Building National Rural Health Delivery Systems
Item
- Title
-
Building National Rural Health
Delivery Systems - extracted text
-
H-ALTH C£tt
^26, V
I Block
Kofarnfingala
®angalore-560034 *
India
ASPECTS OF DESIGN , CONSTRUCTION, MANAGEMENT
AND
OPERATION
I I 341 I
A SAG
AHMEDABAD
COURTESY:
DIRECTORATE OF HEALTH SERVICES
GOVERNMENT OF MAHARASHTRA
study action group, palaL bldg., behind hotel capri, relief RD. AHMEDABAD- H
COMMUNITY HEALTH cell
3UILDING NATIONAL
RURAL HEALTH
DELIVERY SYSTEMS
ASPECTS OF DESIGN, CONSTRUCTION, MANAGEMENT,
AND
A SAG
OPERATION
COURTESY:
DIRECTORATE OF HEALTH SERVICES
GOVERNMENT OF MAHARASHTRA
IahMEDABAD STUDY ACTON GROUP, DALAL BLDG., BEHIND HOTEL CAPRI, RELIEF RD. AHMEDABAD - 1 |
CONTENTS
FOREWORD
CHAPTER I: Antecedents
CHAPTER II: Perspectives
CHAPTER III: The Need For Health Services at
Village Level
CHAPTER IV: The Concept Of The Rural
Hospitals
CHAPTER V: Facilities For A Primary
Health Centre
CHAPTER VI: Facilities Required In
A Rural Hospital
CHAPTER VII: Cost Analysis And Optimisation For A
Rural Health Delivery
System
CHAPTER VIII: Recommendations For RH/PHC Management
Organ!3 ation
CHAPTER IX: Procedures And Recommendations For RH/PHC
Design,
Construction
And Commissioning
FOREWORD
At the time we were invited by the Directorate of Health
Services,
Government of Maharashtra, to explore the
possibilities of making reductions in cost of rural
hospitals and primary health centres, we were involved
in studying the physical condition of the Lowest Income
Decile (poorest 10%) children of 3600 families in 60
villages of DhoIk a Taluka,
Ahmedabad District.
This led
to further studies and a proposal for "Comprehensive
Assistance to Low Income Rural Mothers and Children".
It was an opportune contrast to examine from government
level, the problems associated with developing national
rural health improvement systems.
It appears that there is an irreconciliable difference in
the role of government-provided medical services and in
the role of community health services.
Medico-legal cases,
though few, cast their shadow, over the attitudes government
doctors must take in dealing with communities and the general
public.
Although definitely required,
a good deal more thought is
necessary regarding the modalities of Health Services
expansion.
Jagdish Nazareth
April 4,
1905
CHAPTER I
Antecedents:
Thia note ia baaed on:
a)
Experiences gained by village level health surveys
and action on the physical status of children from
poor rural families in a block of 60 villages, in
Dholka taluka,
b)
Ahmedabad district, Gujarat State.
Discussions and observations during two field trips
in 8 districts of Mahatrashtra organised by the
Directorate of Health Services, to dispensaries,
primary health centres and rural hospitals in
October 1983 and June 1984.
2
CHAPTER II
Perspectives:
all medical and health
At the time of Independence,
matters were regulated by the office of the SurgeonGeneral.
Under him,
there wore Civil
State and District levels.
Hospitals at
The function of the Civil
Hospitals were related largely to thfe medical or
curative aspect and the medico-legal
post-mortems,
aspect such as
accidents, etc.
In the 1960s the Government of India and the State
Governments ; began work on several preventive health
measures such as:
sanitation,
small-pox and malaria eradication,
This led to the
and family planning.
setting up of the Primary Health Centre network at
block
and tehsil-levol.
Because of the shortage of
medically qualified personnel, many of these personnel
were termed para-medical staff,
because they held
qualifications such as graduate degrees in Science.
These para medical
staff were subsequently placed
under the District Health Officers (DHO), who were in
turn,
incorporated into the Zilla Parishad
(ZP)
structure•
In 1970,
the Government decided to
amalgamate medical
and para-medical staff in Maharashtra.
The Directorate
of Health Services was created to deal with the task
of preventive and medical
services in rural
areas.
At
the same time, other Directorates for Medical Education
and Research,
for Drug Control,
and for Employees State
Insurance Scheme medical
services were hived off the
Surgeon General’s office.
The large urban teaching
were therefore placed outside the purview of the
Directorate of Health Services.
5
During ths 1970s ths Government expanded the Primary
Health Centre
(PHC) network under the ZPs and DHOs.
