referral health services for south western railway
TRANSCRIPT
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Indian Railway is an organization with about 64,500 km of track
covering almost all parts of India and employing about 14 lacs of
employees. The railway has committed to providing comprehensive
health care services to its employees, their families and other
beneficiaries. To cater to the health needs of the beneficiaries of
railway health care, the railway has a huge health organization with
all levels of health care viz Primary, Secondary, Tertiary healthcare
services at field level, divisional level and zonal level respectively
and referral services to outside agencies as well.
Need for the Study:
In 1997, the ministry of railway felt that there is a need for the
reorganization of the railway by forming nine newer zones for
effective administration by decentralization. Two of the nine new
zones have already started functioning from October 2002.
Remaining seven zones start functioning from April 2003. Since the
new zones are being formed, there may be a need for new hospitals at
zonal level for second level referral services.
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South Western Railway, headquartered at Hubli, Karnataka is one of
the new railway zones to be established. This railway zone is being
organized by taking Bangalore and Mysore divisions of Southern
Railway and Hubli division of South Central railway. The health
services for Wheel and Axle Plant, Bangalore also come under the
administrative control of South Western railway.
This study aims at studying the existing referral health care facilities
in South Western Railway and examining the need for further
enhancing and strengthening the referral services in South Western
Railway.
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To study the existing referral health services and examine the
need for further enhancing and strengthening referral health
services in South Western Railway Zone and explore various
options for the same and recommending the best.
1. To study the existing referral services in South Western
Railway.
2. To explore the necessity for further enhancing and
strengthening of referral health services in South Western
Railway
3. To examine various means of enhancing and strengthening the
referral services viz upgrading the in-house facilities,
developing a referral system for out side hospitals (out-
sourcing).
4. To suggest the effective means and quantum of enhancement
and strengthening the referral services with minimum
expenditure.
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Development of hospital services after independence:
After attaining independence, there was a rapid industrialization in
the country; but at the same time, there was continuous growth of
population, which caused a number of problems in providing
adequate medical and health services. On the eve of independence,
there were 7400 hospitals and dispensaries in India. There were
1,13,000 beds, giving a population bed ratio of 0.2 beds per thousand
population. There were 19 medical colleges and 19 medical schools.
As a consequence of industrialization and population growth, special
medical and health problems cropped up. Special efforts, therefore,
were made by Government of India to solve these problems. The
Government has set up various committees to recommend the
strategies to tackle the problem. Some of the important committees
are Bhore Committee, Mudaliyar Committee, Jain committee,
Shrivastava committee, Sidhu Committee, Rao Committee, Bajaj
Committee, Chhadda committee and so on.
According to Health Information India (1995-96), India had 146
medical colleges, 15,097 hospitals and over 6,23,819 beds, with
population bed ratio of 0.67 per 1000 population, admitting about
thirty million patients in a year. Of all these hospitals, 4,621 were
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rural hospitals with over 1,22,453 beds and 10,416 were urban
hospitals with 5,01,368 beds. When these hospitals are categorized
according to the ownership, then there are 4,473 Government
hospitals with 3,75,987 beds, 335 local body hospitals with 19,677
beds and 10,289 private and charitable hospitals with 2,28,115 beds.
The population bed ratio at the time of independence was roughly
0.25 per 1,000 population, in 1991, it was 0.75 and in 1995, it was
0.67. Still these figures were far less than the target recommended by
Mudaliyar committee at one bed per 1,000 population. To maintain
the population bed ratio of 1995, it requires adding about 6,000 to
7,000 beds in a year, taking into account the population increase.
On achieving independence, India embarked upon a planned effort for
raising the standard of living of masses and made the health planning
an integral part of the overall socio-economic development.
The recommendations pertaining to the hospital services of the
various committees set up by the Government of India are reviewed.
Bhore Committee (1943-46) recommended a short term plan covering
a period of two to five years for setting a 30 bedded hospital for every
two Primary Health Centers and a long term plan called the three
million plan for setting up a 75 bedded hospital for 10,000 to 20,000
population, secondary units with 650 bedded hospital and a district
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hospital with 2,500 beds in each district with a population of 5 to 7
lacs.
Mudaliyar committee (1961) recommended a population bed ratio of
one per thousand population.
