers in Position Ajnala 1 1 1 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 1 2 1 1 1 1 2 1 1 1 2 2 1 2 1 2 2 3 Batala Dasuya Fazilka Jagraon Maler kotla Malaout Nakodar Pathi Talwandi 1 1 Total 16 1 13 9 4 2 9 7 2 6 1 - Name of Post Post M.D. Medicine Diploma MBBS M.D. Surgery Diploma MBBS M.D. OBG Diploma MBBS M.D. Paediatrics Diploma MBBS M.D. ENT Diploma MBBS M.D. Orthopaedics Diploma MBBS M.D. Dermatologist Diploma MBBS M.D. Psychiatry Diploma Study to Review The Health Care Delivery System provided by PHSC, Punjab MBBS (Contd...) 201 202 Ajnala 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 3 1 10 1 1 2 1 1 7 3 3 Batala Dasuya Fazilka Jagraon Maler kotla Malaout Nakodar Pathi Talwandi Total Name of Post Post M.D. Anaesthesia Diploma MBBS M.D. Blood Bank Diploma Study to Review MBBS M.D. Pathology Diploma MBBS MD/MSc Bio-chemistry Diploma MBBS MD/MSc Microbiology Diploma The Health Care Delivery System provided by PHSC, Punjab MBBS M.D. Radiology Diploma MBBS Dental BDS Diploma Table 2.18 Present Staff Position of Sub-Divisional Hospitals Under PHSC Ajnala 1 1 14 1 13 12 10+2($) 4 2+2(*) 2 2 3 2+1(*) 3 2 5 5 3 2 2 5 3 3 8 1 2 1 1 1 3 9 2 14 12 17 16 5 5 2 2 12(cont.) 7 7 14 25 24 16 18 19 11 13 10 24 2 22+2 (depu.)* 4 4 7 7 3 3 3 2 3 1 21 21 14 14 10 13 6 7 11 3 8 2 2 1 1 2 1 (office) 1 1 1 1 1 1 13 13 12 3 9 3 3 2 2 1 1 1 1 1 1 Batala Dasuya Fazilka Jagraon Malar kotla Malout Nakodar Patti 1 1 12 1 11 13 13 3 3 3 3 2 2 Talwandi 1 11 7 4 10 2 8 5 5 2 2 Name of Post Post Sanction SMO Vacant Ad hock Total in position Sanction Vacant Medical Officer (GDMO & Specialists) Ad hock Total in position Sanction Nursing Staff Vacant Ad hock Total Sanction Technician Vacant Ad hock Total in position Sanction Administrative staff Vacant Ad hock Total in position Sanction Driver Vacant Ad hock Study to Review The Health Care Delivery System provided by PHSC, Punjab Total in position 203 204 Ajnala 23 2 19+2(*) 15 15 2 5 7 3 1 2 1 3 5 7 4 2 23 23 23 25 38 7 19 19 25 25 9 7 7 3 9 7 32 30 30 28 47 7 26 19 21 1 20 Batala Dasuya Fazilka Jagraon Malar kotla Malout Nakodar Patti Name of Post Post Talwandi Sanction Class IV Vacant Ad hock Total in position Sanction Study to Review Others Vacant Ad hock Total in position The Health Care Delivery System provided by PHSC, Punjab • On deputation placed in the SDH $ Gone deputation in other places/outside SDH Table 3.1 General Profile & Facility Survey of CHCs Under PHSC Name of the CHC Badal Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Manawala Description of facilities Accessibility to Railway/Bus Station Yes Municipal Adequate Three day Irregular Three Available Not available Available Average Good Good Good Good No No No No No No Yes No Yes No No No Good Good Average Good Good Good No No No No Average Good Good Average Good Average Average Good Not Applicable Good Good Good Good Good No No No No Available Not available Available Available Not available Not available Not available Not available Not working Not available Average Average Poor Average Average No No No No Available Available Available Available Available Three Double Three Three Three Irregular Irregular Irregular Regular Irregular Irregular Three Available Not available Available Average Good Average Good Good No Yes No No One day Three day Three day Three day Two day Two day Adequate Adequate Adequate Adequate Adequate Adequate Bore well Bore well Municipal Bore well Bore well Bore well Bore well Adequate One day Irregular Three Available Not available Not available Average Good Good Good Good No No No No Yes Yes Yes Yes Yes Yes Yes Yes Bore well Adequate Two day Regular Three Available Not available Not available Poor Average Average Good Average No No No No Yes Bore well Adequate One day Regular Three Available Not available Available Average Good Good Poor Good No Yes No No Yes Bore well Inadequate One day Irregular Three Available Not available Available Average Average Average Average Good No No No No Water Supply Availability of water Storage capacity of Water Supply Electricity - Phase of Electricity Backup Generator/ UPS Availability of lift Ramp facility General Impression -Up keep of garden Cleanliness Sign posting Roads & lighting State of building Any public utility service available in hospital premises chemist Sulabh Sochalaya Restaurants/ canteen Study to Review The Health Care Delivery System provided by PHSC, Punjab Grocery shops (Contd...) 205 206 Name of the CHC Badal Available Partially equipped 2 1 2 No NA Round the clock Yes Yes No No No No No No No No No No No No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No No Round the clock Round the clock Round the clock Round the clock Round the clock Round the clock NA NA NA NA NA NA NA Round the clock Yes Yes No No No No No No No No No 1 0 2 1 1 1 1 2 No NA Round the clock Yes Yes No No 1 1 0 1 0 1 1 0 1 4 1 3 2 1 1 3 1 1 1 No NA Round the clock Yes Yes No No Partially equipped Fully equipped Partially equipped Partially equipped Partially equipped Fully equipped Partially equipped Partially equipped Partially equipped Available Available Available Available Available Available Available Available Available Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha 1 1 1 No NA Yes Yes No No No No No No Yes No No No No No No No No Yes Yes Yes No Yes No Yes Yes No No Yes No No No Yes No Yes Yes No Yes Yes Yes No No No No No No Yes Yes No No Yes No No Yes Yes Yes No No No Yes Description of facilities Manawala Available Partially equipped Ambulance Services If Available Study to Review Total No. of Vehicles No. of Operation TheatresMinor No. of Operation Theatres -Major Intensive Care Units No. of beds in ICU Emergency Services Round the clock Dental Services Delivery Services The Health Care Delivery System provided by PHSC, Punjab Facilities for Post-mortem Mortuary services with cold storage & other preservative facilities available Various management committees, Drug formulary committee Hospital Antibiotic committee Hospital Infection Control Committee Store Purchase Committee Store verification Committee (Contd...) Description of facilities Badal Yes Pull No Yes No Yes No No No Yes Yes Yes No No Yes No No Yes Yes No No Yes Yes No No Yes No Yes Yes No Yes No No No Yes No Yes No Yes Yes Yes Yes Pull Pull Push Push Push Pull Push No No No No Yes No No No Pull Yes Yes Yes No No Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Name of the CHC Majitha No Pull & Push No No No Yes Yes Manawala Yes Push No No No No No Medical Audit/ Death Review Committee System of Supply of Drug items through Is the drug formulary available Is buffer stock maintained Is Reorder level maintained Annual maintenance procedure for costly Equipments Log book/ History sheet maintained for the Equipments Study to Review The Health Care Delivery System provided by PHSC, Punjab 207 208 Name of the CHC Badal Yes Functional No NA No Not applicable No Not applicable No NA Yes Functional Yes Functional Functional Functional Functional Yes Yes Yes Yes Functional Functional Functional Not applicable Functional Yes Yes No Yes Yes Functional Yes Functional Functional NA Functional Not applicable NA Yes No Yes No No No NA Yes Functional Yes Functional Non Functional Functional Functional NA Functional Functional Yes Yes Yes No Yes Yes Yes Functional No NA Yes Functional Yes Functional Functional Functional Functional Nonfunctional Functional Functional Functional Yes Yes Yes Yes Yes Yes Yes Functional NA Functional Non Functional Non Functional Functional Functional Yes No Yes Yes Yes Yes Yes Yes Functional Yes Functional No NA No NA Yes Functional Yes Functional Functional NA Functional Functional Functional Functional Functional Functional Yes No Yes Yes Yes Yes Yes Yes Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Yes Functional Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes Yes Yes Yes No NA Yes No NA Table 3.2 Equipment available at CHCs Description of facilities Manawala Boyles apparatus with circle absorber Functional Study to Review Dental chair Functional Emergency Resuscitation Kit Functional Ophthalmoscopes Functional The Health Care Delivery System provided by PHSC, Punjab Sigmoidoscopes X-Ray Functional Other Major and Minor Operation equipments Table 3.3 Laboratory tests Name of the CHC Badal Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes Yes Yes Yes Yes Yes Manawala Yes Yes Yes Yes Yes Yes Description of facilities Complete Urine Examination Stool Test Special Test Like:-blood urea Blood Sugar Blood Grouping and Matching test Many other routine tests. Study to Review The Health Care Delivery System provided by PHSC, Punjab 209 210 Name of the CHC Badal Yes NA No No No No No Yes Yes No No No No No Yes Yes Yes Yes Don’t know Don’t know Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No No No No Yes Yes No Yes Yes NA Yes No No Yes Yes Yes Yes Yes Yes Yes No Yes NA Yes Yes Yes Yes No Yes NA Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes No Yes NA Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha No No No No No No No No No No No Yes NA NA NA Other Pvt. Hospitals Medical College & Other Other Other Medical College Other Table 3.4 Referral Facilities Manawala Description of facilities Any Referral System in place Study to Review Referral manual available Guidelines given regarding: What to refer When to refer How to refer Colour coded referral cards available Feed-back Mechanism existing The Health Care Delivery System provided by PHSC, Punjab Transport facility provided Maintenance of records/ registers Incentive for following referral route Procedure followed for referral * Tie-up with other hospital (both public