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1 A The Health Care Delivery System Provided by PHSC Punjab Health Systems Corporation Punjab vkjksx;e~ lq[kleink National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi

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3 A The Health Care Delivery System Provided by Punjab Health Systems Corporation (PHSC), Punjab Report 28 vkjksx;e~ lq[kleink National Institute of Health and Family Welfare Baba Gang Nath Marg, Munirka, New Delhi Website: i

4 List of Abbreviations Preface Acknowledgement Study Team vi vii viii viii CONTENTS Executive Summary Introduction 1 Objectives of the Punjab Health Systems Corporation Project 1 Rationale 3 Study Objectives 4 Methodology 5 Study Findings 8 Structural and Operational Framework of Punjab Health Systems Corporation (PHSC) 8 Facility Assessment 18 A. District Hospitals 18 B. Sub-divisional Hospitals (SDHs) 35 C. Community Health Centres (CHCs) 5 ix Views of the Beneficiaries on Quality of Services In-patient Department Out-patient Department 74 Evaluation of the Training Institutes 84 Community Voice 91 Views of the Stakeholders 1 At District Level 1 Deputy Commissioners (D.C) 1 MLA/Elected Representative 12 Civil Surgeons 14 SMO in charge District Hospitals 16 At Sub-Division Level 19 MLA/Elected Representative 19 SMO Sub Divisional Hospitals 11 At CHC Level 113 Elected Representatives at CHC 113 Senior Medical Officers - CHC 114 Observations and Discussion 118 Facility Survey 118 Views of the Beneficiaries 121 Views of the Community (through FGDs ) 125 Views of the Stakeholders 125 Conclusion and Recommendations 127

5 List of Tables 1 District Hospitals 1.1 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 Operation Theatre In-patient Wards Hospital Medical Stores Medical Record Department Hospital Waste Management Support Services User Charges Performance Report Staff Position Specialist Position Sub Divisional Hospitals 2.1 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 Operation Theatres In-patient Department Hospital Medical Stores Medical Record Department 192 iii

6 2.14 Central Supply Department Five Year Performance Report Utilisation of User Charges Medical Officers in Position Staff Positions 23 3 Community Health Centres 3.1 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 Operation Theatres In-patient Department Hospital Medical Stores Medical Record Department Hospital Waste Management Central Supply Department, Laundry Services Dietary Services Medical Officers in Position Five Year Performance Report Staff Positions Utilisation of User Charges Distribution of Patients in Wards Admissions in Different Hospitals User Charges for Services in Various Hospitals Experience at Facility and Quality of Care 24 8 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 246

7 14 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 268 v

8 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

9 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 5% of the 2 District Hospitals located in the different regions of the state and 26% of 37 SDHs and 1% 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 1 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 vii

10 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 Bhatinda Firozpur Gurdaspur Hoshiarpur Jallandhar Ludhiana Muktsar Sangrur Tarantaran Editorial Team 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

11 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 22, 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 8 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 1 District Hospitals, 1 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 28 and 5th March 28. 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 ix

12 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

13 1. 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 million (US$35 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 8 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$16.1 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 1

14 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. Free consultation for all b. 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. c. Full availability of equipment and chemicals, etc. for diagnostic facilities. 2

15 2. 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 22. 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 Chairman V.C.Punjab Planning Board ii) Dr. K.K. Talwar Member Director, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh iii) Dr. P.K. Dave Member Former Director, All India Institute of Medical Sciences (AIIMS), New Delhi iv) Dr. Deoki Nandan Member Director, National Institute of Health and Family Welfare (NIHFW), New Delhi v) Dr. Shakti Gupta Member Medical Superintendent, AIIMS, New Delhi vi) Dr. Sukhdev Singh Member Director, Family Welfare, Punjab vi) Dr. Roshan Sunkaria, IAS Member Managing Director, PHSC Convener Member viii) Shri Tejveer Singh, IAS Coordinator Special Secretary to Government of Punjab Member Department of Planning 3