National Health Policy (1983) recommends that the curative centers
should be related to the populations they serve, keeping in view the
densities of the population, distances, topography, and transportation
facilities. These centers should function within the recommended
referral system, the gamut of general specialties required to deal with
the local disease patterns being provided as near to the community as
possible, at the secondary level of the hierarchal organization. To
maximize the utilization of available resources, new and additional
curative centers should be established only in exceptional cases, basic
attempt being towards upgrading the existing facilities at selected
locations, the guiding principle being to provide the facilities as near
to the beneficiaries as possible. The strategy also is to reduce the
expenditure by utilizing the cheap and locally available resources and
appropriate architectural designs and engineering concepts and
economic investment in equipment.
Special, well-coordinated programs are launched to provide physical
and social rehabilitation of those who are mentally retarded, deaf,
dumb, blind, physically disabled, infirm, and aged.
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Policy of railway:
True to the ideas of welfare state, the Indian Railway has been
pursuing a policy of progressively improving both the working and
living conditions of staff and providing them with maximum
possible amenities in several spheres including medical facilities.
(IRMM, Para-101)
Mission Statement of Indian Railway Medical Service: Total patient
satisfaction through humane approach and shared commitment of
every single doctor and paramedic to provide quality health care
using modern and cost effective techniques and technologies.
(IRMM, Para-108)
In April 1954, the MOR appointed a one-man commission under
Dr.E.Somasekhar to present a detailed scheme on planned expansion
of medical facilities on Indian railway.
With a view to examine and implement the said scheme, a separate
cell was created at the Railway Board in 1955. There has been a
progressive improvement and expansion of the curative and
promotional services on IR since then, resulting in an appreciation
from the Kunzru Committee (1963) as being second to none in the
country.
All Zonal railways have now a uniform organization of medical
services. The policy in this respect is based on the realization that the
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expenditure in this direction would pay the dividend in the long run.
The output of a contended and healthy worker who is relieved of
mental and financial worries on an account of his own or some family
members sickness will be better and more conductive to the efficient
running of railway.
To meet the primary health care needs of the beneficiaries, the
railway run health units, each catering for the needs of about 2,000 to
7,000 population and the distance between two health units 80 km to
160 km.
The railway has Divisional Hospitals, one each is a division and sub-
divisional hospitals depending upon the requirement, which serve as
first referral centers with services in basic broad specialties viz
medicine, surgery, obstetrics and gynecology, pediatrics and
ophthalmology. The services of other broad specialties are also
available in these hospitals depending upon the availability of doctors
in a particular specialty. The railway also hires the services of the
honorary consultants for the specialties in which the in-house
specialists are not available.
The zonal hospitals, one each in a zone serve as second level referral
centers. These hospitals provide services in all the broad specialties
and in a few super specialties. As far as super specialty services are
concerned, different zonal hospitals provide services in different
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super specialties for effective and economic utilization of resources.
The zonal hospitals also hire the services of the honorary consultants
of outstanding caliber in both broad specialties and super specialties.
At present, the railway has about 605 health units, 56 sub divisional
hospitals, 55 divisional hospitals and 9 zonal hospitals.
Criteria for opening a railway hospital(IRMM Para 302(2) & (4)):
The bed strength of existing RH may be considered for increasing
suitably when the BOR exceeds 110 percent and where every
available space in the building has already been utilized for indoor
beds.
Building or rooms for ancillary services, such as laboratory, X-ray
department, physiotherapy unit etc, should be provided in those
hospitals where there is justification for the same.
Criteria for increasing bed-strength of a hospital(IRMM, Para 303):
All proposals for increasing the bed-strength of a hospital should be
subjected to the following evaluation.
For the month preceding the month during which the
evaluation is undertaken a list has to be made-out of all patients
admitted to the hospital giving the following details.
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1. Serial number
2. Name
3. Age & Sex
4. Disease
5. Date of Admission
6. Date of Discharge
7. Date of Operation (If Operated)
8. Place from where referred
Thereafter, about 5% of these cases are randomly (Using
Fischers Table) scrutinized minutely and critically by calling
for their complete case papers.
1. If it were really necessary for all those to have come to
the hospital.
2. If they could not be disposed off at the periphery by
developing facilities there.
3. If a few could not have been admitted in a nearer
hospital even if it was necessary for these cases to have
been referred to.
4. If some of them could not have been discharged earlier
with better discharge notes for a good follow up in the
OPD/Health unit.
