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Report STANDARDIZATION OF MEDICAL INSTITUTIONS IN KERALA

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									                  REPORT
                       ON

STANDARDIZATION OF MEDICAL
 INSTITUTIONS IN THE KERALA
HEALTH SERVICES DEPARTMENT




    Sector Investment Programme
Supported by Department of Health & Family Welfare,
               Government of India
                        &
              European Commission




                         1
        Members of the Committee for Standardization of
                     Government Health Institutions.


Dr K K Arjunan
Retired Additional Director of Health Services
Directorate of Health Services
Trivandrum.

Dr Mohanan Nair
Principal Kerala State Institute of Health and Family Welfare
Trivandrum
&
Director
Indian Institute of Diabetes,
Trivandrum.

Dr Raman Kutty
(Health Economist)
Executive Director
Health Action by People
Trivandrum

Dr K R Thankappan
Additional Professor
Achutha Menon Center for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Trivandrum.

Dr K Vijayakumar
Professor
Department of Community Medicine
Medical College
Kozhikkode

Mr Joseph Gregory
Retired Senior Administrative Assistant
Directorate of Health Services
Trivandrum.




                                           2
                                    Introduction


           Organisation of Health care services in Kerala


Situational Analysis

       Kerala is noted for its achievements in the fields of health and education.       It is
the only state in India having at least one health care delivery institution in each of its
Panchayath. Moreover all Panchayaths, except a few, have Primary Health Centres.
Kerala Health Services is the second largest department under the government with
about 45,000 employees working in about 1272 institutions under it. If the grass root
level institutions viz. the sub centres (5094) are also considered, institutions may go up
to about 6366. At present there are about 41 categories of institutions under the Kerala
Health Services with more than 295 categories of employees. Thus there are Sub
centres, Dispensaries, mobile health units, Government hospitals, Mini Primary Health
Centres, Block Primary Health Centres, Community Health Centres, Taluk Head
Quarters Hospitals, District Hospitals, General Hospitals, Government Hospitals and
Speciality Hospitals such as Women and Children Hospitals, T B Hospitals, Leprosy
Hospitals and Mental Heath Centres.


       Kerala is a small state in the Southern part of the nation with a long sea belt in
the western side and Western Ghats on its eastern side. The total area of the state is
38,863 Sq. Kms and has the following revenue divisional characteristics:

        Number of Districts                          -        14
        Number of Taluks                             -        63
        Number of C.D. Blocks                        -        152


       According to the Panchayath Raj Act, the administration of the state is re-
distributed among Local Self Government Institutions (LSGIs) as follows:
        Grama Panchayaths             -           991



                                            3
       Block Panchayaths              -           152
       Municipalities                 -            54
       Corporations                   -             5
       District Panchayaths           -            14


   Though the state is small in area, it has a high density of population. The total
population of the state is 3,18,38,619 (2001 census). The literacy rate of both male and
female population is very high when compared with that of the remaining parts of the
nation. Health indicators of the state are almost at par with those of developed countries
and show wide differentials between the other parts of the country.



        Kerala Health Services, as was stated earlier, has different levels of institutions
under it through which service delivery is accomplished. Thus it has under it:
       General Hospitals                                     :    5
       District Hospitals                                    :   11
       Taluk Hospitals                                       :   41
       Govt. Hospitals                                       :   55
       Community Health Centres                              : 107
       Block PH Centres                                      : 117
       Mini PH Centres                                       : 821
       Govt. Dispensaries                                    :   19
       Leprosy Hospitals/sanatorium                          :    3
       Mental Health Centres                                 :    3
       District TB Centres                                   :   14
       TB Clinics                                            :    8
       TB. Hospitals                                         :    1
       Other Types of Institutions                           :   67
                                             Total : 1272
       FW Sub Centres                                        : 5094
                        Grand Total             : 6366
       (DHS data)




                                            4
       The employees of the department include Medical, Para medical and other
categories of staff. Thus there are Doctors, Hospital Staff, Field staff, ministerial staff
and various other categories of more than 295.

        Though the department is responsible for the health and medical care of entire
population of the state, through its over 6366 institutions, it can be seen that these
institutions are not categorised under any standard pattern and often their functioning is
far from satisfactory.
        It is to be noted that the number and distribution of various health care
institutions under Health services department are not distributed as per a standard
norms, but often based on other socio-political and economic factors. As also, there is
gross disparity in the number of institutions in across panchayats, across Municipalities,
across Taluks and across Districts. There exists no uniformity in service provision, bed
strength and staff structure. Some institutions are too small and under-developed
whereas certain others of the same category are too unwieldy. Bed strength of certain
institutions is too large when compared to that of some others of the same category.
There are vast differences in infrastructure facilities available. Institutions of the same
category often differ widely in quantity and quality of services provided.
        The utilisation of the infrastructure, bed strength and staff strength also vary.
There are institutions where the sanctioned bed capacity are fully utilised and even over
crowded. But on the other hand in certain institutions the average daily censes of
inpatients may even be below 50% of the sanctioned in some others. Recent studies
have actually estimated the unused/underused potentials of many of these institutions.
Some reasons cited for such a state of affairs include:
        1. Non-availability of building/ lack of proper electrification/lack of water and
            sanitation facilities.
        2. Lack of periodic or annual maintenance of buildings resulting to
            dilapidated conditions.
        3. Lack of manpower: Often buildings are constructed even without an eye on
            the staff and equipment required; the ultimate result that the structures
            completed most often kept idle for want of manpower and sufficient
            equipment. Sometimes the staff posted to the so called “Unattractive and



                                             5
           difficult areas” abstain from duty by availing leave resulting in idling of a
           facility.
       4. Lack of sufficient equipment and furniture.(rusty and un-repaired cots,
           sometimes with only 3 legs, torn and spoilt mattress and torn dirty bed
           sheets or their simple absence is a common sight in many of the government
           health care institutions)
       5. Majority of them may not even have basic clinical investigation facilities
           and may even lack life supporting facilities like round the clock availability
           of oxygen etc.
       6. Another major lacuna is the lack of skilled manpower. It is often difficult to
           attract sufficiently qualified medical manpower to several areas due to
           various problems related to pay and working conditions and also due to the
           lack of specialists. In some of the Community Health Centres, it is often
           difficult to get sufficient number of Gynaecologists and Anaesthesiologists.
           Similar is the case with properly qualified and trained supporting staff for
           services delivery.


       There is demand for more institutions, more inpatient facilities, and better
quality medical and paramedical services and for better amenities at all levels of service
provision. The inadequacy in facilities, infrastructure and the impoverished staff
strength always make problems more awkward and the situation creates room for public
complaints often drawing adverse media attention.


       The Health Services Institutions differ a lot among themselves and some of them
lack in infrastructure, equipment and staff strength to deliver quality health care to the
expectation of the public; thereby failing to satisfy the their demands. It is to be noted
that the state budgetary allocations to health was not growing enough to meet the new
needs arising from new disease profile, public demand and technological changes; and
was declining every year for the past few decades.


       The table shows the percentage of allocation in each year and this table is taken
from the “Ninth Five year plan 1997-2002 Report on the steering committee on Health,




                                            6
Water supply & Sanitation and Nutrition of State Planning Board” and “12th report of
the Administrative Reforms Committee. (Kerala Administrative Reforms Committee
report- May 2001.)”


Investment and Expenditure on health under Five-year plans- Kerala.
                                                                (Rs. In Lakhs)
                                        Table-1

                                                              % of health
                                                  Outlay on                  Expenditure
       Plan Period                Total Outlay                 outlay on
                                                   health                     on health
                                                              total outlay

            First Plan(1951-56)        3003.00      192.00          6.39          258.96

         Second Plan(1956-61)          8700.71      874.74          9.74          655.46

          Third Plan (1961-66)        17000.00     1340.00          7.94         1588.49

Annual Plans(1966-67to 68-69)         14437.00      495.00          3.43          495.02

           Forth Plan 1969-74)        25840.00     1044.00          4.04          859.21

           Fifth Plan (1974-78)       56890.00     1249.00          2.19         1477.31

Annual Plans(1978-79to79-80)          42870.00      903.00          2.11          902.75

          Sixth Plan (1980-85)       155040.00     3595.60          2.32         5044.68

        Seventh Plan(1985-90)        210000.00     5050.00          2.40         6972.32

        Annual Plan (1990-91)         66020.00     1700.00          2.57          894.87

        Annual Plan (1991-92)         77500.00     1955.00          2.52          155.16

          Eight Plan (1992-97)       546000.00    12000.00          2.20      16952.00
       (State Planning Board data)




       The above table shows that the percentage of health outlay on total outlay is
decreasing in all plan periods.




                                           7
                                         Table-2

                              Year    Percentage of funds
                                      earmarked for health

                       1960-61                    10.45%

                       1970-71                     9.58%

                       1980-81                     8.19%

                       1990-91                     9.86%

                       2000-01                     5.75%
                    (State Planning Board data)


          In 1960-61 the budget provision was 10.45% of total allocations where as in
2000-01 it has declined to 5.75%. This has resulted badly in maintaining the level of
facilities and also desired levels of up-gradation could not be satisfied. The increased
expectation of the public and the deterioration in facilities in Govt. health care
institutions have resulted in a gross mismatch leading to chaotic situations in the system,
often leading to confrontation between the staff members of these institutions and the
public.


          This backward situation demands remarkable change and that too within a time
limit. The present set up of Sectoral developments/improvements in facilities and
service based on socio-political and economic factors require modification to ensure
uniformity among each type of institutions in facilities and service delivery. As has
already been stated, the demand and the expectation of public are very high, whereas the
facilities and services provided in Government medical institutions are often not at
levels to satisfy these demands. This is far more true in the case of newer technologies
for diagnosis, treatment etc. where the dominant private sector often sets the standard.
The people often compare facilities and technologies available in the public sector
institutions with those available in the private sector with the obvious aftermath of
adding to the dissatisfaction of the beneficiaries.        The Government Health care
institutions are to be strengthened with newer technological innovations to co-exist with




                                            8
upcoming and rapidly expanding hi-tech private institutions and to satisfy the increased
expectation of the people.


       The state is also in the process of bringing out its own Health Policy along the
lines of the National health Policy 2002 which has the set objectives of: -

       o Achieve acceptable standard of good health amongst the general population
           of the country.
       o Approach would be access to the decentralised public health system by
           establishing new infrastructure and upgrading the existing one wherever
           necessary.


        To achieve the above objectives, it is imperative to ensure a minimum service
delivery to all sections of population irrespective of area, socio-political and economic
factors. For this, Government Medical institutions are to be reformed and strengthened
in terms of infrastructure, equipment and manpower to render more equitable health
care to all. In other words, these institutions are to be standardised to comply with the
needs of the public.
        If one looks at the profile of health services institutions in Kerala, it could be
seen that there are institutions ranging from century old ones to recently sanctioned.
Over the past half-century buildings of these several institutions were built and several
have undergone transformations. In the past few decades some of the institutions were
re-designated or renamed. For instance, majority of the Government Dispensaries were
converted to Mini Primary Health Centres and some of the old Taluk Head Quarters
Hospitals were re-designated and converted to Community Health Centres.
       Along with the development and construction of various levels of institutions,
political and regional considerations also played a lot and differentials in the
development and status of these institutions was the ultimate result. Resources and
funds made available from various sources were pumped in to the sector with the
ultimate result that several buildings were constructed in various institutions in a
haphazard manner. Individual facilities were built during the past few decades using the
resources from state government, central government and various funding agencies.
India Population Project, the Child Survival and Safe Motherhood programme and the



                                            9
recent Reproductive and Child Health Programme are all examples of such endeavours.
Recently, the welfare fund available to Members of Parliament and Legislative
Assembly are also being made use of for building such infrastructure. Part of the “Plan
Fund” of Ninth Five Year Plan was also used for infrastructure development in the
decentralisation process. As a result of these interventions considerable infrastructure
had been built in the health care sector in the state.


Need for standardization of institutions
        Unfortunately this sort of infrastructure development was done, often without an
eye on their utilisation. The leading spirit for such constructions was regional and local
pressures rather than a uniform and need based principle for such procedures. Very
often the epidemiological and demographic characteristics of the regions were ignored
in planning such constructions.          Other political and social factors also played
considerable role and ultimately a situation has arisen in which there is no uniformity in
available infrastructure or service provision even in the same level of institutions.
        There are mini Primary Health Centres, catering to 25,000 to 30,000
populations, with varying bed strengths from 6 to 60.       In the case of Block Primary
Health Centres and Community Health centres also such disparities exist. In Idukki
district, the district hospital in Painavu is less equipped and less developed than the
Taluk Head Quarters Hospital at Thodupuzha and an interesting situation of referral
from a higher level to a lower level often takes place. Such disparities often play havoc
in the planning and development process.

        Realizing this handicap the government felt the urgent need for standardizing the
infrastructure and service provision in various levels of health services institutions.
There has to evolve a pattern in which one may be able to predict the type of services
that could be provided/expected to be provided from each levels of institutions. Such an
endeavour will also result in narrowing down the gap in development of various
institutions and nomenclature and designations will indirectly convey the status of the
institution and service delivery from it.
        Ultimate goal of such an exercise is to standardize the infrastructure facilities
and manpower in each level of these institutions leading to standardisation of service
provision. One another prerequisite for such an outcome is to have standardized



                                             10
management and referral protocols. Such an endeavour is not attempted due to various
reasons and could be accomplished only after the physical standardization is completed
and hence the logical sequence would be to attempt the standardization first followed by
development of management and referral protocols.


AN APPROACH TO STANDARDIZING SERVICE PROVISION AT
VARIOUS LEVELS


       When discussing the various medical interventions to be provided through the
public hospitals, we have to recognize that all health care interventions fall into some
natural groups. These would include:


i   Those that are low cost, but high volume, i.e., there would be a great demand for
    such services: outpatient consultations for minor ailments would fall into this group.
    Almost every one would need such a medical input at least once a year. We can
    include routine preventive interventions such as immunizations, and basic antenatal
    services, in this group.


ii Those that are of higher cost and moderately high volume, such as many surgical
    interventions. Most people would need it once in a lifetime or so; some more
    frequently. Caesarean section and other complicated deliveries could also be
    grouped along with these.


iii Those that require continued medication, which may add up to a significant cost in
    the long run. Diabetes, high blood pressure, many psychiatric illnesses, some
    orthopaedic problems all would fall naturally into this group. As the state advances
    in its epidemiologic transition, we can expect a great increase in the number of
    people needing this kind of care.


iv Those interventions that entail very high cost, but are comparatively rare in
    occurrence, such as a kidney transplant, hip replacement, bypass surgery etc.
    Interventions of a recurrent nature but entail much cost, like dialysis, can also be



                                           11
   grouped along with these. The demand for these interventions can be expected to
   increase, partly as a consequence of the ageing of the population and the
   epidemiological transition, and partly as a result of technological advances.


       If we include preventive and promotive interventions to those of a curative
nature, all of them together can be categorized on another dimension. There are some
that carry significant externalities. This means that when one person receives this
intervention, other people also benefit. Most well known examples of these would be
immunizations, and treatment for infectious diseases such as tuberculosis and sexually
transmitted diseases. Many other conditions do not have this character; and treatment
would benefit only those who suffer from the disease.
       Another useful categorization is to divide health interventions into those that
have the features of „public goods‟, and those that do not. Public goods are identified by
(a) their non-exclusivity, i.e., if they are made available to anyone, they are available to
all; and (b) their „non-rival‟ character: one person‟s use of the service does not reduce
the amount available for others. Because of these characteristics, there will not be
providers willing to supply this service in the market, since it will be possible for some
people to consume them without actually paying for them. Therefore the government is
usually expected to provide this service, if we want optimum production. Health
education campaigns, and generally all information, education and communication
(IEC) strategies, fall into this type of intervention. Individual preventive interventions
like immunization partly exhibit the characteristic of a private good: their benefits
accrue exclusively to the immunized person. However, when there is a pool of immune
people in the community, the level of „herd immunity‟ rises, and this prevents the
further spread of the infection. This benefit of immunization can be enjoyed by even the
immunized: therefore, beyond a certain level of coverage, immunization campaigns
become public goods.


       Taking all these into consideration, all health interventions may be classified
into five groups: (i) public goods (ii) interventions with significant externalities (iii) low
cost, high volume interventions (iv) intermediate cost, infrequent interventions (v) very
high cost, rare treatment modalities.