Each PHC catered to approximately one taluka,
block.
tehsil or
Because of the inheritance of preventive
traditions, the PHCs were expected to supervise village
level
sub-centres and dispensaries,
and periodically
hold camps on various health matters.
The PHCs normally had 6 beds for in-door patients and an
operation theatre.
subsequently,
However,
for reasons detailed
PHC doctors normally
found it necessary to
refer most cases of medical surgery to the district civil
hospitals.
The operation theatres were used for deliveries
and family planning operations.
In the mid-70s, most
known as a Rural
PHCs received another building
family Welfare and Planning Centre.
These RFWPCs also had operation theatres, which again,
were used mainly for family planning operations.
In the 1900s it began to be felt that the emphasis on
preventive health measures was working to the detriment
of the medical aspects.
appendectomies,
For simple emergencies like
pregnancy complications,
premature
babies and accident victims, the place of automatic
referral was the district hospital.
Accordingly it was decided to insert a 3rd tier between
the
PHC and the district hospital, known as the rural
hospital.
The decision however is quite recent and
many points of debate and discussion have emerged.
This
Note is an attempt to detail and synthesize the possibilities
and implications arising out of this decision.
4
CHAPTER III
The Need For Health Services at Village Level:
It would be interesting to itemise the normal need for
health and medical
services a village usually requires □
on an ongoing basis:
- Ante-natal maternal medical examination and treatment
- Natal services
- Referral of complicated cases in delivery
(emergencies)
- Treatment of post-natal complications (peritonitis
tetanus)
- Abortions and Medical Termination of Pregnancies
- Family planning operations: vasectomies,
tubectomies,
1aparo scopy
- Neo-natal immunisation
- Paediatric illnesses
- Appendectomies
- Tubercolosis detection and control
- Worms infestation
- Agricultural accidents (particularly in tractorised
and mechanised areas)
- Road accidents
- Snake and rabid animals
(dogs, monkeys) bite
- Opthalmological troubles
- Post-mortems
- Fevers
- Burn cases
The occurrence of these events can be
predicted by statistical analysis,
faitly reliably
except for the family
planning operations which are part of the purposive or
intentional programme of the Directorate of Health Services.
5
However,
it appears that in no PHC or
Rural Hospital that we visited, was
there any attempt to measure the need
for medical
village,
and health services at the
block or multi-block
(rural
hospital) level.
Nor was there any systematic attempt
being made to relate the provision of
DHS medical services in the area, with
the provision of medical services
through other local, private,
voluntary
or otherwise organised institutions.
Thus the whole programme for delivery of health services
appears at this point in time, to be proceeding without
regular analysis of:
a)
the need for medical and health services in the
command area
b)
The existing local supply of such services
The main driving force for the rural
health delivery
system appear to be t argets derived from State level
demographic data, being apportioned from above.
A point that 3 or 4 medically and surgically qualified
doctors made at various rural hospitals was that nobody
at higher levels of DHS seemed to be interested in the
medical
aspects of out-patient and in-patient care.
they wished to know was the Family Planning record.
This point needs to be stressed because
there appears to be a very majpr linkage
between the number of deliveries and
family planning operations.
All
6
The Rural Hospital and PHC doctors at a number of
places told us that women who have just delivered
their babies are the most highly self-motivated cases
for Family Planning operations.
And just after
delivery is also the most convenient time- medically
speaking- to undertake tubectomies.
There is reason to believe that in most PHCs and Rural
Hospitals (RH) the lack of systemic interest in the
welfare of pregnant mothers,
the thoughtlessness of the
facilities (or lack of facilities) provided, the near
total absence of sanitation maintenance, is a great
hindrance to the increase in the number of deliveries
at the PHC or RH in comparison to what it could be.
This in turn affects Family Planning performance.
The attitudinal gap is very major,
very serious,
and
more thought must ba given in DHS to foster and support
a more need-responsive and patient-responsive approach
to rural health*
PHCs and RHs must be encouraged to
draw up their own plans Tor provision of health and
medical services and creation of facilities based on
the need in the area and their own capabilities in
attracting patients.
7
CHAPTER IV
The Concept of The Rural Hospital:
It may not be an exaggeration to say that the currently
accepted concept of the role of a Rural Hospital has been
based on the work of Dr s’.
taluka in Maharashtra.
Raj and Mabel Arole at Oamkhed
This Rural Hospital functions as
the base of an out-reaching health-cum-medical delivery
system that combines preventive and curative operations,
which tries as far as possible to upgrade a village’s*
ability to look
after its health problems on its own with
a minimum amount of outside supply of routine
services,
professional
facilities and medicines.