5. If the stay could not have been made shorter by quicker
investigation, better diagnosis, and active treatment.
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If a systemic appraisal as indicated above, shows a very small
number of cases, which should not have been admitted, the
significance is enormous.
It may be possible to find out if a certain disease is endemic
and if it is advisable to take special preventive steps or create
suitable facilities to bring down the number of such reference.
The facilities in an hospital is considered to be optimally utilized if
the BOR is between 70 to 85, according to various authorities.
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Consequent to the reorganization of railway zones, there is a need
for enhancing and strengthening of referral health services in South
Western Railway.
The author visualizes the following alternatives, which require
individual evaluation for recommending the best one
1. Referring patients to existing zonal hospitals in Secunderabad
and Chennai.
2. Referring the patients to outside recognized hospitals and pay
the hospital bills at agreed rates or by system of reimbursement
A system of out-sourcing the referral services.
3. Developing an in-house facility.
a. Up-gradation of any of the existing railway hospitals as
zonal hospital
b. Construction of a separate zonal hospital for SWR.
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The study area comprises of the hospitals situated in geographical
area through which the tracks of SWR run. The South Central
Railway Zonal Hospital at Secunderabad serves as a reference
hospital for comparison and standardization.
The period of study is of two and a half months duration, from
15 October 2002 to 31 December 2002.
The study is a combination of various types of study such as
Exploratory, Problem anticipatory and solving, Designing and
Modifying Systems and Evaluation of Options. In its entirety, the
nature of study does not fit into any defined categories but comprise
the components of different types of study.
Different hospital records such as Annual Narrative reports, Hospital
and Departmental Budget, Financial Statement, various policy
documents of MOR & RB, Referral files, Reimbursement and
payment records of Railway Hospitals at Secunderabad, Hubli,
Bangalore, Mysore, and Wheel and Axle Plant form the basic tools,
which give relevant data for the study.
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For evaluating the option of utilizing the existing zonal hospital in
Chennai and Secunderabad, the adequacy of referral facilities in SR
and SCR is studied to find out whether they can still accommodate
the patients from SWR.
For evaluating of the option of out-sourcing the referral health
services, the referral system and the pattern of reimbursement (other
than cardiac cases) and bill payment are studied and applied to the
situation, assuming that the patients who were previously referred to
existing railway hospitals will now be referred to outside hospitals.
For evaluating the option of constructing a new zonal hospital for
SWR and of the option of upgrading the facilities at any of the
existing hospitals to zonal hospital, the referral patterns of the four
railway hospitals are studied. This gives the estimate of the size of the
new zonal hospital required or the number of additional beds to be
added to the existing facility. The expenditure incurred for running
the zonal hospital at Secunderabad is taken as reference for evaluating
the cost of running a new zonal hospital for SWR or for upgrading the
existing facility at any of the Railway hospitals. Zonal hospital at
Secunderabad is taken as reference hospital for comparisons because,
it is one of the two zonal hospital till now catering to the referral
needs of a part of a population to come under SWR and it is assumed
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that the bed strength of the proposed hospital would be approximately
same as that of zonal Hospital Secunderabad.
The location for zonal hospital would be based on study of the
distribution of the population and policies of railway.
The costs involved in all the options are evaluated. Taking into
consideration, the present policy of the MOR, the best possible option
would be recommended.
Limitations of Study:
The existing hospitals, which will come under SWR are at
present under administrative control of different authorities, as
Southern railway (Bangalore and Mysore), South Central
Railway (Hubli) and Wheel & Axle Plant (Railway Hospital,
Wheel and Axle Plant). Hence, the policies, the procedures,
and the documentation in different hospitals differ.
Documentation in some railway hospitals is inadequate.
Records of more than one year past in some hospitals are not
available.
After going through the records of past three to five years, in
hospitals where all the past records are available, the statistical
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figures were found to be consistently same with only minor
variations.
To over come the above mentioned deficiencies, first, the facts
and figures are standardized and then applied in the study. For
example, if the reimbursement particulars of only nine months
are available, then the figures are mathematically upgraded for
one year and then applied to the study.
Due to the factors mentioned above, it was decided to analyze
the data of year 2001-02 only, instead of taking the averages of
past few years.