                                             12
         According to the WHO, (World Health Report 2000), for making explicit
decisions on rationing, i.e., when designing the package of services to be made available
at each level, it is important to take stock of many of these characteristics. It should also
be aware of the burden of disease in the community, and the locally cost effective
interventions that can be used. This would also weigh very much on decisions as to
what interventions should be subsidized by government. Finally, the mechanisms for
accountability and quality assurance should also be built into the system at each level.
         Equity considerations also play an important part in the societal choice of
acceptable health intervention packages. In many decisions on health care, there is
bound to be a trade-off between equity and efficiency, and society may collectively
decide (sometimes through voting) that they are willing to forego some efficiency (cost
containment) for the sake of equity. For instance, society may require that a separate
hospital may be built for an isolated community in a remote island or mountain, though
higher health gains may be obtainable through a comparable investment for
improvement of existing facilities in the mainland. Equity considerations dictate that we
should treat alike all those whose health needs are comparable, while giving preferential
care to those whose needs are more urgent.
         All public goods, low cost, high volume interventions, as well as most of those
that carry externalities, should be available at the primary health centre level, as the
first institution that the patient would call on. Thus immunizations, treatment for most
of the common infectious diseases, routine outpatient consultation, minor surgery such
as dressing of wounds, drainage of abscesses, etc should be provided at the Primary
Health Centre.
         Simple laboratory examinations like urine sugar examination, blood examination
for haemoglobin, malarial parasite and such should be routinely available at the PHC
level.
         Some interventions that would be recurrent and long term, such as routine
checking and treatment of uncomplicated high blood pressure, diabetes, etc would also
have to be taken up by the PHCs, as the incidence of these diseases among the rural
population can be expected to increase.
         The Block-PHCs (those with more than one doctor and supporting staff) and
mini-PHCs (those with only one doctor) should continue to be nodal points for the




                                             13
public health and preventive functions of primary health care provision. The nature of
this work may have to change from that prescribed at present, which is heavily focused
on infectious disease control and maternal and child health activities. While many of
these may have to continue, because of the fall in incidence of many infectious diseases
as well as the falling birth rates, the work load from these may be much less than what it
was formerly. On the other hand, Kerala is witnessing the emergence of an epidemic of
chronic diseases such as diabetes, heart disease, and hypertension. We have to devise
effective community level prevention programmes for these, for which the PHC is
ideally suited to be the fulcrum. Many of them may have to be channelled through
schools, thus enlivening the now defunct school health programme.
       In the case of Taluk and other intermediate hospitals and CHCs, they should be
able to provide more sophisticated specialty care in ophthalmology, ENT, dental,
paediatric, obstetric, orthopaedic and other specialties, with a full fledged labour room,
operation theatre, anaesthetists, and other support staff. Specialties such as physical
medicine, psychiatric medicine, can be developed at the Taluk hospitals. Thus most of
the first three groups of interventions, should be available at the Taluk hospital and
levels lower to them. Preventive and promotive efforts should form part of the primary
care structure, up to the CHC, and clinical and surgical interventions of a simple nature
should be offered at levels up to the Taluk Hospital. Services should be planned in such
a way that 90% of the population‟s health needs would be met at these levels, and only
around 10% would need to go to the higher levels of the health care pyramid.
       District hospitals should grow into tertiary care institutions, almost on par with
the medical college hospitals, except for the teaching function. Similarly, more
sophisticated ophthalmic, ENT, paediatric and dental care, should be offered through
district hospitals. Most of the items listed in group (iv), i.e., intermediate cost,
infrequent interventions, would be undertaken at district hospitals.         However, the
introduction of inputs needing more complexity, such as cataract surgery, complicated
ear surgeries, etc, would entail ensuring the availability of facilities, and personnel with
experience and skills.
       Ideally, most deliveries should take place in CHCs and Taluk hospitals. These
should be ready, both in terms of staff as well as equipment, to deal with all obstetric
and neonatal emergencies. Provision of the facilities for Caesarean section and delivery




                                            14
of complicated pregnancies would be dependent on the presence of an experienced
obstetrician, anaesthetist, and facilities for blood transfusion. Each of these institutions
should be equipped to handle blood transfusions. This may require considerable
upgrading from the present level in many instances.
       Providing sophisticated services at the CHC level would involve scaling them up
considerably in terms of equipment and facilities. The government should consider the
cost implications of these. Options like availing donor funding for capital investment in
these intermediate level institutions should be actively considered. The government
should empower the block Panchayaths to muster and invest local resources for this
purpose.
       The standardization of services should also spell out the list of essential drugs
that would be made available from the hospital pharmacy at each level. This has to be
based on the drug formulary, which will be developed. Each level of hospital can also
be encouraged, with help from the local self-government or the governing council of the
hospital, to start „fair price‟ drug stores. These will store a wider spectrum of low cost,
mostly generic drugs than what is in the essential drug list.



       Standardization should also lead to the development of a referral protocol,
outlining the chain of referral from the first contact with the health system to the higher
levels. It should specify at what level any particular health condition is expected to be
dealt with, in the health system.

       Government Health Services in the state need to be re-oriented to meet the new
health challenges that Kerala is facing. The effort to bring this about should start with
detailed studies leading to standardization and costing of services at various levels, and
redefinition of the roles of personnel. Standardization should include putting in place a
workable referral protocol, and instituting drug formularies at various levels. The
objective of the exercise should be to bring most of the frequently needed services
within easy reach of the population, especially the rural poor.




                                            15
                           Existing Health Institutions

        There are 1272 Govt medical institutions ranging from Primary Health Centres
to General hospital under Health Service Department. Some of these institutions were
constructed in places where land was made available free of cost. These Institutions are
under 33 categories viz. Mini PHCs, Block PHCs CHCs, Taluk Head Quarters
Hospitals, Dist. Hospitals, Speciality Hospitals, General Hospitals, Intermediary
Hospital and Dispensaries. The District Level distribution and Bed ratio distribution
also vary from institution to institution and district to district. There are 564 Primary
Health Centres without bed and 183 PHCs with up to 50 beds. There is one Mini PHC
with more than 50 beds. There are 73 PHCs with bed ranging from 16 to 41. In case of
CHCs there is one CHC without bed and 2 CHCs with more than 200 beds. Rest of 105
CHC has bed strength in varying capacities from 1 to 199. In case of Taluk Hospitals
the bed strength vary from 10 to 499. The District Hospitals also bed strength varies
from 100 to 699. In the case of General Hospitals the bed strength vary from 100 to
800. So, at present there is much difficulty to standardise the institutions as per bed
strength and to earmark each level of institutions to particular bed strength.


        The number of institutions also varies across districts. In Thiruvananthapuram
District there are 113 institutions where as in Wayanad district it is only 40. The
distribution of hospitals in Idukki, Wayanad, Kasaragode also vary in terms distance
from each institutions. So, there is a problem to fix the institutions in a particular point
or to fix a particular district to institution to institution.




                                                16
                        Distribution of Medical Institutions according to number of beds: -
                                                                            Table-5
                                                                              Number of Beds
Sl.No      Type of Institution




                                                                                                                                                                                                   Total
                                                    10-15



                                                                16-19




                                                                                                                                                                                   700 &
                                                                                                                                                                                           Above
                                                                             20-29


                                                                                         30-49


                                                                                                     50-99
                                          1-9




                                                                                                                 100-


                                                                                                                              200-


                                                                                                                                           300-


                                                                                                                                                        400-


                                                                                                                                                                     500-

                                                                                                                                                                            600-
                                                                                                                        199


                                                                                                                                     299


                                                                                                                                                  399


                                                                                                                                                               499


                                                                                                                                                                            599

                                                                                                                                                                                    699
                                 0
 1      BPHC                         19     11          32          21        17          14             3               -            -            -            -           -      -       -       117
        Central Prison
 2      Hospital                      -         -           -           -            -           1           -           -            -            -            -           -      -       -               1
 3      CHC                           1         6       14          14        13          36          13                 8            2            -            -           -      -       -       107
 4      Dental Mobile Unit            1         -           -           -            -           -           -           -            -            -            -           -      -       -               1
 5      Govt. Dispensary             15         1           -           -            -           3           -           -            -            -            -           -      -       -          19
 6      Dispensary Bi- weekly         2         -           -           -            -           -           -           -            -            -            -           -      -       -               2
        Dispensary Central
 7      Jail                          2                     -           -            -           1           -           -            -            -            -           -      -       -               3

        District Hospital
 8                                    -         -           -           -            -           -           -           3            3            1            -           3      1       -          11
        District TB
 9      Centre/Clinic                15         -           2           -            -           2       3               -            -            -            -           -      -       -          22
 10     Fisheries Dispensary          5         -           -           -            -           -           -           -            -            -            -           -      -       -               5
 11     Floating Dispensary           1         -           -           -            -           -           -           -            -            -            -           -      -       -               1
 12     Forest Dispensary             1         -           -           -            -           -           -           -            -            -            -           -      -       -               1

        General Hospital
 13                                   -         -           -           -            -           -           -           1            -            -            -           2      -       2               5

        Govt Hospital
 14                                   -         -           -           -            -    15          31                 5            2            1            -           -      -       1          55
        Govt Hospital
 15     Fisheries                     1         -           -           -            -           -           -           -            -            -            -           -      -       -               1
 16     GRD                           5         -           1           -            -           -           -           -            -            -            -           -      -       -               6
        Health Clinic, MLA's
 17     Hostel                        1         -           -           -            -           -           -           -            -            -            -           -      -       -               1
        Institute of Chest
 18     Diseases/TB Hospital                    -           -           -            -           -       1               1            -            -            -           -      -       -               2
 19     Leprosy Control Unit         14         -           -           -            -           -           -           -            -            -            -           -      -       -          14

        Leproy Hospital               -
 20                                             -           -           -            -           -           -           -            1            -            -           -      1       -               2

        Leprosy Sanatorium            -
 21                                             -           -           -            -           -           -           -            -            -            -           -      -       1               1
 22     M.M.Unit                     2          -           -           -            -           -           -           -            -            -            -           -      -       -               2
 23     MCH Unit                     1          -           1           2            -           -       1               -            -            -            -           -      -       -               5

        Mental Health Centre          -
 24                                             -           -           -            -           -           -           -            -            -            -           1      -       -               1
 25     Mental Hospital               -         -           -           -            -           -           -           -            -            1            1           -      -       -               2
 26     Mobile Dispensary            12         -           -           -            -           -           -           -            -            -            -           -      -       -          12
        Mobile
                                     1
 27     Ophthalmology Unit                      -           -           -            -           -           -           -            -            -            -           -      -       -               1




                                                                                 17
28   PHC                       564    34   149     16     36    21     1      -      -         -   -   -   -   -   821
29   Police Hospital             -     -     3       -     -    1       -     -      -         -   -   -   -   -     4

     SCD                         -
30                                     -     -       -     -       -    -     -      -         -   -   1   -   -     1
31   THQ Hospital                -     -     2       -     1       -   2     24     11         -   1   -   -   -    41
32   Tribal Mobile Disp.         1     -     -       -     -       -    -     -      -         -   -   -   -   -     1
33   W&C                         -     -     -       -     -       -    -     1     1          1   1   -   -   -     4
             Total             664    52   204     53     67    94     55    43     20         4   3   7   2   4   1272

      (DHS data)
      NB: Medical Colleges and allied Institutions under Department of Medical Education
      are not included.




      Category & District wise List of Medical Institutions under Health Services Dept.


                                           GENERAL HOSPITALS
                                                         Table-6

                       Name of Hospital                                           Bed Strength
                       General Hospital, Thiruvananthapuram                              747
                       General Hospital Pathanamthitta                                   166
                       General Hospital Ernakulam                                        778
                       General Hospital Kozhikode                                        580
                       General Hospital Thalassery                                       541




                                                  W&C Hospitals
                                                         Table-7

                       Name of Hospital                                     Bed Strength
                       W&C Hospital, Thiruvananthapuram                     422
                       Victoria Hospital Kollam                             188
                       W&C Hospital Alappuzha                               308
                       W&C Hospital Mattancherry                            132
                       W&C Hospital Kozhikode                               285



                                                           18
                       District Hospitals
                             Table-8

Name of District Hospitals                   Bed Strength
DH Kollam (AA Rahim Memorial)                    531
DH Kozhencherry                                  98
DH Alappuzha                                     174
DH Kottayam                                      350
DH Idukki, Painavu                               130
DH Thrissur                                      240
DH Palakkad                                      582
DH Manjeri, Malappuram                           501
DH Mananthawady, Wayanad                         271
DH Kannur                                        615
DH Kanhangad                                     189




                     TALUK HOSPITALS
                             Table-9


   Name of Taluk Hospital                   Bed Strength
   THIRUVANANTHAPURAM.
   THQH Neyyattinkara                            436
   THQH Chirayinkil                              243
   KOLLAM
   THQH Kottarakkara                             216
   THQH Punalur                                  144
   THQH Karunagappally                           190
   THQH Sasthamkotta                              15




                               19
PATHANAMTHITTA
THQH Mallappally              22
MC Cheriyan memmorial Ranni   12
ALAPPUZHA
THQH Harippad                 144
THQH Mavelikkara              247
THQH Pulinkunnu               106
THQH Cherthala                251
KOTTAYAM
THQH Changanassery            207
THQH Kanjirappally            142
THQH Palai                    149
IDUKKI
THQH Peerumedu                54
THQH Thodupuzha               144




ERNAKULAM
THQH Cochin                   240
THQH Thrippunithara           146
THQH Aluva                    205
THQH Paravur                  155
THQH Perumbavoor              211
THQH Moovattupuzha            166
THRISSUR
THQH Kodungallur              164
THQH Irinjalakkuda            216
THQH Chavakkad                140
THQH Vadakkancherry           117
THQH Chalakkudi               144
PALAKKAD




                        20
  THQH Chittur                            108
  THQH Ottappalam                         171
  THQH Mannarkkad                         119
  MALAPPURAM
  THQH Ponnani                            125
  THQH Tirur                              164
  THQH Perinthalmanna                     177
  THQH Nilambur                           142
  THQH Thirurangadi                       157
  KOZHIKODE
  THQH Quilandy                           153
  THQH Badagara                           210
  WAYANAD
  THQH Sulthan Batheery                   57
  KANNUR
  THQH Taliparamba                        159
  KASARGOD
  THQH Kasargod                           212




                   LEPROSY HOSPITALS
                            Table-11

Name of Leprosy Hospital               Bed Strength
Leprosy Sanatorium, Nooranad               993
Leprosy Hospital, Koratty                  660
Leprosy Hospital, Chevayoor                263




                               21
                                TB Hospitals
                                 Table-12
    SCD Pulayanarkottah                                   508
    MCH Chest Hospital, Mulankunnathukavu                  75
   ICD Kozhikode                                          100
 (DHS data)


                            Mental Hospitals
                                 Table-13
    Mental Hospital, Thiruvananthapuram                   507
    Mental Hospital, Thrissur                             361
    Mental Hospital, Kozhikode                            474
(DHS data)




                         DISTRICT WISE SUB CENTRES
                                  Table-14

District                                       Number of Sub centres
Thiruvananthapuram                                     455
Kollam                                                 449
Pathanamthitta                                         260
Alappuzha                                              368
Kottayam                                               359
Idukki                                                 231
Ernakulam                                              351
Thrissur                                               492
Palakkad                                               471
Malappuram                                             508
Kozhikode                                              389
Wayanad                                                204
Kannur                                                 352
Kasaragode                                             205
                 Total                                 5094



                                    22
      (DHS data)


        After examining these particulars in detail, the Committee for Standardization of
Health Services institutions has come out with suggestions to reorganise the levels of
institutions.



        To standardize the service provision, infrastructure, manpower and equipment
at various levels of institutions the committee recommends a hierarchy of Sub Centre
(grass root level), Primary Health Centre (Grama Panchayath Level), Community
Health Centre (Block Panchayath Level), Taluk Hospital/Urban CHC (Taluk/sub
district level) and District Hospitals (District Panchayath Level) and General
Hospitals - the super speciality tertiary level institutions that will also provide
teaching, training and research and some of them will have to be developed to
Centres of excellence.



        All District Panchayaths may identify and develop one institution at the level of
District Hospital where there is no district hospital. As a policy matter it is to be
decided as to whether the administrative control of the General Hospital is to be vested
with District Panchayaths or with department itself.