In the DHS concept,
a 30 bed rural hospital is expected
to cater to the referral needs of 3 or 4 PHCs for all but
the most major medical emergencies.
to cater to
Thus an RH is expected
a population of about 300,000,
after system expansion
for about 150,000.
at present,
In several cases,
PHCs are being up-graded to Rural Hospitals.
some relatively
and
In the process
serious personnel problems are in the
m ak i n g .
0 PHC staff are Zilla Parishad employees with touring
duties in the villages.
° Rural Hospitals are expected to
be headed by
Class I
medically and surgically qualified officers reporting
to the Dy.
Director of the concerned DHS circle.
(There are 8 circles covering Maharashtra State.)
0 If the Medical
Superintendent of the Rural Hospital
is asked to report to the Chief Executive Officer
and District Health Officer of the Zilla Parishad,
conflicts of professional standing are expected to
arise.
8
0 Rural
Hospital staff drawn from the District
Hospital staff have raised issues of working
hours and touring duties which are subject to
different regulations there.
Will they remain
State Government employees? or will they become
ZP employees?
0 Rural Hospital doctors say that touring duties for
doctors interfere with 24 hour availability needed
to deal with emergencies that are brought to the
ho spit al.
° Rural Hospital doctors complain that they do not
receive non-Practising Allowance like PHC doctors*
To persons from a voluntary agency these issues appear
trivial compared to the needs of rural people.
the
However,
fact that such issues arise and are discussed for
much time and with great seriousness will provide some
indicators of what is likely to happen to the health
delivery system after it
years.
has been in operation for a few
Will it be able to rise above personal injuries
and animosities to really
serve the rural people;
For example, most Rural Hospital doctors dread the
prospects of having to work under the Zilla Parishads.
Several PHC doctors have mentioned that:
- their vehicles are misused by
Taluka Panchayat
o ffi ci als-
- their controlling officers are unduly sensitive to
pressures from the Chief Executive Officers of the
Zilla Parishads and the elected representatives.
Cases of 5-6 transfers in as many years are quite
hi gh.
- they resent being put under the administrative
control of the Block Development
Officers who
usually less qualified Chan they
are.
are
9
- their powers to spend money specially, on
maintenance and sanitation are so limited that
they,
are forced to liaise repeatedly with the
Building and Communications department of the
‘Zilla Parishad to little avail.
Rural
Hospital
doctors feel that they will come under
similar pressures.
It would appear
from the above that:.
- the organisatiqnal concept of the Rural Hospital
as the 3rd tier-in a health delivery system, is not
clear to the doctors and staff at the field-level.
- the management structure of the Rural
Hospital and
its linkages with the State Government’s DHS on the
one hand and the local body
(ZP) on the other are
in need of substantial revision and greater clarity.
- the need to insulate the RH - PHC - SC system from
both the State Government and the local body structure
in some ways is essential,
to ensure stability to key
medical staff and some measure of autonomy.
The doctors view point howqver must be balanced by what one
may consider a people’s view point based on our observations
at various places!
- the levels pf sanitation at all places was appalling.
At one PHC turned RH the sewer pipes in the patients
ward were burst and choked for over 6 months.
The
disposal of operation theatre and labour room wastes •
in almost every
ward.
PHC and RH is the ground behind the
It would not be incorrect to say that sanitary
conditions are ^uch as to be criminally negligent.
10
- the lack of privacy for patients particularly in
the
Type Rural Hospital design is distressing.
there was very
little evidence both among doctors
and nurses of sufficient interest or skill at
developmental medicine.
There was very little
rapport between the doctors, nurses and their
patients,
except in some cases, on account of the
.personal qualities of the people concerned.
- there was lack of evidence of any kind of pride in
institution building, among the doctors and nurses.
If anybody spoke it was primarily about individual
target fulfillment specially about Family Planning
operations.
- there was some indications of doctors indulging in
private practice.
In summary it may
be said that it would be dangerous to
leavb rural health solely in the hands of doctors.
But
on the whole, we were extremely impressed by the motivation
displayed by all cadres of the DHS staff, considering
the personal difficulties they are being put to.
situation could be summed up as:
bothers,
”1 care;
The
but nobody else
This feeling where
so what can be done."
everyon e feels himself/herself to be part of an isolated
minority that is powerless to
function effectively with
pride and high morale, must be tackled with greater emphasis
on personnel management inputs.
At upper levels of DHS there was evidence of much sincerity,
motivation and unremitting effort.
with some
level.
But this was viewed
. cynicism and lack of enthusiasm at district
11
The relationship between the concept of the functions
of a rural hospital and the design of its facilities
is organic.
The way
a hospital is conceived to operate,
the way it is built,and the way it works and is
maintained are all integrated.