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Study of the present scenario in existing railway hospitals
in SWR:
Due to the vastness of the information to be discussed, it requires a
large amount of space to present the scenario in a descriptive form.
So the scenario is presented in a tabular form.
Human resources:
Table-1 below gives the over-view of the existing human resources in
SWR.
Table -1, Human Resource, Medical Services, SWR
Job Title
HUBLI
BANGALORE
MYSORE
W&AP
SECUNDERABAD*(
For
comparisiononly)
1 2 3 4 5 6
Medical Director or equivalent 01 01 01 01 02
Medical Officers of all grades 25 07 21 08 40
Hon. Consultants and contract
docs04 06 06 04 10
Asst. Nursing officer NIL NIL NIL NIL 01
1 2 3 4 5 6
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Matron Gr I,II &III 17 05 09 07 34
Nursing sister and Staff Nurse 33 16 22 07 70
Asst. Pharmacy officer 01 NIL 01 NIL 01
Pharmacists, Gr I,II&III 21 08 14 04 32
Lab Suptds. Gr I,II&III 03 02 04 02 06
Physiotherapists Gr I, I & III 01 NIL 01 01 02
Dietician NIL NIL NIL NIL 01
ECG Technician 01 01 02 01 04
Dialysis Technician NIL NIL NIL NIL 06
Radiographer 02 01 04 01 06
OT Assistants and Dressers 15 06 21 07 31
Hospital Attendants & Peons 59 12 42 09 89
Ambulance driver 03 03 05 02 05
Cook 06 04 05 04 12
Other Group C Staff 39 04 14 04 42
Superintending Engineers 01 NIL 01 NIL 02
For comparative purposes only.
Table-2 below gives the over-view of the utilization of existing
referral hospitals in SWR.
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Table-2, Overview of referral health services in SWR
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Hospital Expenditure 2001-02:
Table-3 below gives the Total Hospital Expenditure in various referral
hospitals in SWR.
Table-3, Hospital Expenditure 2001-02 (in Thousands of Rupees):
Divisional
Hospital
Hubli
Divisional
Hospital
Bangalore
Divisional
Hospital
Mysore
Wheel and
axle Plant
Hospital
*Zonal
Hospital
Secunderabad
Serialnumber
HOSPITAL
S
No of
Doctors
Generaly
Specialist
Hon.Consul
Sectioncoveredin
km
Noofemployeesse
rved
Employees+Family(Sizeo
fFamily=5)
NumberofRetiredperso
nsserved
Retired+Family(Sizeof
Family=3)
TotalPopulationSe
rved
TotalNoofbeds
Beds/1000population
Totalinpatientsin20
01-02
AverageNoofInpatient
sperday
BedOccupancyRatio
Out
patients
Per day
Totalcases
Workloadperdoctor
Divisional
Hospital
Hubli
(*Zonal HQ)
0
817 04
1
458
2215
9
+800
*
11079
5
+4000
*
1
5404620
11541
5
+4000
*
14
9
1
.29
4
382106 71 617 62
Divisional
Hospital
Bangalore
0
304 06 500
1137
656880
1
9985599 62479 46
0
.73
1
38525 72 300 27
Divisional
Hospital
Mysore
0
318 06
1
121
1948
497420
1
1463438
10085
8
10
1
1
.00
2
015
5
65 691
44669
Wheel and
axle Plant
Hospital
0
107 04 NA 2213 11065 181 543 11600 36 3.1 1156 14 30 190 25
S.C.Rly
Zonal
Hospital
Secunderaba
d
1
030 10
The figures of this hospital are only for
comparative purpose. These columns are
not relevant to the study.
30
0
2
472
3
180 601
40077
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Salary, wages and
administration38887 18270 36201 10080 68838
Hospital costs
excluding
Medicines
941 340 625 127 1575
Cost of medicines 16744 5500 13877 3450 49922
Cost of
Equipment1751 700 1829 725 7606
Repairs and
maintainance of
equipment119 880 205 632 806
Reimbursement,
payment to otherhospital
1378 1598 397 2714 22564
Welfare
Expenditure172 270 464 75 672
Misc.
Expenditure00 00 00 00 00
Total expenditure 81272 27558 53598 17803 109609
No of employees
and retired23699 13374 20556 2394
Cost of medical
service on each
beneficiary2531 2061 2607 7437
Not relevant to
the study.
* For comparative purpose only.