                                           23
                ACTIVITIES OF THE DEPARTMENT


        The Health Services perform the chief function of delivery of primary health
care in a wholesome manner. Preventive and promotive health care in addition to the
routine curative services and rehabilitation aspects of health care constitute the main
activities of the department. The activities include the establishment and maintenance of
medical institutions with necessary infrastructure, control of communicable diseases,
rendering of Family Welfare services including Maternal and Child Health Services,
implementation of National Health programmes, providing curative services and
administration. The Analytical Laboratories and Public Health Laboratories function as
single-purpose units under the department with independent controlling officers for
each.



The following main recommendations are being made regarding each level of
institutions



   1. Sub-Centre – For every 5000 population in plane areas and for 2500-3000
        population in hilly and difficult areas



   2. Primary Health Centre – One P.H. Centre in every Grama Panchayath. [The
        present mini PHC may be re-designed as P.H.Centre].


   3. Community Health Centres – It is also decided to recommend to sanction one
        CHC in each CD Block initially as first Phase and there after one CHC for every
        One lakhs population in the second phase, subsequently for rendering curative
        services for patients for getting them admitted and treated at these first level
        with the required minimum facilities.




                                             24
       While sanctioning the CHCs the CHCs shall be sanctioned only in CD Block
   and recommend to redesignate the THQH level CHCs as Taluk Hospitals.


   Now every CD Block has at least one medical institution at the level of Block
Primary Health Centre; some have more than one and even more than one Block PHCs
with difference in bed strengths. We recommend there may be one CHC in every Block
Panchayat with minimum of 50 beds and service delivery facility for health care of
major specialities. In block Panchayaths having more than one such institution, one may
be redesigned as Community Health Centre. The others may continue to provide service
at a level that deems fit to the Local Self Government Institutions.


   3. Taluk Hospital- now there is 63 taluks. There are Taluk Hospitals and Taluk
        Level Hospitals with no uniformity in nomenclature and service delivery. Some
        of the Taluk Hospitals were re-designated as CHCs.


       Each Taluk shall have a Taluk Hospital, which may also provide services.
                  When One Taluk Hospital in each Taluk is established to fill up the gap,
       the following institutions are to be upgraded/re-designated to respective Taluk
       Hospitals.


                                           Table-15

       District                    Taluk              Name of Institution to be re-
                                                      designated as THQH

       Thiruvananthapuram          Nedumangadu        CHC Nedumangadu

       Kollam                      Kottarakkara       CHC Kadakkal

       Pathanamthitta              Adoor              CHC Adoor

       Alappuzha                   Chengannoor        CHC Chengannoor

       Kottayam                    Vaikom             CHC Vaikom

       Ernakulam                   Kothamangalam      CHC Kothamangalam

       Palakkad                    Alathoor           CHC Alathoor




                                              25
      Malappuram                 Ernad                CHC Malappuram

      Wayanad                    Vythiri              CHC Vythiri

      Idukki                     Adimali              CHC Adimali

      Idukki                     Nedumkandam          CHC Nedumkandam

      Pathanamthitta             Ranni                CHC Ranni Perinad




5. District Hospitals. Currently there are 14 revenue districts where as only 11
   designated District Hospitals and the remaining three are designated as General
   Hospitals. We propose each district to have a designated District Hospital. The
   districts such as Thiruvananthapuram, Ernakulam and Kozhikode shall have a
   designated district hospital. GH Peroorkada in Thiruvananthapuram, GH Aluva in
   Ernakulam. In Kozhikode district, Kozhikode Taluk has medical colleges and other
   major hospitals, so any of the following Taluk hospitals/CHCs such as Badagara,
   Kuttiyadi and Koilandy can be considered for up-gradation into DH.


6. General Hospitals -There is 5 General Hospitals at present. These hospitals may
   continue as such.


7. Speciality Hospitals -These include Women and Children Hospitals, Mental Health
   Centres, T.B. and Leprosy Sanatoria.
      a. W&C Hospitals may function as such.
      b. T.B Sanatorium may be developed as Departments of Pulmonology.
      c. The Leprosy Sanatoria and Leprosy Hospitals may be redesigned as
          Institutes for teaching, training, research and rehabilitation of patients.
      d. Mental Health Centres are located in Thiruvananthapuram, Thrissur, and
          Kozhikode and these will have to function as per the guidelines and direction
          as per Mental Health act and of Hon. High court.




                                           26
8. Other types of Institutions
          There are 33 types of govt medical institutions with varying service
   delivery facilities. (See the table in page 31). Other departments such as Fisheries,
   Police and Tribal own some of these institutions. These institutions also vary in bed
   strength, and staff position. These institutions have to be retained and functioned as
   such for the time being and the respective departments have to take keen interest for
   its facility development. It may also think the possibility of merging such
   institutions to the developed nearby institutions so that the manpower duplication
   can be avoided and effective utilisation of the manpower. A manpower utilisation
   work-study has to be thought of when the facility in the institutions is improved /
   strengthened.


       When the merging of such institutions is made practical, the infrastructure may/
   can be utilised for some other creative purpose




                                          27
I.      SERVICE DELIVERY AS PER STANDARDISATION
                                         NORMS.

       Preventive, Promotive and Curative are the services delivered through the health
institutions. The Preventive and Promotive services are delivered trough the sub centre,
PHC and CHCs. Curative services are rendered through all the institutions in varying
capacity and standard.


       As a supportive to the curative service delivery there are other services such as
laboratory investigation, dispensing of medicine, providing diet, ambulance services and
post-mortem also rendered.


       The present diet system is not on actual requirement and patient need. Milk diet
and Kanji diet. The milk is supplied in packets and most often patients are actually not
taking. Also the supply is engaged through contracts and the funds are not effectively
utilised. On the other hand there are local NGOs who are supplying food to the patients
and bystanders freely and the food supplied as such is using by the patients as well as
the bystanders. This free diet service is there in most of the major hospitals. So the
present system of diet supply shall be modified as need specific and engaging canteen
system or through NGOs.


       Service delivery in each type of Govt. medical institution is listed below.



                                1. SUB CENTRE


       Sub centre is the first level of contact of the community with the formal health
care delivery system and is the grass root level institution to provide comprehensive
Primary Health Care to the community. The functionaries in a sub centre level are one
male and one female multipurpose health workers (MPWs).          Usually a sub centre is




                                           28
expected to cater to a population of 5000 though it may vary from 3,000 to 8,000
depending on the density of population, geographic terrain and other special
characteristics of the region. As per GOI norms there shall be one Family Welfare
Centre/Sub Centre for every 5000 population; in hilly & tribal areas it is 3000
populations. But now in most of the cases the population of SC/FWC exceeds these
norms.

         Currently there are different types of sub centres in Kerala Health Services.
Examples are old MCH centres; ICDS sub centres and the like.



         All the FW Centres are to be re-designated as “SUBCENTRES” with uniform
staff pattern and service delivery. The service delivery at the sub centre could be the
combination of the service provision of both the workers.



Recommended Service Provision:
         Sub centres are expected to provide promotive, preventive and curative services.
The service provision from sub centres has both institutional and clinic components.
Institutional services include the services to pregnant and lactating women and to
children and various activities related to the implementation of National Health
Programmes and to treatment of minor ailments. The field level activities are related to
specified population or geographic areas assigned by authorities from time to time.
Normally they may be assigned 3,000 to 8,000 populations depending on the density of
population of the area and geographic terrain. The area assigned jointly to a male and
female worker constitutes a “sub centre area”.


Service delivery
    Field visits and home care – Fore noon hours
    Data collection & compilation
    IEC activities: Mother‟s meetings, Adolescent meetings, and Health education
         classes on various topics, School health programs
    Implementation of national programs-reproductive and child health programme:
         Antenatal clinics, Immunisation sessions, Monthly clinic



                                             29
    First aid
    Geriatric care


Urban Sub Centres
       At present there is no Urban Sub centre in urban area under Health Services
Department. For the proper implementation of national health programs and primary
health care delivery in urban area we recommend one Urban Sub centre to cater an
approximate population of 10000 each to deliver all services as in case of rural sub
centre. Here residential facility need not be provided.




                       2. PRIMARY HEALTH CENTRE

       The current pattern of having mini Primary Health Centres is to be dispensed
with. All of them are to be redesigned as Primary Health Centres. Thus there has to be
one designated Primary Health Centre for each Grama Panchayat. In cases where there
is more than one institution in any Grama Panchayat, one of them is to be considered as
the designated primary health centre for the Panchayat and others may continue to
provide curative services.      Public health and primary health care activities in the
Panchayat are to be co-ordinated through the designated primary health centre only.


Service delivery


    Preventive Care
    Implementation of: -
              National programs
              Prevention and control of communicable disease
              Prevention and control of Non-communicable diseases such as Cardio-
               vascular disease, Diabetes Mellitus, Cancer care (Palliative cancer care),
               etc.,
              School Health
              Geriatric Care



                                            30
                Disability Clinic - once in a month while Physiatrist from Taluk Hospital
                First aid management of Surgical and Orthopaedic and other speciality
                 cases.
    Curative service limited to Clinical care-out patient care only
    Limited laboratory investigation service


N.B: - Primary health Centre with IP Facility


          Under the standardised pattern we are not suggesting any provision for primary
health centres with IP facility.       As a policy matter no such institutions may be
sanctioned in future. Since there are lot of institutions currently functioning under this
category, it may not be feasible or possible to stop providing IP services in them
abruptly. So they may be allowed to continue to provide in- patient services.         When
institutions are being considered for up gradation to Community Health Centres (the
current Block Primary Health Centres); these institutions are to be given priority over
the institutions currently not having any IP facility because it will save a lot of troubles
related to infrastructure creation. Also when all the peripheral institutions are developed
with new vision and strengthened with modern facilities; the utilisation in major
hospitals will be limited and it can then go for a specialised and speciality oriented
development.
          In these institutions in addition to the aforesaid service delivery, there shall be
inpatient care for minor ailments.


Note: -
                 In certain Panchayaths there are more than one Primary Health centre
with or and without inpatient facility. In such cases we are of opinion that either of these
institutions with more facilities may be declared as designated PHC of the Panchayath
and remaining may continue as such limiting curative service delivery.




                                              31
                  3. COMMUNITY HEALTH CENTRES

       One in Every Block Panchayath


Service delivery
    Clinical care-with minimum in-patient service provision for: -
             General ailments- Medical and Surgical,
             24 hour delivery service
             Normal Delivery services, Assisted delivery services, Essential &
              Emergency Obstetric (including blood storage facilities) and Essential
              New-born care
             Blood transfusion service
             Essential diagnostic service with ECG and Ultra sound scan service
             Paediatric case management
             Trauma care – basic services
             First aid management of Orthopaedic and other speciality cases.
             Ambulance Services
             Post-mortem
    Preventive Care
       Prevention and control of communicable disease
       Prevention and control of Non-communicable diseases such as Cardio-
          vascular disease, Diabetes Mellitus, Cancer care (Palliative Cancer care),
          etc.,
       School Health Programme
       Geriatric Care
       Preventive / Rehabilitative services
       Implementation of national programs
       Maternal and child health services
       Community psychiatry
       Community dentistry
       RTI/STI and adolescent clinics




                                          32
Note: -
          In certain Block Panchayaths there are more than one Block primary health
          centre/ Community Health Centre with or and without inpatient facility. In such
          cases we are of opinion that either of these institutions with more facilities may
          be declared as designated CHC of the Block Panchayath and remaining may
          continue as such limiting curative service delivery.
          There are Govt hospitals, intermediary hospitals and dispensaries with or and
          without inpatient facilities. These institutions do not come under any of the
          categories recommended above.
          We propose
          i).     The existing institution may be re-designated as primary health centre for
                  the Panchayath where there is no primary health centre.
          ii).    The remaining may continue as such limiting curative services.
iii)      These institutions may be considered for conversion as community health centre
as and when the target of setting up of CHC for every one lakh population as per the
GOI norms


                              4. TALUK HOSPITALS

          These institutions may provide the entire basic speciality services expected at
the first referral level. THQHs are to be equipped to provide all types of secondary level
services.


Service Delivery: -
        Curative services with essential speciality care of all types of specialities such as
          Surgical & Medical Management, Essential & Emergency obstetric care, 24
          hour    delivery    services,   Paediatric   case    management,     Dermatology,
          Ophthalmology,      ENT,    Orthopaedics,    Psychiatry,   Respiratory medicine,
          Radiology and Dental Services. Dental Specialities of Maxillo facial Surgery
          and Conservative may also be provided from this level.
        RCH services through the PP units.




                                               33
    Essential diagnostic services including ECG, X-Ray, USS and laboratory
       services with provision for Biochemistry investigations.
    Trauma care & Emergency medical services
    Ambulance Service
    Post-mortem


                          5. DISTRICT HOSPITAL

       District Hospitals are to provide all types of tertiary level services.      These
institutions are to provide greater quantum of all the services provided at the THQH
level and are also expected to provide the super speciality services like Cardiology,
Neurology, Plastic Surgery, Urology and Paediatric Surgery. Speciality dental services-
Maxillo facial surgery, conservative and Orthodontic- are to be provided at this level.


Service Delivery: -
    Curative services with essential speciality care of all types of specialities such as
       Surgical & Medical Management,
                  Essential & Emergency obstetric care,
                  Paediatric case management,
                  Dermatology,
                  Ophthalmology,
                  ENT,
                  Orthopaedics and
                  Radiology.
      Essential diagnostic facilities including all the facilities available at the lower
       levels and Pathology and Bacteriology services.
      Trauma care casualty services.
      Blood Bank
      I.C.U for Cardiology
      Physical Medicine & Rehabilitation Centres and Occupational Therapy Unit.
      Limb Fitting Centres.
      Ambulance Service



                                           34
      Post-mortem


                          6. GENERAL HOSPITALS.

       General Hospitals are to provide all types of tertiary level services. These
institutions are to provide greater quantum of all the services provided at the District
Hospitals level and are also expected to provide the super speciality services like
Cardiology, Neurology, Plastic Surgery, Urology and Paediatric Surgery. Speciality
dental services such as Maxillo-facial surgery, conservative and Orthodontic- are to be
provided at this level.


Service Delivery
      Curative services with essential speciality care of all types of specialities such as
       Surgical & Medical Management, Essential obstetric care, Paediatric case
       management, Dermatology, Ophthalmology, ENT, Orthopaedics, Plastic
       Surgery and Radiology with provision of modern facilities such as Laproscopic,
       endoscopic, critical care, burns care, cryo surgery.
      Essential diagnostic facilities including all the facilities available at the lower
       levels and Pathology and Bacteriology services.
      Training and teaching courses
      Trauma care casualty services.
      Blood Bank
      I.C.U for Cardiology
      Physical Medicine & Rehabilitation Centres.
      Limb Fitting Centres.
      Ambulance Service
      Post-mortem




                                            35
                        7. SPECIALITY HOSPITALS

W & C Hospital


       Tertiary level referral Hospital of Gynaecology, Obstetric and Paediatrics.
       In districts where there are separate W&C Hospitals, the District hospitals need
not provide these services.         In all those districts where the W&C Hospitals are
geographically closely located to the District Hospitals, it would be worthwhile bring
them under the District Hospitals to dispense with the administrative duplications and
also to increase the efficiency of service provision.


Service Delivery: -
               Obstetric and Paediatric services
               Emergency Obstetric Care and Essential New-born care.
               Anaesthesiology services.
               Infertility Care.
               Newborn Nursery.
               Critical Care Management for Obstetric and Gynaecology Cases.
               Medical & Surgical facilities to assist the Obstetric and Gynaecology.
               24 hour delivery service
               24 hour casualty service
               Special Services such as infertility clinic, well baby clinic and
                Immunisation clinic and RCH Services, Antinational clinic, adolescent
                clinic, counselling service and cancer detection clinic.


   Equipments
       In addition to the routine equipments the following special equipments also
   suggested.
           1. Video endoscopy unit
           2. Video Laproscope with operative accessories
           3. Colposcope
           4. Histeroscope




                                             36
           5. Cryo surgery unit
           6. Laser unit for cauterisation
           7. Bi polar diathermy


T.B. Sanatoria, Hospital & District T.B Centres


       The TB Sanatoria as they exist now have lost their relevance in the present
   context and may be converted to Respiratory Diseases Centres- Departments of
   Pulmonology.       The District TB centres, similarly, may be incorporated to the
   District Hospitals wherever possible.      As in the case of TB Sanatoria, those TB
   hospitals, District T B Centres and other TB Centres with or without in patient
   facilities and are away from the district hospitals may also be converted to
   institution of Respiratory Diseases for the management of respiratory diseases
   including T.B


Service Delivery: -
    Management of all types of Respiratory disease cases
    Management of TB cases
    Implementation of National program on Tuberculosis
    Research on TB and Respiratory diseases.