16 2.2 Terms of Reference The Committee was to make on site visits and to review at least 5% of the 2 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 1% of 37 Sub Divisional Hospitals (SDHs) and 5% of the 111 Community Health Centres (CHCs). 2.3 Study Objectives i) 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. 4

17 3. 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 15 th January to 5 th March Sample Size 1. 5% of 2 District Hospitals (DHs) 1 DHs 2. 26% of 37 Sub Divisional Hospitals (SDHs) 1 SDHs 3. 1% of 111 Community Health Centres (CHCs) 11 CHCs 4. All the Special Hospitals (SHs) 2 SHs 5. All the Training Centres (TCs) 3 TCs Total 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. Amritsar 2. Gurdaspur 3. Taran Taran Doaba 1. Hoshiarpur 2. Jalandhar 5

18 Malwa 1. Bhatinda 2. Ferozpur 3. Muktsar 4. Sangrur 5. Ludhiana 3.5 Data Collection Tools and Techniques 1) Interview schedule for health functionaries/service providers 2) Exit interview schedule for patient satisfaction 3) Checklist for Facility Survey 4) Questionnaire for trainers 5) 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: At district level a) District Collector 1x1 = 1 in no. b) Civil Surgeon 1x1 = 1 in no. c) Local MLA/MP 1x1 = 1 in no. d) SMO/MS at District Hospitals 1x1 = 1 in no. e) Indoor patients 1% of the total admitted in hospital or minimum of 1 patients f) Outdoor patients (OPD) 5% of the OPD attendance or minimum of 2 patients g) Facility Survey of 1x1 = 1 in no. District Hospitals At sub-divisional level a) Local elected representatives at sub-divisional level 1x1 = 1 in no. b) SMOs/MS at Sub-Divisional Hospitals 1x1 = 1 in no. c) Indoor patients 1% of the total admitted in hospital or minimum of 6 patients d) Outdoor patients (OPD) 5% of the OPD attendance or minimum of 2 patients e) Facility Survey of 1x1 = 1 in no. Sub-Divisional Hospitals f) FGD (Male Community Members) 1x1 = 1 in no. 6

19 3.5.3 At CHC level a) Local elected representatives at CHCs 1x11 = 11 in no. b) SMO/MS at CHC 1x11 = 11 in no. c) Indoor patients 1% of the total admitted in hospital or minimum of 3 patients d) Outdoor patients (OPD) 5% of the OPD attendance or minimum of 1 patients e) Facility Survey of the CHCs 1x11 = 11 in no. f) FGD (female community members) 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 Special hospitals a) SMO/MS at Special Hospitals 1x2 = 2 in no. b) Indoor patients 1% of the total admitted in hospital or minimum of 1 patients c) Outdoor patients (OPD) 5% of the OPD attendance or minimum of 2 patients Training institutes a) Facility Survey 1x3 = 3 in no. b) Interview of the faculty 3.6 Data Collection Team 1 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. 7

20 4. 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 2, 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 8 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$16.1 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

21 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 PSACS Under Secretary Health Health - V, VI & VII Branches B PHSC Punjab Health Systems Corporation PSACS Punjab State Aids Control Society SI Social Insurance (ESI) 9

22 The major heads under which the funds were provided were Loan Rs crore, Grant Rs crore and Share of the State Government. Rs.43. crore. Break up of the budget was as follows: Head Rs. in Crore Civil works for renovation, new construction and extension Major/Minor equipment, Surgical Packs and Furniture 66.9 Vehicles and Ambulances 8.49 Medicines, Medical Lab, Supplies Information Systems and Computers Training and Workshop Salaries and Office Expenses Price Contingencies Total Rs 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 1

23 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) Principal State Institute (Badal) DMA AMFA AM Audit EE (C) Mohali EE (C) Patiala EE (C) Jalandhar AAO Dy Dir. (Admn) Accountants AMFA Assistant Manager (Finance & Accounts) Dy Dir. (P&T) AAO Acct Assistant Accounts Officer Accountant Asst. Dir. (Admn) Asst. Dir. (Sur) Admn BB DMA Administration Blood Bank Deputy Manager Accounts Asst. Dir. (HS) DMC EE (C) Deputy Medical Commissioner Executive Engineer (Civil) Asst. Dir. (BB) F & A HMIS Finance and Accounts Health Management Information Systems Asst. Dir (Equip) HS Hospital Services Med Supdt Medical Superintendent P & T Procurement and Transport Stat Anyst Statistical Analyst Sur Surveillance 11