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Evaluation of the option of referring the patients to
existing Zonal hospitals at Chennai and Secunderabad:
At present, south central railway hospital at Secunderabad is the
second referral centre for the patients from Hubli division and
Southern railway hospital Chennai is the second referral centre for
patients from Bangalore and Mysore divisions and Wheel and Axle
plant. Railway hospital Chennai also serves the super-specialty needs
of patients from other zones of Indian railway.
The BOR at Zonal hospital Secunderabad is 60.3. The facility at
Secunderabad appears to be underutilized. The reasons for this
phenomenon is beyond the scope of this study.
The Table-5 gives the clear picture of the health facilities in
reorganized South Central railway.
Table-5, Health facilities in reorganized South Central railway.
Hospital
Population
including
retired
No of
BedsBOR
Beds/1000
population
Secunderabad
Vijayawada
Guntakal
Other Sub-
divisional
hospitals
650065
300 60
203 64
131 70
60 60
1.06
Total 650065 694 63.5 1.06
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The BOR at Zonal hospital Chennai is 84 and it is optimally utilized.
The table-6 gives the overview of health services in the reorganized
southern railway.
Table-6, Health facilities at reorganized Southern railway
Hospital
Population
Includingthe retired
No of beds BOR Beds/1000
population
Zonal Railway
hospital,
Chennai
Total of all other
Railway
hospitals
1600926
505 84
1224 65.1
1.08
Total 1600926 1729 1.08
Following inferences may be made by studying the Tables 5 & 6.
The referral health facility at Secunderabad is slightly under
utilized and the facility at Chennai is optimally utilized.
Due to the increasing cost of medical care in the open market,
there is a possibility in the near future that the facility at
Secunderabad may also be optimally utilized.
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This option of referring the patients to the existing facility is
the most cost effective as no fresh investment or expenditure is
involved.
The population bed ratios in both the reorganized South central
and southern railways would be around unity, and is in
consistent with the Bhore committee recommendations, but
still less than the one recommended in National health policy
1983, of having around 4,000 beds in a district of 10 lacks
population.
Because of the factors mentioned above, this option may be
considered as a short-term measure, until the other facility is
developed in SWR.
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Evaluation of the option of Out-sourcing the referral
services:Assuming that the patients who are at present referred to zonal
hospitals at Secunderabad and Chennai, are referred to out side
hospitals, the projections as in Table-7 may be made. These
projections are purely mathematical in nature. The data of one
scenario is applied to an other scenario
Table-7, (Projections of referrals and referral costs per annum)
Hubli Bangalore Mysore W & APProjected No
of referrals to
outside
hospitals
(Non cardiac)
279 209 445 834
Average
cost of eachreferral in
Rs.
12354 15980 13600 26607
Total cost
of referral
in Rs.
3446766 3339820 6052000 22190238
Total cost of referrals = Rs. 3,48,28,824 per annum.
(See Table-4 for source of figures)
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Evaluation of option of developing an in-house facility:
a) By upgrading any of the existing hospitals.
b) By constructing a new hospital.
Deciding the location of the new facility:
Various parameters for deciding the location of new facility
for SWR are considered as under.
Distribution of the population: The majority of the population
is around Hubli (Table-2).
Length of the section: Hubli division has the lengthiest tracks
on SWR (Table-2).
Transportation facility: This factor does not make much
difference as all the divisions of the railway are interconnected
similarly.
Presence of outside facility: Bangalore and Mysore have very
good outside facilities compared to Hubli so Hubli gets priority
in having a zonal facility over other two locations.
Economy: The hospital presently at Hubli has the highest
number of beds compared to other three hospitals. Up-
gradation of the facility, if recommended would be economical.
Policy: Railway has a conventional policy of having a Zonal
hospital at zonal headquarters
Due to the factors mentioned above, Hubli is the ideal place for
having new facility.
Estimation of the additional Beds Required for SWR
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Table-9 gives the detailed calculations for the projections of BOR in
an up-graded railway hospital at Hubli.
Table-9 Projections of BOR in an upgraded RH-Hubli
A No of Beds at present 149
B Present BOR 70
C Population to be served increase by 4000
D No of referrals expected per month 148
E Average length of stay for referred cases
(in number of days)
18
F Given the No of beds same, BOR expected 126
G No of beds planned in up-graded hospital 220
H For external paying patients (Optional) +40
I Projection of BOR in upgraded hospital. 79
J If 25 beds per super-specialty is added,
then BOR
80
It is assumed that , the external paying patients get admitted to up-
graded railway hospital Hubli, as there are very few other hospitals.