and private) for diagnostic or referral purposes Hospital has a tie-up with (Contd...) Description of facilities Badal NA Yes MCH NA NA MCH MCH Nat. health prog. No Yes Yes Yes No No No Yes Health Ed. MCH MCH MCH No No Yes Yes Yes Yes Yes No NA NA NA NA Monthly NA Monthly NA Fortnightly Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Name of the CHC Majitha Monthly No NA Manawala NA No NA If Available Does the Hospital have any Outreach Area If yes, what services are provided No Yes No Yes Yes No No No Availability of Dharamshala No Yes No Yes No Yes Availability of residential accommodation for the essential staff with in the campus No In-house In-house No No In-house Security arrangement In-house No No In-house In-house Study to Review The Health Care Delivery System provided by PHSC, Punjab 211 212 Name of the CHC Badal No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes No Yes Yes No No No No No Yes Yes No Yes No No No No No No No No No Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha No No Yes Yes No No No No No Yes No Yes Yes Yes Yes Yes No No No No No Yes No No No No No No No No No No No Yes Yes Yes No Yes No No No No No Yes Yes No No No No No Yes Yes No No No No No Yes No No No No No Yes No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Table 3.5 Outpatient Department Manawala Description of facilities MSW Staff Nurse Study to Review Pharmacist Knowledgeable about the OPD (by observation) Separate registration for Male Female Freedom fighters Senior citizens Staff The Health Care Delivery System provided by PHSC, Punjab The registration registers are properly maintained and entries are made neatly All sections of the OPD having proper signage and directional sign Waiting area is adequate Proper sitting arrangement Drinking water facility Ceiling Fans Toilet facility(Separate for Male and Female) Doctor’s Chambers are having adequate space (Contd...) Description of facilities Badal Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Name of the CHC Majitha Yes Yes Yes Manawala Yes Yes Yes Examination table with proper sheet Stool for the patient to sit Examination equipments (like BP apparatus Torch, hammer, etc.) Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Adequate illumination Yes Yes Yes Yes Yes No Injection Room along with facilities and to deal with Emergency situation Yes No Yes No No Yes Minor OT / Dressing Room with all the basic Equipments Yes No No No No Yes Yes Yes No Yes No Dispensaries / Pharmacy with separate counters for male/female/senior citizen/staff Yes Yes Yes Yes Yes No Yes Yes No Yes Laboratory & Imaging Services easily accessible No No Yes Yes Yes Yes Yes Yes Yes Yes The Health Care Delivery System provided by PHSC, Punjab Central Collection Centre for Laboratory Services Yes No No Yes Yes Yes Yes Study to Review 213 214 Name of the CHC Badal Yes No Yes No Yes No Yes Yes No Yes Yes Yes Yes No Yes No No No Yes Yes Yes No Yes Yes No Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes No Yes Manawala Yes No Yes 2 Yes Yes 2 Yes 2 No Yes No No No No No No Yes No Yes Yes No Yes Yes No No Yes No Yes 3 2 1 1 2 Yes Yes No No Yes Yes Yes Yes Yes 1 1 4 Not mentioned 6 Yes Yes Yes Yes Yes No NA Yes 1 No No Yes No No Yes No Yes No No NA 2 NA 1 6 Not mentioned 1 Yes Yes 2 Yes 3 Yes Yes Yes No 2 Yes Yes 2 Yes 3 No Yes No Yes Not mentioned Yes Yes Not mentioned Yes 5 Yes Yes Yes No 3 No No NA Yes 2 Yes Yes Yes No Table 3.6 Emergency (Casualty) Services at CHCs Description of facilities Study to Review Board displaying on call doctors/ specialist and other staff on duty Glow sign board indicating ‘Emergency Services Department’ Emergency Ward attached to Emergency Department If Yes, the no. of beds Triage area The Health Care Delivery System provided by PHSC, Punjab Observation Beds If Yes, No. of beds Trolleys and Wheel chairs available If yes, exact No. Examination rooms with all basic equipments All the registers including MLR available for proper registration Retiring room with toilets for the doctors Call book in prescribed format available (Contd...) Description of facilities Badal Yes No Yes Yes Yes No Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Name of the CHC Majitha Yes Manawala No Waiting area for the attendants of patients with the basic facilities like sitting arrange-ments, drinking water, toilet etc Yes No Yes Yes Yes No Yes Yes No No No No No No Yes No Yes Yes Yes No Yes Yes Yes Yes Yes No Yes No Yes No Yes No Yes Yes Yes Yes Yes No Yes No Yes No Yes No Yes No No Yes No Yes No No No No No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No No No No No No Yes No Yes Yes Yes No Yes No Yes No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Public telephone available No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No Yes No Yes Yes Yes Yes Yes Yes Yes No No No Treatment room-cum-minor OT Major OT Sufficient stock of essential and life saving drugs Oxygen cylinders with attachments Laboratory services Radiology Services Ambulance services Staff trained in BLS Treatment facilities for Dog/ snake bite & Poisoning Availability of Disaster Manual Disaster Alert Code, recall & deployment The Health Care Delivery System provided by PHSC, Punjab Maintenance of dedicated drug store for disaster situation Study to Review 215 216 Name of the CHC Badal Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes No No No No No No No No Yes No No No Yes Yes Yes No Yes Yes Yes Yes No No Yes Yes No No No Yes Yes Yes No No No Yes Yes No Yes No Yes No No Yes Yes Yes Yes No Yes No No No No No No No No No No No No No No Yes Yes Yes Yes Yes No No No No No No No No No No Yes No No Yes Yes No No No No Yes Yes Yes Yes Yes Yes No No Yes Yes No No No No Yes Yes No No No Yes Yes Yes Yes Yes No No No No No No No No No No No No No No Yes Yes Yes No No No No No No Table 3.7 Clinical Laboratories at CHCs Description of facilities Manawala Study to Review Type of laboratories Biochemistry Pathology Microbiology Qualified Pathologist available Biochemist available Microbiologist available Following the universal precaution procedures The Health Care Delivery System provided by PHSC, Punjab Using protective measures i.e. gloves/gowns/masks Specimen collection done centrally Availability of all the chemicals and reagents Observing all the bio-safety measures Regular Internal Quality control measures undertaken Regular External Quality control measures undertaken (Contd...) Table 3.8 Blood Banking Facilities Name of the CHC Badal No NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA No No No No No No No No Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha No NA NA NA NA NA Manawala No NA NA NA NA NA Description of facilities Availability of Blood Bank Trained or qualified medical officer posted as B.T.O. Round the clock availability of trained staff and services Checking & cross matching by B.T.O Proper maintenance of cold chain and refrigerators Australia antigen, HCV, VDRL, M.P. and HIV tests done for Every blood bottle of donor. NA NA NA NA NA NA Efforts made to collect blood through Voluntary Organisation Camps NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Renewal of blood bank/HIV License as per Rules NA NA NA NA NA NA NA NA NA NA Disposal of HIV positive blood bags & bio-safety measures undertaken. NA NA NA NA Availability of Table Top Syringe & needle destroyer and colour coded bags NA NA NA NA NA NA NA NA NA NA NA Feed back of transfusion, and record maintenance of untoward incidences No Yes No No Yes No Yes Yes No NA NA NA NA NA NA NA Radiologist availability No Yes No No Yes No No Yes No No Yes No No Yes No No Yes No No Yes No No Yes Yes Study to Review The Health Care Delivery System provided by PHSC, Punjab Availability of the dark room with all facilities Use of dosimeter and they regularly sent to BARC 217 218 Name of the CHC Badal No Yes Yes No Yes No No Yes Yes No No No No No No No No No Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha No Yes Manawala No Yes Yes Yes No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes No Yes No Table 3.9 Special Investigations at CHCs Study to Review Description of facilities Special investigations like IVP, contrast media etc Round the clock availability of X-ray services/ Sonography Separate register for MLC records The Health Care Delivery System provided by PHSC, Punjab Maintenance of history book and log book of X-ray machines Table 3.10 Operation Theatres at CHCs’ Name of the CHC Badal 1 1 No Yes No Yes No No No No No No Yes Yes Yes Yes Yes No No No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No Yes No No No Yes Yes Yes Yes No 1 1 0 1 0 1 1 1 0 2 1 1 1 1 Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur 2 0 Yes Yes Yes Yes No Majitha 1 1 No Yes No Yes No Manawala 1 1 No No No Yes Yes Description of facilities No. of major OT No. of minor OT Zoning Concept Strictly Followed Maintenance of OT records Maintenance of OT postponement records Emergency light-generator facility for OT Availability of fire fighting equipment & knowledge to use them Yes No Yes No Yes Regular disinfection & sterilisation done at OT Yes Yes Yes Yes Yes No Study to Review The Health Care Delivery System provided by PHSC, Punjab 219 220 Name of the CHC Badal No No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes Yes No No No No No No Not available Not available Available Functional Functional Non functional Available Available Available Functional Non Functional NA Functional Functional Available Functional Available Not available Available Available No No No No No Not available NA Available Non functional Yes Yes Yes Yes Yes No No No No No No No No Available Functional Available