24 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 1. 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

25 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. Chance of foreign training for all doctors and para-medical staff; 2. Substantial training opportunities and fellowships etc. within the country; 3. No change in the terms and conditions of the services, establishment matters will remain wherever they are At district headquarter level There is one Deputy Director cum Civil Surgeon (DD cum CS) in each district and hence a total 2 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 13

26 Authority and implementation of different schemes in the District under National Family Welfare Programme through District Family Welfare Officer and District Immunisation Officer 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 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 (1,) population Total in the State 118 SMO - 1 MO - 2 at each PHC SHC (Subsidiary Health Centre/Dispensary) For 1, population each total in the State: 12 Sub-centre Total with State: (5 population) LHV, Multi-Purpose Supervisor For a Population of 3, (MPHW M+F) LHV M+F MPHW PHC SHC SMO (Lady Health Visitor) (Male & Female) (Multipurpose Health Worker) (Primary Health Centres) (Subsidiary Health Centre) (Senior Medical Officer) 14

27 (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 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 5 hospitals and 2 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. 15

28 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 to 4.27% in FY 3-4 (BE). In absolute term, the allocations have increased from Rs. 257 million in FY to Rs million in FY 3-4 (BE) against the projected level of Rs million. The per capita expenditure on Health at current price has increased from Rs.11 in FY to Rs.292 in FY 3-4. 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 to Rs million in FY 3-4. 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 4-5% of retained revenue from User Charges were used to procure medicines and 2-3% 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. 1% 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 16

29 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. 17

30 5. 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) 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 Bed strength Six District Hospitals were 5 to 1 bedded, three were 1 to 2 bedded and one District Hospital of Jalandhar was found to be 3 bedded hospital. Special hospital at Patiala was 154 bedded and one at Bhatinda was 5 bedded hospital 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 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

31 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 General impression on cleanliness and maintenance of gardens Six district hospitals (6%) were having good cleanliness and four (4%) were average. Among special hospitals, the cleanliness standard was good in Patiala and average in Bhatinda. Five District Hospitals (5%) 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 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 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 Public utility facilities Among all the District Hospitals covered under the study, six had a chemist shop within the premises; majority of District Hospitals (7%) had a canteen as well. Only two District Hospitals did not have Sulabh Shochalaya (Toilet facility) out of 1 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 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. 19

32 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 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 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 Maternity services All the hospitals were having maternity services. Fig 1: Normal deliveries conducted in District Hospitals (Punjab) in the last five years No. of normal deliveries st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 5 Amritsar Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Patiala(SH) Sangrur Taran taran Bhatinda(SH) Districts 2

33 Fig 2: Caesarians done in District Hospitals (Punjab) in the last five years No. of caesarians st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 2 Amritsar Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Patiala(SH) Sangrur Taran taran Bhatinda(SH) Districts Mortuary Out of ten, seven of the District Hospitals (7%) 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 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 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. 21

34 Percentage of drug items which were requested and received were found to be 5 % in four District Hospitals, 4% in one, 6% in one District Hospital and one special hospital, 9% in one District Hospital, 1% in another and only 2% in Patiala special hospital. Percentage of patients getting all the prescribed medicines was found to range between 4% to 75% in most of the hospitals, except in Muktsar where it was only 25% and in Hoshiarpur it ranged from 5% to 1% for OPD patients. However, indoor patients in Hoshiarpur District Hospital were found to receive 1% 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 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

35 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 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. 8% of staff was not getting accommodation in Bhatinda, 7% in Taran Taran, 5% in Hoshiarpur and Ludhiana, 4% in Sangrur and 15 % in Jalandhar. Among special hospitals, 4% of the staff was not getting accommodation in Patiala and 9% 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 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) 23