It is also assumed that the patients requiring the super-specialty
services would be referred to Hubli from other zonal railways, as the
railway has the policy of developing one super-specialty service in
only one zonal Hospital.
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At present following super-specialties, services are provided in
different railway zonal hospitals as below:
J.R. Hospital, W.Rly, Mumbai Gastro-enterologyNephrology
Ambedkar Hospital, C.Rly, Mumbai Plastic Surgery
Burns
Northern Railway Central Hospital Orthopaedics
ENT
Cancer research Institute, Lucknow Oncology
Southern Railway Hospital, Chennai Cardiology
Cardio-thoracic
surgeryEastern Railway Hospital, Calcutta Orthopaedics
It would be commendable if a few super-specialty services are started
at SWR zonal hospital in due course. The services so developed
should be different from the ones already existing in other railway
hospitals. The identifiable services are in Neurology, Neuro-surgery,
Mental Health, Respiratory medicine, Pediatrics and Neonatology etc.
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Computation of current costs of Up-graded hospital at
Hubli:
A detailed estimation of the current costs of running an upgraded
railway hospital at Hubli is done in Table-10.
Table-10, Computation of current costs of Up-graded
hospital at Hubli:
A
Present cost of running Divisional
hospital at Hubli
Rs8,12,72,000
B Cost of running 300 bedded Zonal
hospital, Secunderabad
Rs.10,96,09,000
C Deduced cost of running a 220 bedded
Zonal hospital at Secunderabad (By
using Various mathematical
applications)
Rs.8,90,25,000
D Additional current cost of running an
upgraded zonal hospital at Hubli, (C-A)
Rs.77,53,000
Table-11, Deduction of the costs of running a 220 Bed Zonal
Hospital. (Explanation to item C of Table 10)
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Cost of
running 300
bed Zonal
Hospital
Secunderab
ad
Deduction
of running
a 220 bed
Zonal
hospital
Explanation or procedure adopted
for calculation
Salary, wages and
administration68838 47572
Equivalent to the expenditure of
Divisional Hospital Vijayawada,
having same staff strength and
beds of proposed hospital
Hospital costs
excluding
Medicines1575 1300
Mathematical computation of costs
by standard tables
Cost of medicines 49922 25400
16744 incurred presently at Hubli
+ 8644 costs on expected increase
in referred cases from otherdivisions.
Cost of
Equipment7606 7606
No major change is anticipated as
the equipment required is similar.
Repairs and
maintainance of
equipment806 806
No major change is anticipated as
the equipment required is similar.
Reimbursement,
payment to other
hospital22564 6087
Reimbursement to patients at UBL,
SBC, MYS and W&AP at present
rates. See Table-4
Welfare
Expenditure672 246
!72 incurred presently at Hubli +
74 for increase in Staff
Misc.
Expenditure00 08
Unexpected expenditure of still to
be organized hospital.
Total expenditure 109609 89025Final deduced cost of running a
220 bed Zonal Hospital.
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After the study of the present referral services scenario in SWR, it
was found that the services were inadequate and an additional 70 beds
were required for SWR. For enhancing and strengthening the
referral health services of new SWR, the four options assumed by the
author were analyzed systematically.
The option of utilizing the existing zonal hospitals at Secunderabad
and Chennai was studied and found that the referral facilities at
Secunderabad and Chennai are just adequate for the reorganized
South Central and Southern railways and it would be difficult to
accommodate the patients from other zones.
The option of having the system of referring the patients to the
outside hospitals and paying the bills at agreed rates or by a system of
reimbursement is also studied and found that the cost of opting for
such a system would be Rs. 3,48,28,824 per annum for cases till now
referred to zonal hospitals.
The option of establishing a separate new zonal hospital is unviable
as the number of additional beds required to strengthen the referral
services of SWR is only around 70.
After studying the option of upgrading any of the existing facility at
SWR as a zonal hospital, it was logically found that the location of
such up-gradation would be Hubli. The current cost of opting for
such a system would be Rs.7,75,300.