Functional Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Available Functional Available Functional Yes Yes Yes Yes No Yes Yes Yes Yes Yes No Yes No Not available NA Available Functional Yes Yes Yes No Yes No Available Functional Available Functional No No Yes No Yes No Table 3.11 In patient wards at CHCs Description of facilities Manawala Study to Review Satisfactory cleanliness of wards with adequate house keeping Colour codes of yellow, blue,red,white bin & blue transparent PPF for waste collection, table top syringe & needle destroyer& utilisation Adequate water supply and upkeep of sanitary blocks Adequate and clean toilets and bathrooms Proper and adequate linen on beds The Health Care Delivery System provided by PHSC, Punjab Floor beds/doubling of beds involved Satisfactory upkeep of cots, mattresses, lockers, linen etc. Use of hospital uniforms by patients Availability and functioning of suction apparatus Available Functional Available Functional Condition on availability Availability and functioning of oxygen cylinders with accessories Condition on availability (Contd...) Description of facilities Badal Not available NA Available Available Not available NA No Yes Yes Not available Yes Yes Yes Yes Yes Yes Not available Not available Yes Yes Yes Not available No Yes Yes Yes No Yes Yes Yes No No Yes Not available Yes Yes Functional Functional NA Functional Available Available Not available Available NA NA Functional Functional NA NA Functional Available Not available Not available Available Available Not available Not available Available Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Not available NA Available Name of the CHC Majitha Not available NA Available Manawala Not available NA Available Availability and functioning of venesection/ LP/ tracheostomy tray Condition on availability Availability and functioning of emergency light /wheel chairs/stretcher trolley Functional Yes No Yes Not available No Yes Yes Yes Not available Yes Yes Yes Functional Condition on availability Functional Yes No Yes Not available Yes Yes Functional Yes Yes Yes Not available Yes Yes Functional Yes No Yes Not available No Yes Functional Yes Yes Yes Not available No Yes Stationeries, forms and various updated registers etc. Concept of progressive patient care Adequacy and working of fans and lights Satisfactory availability of diet Quality of care Maintenance of various registers, records, etc. Study to Review The Health Care Delivery System provided by PHSC, Punjab 221 Table 3.12 Hospital Medical Stores at CHCs Name of the CHC Badal Yes No No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No Yes No Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Manawala Yes No 222 Yes No No No Yes Yes Yes No No No Yes No Yes Yes No Yes Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes No No No No No No No No Yes Yes No No No Yes No No No Yes No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes No Yes Yes No Yes Yes No Yes Yes No No Yes No Yes Yes No Yes Yes Yes No Yes Yes Yes No No Yes Yes Yes Yes No No Yes Yes Yes No Yes Yes No Yes No No No No No No Yes No Yes No No Yes Yes No Yes Yes No No No No No Yes No No No No No No Yes No Yes No No No No No Yes No No No Description of facilities Study to Review restriction on entery for unauthorised personnels Staff knowledge on material management, system of FIFO,bin cards, lead time, buffer stock reorder level Availability of vital,essential drugs in sufficient quantity Upkeep of expiry date register and its regular inspection by MO i/c Efforts made to redistribute large stocks of slow moving drugs or near expiry for its utilisation The Health Care Delivery System provided by PHSC, Punjab Proper arrangements to keep drugs as per ABC/VED category and storage of rubber goods as per guidelines Appropriate steps taken to prevent pilferage or drugs Convenient arrangement of issuing drugs to various wards Regular sending of samples to chemical laboratory for checking standards of drugs Circulation of list of available drugs to all MOs, OPD& wards as per generic name Submission of certified bills to office for release of payments with in three days Auction to clear the empty material from store done regularly Availability of fire fighting equipment & knowledge to use them Availability of regularly updated hospital drug formulary Existence of standing drug committee Table 3.13 Medical Record Department at CHCs’ Name of the CHC Badal Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Manawala Yes Description of facilities Availability of medical record room with enough no. of racks etc. Manual Yes No Yes No No No No Yes Manual Manual Manual Manual Manual Manual Manual Manual No Is the medical record computerised or manual Manual Yes Manual No Is it managed by trained medical record officer/technician & supervision provided by MOi/c No No No No No No No Yes Case record is maintained as per WHO classification of diseases (ICD-X) Yes No Yes Yes No No No Yes No No No No No No No Yes No No No Yes Yes Yes Yes Yes Yes No Yes No Yes No No Regular submission of morbidity, mortality reports Yes No No Yes Yes Yes Yes No Yes No No No No No Yes No Is the backup facility kept to safe guard these records Is the effective retrieval system followed Regular death audit meeting held/minutes or meeting recorded/ corrective action taken Yes Yes No Yes Yes Medical audit done at regular interval Yes Yes No Yes No No Study to Review The Health Care Delivery System provided by PHSC, Punjab 223 224 Name of the CHC Badal No Yes Yes Yes Yes No Yes Yes Yes Yes Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No Yes No No Yes No Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes No No Yes No No No No No Yes Yes Yes Yes Yes No No Yes Table 3.14 Hospital Waste Management at CHCs Description of facilities Manawala Study to Review Adequate no. of bins and bags of required colour codes are available Are these placed strategically in all patient care areas Segregation of different categories of waste done at point of generation Collection of waste, packaging, labeling, record keeping done in scientific way Proper transportation of waste collected The Health Care Delivery System provided by PHSC, Punjab Storage facility and duration Disposal/ recycling methods for various categories of waste Availability of autoclave, shredders , incinerators etc. Table 3.15 Central Sterile Supply Department at CHCs Name of the CHC Badal No No Yes Yes No No Yes Yes No Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Yes Manawala Yes Description of facilities CSSD (under supervision of trained staff/ senior nursing officer Yes No No Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Having all the required equipments & autoclaves Yes Yes Yes No Yes Yes Quality control measures are strictly followed Table 3.16 Laundry Services at CHCs Name of the CHC Badal In-house In-house In-house In-house In-house Fatehgarh Ferozshah Goniana Kartarpur Khemkaran Outsourced Longowal Outsourced Machiwara Outsourced Mahilpur Outsourced Majitha Outsourced Manawala In-house Description of facilities Laundry services if in-house Conventional Conventional Conventional Conventional ConvenConvenConvenConven Conventional Conventional Conven tional (dhobi) (dhobi) (dhobi) (dhobi) tional (dhobi) tional (dhobi) tional (dhobi) tional (dhobi) (dhobi) (dhobi) (dhobi) Not adequate Average Average Average Average Average Average Good Good Not adequate Not adequate Adequate Adequate Good Good NA Average Average NA Average Average NA Good Good NA Average Good NA Good Good Adequate Average Good Laundry staff Quality of wash Quality of linen Study to Review The Health Care Delivery System provided by PHSC, Punjab 225 226 Name of the CHC Fatehgarh Not available NA NA NA NA NA NA NA NA Not available Not available Not available Not available Not available Not available Not available Ferozshah Goniana Kartarpur Khemkaran Longowal Machiwara Mahilpur Majitha Not available NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Table 3.17 Dietary Services Manawala Not available Description of facilities Badal Availability of kitchen Facility Not available Study to Review Proper and safe arrangement for storage of raw material NA Measures for pest and rodent control NA Sanitation and hygiene of the cooking area properly maintained NA Regular health checkup for food handlers NA The Health Care Delivery System provided by PHSC, Punjab Availability of modern cooking equipments NA Availability of properly maintained records & registers NA Diet service under the supervision of a qualified dietitian NA Table 3.18 Medical Officers in Position Name of CHC Badal 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Fategarh Feroz shah Goniana Kartarpur Khem Karan Longo wal MachiWara MahilPur Majitha 4 Manawala 1 2 1 Total 10 1 4 7 2 3 2 1 - Name of Post Post M.D. Medicine Diploma MBBS M.S. Surgery Diploma MBBS M.S. OBG Diploma MBBS M.D. Pediatrics Diploma MBBS M.S. ENT Diploma MBBS M.S. Orthopedics Diploma MBBS M.D. Dermatologist Diploma MBBS M.D. Study to Review The Health Care Delivery System provided by PHSC, Punjab Psychiatry Diploma MBBS 227 (Contd...) 228 Name of CHC Badal 1 1 1 1 1 1 1 1 1 1 1 1 1 Fategarh Feroz shah Goniana Kartarpur Khem Karan Longo wal MachiWara MahilPur Majitha Manawala Total 3 1 1 6 2 Name of Post Post M.D. Anaesthesia Diploma MBBS Study to Review M.D. Blood Bank Diploma MBBS M.D. Pathology Diploma MBBS MD/MSc Bio-chemistry Diploma MBBS MD/MSc The Health Care Delivery System provided by PHSC, Punjab Microbiology Diploma MBBS M.D. Radiology Diploma MBBS Dental BDS MBBS Table 3.19 Five Years Performance Report of CHC Hospitals (Punjab) Name of the CHC Badal 30492. 