36 Fig 3: No. of OPD Patients in District Hospital (Punjab) in last five years No. of OPD patients st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 5 Amritsar Bathinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Patiala(SH) Sangrur Taran taran Bhatinda(SH) 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

37 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 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 1 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 No.of patients st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 4 2 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. 25

38 Fig 5: Admissions through emergency in District Hospitals (Punjab) in the last five years No. of admissions through emergency st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 1 Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Sangrur Taran taran Bhatinda(SH) 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 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. 26

39 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 1 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 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. 27

40 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 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 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 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

41 Fig 6: Surgeries performed in District Hospitals (Punjab) in the last five years st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No. of surgeries Amritsar Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Districts Muktsar Patiala(SH) Sangrur Taran taran Bhatinda(SH) 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 29

42 Fig 7: No. of In-patients in District Hospitals (Punjab) in the last five years No. of In-patients st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 2 Amritsar Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Muktsar Patiala(SH) Sangrur Taran taran Bhatinda(SH) 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 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. 3

43 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 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 5% 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 31

44 regular death audit meetings were held and corrective action was taken in only three District Hospitals and special hospital at Patiala 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 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 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 Kitchen facility Kitchen facility was not found available in any of the studied district and special hospitals Utilisation of patient care services Analysis of the last 5 years data showed that in all the District Hospital the number of patients 32

45 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 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 4% to 5% in most of the District Hospitals except at Ludhiana where it went upto 8% and then came down to 5% over the next 4 years. 9. Fig 8: Percent of expenditure of the user charges on Medicine of different District Hospitals (Punjab) Percent cost (Rs) Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Patiala (SH) Fig 9: Percent of expenditure of the user charges in IPF of different District Hospitals (Punjab) Percent cost (Rs) Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Patiala (SH)

46 Regarding expenditure on IPF head, it was found to be to be around 2% in most of the District Hospitals. In maintenance of buildings the expenditure was 5% to 1% over the years except for the Special Hospital of Patiala in the first year, which was recorded around 63%. 7 Fig 1: Percent of expenditure of the user charges on buildings of different District Hospitals (Punjab) 6 5 Percent cost (Rs) Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Patiala (SH) Fig 11: Percent of expenditure of the user charges on equipments of different District Hospitals (Punjab) Percent cost (Rs) Bhatinda Ferozpur Gurdaspur Hoshiarpur Jalandhar Ludhiana Patiala (SH)

47 In most of the District Hospitals, expenditure on medical equipments recorded less than 1% over the years, except at Bhatinda, Ferozpur and Ludhiana where in some years it was more than 1%. 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.) Accessibility All Sub-Divisional Hospitals (SDHs) were easily accessible from the railway station and bus stand and were well connected with the roads 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 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 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 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 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. 35

48 5.2.7 Status of buildings Buildings of eight Sub-Divisional Hospitals were found to be in good condition while at two Sub- Divisional Hospitals (Patti and Talwandi) it was average 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 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 Dental services All the Sub-Divisional Hospitals were found providing dental services except one hospital at Fazilaka Maternity services Maternity services were provided at all the Sub-Divisional Hospitals assessed in the present study 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 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

49 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 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. 37

50 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 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 Sub- Divisional 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 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 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 5%. None of the Sub-Divisional Hospitals were found to have the facility of Dharamshalas 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

51 Fig 12: No. of OPD Patients in Sub-Divisional Hospitals (Punjab) in the last five years 18 No. of OPD Patients st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 2 Ajnala Batala Dasuya Fazilaka Jagraon Malerkotka Malout Nakodar Patti Talwandi 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 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 39

52 Fig 13: Emergency Patients in Sub-Divisional Hospitals (Punjab) in the last five years st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No. of patients 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. 4

53 Treatment facilities for dog/snake bite and poisoning were available at emergency departments of eight SDHs (except Patti and Talwandi) 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 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 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. 41

54 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 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 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 (5/3mA) were available at all the SDHs visited, but they were not found working at Batala and Dasuya SDH. X-ray machines (2/1mA) were available at five SDH and out of these only three were found functional; rest two were pending for condemnation. X-ray machines (moblie/6ma) 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 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