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The option of upgrading the existing facility at Hubli is more
economical compared to the option of out-sourcing the referral
services. The capital cost of upgrading railway hospital Hubli as
zonal hospital (Appendix-I to III), is around 1.3 crores, including the
physical facilities and equipment.
The option of upgrading the existing railway hospital at Hubli as
zonal hospital is more economical and viable.
It is also preferred to start in due course, a few super-specialty
services, not available in other railway hospitals.
SHORT TERM PLAN:
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As a short term measure, for a period of about one year,
the existing facilities at Secunderabad and Chennai
may be utilized for referring the patients for specialized
care, till the in-house facility for SWR is developed.
MID-RANGE PLAN:
About 50-75 beds should be added to the existing
hospital at Hubli in first years. The services in all the
broad specialties should be started by the completion of
one year of organization of SWR.
LONG TERM PLAN:
About 20 to 25 beds should be added each year after
the completion of one year of organization of SWR, to
attain bed strength of 275 to 300. The services in one
or two super-specialties should be started each year
during this plan.
The study, Referral Health Services for South Western Railway
was necessitated due to the reorganization of Indian railways.
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In this study, the present situation of the referral health services is
studied. It was found that the referral services at present were
inadequate. Various options for strengthening and enhancing the
referral services, such as utilizing the facilities in other zonal
railways, adopting a system of out-sourcing the referral services,
upgrading existing hospitals in SWR and construction of new zonal
hospital, were studied.
After analyzing all the options, it was found that construction of a
new zonal hospital unviable. The existing facilities at other zones are
just sufficient for the population in the respective zones. The system
of referral to outside hospitals and reimbursement of bills works out
to be costlier than upgrading an existing hospital at Hubli to a Zonal
hospital.
It is recommended, after study and analysis of the situation, that as a
short-term measure for one year, the patients from SWR may be
referred to other zonal hospitals at Secunderabad and Chennai as atpresent. A medium range measure of adding 50 to 75 beds to railway
hospital Hubli in one year and start services in all broad medical
specialties is recommended. A long term recommendation of adding
about 25 bed each year to make the effective bed strength of 275 to
300 and starting services in few broad specialties is also
recommended.
Appendix-I
Additional physical facilities required for upgrading Divisional
Railway Hospital, Hubli as Zonal hospital- A gross estimate:
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A new Out Patient Block has to be constructed.
The ICU presently situated in the first floor of the Hospital
should be brought to the ground floor, constructing a new ICU
block.
Construction of four special rooms adjacent to new ICU.
Setting up new Casualty department with attached exclusive X-
ray unit, mini operation theatre.
Construction of wards to accommodate additional beds.
Computerization of Hospital Management with LAN
networking.
Public announcement system.
Hospital Pager system.
Rebuilding of all toilets in the hospital
Centralised medical gas and vacuum supply.
Construction of accommodation for House-Surgeons Trainee
nurses.
Replacement of all furniture used in patient care.
Provision of head-side reading lamps, call bells for all beds.
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One centralized pharmacy department with five dispensing
counters, to be constructed adjacent to the OP block.
One centralized laundry and linen blocks.
Centralised Sterile Supply Department.
Estimated cost: 50 lacs.
Appendix-II
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Estimation of additional staff requirements for an upgraded
hospital:
Table-12, Additional Staff Requirement for Up-graded Hospital
Job TitleHUBLI
SECUNDERABAD300
bedhospital(For
comparison) D
educedrequirementfor
225-250beddedhospital
ExtraStaffrequired
1 2 3 4 5
Medical Director or equivalent 01 02 02 01
Medical Officers of all grades 25 40 35 10
Hon. Consultants and contract
docs04 10 10 06
Asst. Nursing officer NIL 01 01 01
Matron Gr I, I &III 17 34 30 13
Nursing sister and Staff Nurse 33 70 60 27
Asst. Pharmacy officer 01 01 01 Nil
Pharmacists, Gr I,II&III 21 32 28 07
Lab Suptds. Gr I,II&III 03 06 05 02
Physiotherapists Gr I, I & III 01 02 02 01
Dietician NIL 01 01 01
ECG Technician 01 04 04 03
1 2 3 4 5
Dialysis Technician NIL 06 04 04
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Radiographer 02 06 05 03
OT Assistants and Dressers 15 31 28 13
Hospital Attendants & Peons 59 89 75 26
Ambulance driver 03 05 05 02
Cook 06 12 10 04
Other Group C Staff 39 42 40 01
Superintending Engineers 01 02 02 01
Appendix-3
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Additional basic equipment required to be procured for
upgradation of Divisional Hospital Hubli. (With out super-
specialty services)
(As per RB letter No: 99/H-I/7/85, Dated:08-07-1997.)