The creation of a
hospital is therefore something more than just slapping
a few buildings together under a variety of State level
schemes and programmes.
The amount of redundancy, the incompatibility of facilities,
the lack of good design and attention to detail, the lack
of a high morale, culture and identity
to a Relatively high cost rural
have all contributed
health delivery system.
We feel that it is imperative that the DHS introduce a
procedure to relate the facility
and manpower costs at
PHCs and RHs to the through-put of in-patients and out
patients.
We make this statement although we have been
told that the effectiveness of a PHC and a RH is to be
judged inversely to its OPD and in-patient load because
it is also a preventive system.
So a low OPD and in
patient rate can also be interpreted, under present
conditions,to indicate the efficiency of the preventive
measures being undertaken rather than the sloppiness or
indifference of the staff concerned.
We believe that the Maharashtra Government should seriously
consider a policy of rural health delivery that encourages
organisations such as medical trusts,
to undertake operation
and maintenance of PHCs and Rural Hospitals, with financial
assistance from the Government for construction and
maintenance rather than the present policy of only
Government services expansion.
be regulated by DHS.
These institutions could
Today the average cost of servicing
one OPD patient in a PHC is about Rs.15.00, not considering
the drugs and-medicines he/she reqeives.
?>
12
CHAPTER V
Facilities for a Primary Health Centre:
A PHC presently
serves a population of about 100,000.
After the PHC structure is expanded the population served
mould drop to
about 30,000 in tribal areas and 60,000 in
non-tribal areas.
In the typical command area of a present PHC, one could
therefore expect about 4000 pregnancies and correspondingly
about 3600 births per year.
Our observation is that good
PHCs are covering between 10-15% of the possible deliveries
in their command area.
Perhaps the figure should be at
least 40-50%.
A normal delivery
for a rural mother requires as average
of 3 in-patient days.
If we expect a PHC to cater to
1800
births in a year it should have between 15-20 beds for
maternity cases alone, with a corresponding nursing pattern.
Of course, for a variety of reasons only a few PHCs have
reached a figure of this magnitude.
We suggest that the
PHC pattern must be made sufficiently
flexible to expand
properly working PHCs for maternity cases upto 15-20 beds.
If a PHC conducts about 20-30 deliveries per month they
get about 15-20 tubectomy cases.
Each tubectomy patient
spends an average of 7-10 days in hospital.
Hence it should
be necessary tt) provide twice the number of maternity beds
for female family planning operations-
If a PHC is expected to deal with deliveries, pregnancy
terminations,
tubectomies and other family planning
operations on its own, without referral to rural
hospitals
except in major emergencies,then it is necessary to
13
consider the following:
- there must be an incubator for premature babies.
- there must be a septic ward,
specially for
deliveries that go bad at village level and come
at the last minute to the
PHC.
- Labour room and operation theatre facilities have
to be substantially re-designed as there are many
defects of design and construction which make
caesarian operations hazardous-
However,
if the PHC is not expected to deal with such
matters routinely, then the corresponding facilities at
the Rural Hospital have to be enhanced.
The present RH
Type design has no provision for incubators/septic wards.
In all cases we have found that the capacities of the
sanitary blocks and sanitation systems were grossly
inadequate for the load.
Wherever the Medical Officer
is good, there is a rapid increase in the patient load
and the doctors and nurses accomodate the patients on the
floor and verandah.
But sanitation facilities are not
similarly elastic and they rapidly go out of order.
Then
patients and their relatives - where there is not enough
space outside • are found to use the grounds within the
PHC compound under the cover of night.
The problem is
compounded by the shortage of water we observed at
several
PHCs.
14
CHAPTER VI
Facilities Required in a Rural Ho spit al:
If an RH is expected to cater to the referral needs of
4 PHCs and if it is expected to serve as the headquarters
and supply base for preventive work in
PHCs,
sub-centres
and villages then it must have the following facilities:
A.
OPP Nodule:
1.
Out Patinet’s Waiting Area with Instructional
F acili tie s.
B.
C.
2.
Out-Patients segregated Toilet Blocks
3.
Case Paper Unit
4.
Nale/General
5.
Female/nnte-Natal Examination Room
6o
Paediatric/lmmunisation Unit
7.
Social Workers/Supplement al
Examination Room
Nutrition Unit
Diagnostic Services Nodule :
1.
Bio-medical statistics records section
2.
Laboratory
3.
X-Ray
4.
Tubercolosis Detection and Control Unit
Facility
5.
> Nal ari a/Fi 1 ari a detection and control unit
6.
Post-Nor tem Room
Drugs and Dispensing Nodule:
1.
Bulk Drugs Store
2.
Surgicals Store
3.
Sanitation Chemicals,
4.