17531 15594 18881 27901 649 256 281 608 765 356 1052 1570 2087 2272 120 61 66 107 375 141 174 261 242 233 225 77 51 37 45 61 71 247 72 258 164 348 293 280 139 791 735 616 823 874 744 653 469 594 627 1759 590 1524 1293 605 1121 1242 703 706 271 282 292 547 473 493 762 697 1084 425 1503 249 675 169 1576 241 919 547 2966 1728 1229 807 741 1020 40 55 114 31 32 106 1176 431 2592 1867 713 1401 499 2089 1950 748 1476 523 2940 2017 1482 272 3116 1795 843 629 602 636 465 386 345 140 560 302 526 533 422 189 226 257 250 264 100 104 50034 11354 40925 62492 28756 13061 52710 9940 47352 59030 23310 17066 47052 10804 35013 56222 21008 14038 35166 29461 35158 426 719 1415 1266 1263 573 784 791 725 964 1478 1756 1791 1933 2675 344 364 263 453 466 39209 13792 44249 68949 13504 34748 37673 8688 41371 59152 17797 28788 Fategarh Feroz shah Goniana Kartarpur Khem Karan Longo wal MachiWara MahilPur 20361 26459 24531 33811 37977 413 631 621 328 1072 255 474 518 649 6 13 131 167 106 387 13 131 167 106 365 Majitha 44498 41406 51578 1219 1142 1410 814 805 1314 509 558 500 Manawala 19683 21263 20980 20387 25980 768 956 1296 1703 - Performance (Annual) 1st Yr 2nd Yr OPD attendance last 5 year 3rd Yr 4th Yr 5th Yr 1 Yr st 2 Yr nd In-patient Admitted 3 Yr rd 4 Yr th 5 Yr th 1 Yr st 2 Yr nd No. of Surgeries done 3 Yr rd 4 Yr th 5 Yr th 1 Yr st 2 Yr nd No. of emergencies 3rd Yr 4th Yr 5th Yr 1st Yr 2 Yr nd Study to Review The Health Care Delivery System provided by PHSC, Punjab No. of admission through emergency 3 Yr rd 4th Yr 5th Yr 229 (Contd...) 230 Name of the CHC Badal 18 23 101 84 8 9 0 0 47 0 0 10 7 67 0 1 13 73 Do 47 104 NIL 64 NIL NIL NIL 4 7 76 71 139 13 9 78 82 86 69 10 78 56 64 30 38 43 4 0 0 0 0 56 13 102 23 43 63 6 230 9 42 0 0 NA 0 0 0 NA 0 NA NA 72 151 54 NA NA 31 41 5 0 0 NA 0 0 0 0 NIL 0 0 0 0 0 0 0 1 6 1 1 148 68 282 390 67 352 0 91 72 354 305 68 400 0 145 49 248 237 104 300 0 385 365 293 28 32 40 1 3 7 169 43 283 225 122 315 0 415 197 49 NA 203 133 281 0 378 Fategarh Feroz shah Goniana Kartarpur Khem Karan Longo wal MachiWara MahilPur Majitha Manawala 208 257 264 239 218 - Performance (Annual) 1st Yr 2 Yr nd No. of medicolegal cases 3 Yr rd 4 Yr th Study to Review 5 Yr th 1 Yr st 2nd Yr No. of Postmortem 3rd Yr 4th Yr 5th Yr 1 Yr st 2 Yr nd The Health Care Delivery System provided by PHSC, Punjab No. of Normal deliveries conducted 3 Yr rd 4 Yr th 5 Yr th 1 Yr st 2 Yr nd No. of Caesarians done 3 Yr rd 4 Yr th 5 Yr th Table 3.20 Staff Position at CHC Badal 11 6 1 4 3 2 1 10 5 3 2 1 1 1 1 2 2+7(*) 20 20 3 9 1 8 3 3 2 1 2 2 6 6 1 2 3 3 3 2 2 4 4 4+3(*) 9 3 5 2 5 2 4 1 3 1 1 14 2 12 4 9 5 5 7 3 1 1 4 1 7 5 2 3 3 7 7 1 1 3 4 1 1 5 4 1 2 3 4 5 3 1 2 10 1 9 4 1 3 5 1 4 23 3 20 3 2 2 1 1 1 5 5 6 1 6 1 1 4 4 6 1 4 5+1(*) 1 1 1 1 missing 1 1 Fategarh Feroz shah Goniana Kartarpur Khem Karan Longo wal MachiWara MahilPur Majitha 1 1 5 1 (L.L) 4 4 3+7(*) 2 2 10 7+3(*) Manawala 6 6 5 1 4 5 1 4 6 1 5 40 7 33 Name Post Sanction Doctors/ GDMO Vacant Ad hock Total in Position Sanction Doctors specialist Vacant Ad hock Total in Position Sanction Nursing Staff Vacant Ad hock Total in Position Sanction Technician (MLT) Vacant Ad hock Total in Position Sanction Administrative staff Vacant Ad hock Total in Position Sanction Class IV Vacant Ad hock Study to Review The Health Care Delivery System provided by PHSC, Punjab Total in Position (Contd...) 231 232 Badal 2 2+3(*) 3 3+4(*) 3 3 3 3 1 1 1 1 2 2 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 2 3 1 2 1 1 1 1 1 2 3 1 2 1 3 3 3 2 1+2(*) 2+2(*) 1 3 3 3 3 1 2 Fategarh Feroz shah Goniana Kartarpur Khem Karan Longo wal MachiWara MahilPur Majitha Manawala 5 5 3 8+1(LL) - Name Post Sanction Safai Sewak Vacant Ad hock Total in Position Study to Review Sanction Pharmacists Vacant Ad hock Total in Position Sanction Vacant Ophthalmolo-Gists Ad hock Total in Position Sanction The Health Care Delivery System provided by PHSC, Punjab Vacant Radiographer Ad hock Total in Position Sanction Vacant BEE & Computer Ad hock Total in Position Sanction Vacant MPW/ Trained Dai Ad hock Total in Position Sanction Others (Driver Cook) Vacant Ad hock Total in Position * Placed on Deputation in CHC LL Staff on long leave Table 3.21 Utilisation of User Charges in different CHC of PHSC (Punjab) Total Income (Collection) Medicine 127036 83575 80866 72054 65841 140727 5,70,099 112023 159859 138780 85931 100870 5,97,499 11345 26645 6886 4658 57,465 429198 218989 278851 674991 604410 3469471 167246 197456 1391740 5,73,928 18558 13685 10000 12976 75,571 165769 162089 137195 190755 102112 757920 140129 92113 90569 138416 45184 38388 60074 9395 2,01,847 8337 2080 3522 5944 23,468 98752 29174 31166 27689 21500 208281 112701 48806 4,88,598 2,02,455 182053 87348 110842 2,10,455 72215 86282 50205 75812 39893 3,24,407 8761 83 890 5904 16,770 107849 87476 115240 62794 93508 466867 86891 47429 17888 48060 15659 6261 60687 15809 11391 51130 18378 16423 14765 9123 23,888 13725 9270 0000 22,995 67929 126507 145603 340039 59777 17832 47650 I.F.P. Buildings Equipment ERF A\c Total Expenditure Detailed Expenditure Salary to contractual staff 392586 237963 109866 93815 91106 160134 10,85,470 9386 4633 0000 0000 0000 14,019 45908 114485 44231 204624 0000 0000 99405 99,405 100000 100000 Rogi Kalayan Name of CHC Years 2002-03 399211 348579 310317 368792 533207 25,25,370 215000 400000 280425 366520 219240 1481185 70213 58344 51263 36953 2,66,095 250366 713391 696636 911286 562800 3559998 543636 744866 801568 1,79,218 35426 21298 42493 47001 18,34,100 389692 323200 331667 434410 355131 25,80,965 690227 323920 235849 278619 470469 565264 644881 2003-04 2004 -05 Badal 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Fateh Garh Churian 2005-06 2006-07 2007-08 Total 2004-05 2005-06 Ferozshah 2006-07 2007-08 Total 2003-04 2004-05 Goniana 2005-06 2006-07 Study to Review The Health Care Delivery System provided by PHSC, Punjab 2007-08 Total (Contd...) 233 234 Total Income (Collection) Medicine 217221 166057 322973 211149 220268 11,37,668 43998 29787 48182 41508 108074 2,71,549 36128 33045 36013 29494 58816 1,93,496 106636 123477 210672 138608 NA 5,80,293 44143 97184 148645 143693 NA 4,33,665 1,07,499 32676 16386 20007 12004 9831 19605 64,498 57650 52766 9839 29079 NA 1,49,334 18359 11015 20271 12043 2,20,056 85,667 81,260 12043 11015 12004 9832 19605 64,499 7316 11056 12850 19521 NA 50,743 94624 9228 24930 51864 48769 14430 22396 4745 20705 20491 14193 14855 000 2360 3309 4895 10,564 78000 6000 0000 0000 0000 84.000 30681 8732 6340 000 6,36,972 2,94,838 1,40,708 58670 138152 52473 104888 54948 42694 150704 32813 34387 1072243 1260697 844840 1907024 153339 37876 1827 169371 31049 9327 I.F.P. Buildings Equipment ERF A\c Salary to contractual staff Total Expenditure Detailed Expenditure 431765 450315 478843 492373 474959 23,28,255 103447 130270 128097 161712 207068 7,30,594 124229 79065 66505 54895 164564 3,89,258 281055 366152 51939 322719 NA 13,21,865 12,14,035 NA 330901 382006 285383 215745 5,13,992 130702 65543 80028 79434 158285 6,69,036 241751 159780 98388 79366 89751 22,41,571 469563 413679 572262 359099 426968 Name of CHC Years Rogi Kalayan 2003-04 2004-05 Study to Review Kartarpur 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Khemkaran 2005-06 2006-07 2007-08 Total 2003-04 The Health Care Delivery System provided by PHSC, Punjab 2004-05 Longowal 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Mahilpur 2005-06 2006-07 2007-08 Total (Contd...) Name of CHC Medicine 45970 58492 84299 74884 125567 3,89,212 50853 153708 111935 98497 130392 5,45,385 NA 1,07,777 1,79,740 1,22,149 2,20,740 6,30,406 1,02,643 1,27,786 1,08,489 1,37,261 4,76,179 NA 4,77,820 149071 17841 1,07,034 NA 49,949 14,801 34,452 92,839 1,92,041 66777 18708 91636 10554 107985 45625 62351 14306 21044 18280 9107 43163 107326 1,98,920 NA 64,581 1,08,297 49,541 66,975 2,89,394 2,26,087 1,16,318 1,33,097 57703 38585 40025 66133 39279 32305 48859 11982 20660 3456 7295 4910 15,661 3825 2799 13935 20,559 NA 40568 15717 23037 12824 11255 17070 I.F.P. Buildings Equipment ERF A\c Years Total Income (Collection) Total Expenditure Detailed Expenditure Salary to contractual staff 48000 49565 19135 1,16,700 6410 6,410 NA 4,225 6,280 5,578 15,149 31,232 Rogi Kalayan 2003-04 182930 184678 288735 266770 10,58,623 250717 363384 318580 293193 401442 16,27,316 NA 3,29,175 4,36,904 3,20,209 503043 16,19,252 5,32,964 13,39,394 404630 227145 233467 325598 148554 9,97,075 266790 219896 187891 187379 135510 135119 - 2004-05 Majitha 2005-06 2006-07 2007-08 Total 2003-04 2004-05 Machiwara 2005-06 NA 100000 1,00,000 2006-07 2007-08 Total 2003-04 2004-05 Manawala 2005-06 2006-07 2007-08 Total Study to Review The Health Care Delivery System provided by PHSC, Punjab 235 Table 4. Distribution of Inpatients by Sex, Age Group, Education, Income & type of Health Facility Utilised N=224 District Hospital 2 1.9% 46 43.8% 19 18.1% 24 22.9% 14 13.3% 47 44.8% 58 55.2% 45 42.9% 23 21.9% 26 24.8% 9 8.6% 2 1.9% 0 .0% 1 1.5% 3 4.4% 3 4.4% 24 35.3% 18 26.5% 19 27.9% 12 41.4% 7 24.1% 6 20.7% 4 13.8% 0 .0% 0 .0% 38 55.9% 10 34.5% 30 44.1% 19 65.5% 8 11.8% 4 13.8% 0 .0% 2 9.1% 20 90.9% 4 18.2% 7 31.8% 3 13.6% 4 18.2% 2 9.1% 2 9.1% 6 8.8% 7 24.1% 1 4.5% 17 25.0% 4 13.8% 5 22.7% 37 54.4% 14 48.3% 15 68.2% 0 0% 0 .0% 1 4.5% Sub-Divisional Hospital CHC Special Hospital TOTAL 3 1.3% 112 50.0% 45 20.1% 38 17.0% 26 11.6% 98 43.8% 126 56.3% 80 35.7% 55 24.6% 59 26.3% 20 8.9% 5 2.2% 5 2.2% 236 Socioeconomic dimension of inpatient Less than 15 Study to Review 15-30 Age group 31-45 46-60 Above 60 Male Sex Female The Health Care Delivery System provided by PHSC, Punjab Illiterate Primary Secondary Education Senior secondary Graduate > Graduate (Contd...) Socioeconomic dimension of inpatient 41 39.0% 47 44.8% 12 11.4% 4 3.8% 1 1.0% 0 .0% 1 3.4% 4 5.9% 1 3.4% 11 16.2% 2 6.9% 6 27.3% 3 13.6% 1 4.5% 27 39.7% 9 31.0% 5 22.7% 26 38.2% 16 55.2% 7 31.8% District Hospital Sub-Divisional Hospital CHC Special Hospital TOTAL 90 40.2% 88 39.3% 31 13.8% 12 5.4% 3 1.3% Less than 2000 2001-5000 Income group 5001-10000 10001-15000 Above 15000 Study to Review The Health Care Delivery System provided by PHSC, Punjab 237 Table 5. Admission In Different Categories of Hospitals District Hospital 55 52.4% 49 46.7% 1 1.0% 0 .0% 0 .0% 0 .0% 30 44.1% 13 44.8% 16 72.7% 38 55.9% 16 55.2% 6 27.3% Sub-Divisional Hospital CHC Special Hospital TOTAL 115 51.3% 108 48.2% 1 .4% 238 Socioeconomic dimension of inpatient Emergency Admission through OPD Study to Review The Health Care Delivery System provided by PHSC, Punjab Can’t say Table 6. User Charges for Services in Various Hospitals in Punjab Type of Hospital District Hospital 92 87.6% 13 12.4% 0 .0% 9 8.6% 96 91.4% 0 .0% 89 84.8% 16 15.2% 0 .0% 88 83.8% 16 15.2% 1 1.0% 27 25.7% 62 59.0% 16 15.2% 1 1.5% 58 85.3% 8 11.8% 2 2.9% 22 32.4% 39 57.4% 7 10.3% 23 33.8% 44 64.7% 1 1.5% 5 17.2% 23 79.3% 6 20.7% 0 .0% 28 96.6% 0 .0% 1 3.4% 10 34.5% 12 41.4% 7 24.1% 60 88.2% 21 72.4% 7 10.3% 3 10.3% 1 1.5% 0 .0% 9 13.2% 1 3.4% 3 13.6% 0 .0% 4 18.2% 18 81.8% 0 .0% 20 90.9% 2 9.1% 0 .0% 19 86.4% 3 13.6% 0 .0% 3 13.6% 16 72.7% 3 13.6% 58 85.3% 28 96.6% 19 86.4% SDH CHC Special Hospital 197 87.9% 26 11.6% 1 .4% 23 10.3% 195 87.1% 6 2.7% 176 78.6% 47 21.0% 1 .4% 193 86.2% 27 12.1% 4 1.8% 62 27.7% 129 57.6% 33 14.7% Total Payment Yes Slip/card making No No response Yes Consultancy charges No No response Yes Payment for admission charges No No response Yes Payment for investigation charges No No response Yes Study to Review The Health Care Delivery System provided by PHSC, Punjab Payment for any other No No response 239 240 Type of Hospital District Hospital 79 75.2% 20 19.0% 1 1.0% 4 3.8% 1 1.0% 87 82.9% 13 12.4% 0 .0% 4 3.8% 1 1.0% 85 81.0% 16 15.2% 1 1.0% 3 2.9% 50 73.5% 14 20.6% 3 4.4% 1 1.5% 1 1.5% 0 .0% 1 1.5% 0 .0% 1 3.4% 0 .0% 21 72.4% 7 24.1% 0 .0% 1 3.4% 7 10.3% 8 27.6% 59 86.8% 20 69.0% 0 .0% 0 .0% 0 .0% 1 3.4% 0 .0% 0 .0% 20 90.9% 2 9.1% 0 .0% 0 .0% 0 .0% 21 95.5% 1 4.5% 0 .0% 0 .0% 3 4.4% 0 .0% 0 .0% 9 13.2% 9 31.0% 2 9.1% 56 82.4% 19 65.5% 20 90.9% Sub-Divisional Hospital CHC Special Hospital 174 77.7% 40 17.9% 4 1.8% 5 2.2% 1 .4% 186 83.0% 30 13.4% 1 .4% 5 2.2% 2 .9% 177 79.0% 38 17.0% 4 1.8% 5 2.2% Total Table 7. Experience at OPD/emergency/reception/Admission, Quality of Treatment, Security & Admission Procedure of Various Hospitals Rating experience Good Study to Review Average OPD/Emergency Poor Can’t say No response Good The Health Care Delivery System provided by PHSC, Punjab Average Reception/admission Poor Can’t say No response Good Quality of treatment in hospital Average Poor Can’t say (Contd...) Rating experience District Hospital 54 51.4% 20 19.0% 15 14.3% 16 15.2% 11 10.5% 12 11.4% 77 73.3% 55 80.9% 8 11.8% 3 10.3% 25 86.2% 3 4.4% 1 3.4% 17 25.0% 7 24.1% 14 20.6% 8 27.6% 11 16.2% 1 3.4% 7 31.8% 1 4.5% 3 13.6% 1 4.5% 4 18.2% 17 77.3% 26 38.2% 13 44.8% 11 50.0% Sub-Divisional Hospital CHC Special Hospital Type of Hospital Total Good 104 46.4% 39 17.4% 38 17.0% 43 19.2% 16 7.1% 27 12.1% 174 77.7% Average Security of hospital Poor Can’t say Good Rating of admission Average procedure of hospital Poor Study to Review The Health Care Delivery System provided by PHSC, Punjab 241 242 Type of Hospital District Hospital 64 61.0% 38 36.2% 3 2.9% 63 60.0% 35 33.3% 7 6.7% 76 72.4% 28 26.7% 1 1.0% 81 77.1% 20 19.0% 4 3.8% 0 .0% 15 22.1% 53 77.9% 2 2.9% 21 30.9% 3 10.3% 0 .0% 24 82.8% 5 17.2% 0 .0% 45 66.2% 26 89.7% 6 8.8% 0 .0% 19 27.9% 0 .0% 43 63.2% 29 100.0% 19 86.4% 3 13.6% 0 .0% 19 86.4% 3 13.6% 0 .0% 20 90.9% 2 9.1% 0 .0% 3 4.4% 0 .0% 0 .0% 24 35.3% 6 20.7% 1 4.5% 41 60.3% 23 79.3% 21 95.5% Sub-Divisional Hospital CHC Special Hospital Total N=224 149 66.5% 99 44.2% 3 1.3% 149 66.5% 69 30.8% 6 2.7% 166 74.1% 57 25.4% 13 5.8% 178 79.5% 42 18.8% 3 1.3% Table 8. Patient’s Responses on Quality of Services in Terms of General Cleanliness, Basic Support Services in Ward in Various Health Settings Ward & bed- General characteristics Good Study to Review Ward & bed- General cleanliness Average Poor Good Ward & bed- linen Average Poor The Health Care Delivery System provided by PHSC, Punjab Good Ward & bed- comfort Average Poor Good Ward & bed- light & fan Average Poor (Contd...) Ward & bed- General characteristics District Hospital 44 41.9% 40 38.1% 19 18.1% 2 1.9% 17 16.2% 3 2.9% 0 .0% 85 81.0% 56 82.4% 1 1.5% 3 4.4% 0 .0% 0 .0% 22 75.9% 8 11.8% 7 24.1% 1 1.5% 0 .0% 19 27.9% 2 6.9% 0 .0% 1 4.5% 4 18.2% 1 4.5% 0 .0% 17 77.3% 16 23.5% 11 37.9% 7 31.8% 32 47.1% 16 55.2% 14 63.6% Sub-Divisional Hospital CHC Special Hospital Type of Hospital Total N=224 106 47.3% 74 33.0% 40 17.9% 4 1.8% 36 16.1% 7 3.1% 1 .4% 180 80.4% Good Average Ward & bed- toilet Poor Can’t say Good Average Ward & bed- food Poor Can’t say Study to Review The Health Care Delivery System provided by PHSC, Punjab 243 Table 9. Patients Observation about the Behaviour & Attitude of Nurses, Doctors, Staff during stay in Hospital Type of Hospital District Hospital 92 87.6% 12 11.4% 1 1.0% 0 .0% 97 92.4% 64 94.1% 3 4.4% 1 1.5% 47 69.1% 14 20.6% 0 .0% 7 10.3% 49 72.1% 16 23.5% 1 1.5% 2 2.9% 20 69.0% 6 20.7% 2 6.9% 1 3.4% 22 75.9% 5 17.2% 2 6.9% 0 .0% 0 .0% 2 6.9% 27 93.1% 7 6.7% 1 1.0% 82 78.1% 19 18.1% 1 1.0% 3 2.9% 84 80.0% 20 19.0% 0 .0% 1 1.0% 0 .0% 1 3.4% 0 .0% 21 95.5% 1 4.5% 0 .0% 17 77.3% 4 18.2% 1 4.5% 0 .0% 19 86.4% 3 13.6% 0 .0% 0 .0% 1 1.5% 2 6.9% 0 .0% 21 30.9% 2 6.9% 4 18.2% 46 67.6% 24 82.8% 18 81.8% Sub-Divisional Hospital CHC Special Hospital 180 80.4% 39 17.4% 4 1.8% 1 .4% 209 93.3% 13 5.8% 2 .9% 166 74.1% 43 19.2% 4 1.8% 11 4.9% 174 77.7% 44 19.6% 3 1.3% 3 1.3% Total 244 Good Study to Review Behaviour of nurses during stay in hospital Average Poor Can’t say Good Behaviour of doctors during stay in Average hospital Can’t say The Health Care Delivery System provided by PHSC, Punjab Good Behaviour of rest of staff during stay in hospital Average Poor Can’t say Good Attitude of sisters at admission Average Poor Can’t say Table 10. Patient’s Responses on Quality of Services in Terms of Availability of Medicines in the Ward Laboratory & Radiological Services Type of Hospital District Hospital 13 12.4% 54 51.4% 36 34.3% 2 1.9% 69 65.7% 27 25.7% 1 1.0% 8 7.6% 14 20.6% 2 2.9% 15 22.1% 37 54.4% 15 51.7% 11 37.9% 0 .0% 3 10.3% 1 1.5% 1 3.4% 25 36.8% 3 10.3% 36 52.9% 21 72.4% 6 8.8% 4 13.8% 7 31.8% 14 63.6% 1 4.5% 0 .0% 19 86.4% 1 4.5% 0 .0% 2 9.1% Sub-Divisional Hospital CHC Special Hospital 30 13.4% 125 55.8% 65 29.0% 4 1.8% 140 62.5% 54 24.1% 3 1.3% 27 12.1% Total All available Some available Availability of medicines in the ward None available Can’t say Good Average Facilities for laboratory & radiological investigations Poor Can’t say Table 11. Patient’s Response in Terms of any Money Spent on Medicine 98 93.3% 7 6.7% 0 .0% 105 100.0% 68 100.0% 0 .0% 1 1.5% 67 98.5% 20 69.0% 9 31.0% 0 .0% 29 100.0% 18 81.8% 4 18.2% 0 .0% 22 100.0% 204 91.1% 20 8.9% 1 .4% 223 99.6% Yes Any money spend on medicine No Study to Review The Health Care Delivery System provided by PHSC, Punjab Yes Paid any money to staff member during stay in hospital No 245 246 Type of Hospital District Hospital 60 57.1% 43 41.0% 2 1.9% 69 65.7% 33 31.4% 1 1.0% 2 1.9% 0 .0% 1 3.4% 7 10.3% 1 3.4% 16 23.5% 3 10.3% 45 66.2% 24 82.8% 17 77.3% 3 13.6% 2 9.1% 0 .0% 0 .0% 1 3.4% 0 .0% 30 44.1% 15 51.7% 11 50.0% 38 55.9% 13 44.8% 11 50.0% Sub-Divisional Hospital CHC Special Hospital 122 54.5% 99 44.2% 3 1.3% 155 69.2% 55 24.6% 11 4.9% 3 1.3% Total 101 96.2% 4 3.8% 9 13.2% 59 86.8% 29 100.0% 0 .0% 22 100.0% 0 .0% 211 94.2% 13 5.8% Table 12. Patient’s Responses on Quality of Services in Terms of Adequacy of Information About Rules, Regulation, Disease & Treatment In Health Settings Yes Study to Review Information about rules and regulation No No response Complete Information about disease & treatment by doctor Partial Inadequate The Health Care Delivery System provided by PHSC, Punjab Can’t say Table 13. Satisfactions of the Patients with Services of Hospital at the Various Health Facilities Yes Satisfaction with services of hospital No Table 14. Suggestions for Further Improvement in the Services by the In-patients N = 224 42 15 14 3 10 3 3 12 15 11 5 4 4 4 9 112 Percentage 18.75 6.7 6.25 1.34 4.46 1.34 1.34 5.36 6.7 4.91 2.23 1.79 1.79 1.79 4.02 50 S.No Suggestions for Improvement of the Services for In-patient Department 1. Medicines should be available in the hospital/provide all medicines. 2. Medicines should be provided free of cost or subsidise rate. 3. Health facilities should be provided free of cost to BPL/poor families 4. Quality of medicine should be improved, those are supplied by the hospitals 5. Needs regular visits of higher authorities for day-to-day work of the hospitals/female doctors/specialist should treat gynae. problems & doctors should be available in OPD clinic on fixed days. 6. Doctors should be available in hospitals at night shifts/needs proper care at night shifts in emergency. 7. Behaviour of staff nurses & class-IV employees should be improved towards patients. 8. Other facilities needs to be improved: i) Provision of food for the patients on subsidise rate ii) Needs cleanliness of toilets/separate toilets for male & female. iii) Hospital cleanliness. iv) Drinking water facilities should be available /improved. v) All diagnostic facilities for treatment should be available in the hospitals on subsidise rate or free of cost. vi) Proper Security arrangements for wards & Hospital. vii) Private rooms should be available in hospitals for patients on payment basis/needs sitting arrangements & patient’s attendants. 