Leprosy Hospitals/ Sanatoria


       Leprosy Sanatoria, as in the case of TB Sanatoria are no more relevant to the
state. They could be developed as Centres of Excellence in Rehabilitation and Research
with adequate facilities for reconstructive surgeries, occupational and medical
rehabilitation and Modern technological applications in cosmetic and Skin care; its
research and development. In districts they are located, the limb fitting centres could be
easily clubbed with the services from these institutions thus: management of Leprosy
cases, Management of complications including reconstructive surgery. Rehabilitation of
the cured patients could be achieved in these institutions.




                                             37
Service Delivery: -
    Implementation of national programme on Leprosy
    Diagnosis and treatment leprosy
    Research on Leprosy and Skin diseases
    Reconstructive surgery
    Modern technological applications in cosmetic and Skin care; its research and
       development
    Diagnostic laboratory service
    Rehabilitation


Mental Hospitals


       The Mental Hospitals will have to be developed as regional Mental Health
Centres and may act as the nodal centres for the Implementation of National Mental
Health programme in the regions and also as the teaching, training and research centres
for the zone. In a scenario where the treatment and follow up of the mentally ill is
mainly envisaged through community based efforts and interventions, the activities at
the community and various levels of health care are to be co-ordinated by these centres.
Thus they may provide services for Management of all types of Mental Illness,
Implementation of National Mental Health Programme and play active role in teaching,
training and research in the field of Mental Health.


Services


            OP Department
            Emergency and casualty services
            Speciality clinics –
                             Geriatric Psychiatry
                             Child psychiatry
                             Marital and sexual counselling
                             Suicide prevention clinic
                             Alcohol and substance abuse clinic



                                            38
                 Psycho somatic clinic
 Laboratory service
 X – Ray service
 CT Scan / MRI scan
 Pre admission and Post discharge counselling service
 Nursing service - with qualified nurses out of whom 25% will be DPN
   trained.
 Full fledged service from the psychologists and psychiatric social
   worker for all out patients
 Inpatient service
 Rehabilitation services – applicable to all patients – targeting pre-
   morbid condition
 Recreational service – TV, Sports, Games, Cultural programs, Picnics




                                 39
  II.    INFRASTRUCTURE AS PER STANDARDISATION
                                          NORMS.


        The infrastructure development is not based on the actual service delivery and
requirement; in many of the institutions. The buildings constructed in many of the
institutions are very old and most of them are now in dilapidated condition due to lack
of regular maintenance. Where as in some of the institutions buildings are constructed
due to local interest and most of them are kept idle for want of sufficient staff to run.
The list of idling building has been listed in Table –3. There is local demand from
general public and politicians for the up gradation /improvement of facility with out
looking feasibility and requirement. So it is essential to have a standard norm for
requirement of buildings and other requirements in the building based on the service
delivery from that institution. Here we tried to enlist the minimum requirements.


        The directions in the Indian standards –Basic requirements in hospital planning
has been taken into consideration. The structural design depends on the actual
requirements and availability of land and recourses. The following basic principles shall
be kept in mind when designing the building.


1. Circulation areas such as corridors, entrance hall, and
   Staircases, in the hospital building shall not be less than 30 percent of the total floor
   area of the building.


2. Floor height of all the rooms in the hospital should not be less than 3.00 m.


3. Rooms shall have, for the admission of light and air, one or more apertures such as
   windows and fanlights, opening directly to the external air into and open veranda.




                                            40
4. The architectural finishes in hospitals shall be of high quality in view of
   maintenance of better hygienic conditions specially in sanitary blocks. Flooring
   shall be with marble and glazed tile finish in walls.


5. The design of the building shall ensure control of noise due to walking, movement
   of trolleys etc. Expansion joint shall have a non-metallic beading finish. Doors
   should be openable on both sides in operation theatre and labour room while inside
   in other places.


6. The entrance zone and the ambulalatgory zone of the hospital should have the
   following facilities, reception, registration, cabins for OP clinics, pharmacy, Nursing
   station, emergency medical service section and supporting facilities. Dental Clinic
   may have space for Dental hygiene, consultation cum examination and treatment
   and also Injection room and minor operation room.


7. Diagnostic Zone consists of clinical Laboratories and other investigation, sample
   collection room; the x-ray room consists of Radiology and Fluoroscopy room, Film
   developing and processing room, film drying and storing room, Ultrasound imaging
   room.


8. Intermediate Zone consists of general Inpatient Nursing Unit separate wards for
   male and female and each speciality. Ward concept is fast changing due to policy of
   early ambulation, in fact only a few patient really need to be in bed. The basic
   consideration in placement in wards is to provide sufficient nursing care locating
   them according to the needs of treatment in respective medical discipline, checking
   cross infection. Wards shall be small dormitory concept with 10-15 beds.


       In planning a ward, the aim should be to minimise the work of the nursing staff
and provide amenities to the patients within the Unit. The distances to be travelled by a
nurse from bed areas to treatment, pantry, etc should be kept to be minimum. The ward
unit may be made of desired number of beds at the rate per bed and should be arranged
with a minimum distance of 2.25 m between centre of two beds and a clear 200 mm




                                           41
between the bed and wall. In wards the width of doors shall not be less than 1.2 m.
Isolation unit in the form of one single bedded rooms per ward unit may be provided for
certain case requiring isolation from other patients. An area of 14 m2 for such room to
contain a bed, locker, easy chair for patient, a chair for the visitor and a built in
cupboard for storing clothes is recommended and isolation unit should have separate
toilet facilities.


Type of Ward – Wards may be either nightingale or rigs type.


General Ward Facilities – Each ward unit should have a set of ward ancillaries as
given below
             a) Nursing station
             b) Treatment room
             c) Ward Pantry
             d) Ward store
             e) Sluice Room
             f) Day space, and
             g) Sanitary


Nursing Station
         It should be positioned in such a way that the nurse can keep a continuous watch
to patients. The room shall contain a cupboard to hold materials drug cupboard sink
chair, small table, and space for course systems points and records, separate toilet
facility also    Treatment room for major dressing and complicated treatments. Ward
pantry for collection and distribution of meals should be fitted with hot water supply
refrigerator. Ward Store for storing cloths bed sheets and wards equipments. Sluice
room for emptying or cleaning bed pans, urine bottles and sputum disposing of used
dressing and similar materials and Storage of stool and urine specimen etc.


Day Space for that person who are allowed to sit and relax. Sanitary requirements are
water closets for male and female, ambulation taps, urinals for male, wash basin, baths,
sinks, slab, Kitchen sink and dish washers.




                                              42
Critical Zone shall consists of labour room complex, Operation theatre complex with
preparation of room, pre operative room, post operative room, staff rooms for doctors,
nurses, technician, a separated route through a change room and an air lock area with
sterile corridor and a separate changing room for nurses and technician with toilet with
bathing facility.


Supplies: All sterile goods should have a separate entry point reaching the clean
corridor independently; material should be taken out by the exit only. Store room shall
be provided for storing theatre supply materials and equipments. Operation theatre and
labour room should be made dust proof and moisture proof and corners and junction
should be rounded to prevent accumulation of dust. All doors shall have self-closing
devices. Lighting shall be provided with large windows and general illumination by
means of fluorescent tubes.        The operation room/labour room should be normally
arranged in pairs with scrub up and instrument sub-sterilizing room.


Scrub-up: In this room the operating team washes and scrub-up their hands and arms,
put on their sterile gloves and other covers before entering the operation theatre/labour
room. It should have a single leaf door with closing device and viewing window to
communicate with the operation theatre/labour room. A pair of surgeons with elbow or
knee operated taps are required.


Instrument Sterilization:     It is a sub-sterilising unit attached to the operation
theatre/labour room limiting it to operating instruments on an emergency basis only.
This room should be equipped with high pressure, sterilization apparatus. Instrument
cupboard and a workbench with sinks are required.


Disposal:    There shall be a room for theatre refuses, such as dirty linen, used
instruments and other disposable/non-disposable items shall be removed to a room after
each operation. Dirty linen is sent to laundry though separate exit. The room should be
provided with sink, slop sink, work bench and draining boards.




                                            43
Service Zone comprises Dietary Service (Optional), Central Sterilization and supply,
Laundry Service, Water Supply, Drainage and sanitation, Administrative zone, Office,
Medical records , Hospital Stores.


       Based on the above common requirements here we are trying to enlist a standard
norm for each type of institution about its infrastructural component.


                                     SUB CENTRE


        Building for the stay of JPHN (Quarters cum Office/Clinic facilities)
            Clinic room with waiting and toilet facilities for beneficiaries,
            Office Room- for JPHN with store room
            Office facility for JHI
            Residential facility for the JPHN with:
                                   - Two bed rooms,
                                   - Drawing cum dining room,
                                   - Kitchen,
                                   - Store and work area.
        Provision of water supply (Well inside the compound) and electricity
        Waste disposal facility with drainage system
        Compound Wall


               In case of Urban Sub Centre there is no need of residential facility, only
office and clinic facility need be provided.


                         PRIMARY HEALTH CENTRE

    Building consists of
                      OP room
                      Injection room
                      Immunisation room / Observation room



                                               44
                      Minor Operation theatre
                      Pharmacy room
                      Store room
                      Office rooms
                      Staff room
                      Toilet facilities for patients and staff – all rooms and shall be
                       attached with toilet facility
                      Vehicle with shed
                      Water supply & electricity
                      Waste disposal and drainage system.
    Quarters for doctor
    Quarters for Para Medical Staff            Where ever necessary


NB. Primary Health Centre -With IP Facility


       Under the standardised pattern there is no provision for primary health centres
with IP facility. As a policy matter no such institutions may be sanctioned in future.
Since there are lot of institutions currently functioning under this category, it may not be
feasible or possible to stop providing IP services in them abruptly. So they may be
allowed to continue to provide in- patient services.         When institutions are being
considered for up gradation to Community Health Centres (the current Block Primary
Health Centres) these institutions are to be given priority over the institutions currently
not having any IP facility.


               In such cases separate wards for male and females with toilets and duty
room with toilet facility are to be provided.


                       COMMUNITY HEALTH CENTRES

          OP rooms with separate cabins for each speciality
          Office rooms
          Rooms for LHI/LHS and HS/HI




                                             45
           Injection room
           Immunisation room / observation room
           Minor Operation theatre
           Major Operation theatre
           Laboratory
           Post-mortem room
           Conference room
           Labour room with neonatal resuscitation facility
           Ward with minimum of 50 beds with male, female, Obstetrics and paediatric
            wards, room for infectious disease treatment and delivery care.
           Duty Doctors room
           Duty nurses‟ room
           Pharmacy room
           Toilet facilities for patients and staff – all such rooms shall be provided with
            toilet facility
           Blood Storage
           Store room
           Ambulance with shed
   1.       Water supply & electricity
    Waste disposal and drainage system.
    Doctors‟ quarters
    Nurses Quarters
    Para Medical Staff Quarters



    TALUK HOSPITALS AND TALUK LEVEL GOVT. HOSPITALS
                              AND TALUK LEVEL CHCS.


                The infrastructure facility needed depends on the service delivery
rendered from these institutions and as such the facilities required.
        Wards for each Major and Minor specialities & Administrative cum OP block




                                            46
   Administrative cum OP block
       OP rooms with separate cabins
       Casualty with examination room
       Duty Doctors room
       Duty nurses‟ room
       Doctors‟ room                          (all bath attached)
       Superintendent‟s room
       RMO‟s room
       Nursing superintendent‟s room
       Injection room
       Minor Theatre attach to casualty
       Observation ward
       Waiting place and bath rooms for patients and bystanders
       Laboratory room with blood storage facility
       Pharmacy room
       Labour room Complex
       Major theatre
       Dormitory for bystanders
       Toilet facilities for patients and staff – all rooms and shall be attached with toilet
   facility
       Blood storage facility
       Canteen
   Quarters for Nursing Staff.
   Doctors‟ quarters
              Superintendent
              RMO
              Anaesthetist


Office room complex
       Administrative block – Office room complex
       Conference Hall
              Superintendent‟s room




                                            47
              Lay secretary‟s room
              Office room


Computer room


Storeroom
              Storekeeper‟s room
              Record room for the storekeeper


Medical record library
              Record Librarian‟s room
              Room for Record filing with racks


Water tank and a room for plumber.


Medical OP
      Waiting place with sitting facility
      Doctor‟s examination room with cabin


Surgery OP
      Waiting place with sitting facility
      Doctor‟s examination room with cabin


Gynaecology OP
      Waiting place with sitting facility
      Examination room with antenatal case examination facilities
      Gynaec examination room
      FP counselling room
      Toilet facility


Paediatric OP
     Waiting place with sitting facilities




                                             48
     Clinic room with examination facilities
     ORT corner


Orthopaedics OP
      Waiting place with sitting facilities
      Examination room with cabin
      Plaster rooms
      Nurses‟ room with injection facilities


ENT OP
      Waiting place with sitting facilities
      Examination room with cabin
      Special examination facilities -Audiograms
      Minor surgery room - sinus puncture, foreign body removal etc
      Nurses‟ room with injection facilities


Dental OP
      Waiting room with sitting facilities
      Examination room with cabin
      Minor surgery room for procedures like extraction, scaling, etc.
      Nurses‟ room with injection facilities


Eye OP
      Waiting place with sitting facilities
      Examination cabin
      Room for vision testing and try glass
      Dark room for fundoscopy
      Dark room for refraction testing
      Room for A -scan, Keratometry, Slit lamp
      Minor theatre
      Refractionist‟s room




                                              49
Skin OP
      Waiting room with sitting facilities
      Examination room with cabin
      Minor theatre for biopsy, Cautery, injection, dressing
      Counselling room/Social worker‟s room
      Leprosy health workers‟ cabin
      Nurses‟ room


Psychiatry OP
      Waiting place with sitting facility
      Examination room with cabin
      ECT room and Injection room
      Counselling room
      Observation ward with nurses cabin


Trauma care unit
      Facility for Primary level care


Blood Bank
      As per the guidelines


Operation Theatre
      Major theatre – A, B (Air Conditioned)
      Separate theatre for eye and Gynaec
      Patient‟s waiting room
      Pre- medication room /Pre-Anaesthetic room
      Recovery room
      CSR


Dress changing room for
      Doctors – separate for males and females
      Nurses




                                             50
       Nursing assistant, Hospital Attendant Gr.1 and Gr.2.


Anaesthetist room
Surgeon‟s room
Head nurses room              with toilet facility
Paramedical staff room
ECT room for psychiatrist
Storeroom
Sterilisation room
Drying room for drying clothes for theatre


Ward
    Separate ward for all specialities with maximum of 10 beds for each ward and,
       separate sections for males and females
    Pre and post- operative ward
    Communicable diseases ward
    Geriatric and palliative care ward
    Separate room for ward duty doctors‟, nurses‟, nursing assistants with bathroom
       facility
    Storeroom for all wards


X-ray Department
       Machine room
       Dark room
       Recording room
       Waiting room for patients
       Room for radiologist
       Room for Para-medical staff


Ultra sound scanner
       A/C room,      Toilet and      Waiting place for patients




                                             51
ECG room


Post-mortem room
       Freezer facilities
Power laundry
Biomedical wastage disposal facility


                             DISTRICT HOSPITAL
       Building including
       Wards for each Major and Minor specialities & Administrative cum OP block


   Administrative cum OP block
       OP rooms with separate cabins
       Casualty with examination room, Minor Theatre, Observation ward attached to
casualty
       Duty Doctors room
       House surgeons duty room in Casualty and ward
       Duty nurses‟ room
       Superintendent‟s room
       RMO‟s room
       Doctors‟ room
       House surgeons room
       Nurses‟ room
       Nursing superintendent‟s room
       Changing room
       Injection room
       Waiting place and bath rooms for patients
       24-hour laboratory
       24-hour pharmacy
       Labour theatre complex
       Major theatre



                                         52
         Intensive coronary care unit
         Well-equipped trauma care unit
         Blood bank
         Eye bank – General hospital/ District hospital
         Lecture hall
         Conference hall
         Water supply & electricity
         Waste disposal & drainage system
         Neethi Medical Store
         Canteen


Ambulance shed


Doctors’ quarters
         Superintendent
         Dy Superintendent
         RMO
         ARMO
         Unit head of all the major & minor specialities
         Ambulance Driver‟s quarters
         House surgeon‟s hostel for 20 house surgeons