Linen Storage and Fumigation Unit
5^
Break-bulk,
6.
Injections and Dressings Unit
7.
Store Records and Dispensing Issues Record Room
8.
Cold Store:
Drugs,
Poisons Store
compounding and Dispensing Room
Blood/Plasma/Vaccinag
15
D.
In-Patients Module:
1.
Maternity Ward
2.
Premature and Endangered Babies Ward
3.
Female Family
4.
Septic Cases Ward (Female)
5.
Male General Ward
6,
Male Infectious Diseases Ward (attached toilet bath)
7O
Female Patients Toilet Block
8.
Male Patients Toilet Block
9.
In-Patients Relatives Male-Female Toilet Block
10*
Bed-pan/kidney tray washing unit
11.
Clothes washing and drying area
12.
Babies Clothes/Nappies Washing/drying area
13.
Relatives Sleeping Area
14.
Cooking facility with Ration/Provision and Utensil
Planning Cases Ward
Store and Firewood store
voluntary
(attached toilet bath)
(to be operated by a
agency or charitable trust such as Lions
Club )
15.
All religion worship place
16.
Infected clothes,
17.
Dump for used bottles,
bandages,
cotton incinerator
salines,
drips,
etc for
r ecy cling
E.
18.
Pharmacists Shop
19.
Mattress Fumigation Unit
Operation Theatre and Labour Room Module:
1.
Labour Preparation Room
2.
Surgicals Sterilisation Room
3.
Labour Room
4.
Pre-Operative/Post Operative room
5.
Operation Theatre
6.
Incinerator for operation theatre, labour room
and post-mortem wastes
7.
Surgical cleaning facility
16
Fo
Staff Services Module:
1«
Changing Room:
Lockers:
Toilets:
Bath i
Male/Fern ale
G.
H.
2.
Duty Room:
Nurses
3,
Duty Room:
Medical Officers
4O
Library
5<>
Tea-Club Room/Con ference Room
^Health Extension Services Module:
1.
Drawing-cum-setting up studio
2<.
Duplicati ng/Xeroxing room
3.
Typing
Sanitation and Maintenance
Engineering Unit:
1.
Maintenance Materials Store
2.
Sanitation Engineer’s Office
3.
Staff Room
4.
Workshop for Light Repairs,
Carpentry,
Electrical,
Mechanical
I•
*
Administration Module:
*1.
Health Services Operations Monitoring Room
2.
Record Room
3.
Clerical Room
4.
Administrative Officers Room
These
facilities only if the rural hospital is considered
a seriice facility
and not
J.
for the rural hospital delivery system
as a purely medical referral facility.
Vehicle Module:
1.
Garage for Ambulance
2.
Garage for Jeeps
3.
Motorcycle/cycle Parking lot
17
K•
L.
Re si donti al Module:
Superintendent’s Residence
1.
Medical
2.
Medical Officers Quarters
3.
Staff Nurses Quarters
4.
Class IV Employees Quarters
Offsites Module:
1.
Water Supply
2.
Sewerage
3*
Electricals
4.
Roads
5,
Horticulture
6.
Compound Wall
For each of the individual
it is possible to
creation
(e.g.
facilities in a given module
specify certain bases for
icapacity
in an OPD based on queuing theory) and
certain linkages
(e.g.
variation in sewerage with
intensity of OPD and IPD).
On the basis of such analysis it would be useful to
specify the capacities of:
a) the initial or basic module
b) the incremental module
18
CHAPTER VII
Co st
Analysis and Optimisation For a Rural Health
Delivery
System:
When we were invited by the Government of Maharashtra to
visit Primary Health Centres and Rural Hospitals, our
brief was to produce low-cost designs for PHCs and RHs -
primarily the capital cost component.
However when we look at cost optimisation or cost
minimisation a number of issues arise:
1.
The overall objective might be framed as follows:
’’The greatest benefit to the most people at the
minimum cost per patient.”
2.
This objective implies:
- quantification of facilitias and benefits
to be given to people
- estimation of throughput or capacity
handling ability of the facility
- appropriate design of a ’’line-balanced”
facility without bottlenecks or unnecessary
redundancy
- suitable specification of building construction
materials in relation to local availability
- rapidity in system creation and deployment
- maintenance and continuous incremental
expansion of the system deployed
19
To explain those ideas,
a feu/ examples:
- a PHC or Rural Hospital must have a modular
concept for its OPO.
One examination room can
cater to an OPD of about 1800 patients per month.
For OPD of more than this, the examination rooms
and related facilities such as:
0
case paper issue counters
°-
injection and dressing room
0
drug dispensing counters
0
patients waiting areas
?
out-patients toilet block
°
immunisation unit
°
laboratory
need to be correspondingly expanded in a modular
fashion.