9. Satisfied with the Health Services. 10 No response Study to Review The Health Care Delivery System provided by PHSC, Punjab 247 Table 15. Distribution of Outpatient by Sex, Age Group, Education, Income and Type of Facility Utilised N=580 Type of Hospital District Hospital 116 (40.8) 168 (59.2) 15 (5.3) 110 (38.7) 86 (30.3) 54 (19) 19 (6.7) 82 (28.9) 65 (22.9) 80 (28.2) 30 (10.6) 19 (6.7) 8 (2.8) 5 (3.7) 2 (1.5) 16 (11.9) 26 (19.3) 34 (25.2) 52 (38.5) 56 (49.1) 18 (15.8) 19 (16.7) 13 (11.4) 5 (4.4) 3 (2.6) 19 (14.1) 18 (15.8) 28 (20.7) 29 (25.4) 36 (26.7) 43 (37.7) 46 (34.1) 22 (19.3) 26 (55.3) 6 (12.8) 1 (2.1) 2 (4.3) 12 (25.5) 13 (27.7) 8 (17.0) 10 (21.3) 4 (8.5) 0 (0.0) 6 (4.4) 2 (1.8) 12 (25.5) 70 (51.9) 57 (50) 41 (87.2) 65 (48.1) 57 (50) 6 (12.8) Sub-Divisional Hospital CHC Special Hospital 244 (42.1) 336 (57.9) 35 (6.0) 204 (35.2) 171 (29.5) 112 (19.3) 58 (10.0) 202 (34.8) 130 (22.4) 133 (22.9) 69 (11.9) 33 (5.7) 13 (2.2) Total 248 Male Sex Study to Review Female Less than 15 15-30 Age 31-45 46-60 Above 60 The Health Care Delivery System provided by PHSC, Punjab Illiterate Primary Secondary Education Senior Secondary Graduate >Graduate (Contd...) Type of Hospital District Hospital 85 (29.9) 120 (42.3) 48 (16.9) 14 (4.9) 16 (5.6) 6 (4.4) 3 (2.2) 9 (7.9) 2 (1.8) 1 (0.4) 5 (3.7) 5 (4.4) 30 (22.2) 10 (8.8) 42 (31.1) 36 (31.6) 22 (46.8) 6 (12.8) 2 (4.3) 5 (10.6) 1 (2.1 49 (36.3) 52 (45.6) 11 (23.4) Sub-Divisional Hospital CHC Special Hospital Total Less than 2000 197 (34.0) 220 (37.9) 94 (16.2) 26 (4.5) 29 (5.0) 14 (2.4) 2001-5000 5001-10000 Income 10001-15000 Above 15000 Don’t Know Study to Review The Health Care Delivery System provided by PHSC, Punjab 249 Table 16. User Charges for Services in Various Health Care Settings Type of Hospital District Hospital 268 (94.4) 16 (5.6) 13 (4.6) 269 (94.7) 2 (0.7) 196 (69.0) 82 (28.9) 6 (2.1) 71 46.4% 68 51.5% 58 59.2% 35 57.4% 12 19.7% 22 22.4% 29 22.0% 27 17.6% 5 (3.7) 4 (3.5) 34 22.2% 26 19.7% 11 11.2% 10 16.4% 33 (24.4) 29 (25.4) 97 (71.9) 81 (71.1) 0 (0.0) 1 (0.9) 130 (96.3) 109 (95.6) 41 (87.2) 0 (0.0) 32 (68.1) 15 (31.9) 0 (0.0) 21 13.7% 9 6.8% 7 7.1% 4 6.6% 5 (3.7) 4 (3.5) 6 (12.8) 2 (1.5) 8 (7.0) 4 (8.5) 133 (98.5) 106 (93.0) 43 (91.5) Sub-Divisional Hospital CHC Special Hospital 550 (94.8) 30 (5.2) 28 (4.8) 549 (94.7) 3 (0.5) 406 (70.0) 159 (27.4) 15 (2.6) 153 100.0% 132 100.0% 98 100.0% 61 100.0% TOTAL 250 Yes OPD card charges Study to Review No Yes Consultancy charges No Can’t say Yes Investigation charges No The Health Care Delivery System provided by PHSC, Punjab Can’t say Up to 100 Money spent on medicine 101 - 200 201-500 Above 500 Table 17. Patients Observations about Cleanliness, Basic Support Services and Privacy During Examination in Various Health Care Settings in Punjab Type of Hospital District Hospital 210 (73.9) 65 (22.9) 7 (2.5) 2 (0.7) 235 (82.7) 45 (15.8) 2 (0.7) 2 (0.7) 225 (79.2) 52 (18.3) 3 (1.1) 4 (1.4) 138 (48.6) 135 (47.5) 11 (3.9) 250 (88.0) 27 (9.5) 7 (2.5) 250 (88.0) 31 (10.90) 3 (1.1) 245 (86.3) 34 (12.0) 5 (1.8) 54 (40.0) 10 (7.4) 116 (85.9) 16 (11.9) 3 (2.2) 131 (97.0) 4 (3.0) 0 (0.0) 119 (88.1) 13 (9.6) 3 (2.2) 71 (52.6) 3 (2.2) 1 (0.7) 18 (13.3) 113 (83.7) 3 (2.2) 0 (0.0) 3 (2.6) 1 (0.9) 59 (51.8) 32 (28.1) 22 (19.3) 1 (0.9) 19 (16.7) 84 (73.7) 11 (9.6) 87 (76.3) 15 (13.2) 12 (10.5) 89 (78.1) 16 (14.0) 9 (7.9) 95 (83.3) 5 (4.4) 14 (12.3) 28 (20.7) 42 (36.8) 104 (77.0) 68 (59.6) 2 (1.5) 0 (0.0) 0 (0.0) 2 (1.8) 37 (27.4) 39 (34.2) 96 (71.1) 73 (64.0) Sub-Divisional Hospital CHC Special Hospital 41 (87.2) 6 (12.8) 0 (0.0) 0 (0.0) 44 (93.6) 3 (6.4) 0 (0.0) 0 (0.0) 42 (89.4) 5 (10.6) 0 (0.0) 0 (0.0) 22 (46.8) 25 (53.2) 0 (0.0) 46 (97.9) 1 (2.1) 0 (0.0) 47 (100.0) 0 (0.0) 0 (0.0) 47 (100.0) 0 (0.0) 0 (0.0) 420 (72.4) 147 (25.3) 9 (1.6) 4 (0.7) 451 (77.8) 118 (20.3) 5 (0.9) 6 (1.0) 439 (75.7) 107 (18.4) 26 (4.5) 8 (1.4) 250 (43.1) 298 (51.4) 32 (5.5) 499 (86.0) 59 (10.2) 22 (3.8) 517 (89.1) 51 (8.8) 12 (2.1) 506 (87.2) 52 (9.0) 22 (3.8) TOTAL Good General cleanliness Average Poor Cannot say Good Waiting area Average Poor Cannot say Good Light and fan Average Poor Cannot say Yes STD/PCO Booth No Can’t say Yes Separate toilet for women No Cannot say Yes Drinking Water No Cannot say Yes Study to Review The Health Care Delivery System provided by PHSC, Punjab Confidentiality (screened examination room) No Cannot say 251 252 Type of Hospital District Hospital Good Average Poor Can not say All available Some available None available No response Good 66(23.2) 4(1.4) 61(21.5) 159(56.0) 98(34.5) 5(1.8)) 22(7.7) 9(3.2) 275(96.8) 223(78.5) 53(18.7) 5(1.8) 3(1.1) 4(3.0) 131(97.0) 104(77.0) 25(18.5) 3(2.2) 3(2.2) 9(6.7) 4(3.0) 41(30.4) 81(60.0) 39(28.9) 3(2.2) 4(3.5) 32(28.1) 57(50.0) 46(40.4) 1(0.9) 10(8.8) 3(2.6) 111(97.4) 69(60.5) 41(36.0) 0(0.0) 4(3.5) 23(17.0) 37(32.5) 153(53.9)) 70(51.9) 41(36.0) 2(0.7) 1(0.7) 0(0.0) 111(39.1) 19(14.1) 15(13.2) 154(54.2) 92(68.1) 83(72.8) 17(6.0) 23(17.0) 16(14.0) 4(8.5) 35(74.5) 8(17.0) 0(0.0) 30(63.8) 2(4.3) 0(0.0) 15(31.9) 33(70.2) 3(6.4) 1(2.1) 10(21.3) 1(2.1) 46(97.9) 44(93.6) 3(6.4) 0(0.0) 0(0.0) 6(2.1) 5(3.7) 4(3.5) 0(0.0) 3(1.1) 7(5.2) 2(1.8) 2 (4.3) 31(10.9) 17(12.6) 26(22.8) 5(10.6) 244(85.9) 106 (78.5) 82(71.9) 40(85.1) Sub-Divisional Hospital CHC Special Hospital 472 (81.4) 79 (13.6) 14(2.4) 15(2.6) 60(10.3) 364(62.8) 153(26.4) 3(0.5) 294(50.7) 128(22.1) 11(1.9) 147(25.3) 330(56.9) 188(32.4) 11(1.9) 51(8.8) 17(2.9) 563(97.1) 440(75.9) 122(21.0) 8(1.4) 10(1.7) Total Can not say Good Average Poor Can not say Yes No Good Average Poor Can not say Table 18. Quality of Services in Terms of Adequacy of Information, Availability of Medicine, Laboratory Services, Behaviour of Staff Study to Review Adequacy of information given to patient about disease and treatment by doctor Availability of medicines The Health Care Delivery System provided by PHSC, Punjab Facilities for laboratory and Average radiological investigation Poor Behaviour of rest of the staff? Payment to any staff member Rating the quality of treatment in the hospital (Contd...) Type of Hospital District Hospital Good Average Poor Can not say Yes No 61(21.5) 27(20.0) 23(20.2) 223(78.5) 108(80.0) 91(79.8) 22(7.7) 9(6.7) 10(8.8) 5(1.8)) 4(3.0) 1(0.9) 1(2.1) 10(21.3) 30(63.8) 17(36.2) 98(34.5) 41(30.4) 46(40.4) 3(6.4) 159(56.0) 81(60.0) 57(50.0) 33(70.2) Sub-Divisional Hospital CHC Special Hospital Total 330(56.9) 188(32.4) 11(1.9) 51(8.8) 452(77.9) 128(22.1) Behaviour of rest of the staff? Satisfaction with the services of the hospital Study to Review The Health Care Delivery System provided by PHSC, Punjab 253 Table 19. Patients’ Observations Regarding Health Man Power in Various Health Care Settings in Punjab Type of Hospital District Hospital Good Average Poor Can not say Available Not available Available Not available Available Not available Good Average Poor Can not say Good Average Poor Can not say Good Average Poor Can not say 61 (21.5) 3 (1.1) 41 (14.4) 179 (63.0) 23 (8.1) 3 (1.1) 13 (4.6) 245 (86.3) 106 (78.5) 10 (7.4) 0 (0.0) 19 (14.1) 84 (62.2) 21 (15.6) 2 (1.5) 28 (20.7) 3 (1.1) 2 (1.5) 1 (0.4) 0 (0.0) 16 (5.6) 9 (6.7) 264 (93.0) 124 (91.9) 55 (19.4) 31 (23.0) 229 (80.6) 104 (77.0) 28 (9.9) 19 (14.1) 256 (90.1) 116 (85.9) 74 (64.9) 40 (35.1) 89 (78.1) 25 (21.9) 98 (86.0) 13 (11.4) 0 (0.0) 3 (2.6) 66 (57.9) 12 (10.5) 0 (0.0) 36 (31.6) 78 (68.4) 16 (14.0) 1 (0.9) 19 (16.7) 14 (4.9) 3 (2.2) 12 (10.5) 270 (95.1) 132 (97.8) 102 (89.5) 4 (1.4) 0 (0.0) 0 (0.0) 5 (1.8) 1 (0.7) 1 (0.9) 50 (17.6) 30 (22.2) 33 (28.9) 225 (79.2) 104 (77.0) 80 (70.2) Sub-Divisional Hospital CHC Special Hospital 44 (93.6) 3 (6.4) 0 (0.0) 0 (0.0) 46 (97.9) 1 (2.1) 43 (91.5) 4 (8.5) 36 (76.6) 11 (23.4) 44 (93.6) 3 (6.4) 0 (0.0) 0 (0.0) 41 (87.2) 3 (6.4) 0 (0.0) 3 (6.4) 33 (70.2) 4 (8.5) 0 (0.0) 10 (21.3) 254 Study to Review Cooperation at the reception of the counter Availability of doctors Availability of specialists Availability of nurses The Health Care Delivery System provided by PHSC, Punjab Behaviour of doctors Behaviours of specialists Behaviour of nurses Table 20. Waiting Time for Registration, Consultation with Doctors and Specialist, Investigations and Receiving Medicines Type of Hospital District Hospital 235 83.6% 35 12.5% 11 3.9% 281 100.0% 89 55.6% 38 23.8% 33 20.6% 160 100.0% 173 80.5% 24 11.2% 18 8.4% 215 100.0% 134 74.0% 39 21.5% 8 4.4% 181 100.0% 4 5.1% 3 3.8% 79 100.0% 85 81.0% 14 13.3% 6 5.7% 105 100.0% 72 91.1% 79 100.0% 3 3.8% 13 16.5% 13 26.0% 1 2.0% 50 100.0% 73 86.9% 7 8.3% 4 4.8% 84 100.0% 94 90.4% 6 5.8% 4 3.8% 104 100.0% 37 100.0% 63 79.7% 36 72.0% 135 100.0% 114 100.0% 2 1.5% 47 100.0% 13 46.4% 8 28.6% 7 25.0% 28 100.0% 29 78.4% 6 16.2% 2 5.4% 37 100.0% 32 86.5% 5 13.5% 10 7.4% 5 4.4% 2 4.3% 123 91.1% 109 95.6% 45 95.7% Sub-Divisional Hospital CHC Special Hospital 512 88.7% 52 9.0% 13 2.3% 577 100.0% 201 63.4% 72 22.7% 44 13.9% 317 100.0% 347 83.6% 41 9.9% 27 6.5% 415 100.0% 345 80.8% 64 15.0% 18 4.2% 427 100.0% TOTAL Up to 15 minutes Registration time 16 - 30 minutes Above 30 minutes Total Count Col % Up to 15 minutes Specialist consulting 16 - 30 minutes time Above 30 minutes Total Count Col % Up to 30 minutes Investigation time 31 - 60 minutes Above 60 minutes Total Count Col % Up to 10 minutes Study to Review The Health Care Delivery System provided by PHSC, Punjab Time getting medicine 11 - 20 minutes Above 20 minutes 255 Total Count Col % 256 Type of Hospital District Hospital 203 (71.5) 75 (26.4) 3 (1.1) 3 (1.1) 1 (0.7) 3 (2.6) 0 (0.0) 4 (3.0) 1 (0.9) 0 (0.0) 32 (23.7) 45 (39.5) 7 (14.9) 98 (72.6) 65 (57.0) 40 (85.1) Sub-Divisional Hospital CHC Special Hospital 406 (70.0) 159 (27.4) 8 (1.4) 7 (1.2) Total Table 21. Patient’s Experience (Rating) at OPD of Various Health Care Settings N=580 Good Average Study to Review Poor The Health Care Delivery System provided by PHSC, Punjab Can’t say Table 22. Suggestions for Further Improvement in the Services Type of Hospital District Hospital 82 (29.0) 151 (53.4) 2 (0.7) 7 (2.5) 10 (3.5) 20 (7.1) 0 (0.0) 0 (0.0) 1 (0.4) 1 .4% 2 .7% 4 1.4% 1 .4% 2 (0.7) 2 1.5% 1 .7% 0 .0% 8 6.0% 0 .0% 0 .0% 2 1.5% 2 1.5% 7 5.2% 14 10.4% 13 11.6% 0 .0% 0 .0% 1 .9% 0 .0% 0 .0% 0 .0% 1 .9% 3 2.7% 1 .9% 7 5.2% 6 5.4% 0 .0% 1 .9% 58 (43.3) 56 (50.0) 33 (24.6) 30 (26.8) Sub-Divisional Hospital CHC Special Hospital 18 (38.3) 26 55.3% 0 .0% 1 2.1% 0 .0% 1 2.1% 0 .0% 0 .0% 1 2.1% 0 .0% 0 .0% 0 .0% 0 .0% 0 .0% 163 (28.3) 291 50.5% 3 .5% 21 3.6% 37 6.4% 28 4.9% 2 .3% 3 .5% 4 .7% 2 .3% 2 .3% 13 2.3% 4 .7% 3 .5% TOTAL No suggestion Provide all medicine at least to poor people Proper supervision of higher officials Proper care/ emergency care should be provided Provide more doctors or specialists Cleanliness Provision of female doctors Punctuality of staff should be maintained Good behaviour of staff Provide more staff Provision for female privacy Satisfied with present condition Should get costly medicines Study to Review The Health Care Delivery System provided by PHSC, Punjab Provision of food 257 Type of Health Institute = District Hospital Registration time Doctors consulting time 30.48 25.00 30 27.481 209 1 210 120 307 50 0 0 0 120 307 50 23.133 32.919 7.375 0 30 10 12.50 20.00 10.00 200.00 150 1378.487 13000 0 13000 22.24 29.91 9.52 449.77 Specialists consulting time Investigations time Time in getting medicines Money spent to buy medicine 258 Registration time 8.09 5.00 5 7.581 44 1 45 120 0 120 19.875 15.931 120 0 120 5 10 10.00 10.00 17.21 11.99 Doctors consulting time Specialists consulting time Investigations time 21.67 15.00 30 27.208 180 0 180 Time in getting medicines 9.50 10.00 10 8.266 60 0 60 Money spent to buy medicine 245.56 200.00 200 226.589 1260 20 1280 Mean 12.19 Median 10.00 Study to Review Mode 10 Std. Deviation 13.005 Range 104 Minimum 1 Maximum 105 Type of Health Institute = Sub-Divisional Hospital The Health Care Delivery System provided by PHSC, Punjab Statistics Mean Median Mode Std. Deviation Range Minimum Maximum Type of Health Institute = CHC Registration time 6.68 5.00 5 5.112 29 1 30 120 60 150 1 0 0 119 60 150 18.017 13.288 27.301 10 0 5 10.00 10.00 10.00 5.00 5 5.951 30 0 30 18.37 11.40 19.71 7.47 Doctors consulting time Specialists consulting time Investigations time Time in getting medicines Money spent to buy medicine 216.67 150.00 200 220.623 999 1 1000 Statistics Mean Median Mode Std. Deviation Range Minimum Maximum Type of Health Institute = Special Hospital Registration time 7.26 5.00 5 4.623 19 1 20 57 3 60 17.642 5 12.50 18.87 Doctors consulting time Specialists consulting time 26.25 20.00 15 18.540 55 5 60 Investigations time 26.14 20.00 30 19.405 78 2 80 Time in getting medicines 8.59 10.00 10 4.524 19 1 20 Money spent to buy medicine 195.93 100.00 100 186.691 988 12 1000 Statistics Mean Median Mode Std. Deviation Range Minimum Study to Review The Health Care Delivery System provided by PHSC, Punjab Maximum 259 Table 23. Responses of the Deputy Commissioners Amritsar 5 months O.K 50% Partially 70 - 80% Good Can’t say Large Not Good Shortage of staff Shortage of staff Shortage of staff Shortage of staff Average Not well Good Can’t say Good OK Lack of doctors Lack of doctors Large Extent 8 months 1 yrs. 2 months < 2 yrs. < 2 yrs. 1 yrs. 1 yr. Bathinda Ferozpur Gurdaspur Jalandhar Ludhiana Muktsar Sangrur Taran Ta 5 months Good Shortage of staff 40% 260 No Idea BPL Cards No problem BPL Card holders Very low Good Good Red Cross Yes Yes partially Not through DC Not full utilised Inadequate BPL Cards Yes Yes Yes Non-availability is a problem Ambulance not fully equipped Not Good Can’t say Yes Not Good Yes Yes partially Good Satisfactory No No problem Red Cross Not low Satisfactory Yes Not through D.C. Yes Low Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Yes Yes Yes Yes Yes Yes No No Nil Nil ↓ ↓ ↓ CHC ↓ CHC ↓ CHC ↓ CHC Facility/ Name of the District Length of service Overall functioning of CHC, SDH and DH Study to Review Availability of staff Extent of fulfilment of health needs of community Referral services Knowledge of RKS Fund flow The Health Care Delivery System provided by PHSC, Punjab Poor patients exempt from User Charges Motivation Level Perceived Barriers Availability Accessibility Utilisation Acceptability Table 24. Responses of the MLA/elected Representative at District Level Amritsar > 2 yrs. Good Yes Doctors post vacant No Average 30% < 50% Good no. 60% Only poor use it Not much O.K. Fine Not good No No 2-3 hrs. Good Rude Nurses & Class IV Scarcity of Ambulance Yes No Satisfactory Average Good Average To some extent 30-60 mins. Good Good Yes BPL Cards Yes. No Yes Less No Some Yes Not enough Shortage of D&N Shortage Sometimes Scarcity Yes, But shortage of Doctors Average Satisfactory OK Average Good Good Well Less in no. >2 yrs. 1.5 yrs. 1 yr. 1.5 yrs. >2 yrs. > 2 yrs. Bathinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Sangrur > 2 yrs. Poor in CHC No doctors Taran Ta > 2 yrs. Not very good Yes Length of service Overall functioning Availability of staff Availability of Medicines in OPD O.K. 80% No Not enough Gynae-Bad 60% No Satisfactory 60-70% Some Average 40% Overall services of Hospital Extent of fulfilment of health needs of Community 2 - 5 mins. Good Good No problem Yes Yes Yes Yes No Yes Yes Satisfactory N.A. Not satisfactory Good Good Not proper Good Good Not much 20-30 mins. 2-3 hrs. Waiting Time Not much Not good OK Not available No Red Cross Funds Not much Satisfactory Very Good Very Good No From NGOs Not much Good Good No ambulance No - Cleanliness Behaviour of staff Referral services Knowledge of RKS Poor patients exempted from treatment charges Perceived Barriers Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Referral Medicines Nil Nil Requires money Medicines not available Nil Less Medicine Nil Scarcity of Medicine Non availability of equipments Nil Nil Ambulance Service Nil Less facilities Nil Nil Nil ↓ CHC ↓ CHC Nil Nil ↓ ↓ Availability Accessibility Study to Review The Health Care Delivery System provided by PHSC, Punjab Utilisation Acceptability 261 Table 25: Responses of the Civil Surgeons Bathinda 2 years Over utilised Well Well CHC-poor DHGood Except CHC rest well Well CHC OPD lacks manpower rest O.K. Not fully Utilised 1.5 years 1.5 years 1.5 years 2.5 months 2 months Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Sangrur Taran Taran 1.5 years CHC-Average, SDHGood, DH-New, coming up 262 50 50 50 Full 60% 50 - 60% Satisfactory Large extent Not fulfilled at Village level No Long Not good Satisfactory Less Good Cordial No 90% 70% 100 100% 50.8 70 87 100 70 100% 50.8 70.8 90 90 50 10 - 15% 60 50 20 50 80.9 80.9 60 - 70% 40 90 90 Large extent Yes Nil Not good Good Good Doctors Good Nurses-O.K No problem Good Ambulance shortage No problem Good Good Very Good Good Less Long Less Long No No No Yes No Long O.K. Good No Long Not clean Average No Less Average Needs improvement Less no. of ambulance Slight delay Ambulance with payment No problem Satisfactory Satisfactory Not good Only user charges User charges No problem No funds Low Good Satisfactory V.Good O.K. Low Good Good Low Low Nil CHC ± Nil Nil Nil Nil Lack of Manpower in SDH & CHC Nil Nil Nil Nil Nil Nil Nil Medicine facility Nil Yes No No O.K. O.K. Nil Nil Nil ↓ CHC Nil ↓ CHC Nil Nil Nil Nil O.K. ↓ CHC ↓ CHC ↓ CHC ↓ CHC Amritsar Length of service <1 year Overall functioning of CHC, SDH and DH OPD - O.K, IndoorProblem Study to Review Bed Occupancy (%) CHC SDH D.H. Extent of fulfilment of health needs of Community Medicine in OPD Waiting Time Cleanliness Not proper The Health Care Delivery System provided by PHSC, Punjab Behaviour of staff Overwork leads to irritation Referral services No driver, only 1 ambulance Fund flow No problem Only under NRHM Manpower Management Motivation level Perceived Barriers Availability Accessibility Utilisation Acceptability Table 26. Responses of The SMOs Incharge of District Hospitals Amritsar < 2 yrs. Adequate Specialists lacking 60-70% Very few Yes (Recently) Yes More for OPD Shortage of paramedics, staff Nurses 100% Yes Yes (Recently) Available Full 100% 100% Full Yes Yes Yes Yes Yes By poor patients mostly Yes No money given Yes Yes On contract Yes No problem Yes Yes No Yes Yes Yes Yes Yes Yes Some 98-100% 100% 75-76% 70% 75% Less Specialists Adequate Sufficient Doctors. Less class IV Shortage of nurses & Jr.doctors No security guards > 2 yrs. < 2 yrs. 15 days > 2 yrs. 4 yrs. < 2 yrs. 3 yrs. Bathinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Sangrur 3 years Radiologist – absent. EMO, Psychiatrist vacant 74% Mostly all Yes Not under PHSC 80% Taran Taran 5 months Shortage of staff 60-70% Not all Yes Yes Over used Length of service OPD Services- Staff strength 80% Yes BPL Yes Available By poor and middle class 1:2 1:2 Satisfactory Yes No problem Yes Yes Yes Yes Shortage No problem Yes Yes Yes Not good O.K. OK Outsourced Yes 1:7 1:6 1:25 Nurses Less (1:40) 1:4.5 1:20 - Bed Occupancy Rate (%) Medicines to poor in OPD Existence of RKS Information regarding NHP Extent of fulfilment of health needs of Community IPD Services Nurse/Bed ratio 1:5 On contract On call Sanctions from CS/DMC Yes 1:5 1:5 Difficult to maintain