Office
                Superintendent‟s room
                Lay secretary‟s room
                Office room
                Computer room
                Storeroom
                Storekeeper‟s room
                Record room
                Medical record library
                Record Librarian‟s room




                                            53
              Room for Record filing with racks
      Water tank and a room for plumber
      Vehicle shed


Medical OP
      Waiting place with sitting facility
      Doctor‟s examination room with cabin
      Nurses‟ room with Injection and observation facility
      Counselling room


Surgery OP
      Waiting place with sitting facility
      Examination room with cabin
      Nurses‟ room
      Minor theatre with special examination facility


Gynaecology OP
      Waiting place with sitting facility
      Examination room with antenatal case examination facilities
      Gynaec examination room
      FP counselling room
      Nurses‟ room with injection and observation facilities
      Toilet facility


Paediatric OP
    Waiting place with sitting facilities
    Clinic room with examination facilities
    Nurses‟ room with facilities for immunisation, injection facilities
    ORT corner




                                            54
Orthopaedics OP
      Waiting place with sitting facilities
      Examination room with cabin
      Plaster rooms
      Nurses‟ room with injection facilities


ENT OP
      Waiting place with sitting facilities
      Examination room with cabin
      Special examination facilities -Audiograms
      Minor surgery room - sinus puncture, foreign body removal etc.
      Nurses‟ room with injection facilities


Dental OP
      Waiting room with sitting facilities
      Examination room with cabin
      Minor surgery room for procedures like extraction, scaling etc
      Nurses‟ room with injection facilities


Eye OP
      Waiting place with sitting facilities
      Examination cabin
      Room for vision testing and try glass
      Dark room for fundoscopy
      Dark room for refraction testing
      Room for A scan, Keratometry, Slit lamp
      Minor theatre
      Refractionist‟s room and refractionist‟s training room


Skin OP
      Waiting room with sitting facilities
      Examination room with cabin




                                              55
      Minor theatre for biopsy, cautery, injection, dressing
      Counselling room
      Leprosy health workers‟ cabin
      Nurses‟ room


Psychiatry OP
      Waiting place with sitting facility
      Examination room with cabin
      ECT room
      Counselling room
      Observation ward with nurses cabin


Burns unit


Blood Bank
      As per the guidelines


Operation Theatre
      24-hour emergency operation theatre
      Major theatre – A, B, C (Air Conditioned)
      Separate theatre for eye and Gynaec
      Patient‟s waiting room
      Pre-Anaesthetic room


Recovery room


Dress changing room
             Doctors – separate for males and females
             Nurses
             Nursing assistant grade 1 and grade 2
      Anaesthetist room
      Surgeon‟s room




                                            56
       Head nurses room              with toilet facility
       Paramedical staff room
       ECT room for psychiatrist
       Storeroom
       Sterilisation room
       Drying room for drying clothes for theatre and bleaching solution tanks


Ward
    Separate ward for all specialities with minimum of 10 beds, separate sections for
       males and females
    Pre and post- operative ward
    Communicable diseases ward
    Geriatric and palliative care ward
    Separate room for ward duty doctors‟, nurses‟, nursing assistants with bathroom
       facility
    Storeroom for all wards


X-ray Department
       Machine room
       Dark room
       Recording room
       Room for radiologist
       Room for Para-medical staff
       Waiting space for patients


Ultra sound scanner
       A/C room
       Bathroom
       Waiting place for patients


ECG room




                                            57
Post-mortem room
      Freezer facilities
      Power laundry
      Biomedical wastage disposal facility




                           GENERAL HOSPITAL


      Building including
      Wards for each Major and Minor specialities & Administrative cum OP block


Administrative cum OP block
      Wards for each Major and Minor specialities
      OP rooms with separate cabins
      Casualty with examination room
      Duty Doctors room
      House surgeons duty room in
      Casualty and ward
      Duty nurses‟ room
      Superintendent‟s room
      RMO‟s room
      Doctors‟ room
      House surgeons room
      Nurses‟ room
      Nursing superintendent‟s room
      Changing Room
      Injection room
      Minor Theatre near casualty
      Observation ward
      Waiting place and bath rooms for patients
      24-hour laboratory
      24-hour pharmacy



                                        58
         Labour room
         Major theatre
         Intensive coronary care unit
         Well-equipped trauma care unit
         Blood bank
         Eye bank – General hospital/ District hospital
         Lecture hall
         Conference hall
         Administrative block
         Water supply & electricity
         Waste disposal & drainage system
         Neethi Medical Store
         Canteen


Ambulance shed


Doctors’ quarters
         Superintendent
         Dy. Superintendent
         RMO
         ARMO
         Unit head of all the major & minor specialities
         Ambulance Driver‟s quarters
         House surgeon‟s hostel for 20 house surgeons


Office
                Superintendent‟s room
                Lay secretary‟s room
                Office room
                Computer room
                Storeroom
                Storekeeper‟s room




                                            59
              Record room for the storekeeper
              Medical record library
              Record Librarian‟s room
              Room for Record filing with racks
      Water tank and a room for plumber
      Vehicle shed


Medical OP
      Waiting place with sitting facility
      Doctor‟s examination room with cabin
      Nurses‟ room with Injection and observation facility
      Counselling room


Surgery OP
      Waiting place with sitting facility
      Examination room with cabin
      Nurses‟ room
      Minor theatre with special examination facility


Gynaecology OP
      Waiting place with sitting facility
      Examination room with antenatal case examination facilities
      Gynaec examination room, FP counselling room
      Nurses‟ room with injection and observation facilities and Toilet facility


Paediatric OP
     Waiting place with sitting facilities
      Clinic room with examination facilities
      Nurses‟ room with facilities for immunisation, injection facilities
      ORT corner




                                             60
Orthopaedics OP
      Waiting place with sitting facilities
      Examination room with cabin
      Plaster rooms, Nurses‟ room with injection facilities


ENT OP
      Waiting place with sitting facilities
      Examination room with cabin
      Special examination facilities -Audiograms
      Minor surgery room - sinus puncture, foreign body removal etc
      Nurses‟ room with injection facilities


Dental OP
      Waiting room with sitting facilities
      Examination room with cabin
      Minor surgery room for procedures like extraction, scaling etc
      Nurses‟ room with injection facilities


Eye OP
      Waiting place with sitting facilities
      Examination cabin
      Room for vision testing and try glass
      Dark room for fundoscopy
      Dark room for refraction testing
      Room for A scan, Keratometry, Slit lamp
      Minor theatre
      Refractionist‟s room and refractionist‟s training room


Skin OP
      Waiting room with sitting facilities
      Examination room with cabin
      Minor theatre for biopsy, cautery, injection, dressing




                                              61
      Counselling room
      Leprosy health workers‟ cabin
      Nurses‟ room


Psychiatry OP
      Waiting place with sitting facility
      Examination room with cabin
      ECT room
      Counselling room
      Observation ward with nurses cabin


Burns unit


Blood Bank
      As per the guidelines


Operation Theatre
      24-hour emergency operation theatre
      Major theatre – A, B, C
      Separate theatre for eye and gynaecology with A.C
      Patient‟s waiting room
      Pre-Anaesthetic room
      Recovery room
      Dress changing room
             Doctors – separate for males and females
             Nurses
             Nursing assistant grade 1 and grade 2
      Anaesthetist room
      Surgeon‟s room
      Head nurses room                  with toilet facility
      Paramedical staff room
      ECT room for psychiatrist




                                            62
       Storeroom
       Sterilisation room
       Drying room for drying clothes for theatre and bleaching solution tanks


Ward
    Separate ward for all specialities with maximum of 10 beds in each section/ward
       with separate sections for males and females
    Pre and post- operative ward
    Communicable diseases ward
    Geriatric and palliative care ward
    Separate room for ward duty doctors‟, nurses‟, nursing assistants with bathroom
       facility
    Storeroom for all wards


X-ray Department

       Machine room

       Dark room

       Recording room

       Waiting room for patients

       Room for radiologist

       Room for Para-medical staff

Ultra sound scanner

       A/C room,

       Toilet and

       Waiting place for patients



ECG room

Post-mortem room with Freezer facilities




                                          63
                            SPECIALITY HOSPITALS


W&C Hospital
Building including

Wards for each Major and Minor specialities & Administrative cum OP block



Administrative cum OP block

       Wards for each Major and Minor specialities

       OP rooms with separate cabins

       Casualty with examination room

       Duty Doctors room

       House surgeons duty room in

       Casualty and ward

       Duty nurses‟ room

       Superintendent‟s room

       RMO‟s room

       Doctors‟ room

       House surgeons room

       Nurses‟ room

       Nursing superintendent‟s room

       Injection room

       Minor Theatre near casualty

       Observation ward

       Waiting place and bath rooms for patients

       24-hour laboratory




                                         64
      Labour room

      Major theatre

      Blood bank

      Conference hall

      Administrative block

      Water supply & electricity

      Waste disposal & drainage system

      HDC Medical Store

      Canteen

Ambulance shed



Doctors’ quarters

      Superintendent

      Dy. Superintendent

      RMO

      ARMO

      Unit head of all the major & minor specialities

      Ambulance Driver‟s quarters

      House surgeon‟s hostel for 20 house surgeons



Office Room Complex

             Superintendent‟s room

             Lay secretary‟s room

             Office room

             Computer room

             Storeroom




                                         65
             Storekeeper‟s room

             Record room for the storekeeper

             Medical record library

             Record Librarian‟s room

             Room for Record filing with racks

     Water tank and a room for plumber

     Vehicle shed



Medical OP

     Waiting place with sitting facility

     Doctor‟s examination room with cabin

     Nurses‟ room with Injection and observation facility

     Counselling room



Surgery OP

     Waiting place with sitting facility

     Examination room with cabin

     Nurses‟ room

     Minor theatre with special examination facility



Gynaecology OP

     Waiting place with sitting facility

     Examination room with antenatal case examination facilities

     Gynaec examination room

     FP counselling room

     Nurses‟ room with injection and observation facilities




                                           66
      Toilet facility



Paediatric OP

     Waiting place with sitting facilities

      Clinic room with examination facilities

      Nurses‟ room with facilities for immunisation, injection facilities

      ORT corner



Blood Bank

      As per the guidelines



Operation Theatre (Air Conditioned)

      24-hour emergency operation theatre

      Major theatre – A, B, C

      Separate theatre for eye and gynaec

      Patient‟s waiting room

      Pre-Anaesthetic room

      Recovery room

      Dress changing room

              Doctors – separate for males and females

              Nurses

              Nursing assistant, Hospital Attendant Gr.1 & Gr.2.

      Anaesthetist room

      Surgeon‟s room

      Head nurses room           with toilet facility

      Paramedical staff room




                                             67
       Storeroom

       Sterilisation room

       Drying room for drying clothes for theatre and bleaching solution tanks



Ward

    Separate ward for all specialities with maximum of 10 beds, separate sections
       for males and females

    Pre and post- operative ward

    Communicable diseases ward

    Geriatric and palliative care ward

    Separate room for ward duty doctors‟, nurses‟, nursing assistants with bathroom
       facility

    Storeroom for all wards



X-ray Department

       Machine room

       Dark room

       Recording room

       Waiting room for patients

       Room for radiologist

       Room for Para-medical staff



Ultra sound scanner

       A/C room, Toilet room

       Waiting place for patients



ECG room



                                          68
Power laundry

Biomedical wastage disposal facility



MENTAL HEALTH CENTRE
Infrastructure

Out Patient Department

        4 consulting rooms for psychiatrists with emergency exit facility.

        One counselling room for clinical psychologists

        One counselling room for psychiatric social workers.

        Injection room cum dressing room

        Nursing station

        Waiting hall with adequate chairs and additional space

        Observation wards for male and female patients with 5 beds each

        Dispensary with adequate space for keeping medicines and furnished area
          for patients waiting for medicines.

        Adequate space for medical records

        Computer in each cabin of psychiatrists, clinical psychologists, psychiatric
          social workers and networking with computers in the records library and
          Superintendent‟s office.

        Laboratory facility



INPATIENT CARE

             Separate wards having 20 beds with:

                    Space for recreation,

                    daily living space,

                    attached dining hall,

                    Doctors room,



                                           69
                        Nurses room,

                        Treatment room,

                        Duty staff room and

                        Store room.

       N.B.: -Priority should be given for open wards where relatives or bystanders can
stay with the patients. Dormitory facilities should be offered.

        Psychiatric intensive care unit with 10 beds each for male and female
           patients.

        ECT Room

        ECG Room

        Two De-addiction wards necessary security facility separately for male and
           female patients.

        Two Geriatric Psychiatric wards having 20 beds each for males and female
           patients.

        Two rehabilitation wards having 20 beds each.

        Two child Psychiatric wards with 10 beds each.

        Single overhead tank for adequate water supply

        Generator with capacity to cater to the need of the entire campus when
           power failure occurs

        Safety alarm system

        Administrative Block

                Superintendent‟s room

                RMO‟s Room

                House Surgeons‟ Room

                Nursing Supt „s Room

                Dy Supt.‟s Room

                Conference Hall




                                           70
                 Lecture Hall

                 Library Room

                 Lay secretary‟s room

                 Office room

                 Computer room

                 Storeroom

                 Storekeeper‟s room

                 Record room for the storekeeper

                 Medical record library

                 Record Librarian‟s room

                 Room for Record filing with racks



TB SANATORIUM AND HOSPITALS


                In these hospitals the number of patients have already been reduced due
to the changed scenario in treatment protocol. So these institutions are to be modified as
department of Pulmonology for the better utilisation of the existing infrastructure
inpatient facility,



LEPROSY SANATORIUM AND HOSPITALS


        In these hospitals the number of patients have already been reduced due to the
changed scenario in treatment protocol and decrease in the incidence of leprosy. So,
these institutions are to be modified as institutes for teaching, training, research and
rehabilitation, for the better utilisation of the existing infrastructure inpatient facility




                                               71
              MANPOWER REQUIREMENTS AS PER
                      STANDARDISATION NORMS.

       The present staff pattern was introduced in 1961 and there was no substantial
and scientific revision thereafter, except in the case of Doctors and Nurses.           The
common grievance projected is about the inadequacy of almost all categories of staff in
medical institutions. The excess workload, now in existence, will definitely lead to
inefficiency also.


       While considering a revised staff pattern, special care should be given to cover
the leave absence of all categories of staff, as the hospital staff are eligible to avail (52
weekly off + 20 casual leave +23 public holidays =95 days) leave and weekly off/Night
off comprising nearly one fourth of the total days in a year. Necessary provision, to
cover this absence by sufficient manpower may be made while giving a standard
revision on staff pattern to deliver quality service.


       As in the case of Ministerial Staff, a detailed study has been conducted by the
P&ARD in Govt. during 1998, and a report on the subject was given for
implementation; which can be considered as basic tool for the revision of staff pattern of
ministerial staff. In this report the work study team of P&ARD in Govt. have suggested
a formula as noted below both for Hospitals with less than 300 beds and with bed
strength of 300 or more; for computing the requirement of ministerial staff; which can
be made applicable in all cases hereafter.



(a)    Bed strength below 300-         N=0.0125 b + 0.0143s + 0.02p
       Bed strength 300 or more-N=0.0083 b (>=4) + 0.01175 + 0.0133p
[Where N is the number of clerical post required; b number of beds; s number of staff &
p number of pay wards]




                                             72
       In respect of the requirement of the ministerial staff in Govt. Medical
Institutions we suggest that the recommendations made by the work-study team of
P&ARD in Govt. may be implemented in all institutions.


       Three-shift duty system has to be implemented up to the Taluk level Hospitals.
The present pattern of hospital staff requires a revision, considering the leave absence
enhanced workload etc. Existing staff pattern is given below: -


1. Nursing staff                       -     1 for every 6 Beds
2. Nursing. Asst.                      -     1 for every 10 beds
3.Hospital Attendant. Gr-I             -     1 for every 50 beds
4.Hospital Attendant Gr-II             -     1 for every 12 beds


       In this pattern no provision is made for special units like outpatient department,
operation theatre, labour room etc. and also to cover the leave absence.


       The committee propose no change in the existing staff pattern, but of opinion
that necessary provision should be given for the coverage of leave absence and also for
the excess work load in various departments like causality, outpatient department,
operation theatres, labour room etc.


       Certain categories of staff are out dated and the existence of these categories of
staff is to be discontinued. Following are the categories of staff - Dhobi, Barber,
Gardener, Van cleaner, Head Cook etc.