55 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 No. of Normal Deliveries st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 1 Ajnala Batala Dasuya Fazilaka Jagraon Malerkotka Malout Nakodar Patti Talwandi Sub-divisional Hospitals Fig 14: Caesarians done in Sub-Divisional Hospitals (Punjab) in the last five years No. of caesarians st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 1 Ajnala Batala Dasuya Fazilaka Jagraon Malerkotka Nakodar Patti Talwandi Sub-divisional Hospitals 43

56 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 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 No. of Patients st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 2 1 Ajnala Batala Dasuya Fazilaka Jagraon Malerkotka Malout Nakodar Patti Talwandi Sub-divisional Hospitals 44

57 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 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 45

58 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 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 1 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 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

59 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 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 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 Kitchen facility Kitchen facility was present only at Maler Kotla Sub-Divisional Hospital, with proper and safe arrangement for storage of raw material 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. 47

60 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 4% to 45% in most of the Sub-Divisional Hospitals except at Ajnala where maximum expenditure made on first 4 years (22-6) whereas very low during the year Fig 16: Percent of expenditure of the user charges in medicine of different Sub-Divisional Hospitals (Punjab) 1 Percent cost (Rs) Dasuya Fazilka Ajnala Batala Jagraon Malar Kotla Malout Patti Talwan-di Saboo Fig 17: Percent of expenditure of the user charges in IPF of different Sub-Divisional Hospitals (Punjab) Percent cost (Rs) Dasuya Fazilka Ajnala Batala Jagraon Malar Kotla Malout Patti Talwan-di Saboo

61 Regarding IPF, most of the Sub-Divisional Hospitals utilised 2% 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 1% of the user charges over the year, except the hospitals at Ajnala, Jagraon and Talwan-di Saboo where it was more than 1% in some years. Fig 18: Percent of expenditure of the User charges in building of different Sub-Divisional Hospitals (Punjab) 25 2 Percent cost (Rs) Dasuya Fazilka Ajnala Batala Jagraon Malar Kotla Malout Patti Talwan-di Saboo Fig 19: Percent of expenditure of the user charges in equipment of different sub-divisional hospitals (Punjab) 35 3 Percent cost(rs) Dasuya Fazilka Ajnala Batala Jagraon Malar Kotla Malout Patti Talwan-di Saboo

62 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) Accessibility All CHCs assessed were easily accessible from the railway station and bus stand and were well connected with the roads 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 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 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 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 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. 5

63 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 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 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 Other services (patient care) Except two CHCs all were having dental services and all eleven CHCs were having delivery services Mortuary None of the CHCs were having mortuary or post mortem facilities 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 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 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. 51

64 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 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

65 Outreach services Six CHCs were having an outreach area and services provided were mainly maternal and child health 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 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 2: No. of OPD attendance at CHC hospitals (Punjab) in the last five years Number of OPD Patients st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 1 Badal Fategarh Ferojshah Goniana Kartarpur Khemkaran Longwal Mahilpur Mojitha Machiwra Manawala Community Health Centres 53

66 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 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

67 Fig 21: No. of emergency patients at CHC Hospitals (Punjab) in the last five years st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr No. of patients Badal Fategarh Ferojshah Goniana Khemkaran Longowal Mahilpur Mojitha Manawala Community Health Centres Fig 22: Admission through emergency at CHC Hospitals (Punjab) in the last five years 9 No. of admissions in the Emergency st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 1 Fatehgarh Ferojshah Goniana Kartarpur Khemkaran Longowal Mahilpur Mojitha Machiwara Community Health Centres 55

68 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 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 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 Blood banking services None of the CHCs under the study were having blood bank facility 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

69 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 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 No. of Normal deliveries st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 5 Badal Fatehgarh Ferojshah Goniana Kartarpur Khemkaran Longwal Mahilpur Mojitha Machiwara Community Health Centres 57

70 Fig 24: Caesarians done at CHC Hospitals (Punjab) in the last five years No. of caesarians st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr 2 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

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