- the general location of a PHC or RH in relation to
the villages of the command area,
as well as the
specific site location of the building in the
particular village or town are of great importance
in determining the size of the OPD and to some
extent of the In-Patient load.
For example one PHC was perched on top of a hill
300 feet above the village.
It had a very low
OPD and an even lower In-Patient, which may have
resulted in a 20% capacity utilisation.
- the In-Patient facilities are
of the total
cost.
PHC as well as Rural
Hospital buildings
Yet several PHCs and RHs were hardly using
50% of the
days).
a very major component
In-Patient capacities
(measured in bed-
Further inquiry showed that the capacity
utilisation was low because of a number of other
related factors which were bottlenecks.
e.g.
unusable
operation theatres or insufficient labour room
capacity, or lack of qualified doctors, or shortage
of staff nurses.
20
- in several
locations it is not feasible to use the
proposed type plan for Rural
Hospitals except at a
very high cost in land development.
- in most upgraded medical centres there is a major
problem of redundant facilities.
few of the Rural
We found very
Family Planning Welfare Centre
operation theatres being used because the PHCs
already had an operation theatre.
- on the other hand we found operation theatre
facilities being put to very sparing use because
of lack of other balancing facilities and personnel.
In one rural hospital because blood storage is not
provided and because there are no
facilities to cater
to premature babies, many patients who could have
been - and should have been treated - were referred
to the district hospitals or to private doctors.
- in one very
distant rural hospital
location, we
found that all the items of furniture (e.g.
desks
for medical officers) had been shipped in from
Bombay.
Perhaps the cost of transport isolf would
equal the cost of furniture.
- in the matter of common building materials such as
bricks we found in Some cases very
70 kilometres although bricks
long leads e.g.
(possibly not of
similar quality) were being made within 5 kilometres.
- we found that the construction times for almost .all
PHCs and RHs were abnormally long.
reason was the very
Part of the
long procedure of approval,
which is reproduced in the npxt chapter-of thie note.
21
The cost of a building may be related to:
- cost of building materials
(about 65% of
total cost)
- cost of labour
(about 25%)
- cost of supervision and management
However,
(about 10%)
because of an absence of an opportunity
several decisions that might
cost to time lost,
have resulted in a building becoming useful a few
years earlier than it^ actually took, were not taken.
we found some lack of integration between the
building design and the equipments ordered for a
rural hospital
we found that many operation theatres were defectively
designed - to the point of criminal negligence.
We
found two operation theatres with no exhaust fan.
We
found all operation theatres with no air intake
f aciliti es.
Thus,
as soon as the exhaust fan begins
operating in a substantially closed theatre a vaccuum
is created which exerts a pressure on the door causing
it to open inwards.
The only air inlet in many/cases
was the gap between the door and floor.
Air that is
introduced in this manner is likely to have a high
germ count.
In some cases we found the operation
theatre next to the general entrance to the facility,
instead of being protected by a pre-operation
preparation room.
we found many operation theatres did not have
separate and protected water supply.
at one rural hospital we found the water supply to
the in-patient ward entering a cement concrete
ground level storage reservoir which was surrounded
by leaking sewerage’ pipps and adjacent to the toilet
b lock.
COMMUNITY HFA! th rn .
34/
4?/‘.
Floc
;
m
.
A
22
- at all places we found broken and unrepaired
sanitation facilities.
had unsatisfactory
Even operation theatres
levels of cleanliness.
Cost optimisation has therefore to be considered as
f o Hows:
1.
Effectiveness of facilities to provide the
services desired in the long term.
2.
Throughput of
- outpatients
- in-patients
- out-reach services in the command area
3.
Contingency levels to be maintained for epidemics
and emergencies.
4.
Improvement in morbidity and mortality rates in
the command area.
It is recommended that such detailed system studies be
undertaken for a few PHCs and RHs in each DHS circle in
order to arrive at appropriate methodologies for assessing
the Levels of services to be reached and the capital and
recurring costs to be incurred.
23
CHAPTER VIII
Recommendation^
For RH/PHC Management Organisation:
PHCs and Rural Hospitals must be given the freedom to
develop their own identities.*
These identities have to
be developed:
A.