       In medical institutions, certain categories of staff were sanctioned and
continuing at present under family welfare programmed by G.O.I exclusively for the
said programme, for which they are being paid from fund of Family Welfare Program
and as such these categories of staff are to be retained separately for the programme,
while considering the revised norms for staff pattern.




                                           73
        Specialties Units in hospitals having bed strength of 100 or more have already
been sanctioned in the department vide G.O. (MS) No.120/2002/H&FWD. Dated. 28-
05-2002.These units shall be provided as specified in the government order.


        Multi purpose worker schemes have been implemented in the department since
1-10-1983, but the full complements of field staff is yet to be sanctioned and filled.


        Constitution of Hospital Development Committee/Hospital Development
Society and collection of various charges through these independent bodies have
attributed more financial responsibilities to the superintendents of the hospitals and
these officers are subjected to liabilities due to lack of proper ministerial assistance and
supervision in transaction. The present system of posting, staff to HDC from outside
the department on daily wage basis leads to misappropriation. Hence it is suggested
that the post of cashier/accountant may be created in all hospitals, exclusively for
HDC/HDS, with specific responsibility for the transaction of the HDC funds and for the
maintenance of accounts of its funds.


        Since the Primary Health Centres do not have enough assignments for a fulltime
peon it is suggested that the post of peon in Primary Health Centres may be
interchanged with that of the post of Hospital Attendant Grade I, so that the services of
the later can be utilised both for office and for the clinical side.


        The present system of posting of cleaning staff viz. part time sweeper, Hospital
attendant Gr1 & Gr.II in hospitals with a bed strength of 100 or more requires a change /
modification, as these categories of staff are not attending to their work effectively and
efficiently. The committee is of opinion that it is high time to think to hire out this
cleaning work on contract basis and we suggest that this system may be introduced as a
pilot scheme in any one of the institutions for the present, to find out the feasibility of
the system.


        In the case of nursing assistants and above categories, the job responsibilities are
technical in nature – assisting the nurses and doctors in the treatment of patients. Now




                                              74
these posts are filled up through promotion from the categories that are employed and
recruited for doing cleaning work. It is high time to think of a separate recruitment
system fixing a qualification, which is equitable to deliver the services in that cadre- a
direct recruitment-. Many hands with equitable qualification are available in the state
for appointment in this technical post. Hence it is suggested that the present system of
filling these posts by promoting from the feeder category may be dispensed with and
filled directly after prescribing suitable qualification for the post.


        In certain institutions the bed occupancy rate is low rather than the actual
sanctioned bed strength due to various reasons. As also, in speciality hospitals like
Leprosy sanatorium Nooranad, Leprosy hospital Koratty, and Chevayoor and
Sanatorium for Chest Diseases Pulayanarkottah, the number of inpatients is very much
less than the sanctioned bed strength. In all these institutions full complement of staff as
per approved staffing pattern were sanctioned and many of them are idling. It is highly
essential to have a detailed scientific study on the sanctioned strength of various
categories of staff with reference to the present bed occupancy rate.


        Considering all these aspects the committee proposes the following staff
strengths in various institutions under Health Services Department.


Staff Pattern Proposed.

                                    1. SUB-CENTRE
For every 5000 population in plane areas and for 2500-3000 populations in Hilly and
        difficult areas the following staff is recommended.
                Junior Public Health Nurse – 1
                Junior Health Inspector –1.


                       2. PRIMARY HEALTH CENTRE –
One P.H. Centre in every Panchayath with out in patient facility
                        1. Medical officer      -       1




                                              75
              2. Staff Nurse          -      1
              3. Pharmacist           -      1
              4. Hospital Attendants -       2
              5. Lab Technician       -      1
              5. Nursing Assistant -         1
              6. Clerk                       -      1
              7. P.T.Sweeper (PTS) -         1
      Field Staff: -
              8.Health Inspector      -      1
              9.Lady Health Inspector-       1
              10.Junior Public Health Nurse - as per norms
            11. Junior Health Inspector      - as per norms




3. COMMUNITY HEALTH CENTRE - PROPOSED BED
                       STRENGTH (MINIMUM) 50.
      One in every Block Panchayat
      Staff strength may be as follows.
              1. Medical Officers     General Medicine        -      1
                                      General Surgery         -      1
                                      Obstetrics and Gynaec -        1
                                      Paediatrics             -      1
                                      Anaesthesia             -      1
                                      Family Welfare/General-        2
Superintendent         Administrative cum Public health       -      1


            2. Nursing Staff – 8 [+ 2 as leave reserve]       - 10
                  3. Pharmacist                     -                1
                  4. Laboratory Technician                           2
                  5. Laboratory Attender                             1
                  5. Ophthalmic Asst.                                1
                  6. Nursing Asst.                                   6



                                     76
                            7. Hospital Attendant- Gr-I                      2
                            8. Hospital Attendant-Gr-II                      5
                            15. *Store keeper cum accountant (LDC)1
                            16. Driver                                       1
                            17. Clerk                                        1
                            18. *Computer (Data entry operator)     1
                            19. Peon                                -        1
                            20. Part time Sweeper                            1
                            21. Radiographer                                 1


   Field Staff: -
                            9. Health Supervisor                             1
                            10. Lady Health Supervisor                       1
                            11. Health Inspector                             1
                            12. Lady Health Inspector               1
                            13. Junior Health Inspector     - As per norms
                            14 Junior Public Health Nurse   - As per norms
*Both these posts are LDC category where as the designation mentioned above is the
existing name as per the GOI pattern.


    4. TALUK HOSPITALS- (PROPOSED BED STRENGTH 250).


       1. Medical Officers      - as per pattern in G.O (MS) No.120/2002/
       H&FWD. Dt. 28-5-2002
                      i. General Medicine       2 units
                     ii. General Surgery        2units
                     iii. Ob& Gynaec            2 units
                     iv. Paediatrics            2Units
                     v. Anaesthesia             1 Unit
                     vi. ENT                    1Unit
                    vii. Ophthalmology          1 Unit
                    viii. Dermatology           1 Unit




                                               77
                 ix. Psychiatry              1Unit
                 x. Junior Specialist for
                     Clinical Pathology      -1
                 xi. Dental Surgeon          -1 Unit
                     (Consists1-Orthodontics and 1- Maxillo-facial)
       Superintendent - Administrative cum public health person and health officer
   of the Taluk
            (One unit consists of one senior and one junior specialist)


2. Nursing Supt. Gr-I       -      According to the pattern
3. Nursing Supt.Gr-II       -                     -do-
4. Nursing Staff     -      According to the Bed Strength plus
   Two each for OT, LR, OP + 4 for casualty +25% leave reserve
5. Pharmacist                      -         3
6. Store Supt.                     -         1
7. Laboratory Technician           -         2
8. Laboratory Attender                       2
9. Opth. Asst. / Refractionist     -         1
10. E.C.G. Technician              -         1
11. Dental Hygienist               -         1
12. Dental Mechanic                          1
13. Radiographer                   -         1
14. X-ray attender                    -      1
15. Medical Record Librarian       -         1
16. Medical Record attender        -         1
17. Plumber cum pump operator -              1
18. Power Laundry Operator         -         1
19. Sterilization Technician       -         1
20. Audiologist                    -         1
21. Public Relations Officer       -         1
22. Counsellor                     -         1
23. L.H.I                          -         1




                                            78
24. JPHN                            -      2 for P.P.Unit
25. Driver                          -      1    -do-
26. P.T.Sweeper                     - according to sweeping area.
27. Lay Secretary & Treasurer       -      1
28. Ministerial Support            -[As per Work study report]
29. Cashier/Accountant for HDC -           1
30. Typist                          -      1
31. Peon                            -      2
32. Nursing Asst.- According to the Bed Strength plus
    One each for OT, LR, OP+ 4 for casualty +25% leave reserve
33. Hospital Attendant- Gr-I        - According to the Bed Strength     _ One each
    for OT, LR, OP      + 4 for casualty +25% leave reserve
34. Hospital Attendant –Gr-II       – According to the Bed Strength _ One each for
    OT, LR, OP+ 4 for casualty +25% leave reserve


 5. DISTRICT HOSPITALS- PROPOSED BED STRENGTH –500.


1. Superintendent                   -1
2. Medical Officers          -as per pattern in G.O (MS) No.120/2002/
    H&FWD. Dt. 28-5-2002
3. Clinical Pathology               -      1 unit.
4. Nursing Supt.-Gr-I               -      According to Pattern
5. Nursing Supt.-Gr-II              -            - do-
6. Nursing Staff- According to the Bed Strength plus Two each           for OT, LR,
OP + 4 for casualty +25% leave reserve. (For ICU         additional nursing staff @
one for each sanctioned bed also
    to be provided.)
7. Store supt.                      -      1
8. Pharmacist cum Store keeper -           1
9. Pharmacist                       -      4
10. Jr. Scientific Officer          -      1
11. Lab Technicians                 -      4



                                         79
   12.Laboratory attender           -      2
   13. Blood Bank Technician        -      3
   14. Radiographer                 -      2
   15.Xray attender                 -      2
   16. Ophthalmic Asst.             -      2
   17. Dental Mechanic              -      1
   18. Dental Hygienist             -      2
   19. ECG Technician               -      2
   20. Sterilization Technician     -      1
   21. Power Laundry Attender       -      1
   22. Plumber cum pump operator -         1
   23. Electrician                  -      1
   24. Audiologist                  -      1
   25. P.R.O                        -      1
   26. Counsellors                  -      2
   27. Sergeant                     -      1
   28. Administrative Assistant     -      1
   29. L.S.&T (Senior Supt.)        -      1
   30. Ministerial Support          -      as per Work study report
   31. Cashier/accountant           -      1(HDC)
   32. Data entry operator/typist   -      2
   33. Nursing Asst. -According to the Bed Strength plus One each for OT, LR, OP +
          4 for casualty +25% leave reserve
   34. Hospital Attendant-Gr-I According to the Bed Strength    plus    One each for
OT, LR, OP+ 4 for casualty +25%leave reserve
   35.Hospital Attendant-Gr-II According to the Bed Strength plus One each for OT,
      LR, OP+ 4 for casualty +25% leave reserve
   36. P.T.Sweeper             -    According to the sweeping area
   37. Driver                  -    1
   38. F.W.Staff                    -      As such sanctioned for P.P.Unit
   39. Medical Record Librarian-    3
   40. Medical record attender -    2




                                         80
41. Peon                  -      3




                         6. GENERAL HOSPITALS.


      Since a uniform bed strength is not prevailing for General Hospitals; for the
   present, the staff pattern suggested for district hospitals may be extended to
   General Hospitals also, taking into consideration of bed strength.




                      7. SPECIALITY HOSPITALS.


W&C Hospital
      1. Superintendent                  -      1
      2. Medical Officers        -as per pattern in G.O (MS) No.120/
      2002/ H&FWD. Dt. 28-5-20023.
      3. Nursing Supt.-Gr-I              -      According to Pattern
      4. Nursing Supt.-Gr-II             -             - do-
      5. Nursing Staff                          -       According to Bed strength
                                                plus one each for OT and OP and 2
                                                for Labour room plus 25% leave
                                                reserve.
      6. Store superintendent                   -       According to bed strength.
      7. Pharmacist store Keeper         -      1
      8. Pharmacist                      -      3
      9. Medical Record Librarian        -      2
      10. Lab Technicians                -      2
      11. Radiographer                   -      1
      12. Sterilization Technician       -      1
      13. ECG Technician                 -      1
      14. Blood Bank Technician          -      1



                                       81
           15. L.S.&T                               -        1
           16. Ministerial Support                  -        According to Work-study
                                                    report
           17. Cashier/Accountant           -       1 (H.D.C)


           18. Peon                                 -        2
           19. Nursing Asst.-                                According     to   the    Bed
           20. Hospital Attendant-Gr-I      -                Strength plus One each
           21. Hospital Attendant-Gr-II     -                for OT, LR, and OP +25%
           22. Driver                -      1              leave reserve
           23. F.W.Staff             -As such sanctioned for P.P.Unit
           24. Power Laundry Attender       -       1
           25. Plumber cum pump operator 1
           26. Electrician                  -       1
           27. P.R.O                        -       1
           28. Counsellor                   -       1
           29. Part time sweeper according to sweeping area


LEPROSY HOSPITALS.

       We have three Leprosy Hospitals (Leprosy Sanatorium - Nooranadu, Govt.
Leprosy Hospitals – Koratty & Chevayoor) in our state.

       The inpatients are diminishing due to the decreased Endemicity of leprosy and
changed treatment protocol. So the staff / posts are excess in these institutions. When
these institutions are modified as recommended, the excess staff/posts if any identified
may be adjusted/ redeployed against the requirements.


TB HOSPITALS.
       The inpatients are diminishing due to the changed treatment protocol. So the
staff / posts are excess in these institutions. When these institutions are modified as
recommended, the excess staff/posts if any identified may be adjusted/ redeployed
against the requirements.




                                          82
MENTAL HOSPITALS/MENTAL HEALTH CENTRES

                                  Proposed man power
                                         Table-16
                      Personnel                        For 500 beds

 Psychiatrists                                              10

 Medical Officers                                           20

 Clinical Psychologists                                     20

 Psychiatric Social Worker                                  20

 Nurses                                                     100

 Administrative assistant                                    1

 Lay Secretary and Treasurer                                 1

 Nursing Superintendent Gr. I                          As per pattern

 Nursing Superintendent Gr. II                               ,,

  Nursing Assistants and                                     ,,
 Hospital Attender
 Hospital Attendant Gr.II                                    ,,

 Hospital Attendant       Gr. I                              ,,

 Cooks                                                      20

 Kitchen Supervisor (Dietician Gr. II)                       1

 Dobby                                                       5

 Librarian                                                   1

 Boiler Operator                                             1

 Medical Records Officer                                     1

 Medical Records Librarian                                   1

 Medical Record Attendant                                    1




                                           83
Occupational Therapy Instructors        31

Occupational Therapist                  11

 E E G Technician                       2

E C G Technician                        1

Radiographer                            1

Junior Scientific Officer               1

Lab Technician                          5

Lab Attendant                           1

Store Superintendent                    1

Pharmacist-Storekeeper                  1

Pharmacist                              1

Telephone Attendant                     3

Electrician                             1

Mechanic                                1

Plumber                                 1

Confidential assistant                  1

                                        7
Lower Division Clerk/UDC
                                        2
Typist
Cashier/accountant                      1

X-ray Attender                          1

Peon                                    2

                                        4
Security guard
Driver                                  1




                                   84
OTHER TYPES OF INSTITUTIONS.


       This includes all other institutions, which do not come under the purview of the
recommended standard norms of institutions. This includes Govt. Hospitals,
Dispensaries with and or beds, TB Clinics, Certain PHCs etc. As these institutions are
out of pattern, we suggest that these institutions shall be converted/modified /upgraded
to the standard norm institutions. The present staff strength now available in these
institutions may continue as such.




                                          85
              EQUIPMENT REQUIREMENTS AS PER
                         STANDARDISATION NORMS



        Considering the vast and explosive expansion in the field of technological
innovations in the field of medicine, the attempts to list out the equipment for various
levels of service provision becomes formidable. Making a comprehensive list nor
feasible because of the inherent danger of any equipment becoming obsolete at any
point of time and necessity of adding newer equipment to the armamentarium of the
service providers as and when they became available. Even in such a context one can‟t
afford not to have standardised lists of at least minimum/optimum equipment for
various levels institutions. Though preparing such a list is a major task the committee,
based on the consensus evolved in the meeting called by the Director of Health
Services, in which specialist from various specialties took-part, we are presenting a list
of equipment.    This would have to be updated incorporating latest technological
changes. Taking stock of the vast innovations occurring in the field of Medicine, it is
recommended that the list have to be periodically updated at intervals of at least 2 years
and not more than 3 years under any circumstances.




Equipments

        The following are the list of equipment as per relevant Indian standards to
be made available in each section/ unit and this shall be modified as per the
requirements in different levels of institutions.