For ENT Department:
1. Rigid Bronchoscope 01 set
2. Full set Sinoscope 01 set
3. Audiometer 01Set Approx cost---Rs.6 lacs.
For Radiology department:
1. Ultrasonogram equipment with colour Doppler. 01 No.
Approx cost---Rs.8 lacs.
For Surgery Department:
1. Orthopaedic fracture table 01 No. Approx cost---Rs.1
lacs.
2. Electric power drill 01 No. Approx cost--Rs.60,000
3. Suction Apparatus 02 Nos. Approx cost--Rs.50,000
4. C-Arm image intensifier 01 No Approx cost--Rs.12lacs
For Anaesthesiology Department:
1. Monitor with Defibrillator 01 Nos Approx cost---Rs.1 lacs
2. Central medical gas
and vacuum unit. Approx cost--Rs.13 lacs
3. Ultraviolet disinfection system Approx cost--Rs.75,000
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4. Shadowless lamps OT 02 Nos Approx cost---Rs.2 lacs
5. Boyles Ultima 01 Nos Approx cost---Rs.5lacs
6. OT Table 01 Nos Approx cost---Rs.10lac
For Gynaec Department:
1. Ultrasonogram machine 01 No Approx cost---Rs.8lacs
2. Double puncture laparoscope 01 set Approx cost---Rs.2lacs
Ophthalmology Department:
1. Auto refractometer with computerized vision tests 01 Nos
2. B-Scan keratotomy to test power of IOL 01 Nos
3. Auto field analyzer 01 Nos
Approx cost---Rs.5lacs
Medical and Surgical wards:
1. Pulse oxymetres 04 Nos
2. High and low ICU metal beds 08 Nos
3. Water beds 04 Nos
4. Bed side monitors for ICU 04 Nos
5. Defibrillators 04 Nos
6. Spirometers 02 Nos
Approx cost---Rs.7lacs
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1. Annual Narrative Report-Medical Department: (2001-02),
South Central Railway, Rail Nilayam, Secunderabad.
2. Annual Narrative Report-Medical Department: (2001-02),
Southern Railway, Chennai
3. Annual Narrative Report: (2001-02), Divisional Railway
Hospital, Bangalore, India.
4. Annual Narrative Report: (2001-02), Divisional Railway
Hospital, Hubli, India.
5. Annual Narrative Report: (2001-02), Divisional Railway
Hospital, Mysore, India.
6. Annual Narrative Report: (2001-02), Railway Hospital,
Wheel and Axle Plant, Bangalore, India.
7. Financial Advisor and Chief Accounts Officer, South Central
Railway: (April 2002) Distribution of Final Grant For The
Year 2001-02-Medical Department South Central Railway,
Secunderabad.
8. Financial Advisor and Chief Accounts Officer, Southern
Railway: (April 2002) Distribution of Final Grant For The
Year 2001-02-Medical Department Southern Railway,
Chennai.
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9. Financial Advisor and Chief Accounts Officer, Wheel and Axle
Plant: (April 2002) Distribution of Final Grant For The Year
2001-02-Medical Department Wheel and Axle Plant,
Bangalore.
10. Health System Management: (2001), Vol-02: Indira Gandhi
National Open University, New Delhi .Pp 1-30.
11. Indian Railway Medical Manual: (2000), Vol-01: Railway
Board, New Delhi. Para 101, 108, 302(2) and 302(4).
12. Health System Management: (2001), Vol-04: Indira Gandhi
National Open University, New Delhi. Pp 21-34.
13. Organization and Management of Hospitals: (2001), Vol-03:
Indira Gandhi National Open University, New Delhi. .Pp 65-
82
14. Park.K, :(2001), Text Book Of preventive And social
medicine,16 Ed: M/S Banarsidas Publications:Jabalpur, India.
Pp. 613-631
15. Standardization of Hospital Equipment: Railway Board,
Policy Letter No: 99/H-I/7/85, Dated 08-07-1997.