Before the PHC/RH is constructed:by preparation of
a full-scale Feasibility Report that will
- survey the need for health and medical services
in the command area
- take into account private,
voluntary and
medical educational health facilities in the
are a
- identify the key tasks of the PHC/RH for the
next 5-10 years
B•
While the PHC/RH is being Constructed: by
- creating a PHC/RH Construction Committee with
complete supervisory powers
- providing the PHC/RH Construction Committee with
a Bank Account and a Letter of Credit for cost
inflations on Capital Works as to ensure that
the work is not delayed on account of cash-flow
problems
— separating the budgets for building materials
and for construction labour in both physical
as well as value terms and separately monitoring
them
24
- subjecting procured building materials to
quality control checks? through empanelled
architects?
civil engineers and structural
engineers
“ specifically naming the arc hit ects,structural
engineers and civil engineers who have been
responsible for construction and design on a
plaque in the building
- involving a local mason,
plumber and carpenter
in the labour contract, with an understanding
that they will also do the maintenance later on,
on a rate contract basis.
This would create a
stake in doing a good job and doing it at a
low cost.
Co
While the PHC/RH is in Operation:
by
- creating an autonomous Management Committee with
local and outside members serving a term of 5
years.
These members to have as far as possible
suitable qualifications/experience
- empanelling private doctors and encouraging them
to use under-utilised facilities such as operation
theatres,
X-Ray facilities,
laboratories, on
payment of a concessional rate.
This money should
be received by the Management Committee and 50%
disbursed to the concerned hospital staff
- making oho officer the Chief Executive of the
Hospital/PHC,
serving under the Management
Committee, with powers to spend funds on
sanitation and maintenance as required
25
- making one of the primary
functions of the
Chief Executive the responsibility for sanitary
condi tions
- instituting a system of Visitors in various
medicalp
health disciplines (including sanitation)
to inspect the hospital’s various departments,
examine the functioning and operation and report
on the conditions prevailing to OHS.
- providing the Management Committee of a RH/PHC
with the right to accept or reject staff
proposed for permanent transfer#
(Staff not
being accepted on transfer should revert to a
circle level pool
for PHCs and State-level
pool for RHs.)
- providing for incremental expansion of PHC3/RH3
on a modular basis as they achieve full utilisation
of out patient and in-patient throughput
capacitiesautomatically
This expansion fund could be
linked to the funds collected from
patients by an appropriate multiplier factor.
E.g.
Every Rs.1.00 collected from an in-patient
above 70% capacity utilisation mill entitle the
PHC/RH to Rs.10.00 for capital expenditure on
In-Patient facilities.
26
CHAPTER IX
Procedures and Recommendations for RH/PHC Design, Construction
and Commissioning
Existing Procedure for Constructing a Primary Health Centre:
1.
Proposals invided from Zilla Parishads for location of
PHCs by DHSo
- Resolution passed by
General
Body Meeting of the
ZP
- Sanction provided by the District Planning Board
2<>
Proposals are forwarded to the Secretary,
Department by DHS.
Public Health
(No Preliminary Feasibility Report
made at this stage by DHS.)
3.
Secretary,
PHD issues a Government Resolution (GR) for
location of PHCs after taking Cabinet approval with
concurrence of the Finance Department and Planning
Department at the Mantralaya.
4.
On receipt of the GR the Chief Executive Officer (CEO)
in consultation with the District
Health Office (DHO)
fix site and location of the PHC and request District
Collector for transfer of land or NA (non-agricultural)
permission.
The CEO of the ZP can purchase land on a
resolution of the Health Committee.
The State
Government does not reimburse cost of land.
5.
The DHO takes over land on behalf of the ZP.
6.
CEO and DHO request the Executive
plans and estimates.
Engineer to prepare
27
7.
The Executive Engineer requests the Deputy Executive
Engineer to prepare Plans and Estimates.
80
Technical scrutiny is done by the Executive Engineer
and the Plans and Estimates are s0nt to Government
through the DHO and DHS.
9.
Government (Secretary - PHD) issues a GR of
Administrative Approval
(AA) with the sanction of
grants for Building Construction.
10.
The DHS consolidates Government
AAS for all PHCs
and Rural Hospitals in a District and places the Grant
at the disposal of the DHO.
11.
The DHO in turn places the grant at the disposal of
the
Executive Engineer to be disbursed by the Chief
Accounts and ,Zin an ci al officer (Thereafter the DHO
has no control on the execution of construction works)
12*
In case of escalation above 10% of the AA cost
sanctioned the entire process has to be repeated.
13.
The Executive Engineer is responsible for building,
electrification, water supply,
approach roadso
14.
sewerage,
fencing and
These are all part of the AA.
Agency bills for construction contracts are scrutinised
against the Measurement Book maintained by the Jr.
Engineer (at tehsil level) and checked by the Dy.
Executive Engineer.
Payment is made after the Executive
Engineer forwards the Bills to the Chief Accounts and
Finance Officer.
28
15©
On completion, a certificate by the Executive
Engineer is provided and the building is handed
over to the DHO.