Yes No role of SMO Yes 1:6 1:5 On contract Yes No fund Yes Staff Strength Doctors/Bed ratio Cleanliness Emergency Service Available round the clock Fund flow No problem No funds only User Charges Performance appraisal system Perceived Barriers Nil Nil Nil Yes Yes No problem No problem Yes No problem No problem Nil Nil Nil Nil Yes Nil Nil Nil Nil Yes Shortage of staff Shortage of Medicines Shortage of Facilities Yes Nil Nil Nil Nil Yes Lack of information Lack of information Lack of information Nil Yes Not Good Not Good Nil Nil On contract Lack of Staff Nil Nil Nil Yes Nil Nil Nil Nil No Bags supplied Availability Accessibility Study to Review The Health Care Delivery System provided by PHSC, Punjab Utilisation Acceptability 263 Biomedical Waste Management Table 27. Responses of The MLA/elected Representative at Sub Divisional Level Name of the District Bhatinda (Talwaddi) >2 yrs Satisfactory Doctors not available Mostly Not available Yes Less Very few Not all Not all. Only 7 essential ones Good OK Shortage SN, Doctors Yes Yes Yes Specialist not available Satisfactory OK Satisfactory Good Good OK >2 yrs <2 yrs >2 yrs >2 yrs >2 yrs >2 yrs >2 yrs Not much improved Doctors not available Less availability OK Less developed Average Not better 20% Quite some time Good O. K. No No Good Available Yes Yes Average Not good Good Yes Yes Not clean Variable Ambulance on Payment No No No Ferozpur (Fazilzka) Gurdaspur (Batala) Hoshiarpur (Dasuya) Jalandhar (Navodar) Ludhiana (Jagrraon) Muktsar (Malout) Sangrur (Malarkotta) Taran Taran (Patti) <2 yrs Good Yes No antibiotics 264 Not Very. Good Satisfactory OK OPD, Emergency & lab good Full Depends on no of patients Bad Only doctors good, rest bad Ambulance on payment Bad Not much To quite an extent Good 30min– 2hrs Good 30% - 40% Variable, depending upon the availability of doctors Satisfactory Friendly Good Yes Yes Yes Yes Yes No Satisfactory NA Good OK Good OK 15 -30 minutes 2-3 hrs Good 80% Very less Good Very good No idea Yes Nil Nil Low Low Nil Nil Nil Nil Nil Nil Nil Nil Medicine & equipments Nil Nil Nil Nil Nil USG machine Nil Nil Nil Nil Nil Yes Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Nil Facility Length of service Study to Review Functioning of health services in the district Availability of staff Availability of Medicines in OPD Overall services of Hospital Satisfactory Extent of fulfilment of health needs of Community The Health Care Delivery System provided by PHSC, Punjab Waiting Time Cleanliness Behaviour of staff Referral services No transport Knowledge of RKS Poor patients exempted from treatment charges Perceived Barriers Availability Accessibility Utilisation Acceptability Table 28. Responses of the SMO Incharges of Sub-divisional Hospitals Amritsar (Ajnala) 6 months Good 40-65% Yes Yes Yes (except Malaria) 75% 50% 100% 80% 100% Yes (except STD) Yes Yes Yes Yes-all Yes Yes Not functioning Not functioning Yes Yes Yes 50% Yes Yes Tedious Procedure Yes Mostly Some 50-60% 90% 100% 70% 100% 90-100% Poor Adequate less Shortage of Class IV Specialists shortage Adequate Less 50-55% Some Yes-not clear Yes OPD-High IPDLow Sufficient Nurses O.K. Yes No problem Personal perception Nil Nil Nil Nil Nil Doctors Overburdened Yes No funds Yes-weekly review Nil Nil Nil 1:12 1:5 On contract Yes No problem Yes 1:5 1;7 Poor Yes No delay Doctors Bench mark, ACR Infrastructure and staff Behaviour Nil Yes Nil Yes Nil Outsourced Yes (shortage of bags) Nil Yes Yes Specialist absent Nil Nil < 2 yrs. 3 months < 2 yrs. < 2 yrs. 7 months > 2 yrs. 1 yr. Bhatinda (Talwaddi) Ferozpur (Fazilzka) Gurdaspur (Batala) Hoshiarpur (Dasuya) Jalandhar (Navodar) Ludhiana (Jagrraon) Muktsar (Malout) Sangrur (Malarkotta) 3 years Adequate 70% Some Money was received Yes except for STD Average Taran Taran (Patti) < 2 yrs. Good 85-90% Yes Yes Yes 75% Length of service OPD staff strength Bed Occupancy Rate (%) Medicine to poor in OPD Existence of RKS Information regarding NHP Extent of fulfilment of health needs of community 1:3 1:3 Good Yes Only User charges Yes-ACR Yes-ACR & Bench marks Doctors not available Nil Nil Nil No No problem Not much problem O.K. Bench marks for doctors Yes Yes On call Staff absent O.K. Good 1:10 1:10 1: 4 Shortage of staff 1:4 1:4 1: 3.5 - IPD Services (Nurse/Bed ratio) 1:5 1:6 No problem Yes Only Usercharges ACR O.K. O.K. O.K. Yes No fund Yes-ACR Doctor/Bed ratio Cleanliness Emergency services Fund flow Performance appraisal system - Perceived Barriers Lack of staff & medicine Nil Nil Nil Nil Nil Availability Accessibility Study to Review Yes The Health Care Delivery System provided by PHSC, Punjab Utilisation Acceptability Nil Yes Nil Yes – On contract Nil Bags not available 265 Bio-medical waste management Table 29. Responses of the Elected Representatives of CHC Areas Name of the District (CHC) Bhatinda (Goniana) >2 yrs. V.Good Not good Doctors not available (go for pvt. practice) No gynaecologist Yes O.K. O.K. Only MLC cases (<10%) Not much Very Bad No ambulance No Not Good No Long Good Yes Bad Nurses behaviour No Sufficient extent Average Good Average Large extent V.Few Yes Not all Bad Yes Yes O.K. Less O.K. Large extent Good Better now Better now >2 yrs. >2 yrs. > 2 yrs. >2 yrs. >2 yrs. >2 yrs. > 2 yrs. Quiet satisfactory Ferozpur (Firozshah) Gurdaspur ((Fataihgarh Churian) Hoshiarpur (Mahilpur) Jalandhar (Kartarpur) Ludhiana (Machhiwara) Muktsar (Badal) Sangrur (Longwal) Taran Taran (Khem Karan) < 2 yrs. Good 266 >5 yrs. Good Yes Partly Not good 50% 50% 10% Good O.K. Mostly Yes Yes Yes No doctors Yes O.K. 10 - 20% Yes Not all 80% 5 minutes Good No Good No No No V.Good Good Good No No Yes Yes Lacking Yes V.Good Good O.K. 45 mins. - 1 hrs. Nil Not much Long sometimes Good Available but not always Yes Good Yes Not much Needs improvement No ambulance Yes Not Good Yes Not much Satisfactory Good No Very .Good No Not much Good No No Very Good - Amritsar (Manawala) Study to Review Length of service Overall functioning of CHC, SDH and DH Availability of Staff Availability of Medicine in OPD Overall services of the Hospital Satisfactory The Health Care Delivery System provided by PHSC, Punjab Extent of fulfilment of health needs of Community Waiting Time Cleanliness Referral services Knowledge of RKS Behaviour of staff Poor patients exemption from User charges Perceived Barriers (Contd...) Name of the District (CHC) Bhatinda (Goniana) Nil Nil Nil Nil Restricted Nil Lack of Services Nil Quality of Facility to be improved Less doctors Nil Lack of medicines Lack of Medicine Nil Nil Nil Nil Nil Nil Yes Nil Nil No medicine Nil Doctors not available Less Medicine Nil More doctors Ferozpur (Firozshah) Gurdaspur ((Fataihgarh Churian) Hoshiarpur (Mahilpur) Jalandhar (Kartarpur) Ludhiana (Machhiwara) Muktsar (Badal) Sangrur (Longwal) Nil Nil ↓↓ ↓↓ Taran Taran (Khem Karan) Very .Far Nil Nil Nil Amritsar (Manawala) Nil Nil Nil Nil Availability Accessibility Utilisation Acceptability Study to Review The Health Care Delivery System provided by PHSC, Punjab 267 Table 30. Responses of the SMO Incharges of CHCS Name of the District (CHC) Amritsar (Manawala) 1 month Shortage of doctors 10-15% Some Yes Yes Yes Yes Yes Yes 100% 10% 50% 5 – 10% 25.04 15- 20% Shortage Adequate O.K. Less no. of doctors & Class IV Shortage Adequate. Only M.O post vacant Specialists lacking > 2 yrs. 7 months 2.5 yrs. 6 months 6 months >2 years < 2 yrs. 6 months Except medicine all available 10 – 15% Yes Bhatinda (Goniana) Ferozpur Gurdaspur (Firozshah) ((Fataihgarh Churian) Hoshiarpur (Mahilpur) Jalandhar (Kartarpur) Ludhiana (Machhiwara) Muktsar (Badal) Sangrur (Longwal) Taran Taran (Khem Karan) 16 months Shortage 268 30-40% Yes Only T.B. & Malaria 50% 70% Under utilised 1:1.2 1:6 Good No problem Records & meetings DoctorsBench mark O.K. 1:2 1:5 O.K No problem Yes – ACR 1:5 OPD 60-80% IPD=5-10% 100% Yes Yes No to all except T.B Yes Yes Yes Not functioning Not yet formed Yes Yes Yes all except STD Satisfactory Yes Yes except STD Very Less Yes 70.80% Not upto the mark Managed by C.S. ACR Yes No problem Good 1:30 1:7 1:5 1;10 Staff shortage Staff shortage Good No Budget received Appreciation letter 1:3 1:5 Shortage of staff No problem Annual C.R O.K. O.K. DoctorsBench mark 1:7 1:15 Managed by own staff N.A Yes – ACR 1:10 1:4 O.K. Amritsar (Mazitha) Length of service < 2 yrs. Study to Review OPD Staff strength Shortage Bed Occupancy Rate (%) 5-10 Beds are occupied Medicines to poor in OPD Yes Yes (some to be purchased) Existence of RKS Yes Information regarding NHP Yes Not all (i.e. Malaria, STD) The Health Care Delivery System provided by PHSC, Punjab Extent of fulfilment of health needs of Community 90% IPD Services (Nurse/ Bed ratio) Doctor/Bed ratio Cleanliness O.K. Fund flow No problem Through C.S Yes (ACR) Performance appraisal system Yes (Contd...) Name of the District (CHC) Amritsar (Manawala) Bhatinda (Goniana) Ferozpur Gurdaspur (Firozshah) ((Fataihgarh Churian) Hoshiarpur (Mahilpur) Jalandhar (Kartarpur) Ludhiana (Machhiwara) Muktsar (Badal) Sangrur (Longwal) Taran Taran (Khem Karan) Amritsar (Mazitha) Perceived Barriers Staff/ Medicine not available No problems Nil Nil Low Nil Nil Under utilised Nil Less due to lack of funds Nil Nil Nil Nil Needs to be increased Nil Doctor not available Nil Staff shortage Nil Staff not available Nil Low Less no. of doctors Less staff Availability Nil Accessibility Non availability of staff / medicines Yes Yes Yes 2 coloured bags used Yes Nil - Yes Border area Shortage of Drugs - Utilisation No Specialist Acceptability Nil Bio-medical Waste Management Yes Yes Contracted Yes – on contract Yes Study to Review The Health Care Delivery System provided by PHSC, Punjab 269