A.      ENTRANCE ZONE


     A1. Reception and registration
        Chair, metal/wooden, office type
        Chair Plastic moulded



                                           86
     Fire fighting equipments- As per Requirements of statutory body
     Graphic and signature system-Audio-visual display
     Janitor‟s equipments
             -Floor scrubbers
             -Brooms
             -Dusters, etc.
     Notice Board
     Reception, registration desk /counter
     Table, metal/wooden, office/counter
     Trolley for patients
     Water Cooler with ¾ spouts
     Wheel chair


     A-2 PHARMACY
     Chairs, metal/wooden, office type
     Jugs for water, tumblers
     Refrigerator
     Sink unit with desktop work area
     Storage racks
     Table, metal/wooden, office type
     Washbasin


B.   AMBUALATORY ZONE


     B-1     EXAMINATION / CONSULTATION
     Bed sheet
     Bowls
     Chair, metal/wooden, office type
     Chairs, plastic moulded
     Doctors towel
     Dusters
     Diagnostic set (as per the Clinics requirements)




                                         87
   a) Ophthalmoscope
   b) ENT speculum
   c) Torch (Flashlights)
   d) Laryngoscope and auroscope
   e) Tongue depresser
Examination table / stretcher with mattress
Kidney trays
Screen stands
Sphygmomanometer
Stethoscope
Stool, revolving
Washbasin with liquid soap
Dispenser and towel rail
X-ray viewers


B-2 NURSING STATION


Chair, metal/wooden, office type
Dressing drum
Fire fighting equipments (as per Statutory requirements)
Hot plates
Nurses station counter / desk
Notice Board
Refrigerator
Screen stands
Sink unit with instrument work area
Stool revolving
Storage units – storage racks
Table, metal, office type
Trolley, dressing / instruments/Medicine
Trolley patients
Wall clocks




                                   88
    Waste receptacles
    Washbasin with (liquid) soap
    Dispenser and towel rail
    Water cooler
    Washing machines
    Wheel chairs
    X-ray viewer


B-3 DENTAL EQUIPMENT AND INSTRUMENTS (OPTHIONAL)
    Air motor
    Air turbine
    Air viva
    Biopsy kit
    Chair, dental
    Chair, metal, office type
    Chair, revolving
    Dental unit, complete
    Dental X-ray unit and developing Facilities
    Desk for reception counter
    Dressing drum
    Excavators
    Extraction forceps
    Filling instrument set
    Hand piece straight and contra angle
    Minor surgery instruments
    Oxygen cylinder, trolley, gas
    Peri-surgical instrument
    Plastic filling instrument
    Prosthetic filling laboratory and denture processing instruments
    Pulp tester
    Scalers, assorted
    Scalers set sub gingival




                                       89
     Scalers ultrasonic
     Sterilizers
     Suction apparatus
     Table, office
     Tray complete sets for edentulous and dentulour jaws (perforated)
     Wall clock
     Wheel chair
     Wiring set for jaw fractures


C.   DIAGNOSTIC ZONE
     C-1 CLINICAL LABORATORY


     C-1.1 LABORATORY EQUIPMENT AND INSTRUMENTS


     Hemoglobinometer
       Complete      Blood and urine examination Instruments:
     Tubes, glass for pathological work
     Tubes, sedimentation
     Pipettes, dilution for Haemocytometers
     Albuminometer (esbach‟s)
     With stopper, stand and case
     Cover, Glass, Haemocytometer
     Tube culture, screw cap
     Tube Haemometer
     Blood sedimentation rate stand For 6/ 12 tubes.
     Test tubes
     Volumetric flasks
     Beaker
     Urine collection jar
     Glass slides
     Calorimeter
     Centrifuge AC/DC 200 W With 8 buckets




                                          90
Centrifuge tubes (glass)
Laboratory electric ovens
Monocular Microscope
Needle, Hypodermic, all sizes
Needle, Hypodermic, single use
Sterilizer, steam
Sterilizer, steam, portable type
Spirit lamp
Stopwatch
Syringes, all glass, all sizes
Syringes for single use
Water bath, serological wire gauze
Sink unit with worktop area
Washbasin with liquid soap dispenser
   And towel rail.


C-2 IMAGING
Aprons, lead rubber
Chemical mixing plunger
Cassettes with intensifying screens
Chair, plastic moulded
Diagnostic X-ray unit 300/500mA with automatic device
Diagnostic 60 MA X-ray Machine (portable) type
Dark room safe light
Dark room timer
Dark room adoption goggles
Film clips
Film hanger and wall brackets
Hanger for X-ray film
Gloves, lead rubber
Lead numbers for marking X-ray film
Lead sheets




                                      91
     Magnifying glass
     Multi-purpose ultra sound scanner
     Multi-probe ultra sound equipment on trolley
     Rack, Steel
     Step stools
     Stool, revolving
     Tank Thermometer
     Trolley, patients
     Washbasins with towel rail/liquid soap dispenser
     X-ray view box
     X-ray protection screen
     X-ray Film processing tank
     X-ray film cover


D.   INTERMEDIATE ZONE
     D-1 PATIENT AREA


     Bedsteads (including 5 with railing)
     Bedside lockers
     Back rests
     Bed, Fowler‟s
     Bedpans
     Buckets, stainless steel
     Basins
     Screen stands
     Chairs, metal office type
     Chairs, plastic moulded
     Chairs, easy
     Chamber pots
     Chart holder
     Diagnostic set
        a) Ophthalmoscope




                                         92
   b) ENT speculum
   c) Torch (flash light)
   d) Percussion hammer
   e) Laryngoscope and auroscope
   f) Tongue depressor
Dressing drum
Enema cans sets
Feeding cups with spout
Forceps Chetal‟s
Flit pumps
Fly swatters
Fire fighting equipment (as per Statutory requirement)
          a) Buckets with stand
          b) Fire extinguisher
Emergency lamps
Hot plates
Hot water bottles
Holder, case sheet
Icebox
Ice bags
Jugs, enamel
Kidney trays
Kettles
Medicine cups
Medicine trolleys
Mugs
Mattresses for bedsteads
Notice board
Oxygen cylinders with trolleys and flow meters
Oxygen masks
Phototherapy equipment
Refrigerators




                                   93
      Rack, storage
      Racks, test tubes
      Room heaters (radiators/convectors)
      Screen stands
      Step stool
      Stool, revolving
      Spoons
      Suction apparatus
      Sphygmomanometer
      Stethoscope
      Sterilizer instruments
      Scissors, general purpose
      Spirit lamp
      Splints arm
      Splints, Thomas
      Table, metal, office type
      Trolleys, linen and dirty linen
      Table, examination
      Tray, food (stainless steel)
      Tumblers (stainless steel)
      Thermometers, clinical
      Thermometers, rectal
      Waste receptacle
      Wall clocks
      Water coolers with ¾ spouts
      Weighing machines
      X-ray view boxes


Linen Furnishings
      Bed sheets
      Blankets
      Curtains




                                        94
Draw sheets
Dusters
Doctor‟s cots
Doctors‟ towels
Face sponges
Mortuary sheets
Mattresses
Mattresses covers
Pillows cases
Patient coats or jacks
Patient Pyjama
Pillows


D-2 NURSING STATION


Chair, metal, office type
Dressing Drum
Fire fighting equipments (as per Statutory requirements)
Hot plates
Nurse‟s station counter/desk
Notice Board
Refrigerator
Screen stands
Sink unit with instrument work area
Stool, revolving
Storage units – storage racks
Table, metal, office type
Trolley/dressing/instruments/Medicine
Trolley, patients
Wall clocks
Waste receptacles
Washbasin with (liquid) soap, Dispenser and towel rail




                                  95
     Water cooler
     Washing Machines
     Wheel Chairs
     X-ray viewers


E.   CRITICAL ZONE
     E-1. OPERATION THEATRE EQUIPMENTS


     Bowels, stainless steel
     Basin, stainless steel
     Brush, nail
     Buckets, stainless steel
     Bucket with lid
     Catheter, rubber
     Diathermy machine
     Dressing drum, all sizes, Stainless steel
     Lamp shadow less:
        a) Ceiling lamp
        b) Portable type
     Sink unit with work top area
     Sterilizer:
        a)    Sterilizer hot and cold water
        b) Bowels and utensils
     Suction apparatus
     Stand, I.V.
     Stool, revolving stainless steel
     Stand with wheel for single basin
     Slippers
     Table, operation, hydraulic:
              a) Major
              b) Minor
     Table, instruments




                                          96
Trolley, dressing drum
Trolley, patients
Trolley, instruments
Tube, Ryles
Urinals (male and female)
X-ray view box
Wheel chairs


E-2. LABOUR ROOM INSTRUMENTS AND EQUIPMENT
Aprons rubber
Washbasin
Bowl for placenta, stainless steel
Bed pans, stainless steel
Can, douche
Catheter, rubber and metal
Cradles, baby
Chair, Wheel
Cabinet, instruments
Craniotomy set
Dispensing measures
Dressing drum
Forceps:
       a) Artery
       b) Obstetric, wringles
       c) Obstetric, Ferguson
       d) Ovum
       e) Sponge holding
       f) Dissecting
       g) Cheatles
Feeding cups
Foetoscope
Hot water bottle




                                     97
Handle for surgical blades, Bard Parker type
Ice bags
Jug, stainless steel
Laparoscope, single puncher
McIntosh
Mouth gag
Needle holder
Needle, lumber puncture
Ophthalmoscope
Probe, uterine
Pint measures
Pelvic meter
Shadow less lamp
Sinks with (liquid) soap dispensers
Suction apparatus
Sound, uterine
Stand:
         a) Basin
         b) I.V
         c) Towel
         d) Test tube
Stethoscope
Syringes, single use and reusable type
Slippers
Scissors:
         a) Bandage, Lister‟s
         b) Stitch cutting
         c) Episiotomy
         d) Curved and straight
Speculum,
Step stool
Table:




                                      98
          a) Obstetric, labour
          b) Examination
Trolley:
          a) Patients
          b) Dressing
Torch (flash light)
Trays
Tubes:
          a) Rhyles tube
          b) Foetus
Thermometer, rectal
Tubes, baby bath
Urinals
Weighing machine, baby
Wheel chairs
Washbasin
X-ray view box


E-3 ANAESTHESIA EQUIPMENT AND APPLIANCE
Airways, anaesthetic
Airways, Guedal, rubber
Boyle‟s apparatus
Cylinders:
   a) Oxygen gas/trolley/cylinder
   b) Nitrous oxide
Catheter, oral, endotracheal
Catheter, endotracheal, nasal
Forceps endotracheal for     introducing endotracheal tube
Facemasks
Laryngoscope
Mouth gag, Mason
Spray laryngeal, McIntosh type




                                    99
     Tube endotracheal


F-   SUPPORT SERVICE ZONE
     F-1. KITCHEN EQUIPMENT
     Bowl, wash
     Chair, steel, office type
     Cans, 100 litres
     Clock
     Cooking range with oven
     Fryer (deep fat)
     Gas burners (domestic)
     Kitchen knife
     Plates for serving
     Potato peeler
     Rack for utensils
     Refrigerator
     Sink units with worktop
     Spoons, stainless steel
     Strainers
     Table office type
     Trolley for hot food
     Tablecloth
     Tableware
     Towels
     Tumblers
     Trays, food
     Weighing machine


     F-2. CENTRAL STERILE ROOM SUPPLY
     Buckets, stainless steel
     Basin, wash
     Bottles, wide mouth




                                 100
Brush, nail
Chairs, office type
Catheter, rubber all sizes
Catheterisation sets
Cans
Cabinet, steel
Cabinet instruments
Dressing sets:
         a) Suture needles
         b) Artery forceps
         c) Scalpel blades
Funnel
Forceps:
         a) Artery
         b) Dissecting
         c) Allis


Gloves
Gloves Box
Handle for Bard Parker blade
Hypodermic needles:
         a) Single use all sizes
         b) Reusable type all sizes
I.V sets (preferably single use type)
Irrigation sets:
         a) Syringes
         b) Catheter
Kidney tray
Medicine glass
Lumber puncture sets
Needles:
         a) Spinal




                                      101
         b) Sternal puncture
         c) Liver biopsy
         d) Aspirating
         e) Aneurysm
         f) Sharpener
         g) Holder
Proctoscopes
Pint measure
Sink units with work area tops
Stitch removing sets:
         a) Forceps
         b) Scissors
Sterilizer, steam (Autoclave)
Sterilizer, hot air
Scissors:
         a) General type
         b) Mayo‟s
Sponge Nylon
Screws clamp
Speculum
Suction apparatus
Stopcock, three ways
Tubes:
         a) Foetus tube
         b) Stomach tubes
         c) Ryles tubes
      d) Tracheostomy
Trays
Towel clip
Trocar cannula
Trace dilator
Trolley, closed and ordinary




                                 102
    Table Office type
    Tracheostomy set
    Venesection sets
    Wrapper
    Waste paper baskets


EPISIOTOMY TRAY
    Bowl, stainless steel
    Forceps dissecting
    Scissors episiotomy
    Sponge holder
    Syringes and needles


SATURE TRAY
    Forceps
            a) Dissecting
            b) Artery, mosquito type
            Needle, suture
    Needle holder
    Syringes and needles, single use and reusable
    Scalpel with blade
    Scissors, suture
    Spinal sheet with hole
    Tray with wrapper
    Towel


BABY TRAY
    Bowl, stainless steel
    Forceps:
            a) Dissecting
            b) Artery
    Kidney tray




                                       103
    Mucus suction with Catheter
    Scissors, cord cutting
    Thread for cord tying


RESUSCITATION TRAY FOR NEW BORN BABIES
    Mucus suckers
    Ambubag
    Oxygen mask
    Endotracheal tubes
    Laryngoscope
    Suction catheters


DELIVERY TRAY
    Bowl for placenta
    Catheter rubber plain
    Forceps:
    a) Artery
    b) Bowel
    Gynae sheet
    Kidney tray
    Sponge holding forceps
    Table, obstetric, labour
    Tray with wrapper


FORCEPS TRAY
    Bowel, wash
    Brain crusher
    Forceps:
       a) High with weight
       b) Low
       c) Vacuum
       d) Artery




                                  104
    Gynae sheet

    Kidney tray

    Sponge holding

    Scissors

GRANIOTOMY SET

    Cannula, Dreus smith

    Catheter, metal

    Forceps, high

    Hooks, Embryotomy

    Perforator skull

    Scissors craniotomy

GENERAL INSTRUMENTS SET
    Forceps:
       a) Artery, mosquito, straight and curved
       b) Kocher‟s pattern
       c) Allis, tissue
       d) Peritoneum, Bab-Cock‟s pattern
       e) Hernia ring
       f) Intestine holding, Dennis brown
       g) Dissecting
    Handle for B.P blade
    Needle Holder
    Needle aneurysm
    Retractors:
       a) Langenback‟s pattern
       b) Cerny‟s pattern
       c) Morison‟s pattern
       d) Durham‟s pattern
       e) Volkman‟s pattern



                                     105
           f) Deaver‟s pattern
     Suction nozzle, for such apparatus
     Sponge holding forceps
     Scissors:
           a) Mayo‟s pattern straight and curved
           b) Sharp and blunt
           c) Wire cutting
           d) Metzemboum‟s pattern
           e) Towel clips


LEPARATOMY SET
  Clamp:
           a) Payr‟s crushing
           b) Intestinal non-crushing
     Forceps:
           a) Right angle
           b) Allis pattern
           c) Artery
           d) Peritoneum, Bab-Cock‟s
           e) Dissecting (McIntosh‟s)
           f) Dissecting (Gillie‟s)


     F-3. HOUSEKEEPING EQUIPMENT
     Brooms, mops etc.
     Cabinet steel
     Chairs, metal, office type
     Meat chopper
     Meat block
     Mop ringer with water tank
     Table, metal, Office type
     Trolley linen/housekeeping
     Washing machine for floor cleaning




                                          106
G.   ADMINISTRATIVE ZONE


     G-1 OFFICE EQUIPMENT
     Table with Double drawers
     Chairs, metal office type
     Chairs, plastic moulded
     File cabins
     Jugs for water
     Office equipment:
        a) Paper weight
        b) Pen stands
        c) Racks
        d) Stationery items
     Steel cabinets
     File rack
     Cash Chest
     Typewriter
     Waste receptacles


     G-2 CENTRAL STORE
     Chairs, metal, office type
     Instruments cabinets
     Steel stools
     Steel cabinets
     Storage racks
     Table, metal, office type
     Trolley for General Medical Store
     Waste receptacle
     Weighing scales




                                         107
         The above mentioned is a typical pattern of equipments, instruments and
furniture required in a medical institution as per Indian standard. Over and above; here
enlist an additional list of equipments, furniture and instruments required in each type of
institution and speciality wise. All these are subject to periodical revision according to
modernisation in treatment.