(it may be observed that
structural engineering and architectural
supervision is done only on buildings costing
more than Rs© 50 lakhs.)
16©
DHO may refuse to take possession but otherwise
has no control on the release of the Building
Completion Certificate.
17.
Running-in of a new building is done out of the
statutory 3% maintenance grant placed at the
disposal of the Executive Engineer of the Zilla
Pari shad for all buildings in his care.
(There is no control on the use of the maintenance
grant sanctioned for the PHC being actually used
The Executive Engineer uses the
for this purpose.
entire grant according to his own priorities.)
Comments on this Procedure:
1.
It will be apparent that no where in this procedure
is a Preliminary
Feasibility Project Report prepared
for construction of a PHC or a RH making an integrated
evaluation of site, communications^ medical problems
to be tackled,
2.
etc.
Departmental execution of PHC/RH buildings by the
Executive Engineer of the District Panchayat is not
desirable.
3.
A possible alternative procedure could be as follows:
(a)
an apex State Level Hospital Construction and
29
Capital Maintenance Organisation should
consolidate,
approve and provide plans,
designs,
structural engineering and estimates.
(b)
at circle-level
(8 circles) there should be
appointed a PHC/RH Architect and Structural
Engineering Firm on a long-term basis
which
would provide detailed supervision for construction
and future expansions.
They
should be charged
with long-term storage of construction drawings
of each building.
Design proposals to originate at circle level and
receive approval at Staterlevel.
(c)
at district level DHO and Executive Engineer
should be part of a Hospital
Building Supervision
committee which will fix turnkey construction
engineers and contractors for sub-centres,
PHCs
and RHs as per Design and Plans prepared by the
Circle Architect and Structural Engineers.
(d)
Departmental execution by Dy
Executive Engineer
at Taluka level should only be resorted to in
case of failure of contractor.
(e)
At RH and subordinate PHC level a committee to
supervise and make payments to engineers and
contractors according to progress of work.
This committee to include as chairman,
the Doctor
in charge of the RH.
The RH/PHC Doctor-in-charge to draw up the
Preliminary
Feasibility Report that provides
the design brief to the Circle Architects and
Structural Engineers*
’
30
Suggested Procedure for Construction of RHs/PHCq:
1.
Doctor in charge of RH and subordinate PHCs and SCs
to draw up the Preliminary
Feasibility Report for each
facility providing:
a)
Projection of OPD
b) Projection of Maternity Admissions
c)
Projection of FP cases
d)
Projection of other in-patient admissions
a) Projection rural health care services.
e.g.
immunisations, tubercolosis detection and
control,
etc.
A budget of Rs.20,000 for PHCs and Rs.60,000 for RHs
may be made for preparation of such Reports.
2.
Capacity of various Modules to be fixed by the Circle
Architects/Engineers based on approved PFR estimates.
Sanitary capacities to be specifically oversized.
3.
Plans and Designs and Estimates prepared by Circle
Architects/Engineers to be approved at State-Level
by the Hospital Designs and Construction Approvals
Organisation for RHs/PHCs.
4.
Approved Plans and Designs to be
forwarded to DHO and
EE of concerned District for Supervision of Construction
and fixing of Construction Engineers and Contractors*
6.
10% Cost Overruns to be sanctioned by District
Construction Supervision Committee.
20% cost overruns
by Circle and upto 40% cost overruns by State-level
Hospital Designs and Construction approvals
Organisation.
Construction schedules need to be strictly monitored
at the Circle level and expedited if necessary.
31
Suggested Procedure for Maintenance,
1O
Upgrading, Expansion:
The Maintenance Budget of a PHC should be fixed at 8%
For a RH it should be 10% of Capital
of Capital Cost*.
Cost •
2©
The Maintenance Budget to be distributed as follows:
for PHCs
a) With Circle Office
b) With Dist.
Committee
c) With RH/PHC Committee
for RHs
1%
1.5%
1.5%
2.0%
3.5%
6.5%
6.0%
10.0%
Certain segments of expenditure should be reserved as
fo Hows:
To RH/PHC
To Diet.
To Circle
a) Sanitary Maint enance
100%
-
•
b) Building Repairs
6 0%
40%
-
c) Electricals
20%
80%
d) Hospital Equipment
10%
30%
70%
e) Furniture
100%
-
-
f)
80%
10%
10%
Horticulture
These allocations are arbitrary and ill ustrative of what
actually may be necessary,
after proper analysis is done
of maintenance needs.
4.
The accumulation of Repairs and Maintenance grant allotments
at the Circle level will ensure that the maintenance funds
are spent on hospitals needing substantial maintenance
every few years.
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