Sub Centre.
   1. B.P Apparatus & Stethoscope
   2. Examination Table
   3. Sallie‟s Hemoglobinometer
   4. Sub Centre Kit
   5. Autoclave
   6. Steriliser
   7. Office Furniture- Table, Chair, Stool, Almarrha & Bench with Back


PHC
   1.          B.P Apparatus
   2.          Examination Table
   3.          Trolley
   4.          Electric Sterilizers
   5.          Needle destroyer
   6.          Wheel chairs
   7.          Oxygen cylinders with flow meter, stand
   8.          Metallic Buckets with lid (by operating)
   9.          Nebulisers
   10. Shadow less lamp
   11.         ECG Machine,
   12. Furniture- table, Chair, Bench with back, Almarrha,
               Cots, Labour cots, Bed side locker etc.
   13. ECG Machine
   14. Glucometer/ simple auto-analyzer
   15. Autoclave




                                           108
CHC
   1.          B.P Apparatus
   2.          Examination Table
   3.          Trolley
   4.          Electric Sterilizers
   5.          Needle destroyer
   6.          Wheel chairs
   7.          Oxygen cylinders with flow meter, stand
   8.          Metallic Buckets with lid (by operating)
   9.          Nebulisers
   10. Shadow less lamp
   11.         ECG Machine,
   12. Furniture- table, Chair, Bench with back, Almarrha,
               Cots, Labour cots etc.
   13. Glucometer/ simple auto-analyzer
   14. Ultrasound scanner
   15. X-ray
   16. Oxygen Cylinders
   17. Suction apparatus
Lab.


  1.           Laboratory equipment for doing routine tests
  2.           Laboratory equipment for Biochemical & Serological
               tests
  3.           Refrigerators


Theatre
               Boyle‟s apparatus
               Pulse oxymeter
               Cardiac Monitor
               Shadow less lamps




                                          109
              Operation Table
              Autoclave Horizontal
              Sterilizer, Suction apparatus
              Phototherapy unit with warmer.
              Amboo bag


Taluk Hospitals


      Causality Unit


      I.V. Stands
      Oxygen Cylinders
      Nebulisers
      Amboo bag with resuscitating instruments
      Shadow-les lamps
      Needle destroyers
      Electric Sterilizers
      ECG machine
      X-ray Unit (Portable)
      Cardiac Monitors
      Defibrillators
      Electric Cautery
      Suction apparatus


      Labour Room


      Shadow less lamps
      Phototherapy unit with warmer
      Amboo bag
      Ultra Sound Scanner


      Theatre




                                          110
      Boyle‟s Apparatus
      Pulse Oxymeter
      Operation table
      Sterilizer
      Autoclave vertical & horizontal
      Trolley
      Trays
      Cardiac Monitors
      Suction apparatus
      Shadow less lamps
      Refrigerators
      Bipolar Cautery




District Hospital


Equipments for ICU Units
      Cardiac Monitor
      Defibrillator
      Suction Apparatus
      Centralized Oxygen System
      Thread mill Test
      Echo Cardio gram
      Colour Doppler
      Pulse Oxymeter
      Infusion Pump
      Ultra Sound Machine
      L.P. Set
      Liver aspiration set
      Glucometer
      X-Ray




                                        111
       Laprotomy set
       Ventilator


       Instruments and equipments for all types of Operations such as Laprotomy,
Thyroidectomy, Tracheostomy etc.


       Fibro endoscopes – for Oseophage, Trachea, Rectal, Foetal Heart Monitor,
Video-Laparoscope with accessories, C- Arm, Rapid Autoclave, Fibro-optic
Laparoscope, Digital Infusion set, Portable X-ray, Photo therapy Unit,
Radiology Dept
   1. Radiology department should be equipped to take up the work of General
       Hospital and other peripheral govt. Institutions in the district where the facility is
       not available.
   2. Department should have facilities for conventional radiology, special
       investigative procedures and imagelogy.
   3. There shall be provision for uninterrupted supply of essential items like X-ray
       films and chemicals to the department.
   X-ray machines (Diagnostic)
   1. 1 X-ray machine without image intensifier fluoroscopy and spot film devise of
       500 MA for special investigative procedures to be provided.
   2. 2 X-ray Units for routine radiography
   3. 1 X-ray unit of at least 300mA attached to the casualty/Emergency medical
       service block providing 24-hour emergency service to the public.


Ultrasonography
       High resolution scans with colour Doppler, printer and multi-format camera
       Spiral CT Scan


Department of Dermatology & Venerology
Additional Requirements:
       Separate Lab attached - Skin unit especially for STD cases
Facilities for doing the following investigations also to be set up.




                                            112
      Routine Blood Exam – Urine Exam
      Blood VDRL
      TPHA
      Blood fw – HIV – I, II (ELISA Test)
      HBSAg


   Cosmetology unit
          a) Instruments required
                     -   Electric Cautery unit
                     -   Cryosurgery unit
                     -   Iontophoresis
                     -   Laser for epilike
                     -   PUVACHAMBER
                     -   Perm


   Operation Theatre
   Equipments-for each table – Anaesthesia Machine
                                  Anaesthesia Ventilator
                                 Pulse Oxymeter
                                Cardio scope
                                BP Apparatus
                                Suction apparatus
                                Capnograph
                                Amboobag
                                Defibrillator.
                                Central supply of oxygen & nitrous oxide


Critical Care Unit
      -Pulse Oxymeter
                                Cardio scope
                                BP Apparatus
                                Capnograph




                                             113
                    Ventilator
                    Suction Apparatus
                    Adjustable Coats with drip stand
                    T-Pice
                    Ventimask
                    CPCR set – Amboo bag
                    Defibrillator with monitor
                    Face Mask
                    Laryngoscope with Endotracheal tubes
                    Adjustable cots with drip stands-2
-   Syringe pump
-   Pulse Oxymeter
-   ECG Monitor
-   NIBP Monitor
-   Suction apparatus
-   Emergency Lamp
-   X-ray lobby
-   Boyles machine with oxygen cylinder
-   Bains circuit
-   Amboo bag
-   Endotrachal tube-different sizes
-   Mask
-   Airway
-   Laryngoscopes with different blades
-   O2 Ventimask, Polymask, CPAP mask
-   Intensive Spirometry
-   Nebuliser-2
-   T-piece
-   Defibrillator
-   Thermometer
-   Thermometer for monitoring CCU temp.
-   Two-side lamp for each cot




                                 114
           -   Chart board
           -   Drug Trolley
           -   Refrigerator
           -   Steriliser
           -   Cidex container
           -   Instrument for fumigation
           -   Chairs, Bookshelf
           -   ABG Machine
           -   IVF – TPN (Total Parenteral Nutrition)


Intensive Coronary Care Unit
       An ideal Intensive coronary care unit shall have a plinth area of 484.2 with ICU
room, Monitoring Area, ICU Information area, Echo ventilator room, passage space,
toilet, Nurses Room with toilet facility, Doctor‟s room with toilet room, X-ray room,
Office Room, Rehabilitation area, Male and Female wards with toilet facilities, TMT
Room , Computer Room, Preventive Clinic room, ECG Room, Out patient room with
passages and waiting areas.
       The Instruments , equipments and furniture required are listed below:-
       1   Cardiac beds with wheels and over bed tables
       2   Cardiac monitors- ECG, NIBP, O2 satn
       3   Diginfusa
       4   Defibrillator
       5   Pulse Oximeter
       6   Arterial Blood gas analyzer
       7   ECG Machines Page writer(Portable)
       8   BP apparatus
       9Portable ECHO Machine
       10 Ventilator
       11 Centralised Oxygen
       12 Centralised A/c
       13 Generator Connection
       14 Chairs




                                           115
15 Central Monitor (Multi channel)
16 Central Table
17 Refrigerator
18 X-ray lobby
19 Portable X-ray Unit
20 Defibrillator with ext.pacer
21 C Arm
22 Fluroscope
23 Monitor
24 Pacing Table
25 Pulse Generator
26 Drug Trolley
27 Almirah
28 Heater
29 Sterilizer
30 Adjustable Stretchers
31 Wheel chairs
32 Computer
33 Uniforms for the patient
34 Mattresses
35 Pillows
36 Mattress Covers
37 Pillow covers
38 Bed Sheets


Doctor's Room
1      Table
2      Chairs
3      Bed
4      Mattress
5      Pillow




                                  116
Chest pain room
1      Table
2      Chairs
3      Bed
4      Mattress
5      Pillow


Nurses Room
1      Table
2      Chairs
3      Bed
4      Mattress
5      Pillow


Bystanders Room
1      Chairs
2      Small Table
3      Cupboard


Bathrooms 2
1      for staff
2      For patient
3      Urinals
4      Bed pan


Ward
1      Tanle
2      Chairs
3      Beds (Cardiac bed)
4      Stools
5      Centralised oxygen cupboards
6      Stretcher




                                117
7    Wheel chairs


Nurses Room
1    Table
2    Chairs
3    Almirah
4    Bed
5    Drug Trolley
6    Water Tap
7    Bath Room


TMT Lab
1    TMT Machine
2    Defibrillator
3    A/C Machine
4    Examination bed
5    Chairs
6    Table
7    Almirah
8    Emergency Drug Trolley
9    Generator Connection
10   Holter Monitor Machine




Echo Lab
1    Echo Machines
2    Examination Cot
3    Tool rest
4    Chairs
5    Almirah
6    Tables
7    Water Tap




                              118
       8      Generator Connection


       OP
       1      Table
       2      Chairs
       3      Stools
       4      Examination Cot
       5      X-ray
       6      Almirah
       7      Nurses Room
       8      Doctors Rom


       ECG Room
       1      ECG Machines
       2      Bed
       3      Table
       4      Chairs
       5      Almirah
       6      Stools


Ophthalmology Speciality


PHC
       In PHCs the services such as screening for identification of cataract, glaucoma
screening school medical check up and treatment of primary ailments of eye is to be
provided.
Equipments required to provide above services are: -
       1. Trial set
       2. Torch
       3. Tonometer
       4. Vision Chart both distant and near vision




                                         119
CHC
       In CHCs even though the Ophthalmologist post is not recommended, there is a
post of Ophthalmic Assistant, who can deliver some of the services such as cataract
detection, screening for eye diseases such as glaucoma and other primary ailments and
school health screening.


       To deliver the above services the following equipments are to be made
available:-
              1. Trial set
              2. Torch
              3. Tonometer
              4. Vision Chart both distant and near vision


Taluk Head Quarters Hospital


       In THQHs there are facilities for providing both clinical and surgical services.
              1. Screening for cataract
              2. Screening for refractive error
              3. Correction by prescription of glasses.
              4. Glaucoma evaluation and management
              5. Minor and major surgeries of eye
              6. Contact Lens Clinic
              7. Eye bank facilities- act as a eye collection centre
              8. Other eye care services


Equipments
                     1.          Trial set
                     2.          Vision Chart both distant and near vision
                     3.          Colour vision chart
                     4.          Ophthalmoscope
                     5.          Torch
                     6.          Tonometer




                                              120
                   7.           Streak Retenoscope
                   8.           Slit Lamp
                   9.           Keratometer
                   10. A Scan
                   11. Perimeter and Bjerrum‟s screen
                   12. Operation Table and Chair
                   13. Operating microscope
                   14. Lensometer
                   15. IOL Surgery set
                   16. Refrigerator
                   17. Eye collection bottles




District & General Hospital


       There are facilities for providing both clinical and surgical services and also eye
care services in the peripheral areas through the mobile units.
    Screening for refractive error and Correction by prescription of glasses.
    Minor and major surgeries of eye
    Contact Lens Clinic and
    Squint clinic
    Contact Lens Clinic
    Other eye care services
    Vitero-retinal surgeries
    Eye bank facility
    Laser Procedures such as
           a. Pan retinal Photo coagulation,
           b. Yag capsilotomy,
           c. Keratoplasty,
           d. Squint devaluation and surgeries,
           e. Keyhole cataract surgeries and other major surgical procedures.




                                            121
Equipments
   Trial set
   Vision Chart both distant and near vision
   Colour vision chart
   Ophthalmoscope
   Torch
   Tonometer
   Streak Retenoscope
   Slit Lamp
   Synoptophore
   Keratometer
   A Scan
   B Scan
   Contact Lens set
   Perimeter and Bjerrum‟s screen
   Operation Table and Chair
   Operating microscope
   Phacomachine
   Surgical Instruments such as
   IOL Surgery set
   Keratoplasty set
   Vitreo-retinal surgery instruments
   Lensometer
   Aplanation Tonometer
   Yag Laser
   Argon Laser
   Fundus camera with facility for flurocine
   Angiography
   Laser unit – Yag laser, argon laser,
   Specular microscope
   Cornial topography with packy meter
   Cataract surgery set




                                         122
    Glaucoma surgery set
    Rapid auto clave


ENT
       In Taluk hospitals treatment for treatment and Minor surgical interventions and
operations such as Tonsillectomy, SMR, Trachiostomy can be provided. In District and
major hospitals all minor and major surgical procedures can be provided. The
equipments are to be provided according to the service delivery in each type of
institution. The following are a list of ENT Equipments.
                  1.          Head Mirror
                  2.          Bull‟s eye lamp
                  3.          Aural Syringe
                  4.          Instrument for antrum wash- with
                              Higgson‟s syringe & trocar and canula
                  5.          Kilian‟s speculum
                  6.          Nasal dressing forceps
                  7.          Hartman forceps
                  8.          Wax hook
                  9.          Eustachian catheter
                  10. Indirect Laryngoscope
                  11. Torch
                  12. Audiogram
                  13. Suction apparatus
                  14. Tonsillectomy set
                  15. SMR Set
                  16. Trachiostomy set
                  17. Oesofagoscope
                  18. Bronchoscope
                  19. Mastiodectomy set
                  20. Endoscopic set (FESS)




                                          123
Paediatric
                      i. Amboo bag
                     ii. Oxygen cylinder
                    iii. Endotrachal tube
                    iv. Paediatric Laryngoscope sets
                     v. Oxygen food
                    vi. Suction Apparatus
                    vii. Electric and food suction
                   viii. Pulse oxy meter
                    ix. B.P. Apparatus
                     x. B.P. Monitor
                    xi. Paediatric ventilator
                    xii. Peritoneal dialysis unit
                   xiii. Lab service for drug gas analysis
                   xiv. Trans coetaneous bilirubinometer
                    xv. Auto scope
                   xvi. Ophthalmoscope
                   xvii. Radiant warmer
                  xviii. ECG Monitor
                   xix. Portable X-ray unit
                    xx. Nebulisers
                   xxi. Bondmaro biopsy set
                   xxii. Liver biopsy set
                  xxiii. LP set


Orthopaedic Speciality
         In PHCs and CHCs Provision for First aid facilities are needed.
         Splint
         In THQHs the service delivery for closed reduction, Open reduction to some
extent, external fixation and tendon repair can be provided. The instruments required
are: -
Surgical instruments for soft tissue surgery and orthopaedic equipments. Such as: -




                                              124
               Grill
               Bone clamps
               Bone holding forceps
               Osteotome
               View guge
               Bone cutting forceps
               Retractors
               Bone taps etc.,


       In District and General Hospitals in addition to above service delivery special
services such as
       Laminactomy
        Joint Replacement surgery
       Arthroplasty etc. can be provided.


Equipments required are: -
               Grill
               Bone clamps
               Bone holding forceps
               Osteotome
               View guge
               Bone curetting forceps
               Retractors
               Bone taps etc.,
               Portable X-ray
               Colour Doppler
               C-arm
               Surgical operation set such as
               Laminactomy set
               Joint replacement surgery set




                                            125
Dental Speciality

        As per standardised pattern Institutions such as General hospitals shall have the
speciality units of Ortdontics, Oral Surgery and 1 Assistant Surgeon, Dental. In District
Hospitals there shall be 1 Dental unit with Orthodontics and Oral surgery specialist
each.

        Dental Units are functioning in 5 General Hospitals 11 District Hospitals, 36 out
of 41 Taluk Head Quarters Hospitals, 5 CHCs out of 107 CHCs, 14 Govt. Hospitals out
of 55 Govt. Hospitals, 2 PHCs and 1 Mobile Unit.



        In Taluk Hospitals, Taluk Level Govt. Hospitals, CHC and PHC wherever the
units are available it will continue as such.   In all Dental Units there shall be 1 Dental
Hygienist and 1 Dental mechanic in Taluk and Taluk level hospitals and in General
Hospitals and Districts Hospitals 2 Dental Hygienist and 1 Dental Mechanic.



Service Delivery: -

           o General Hospital
                   All Oral Surgery including Maxillo Facial Surgery
                   All Orthodontic Corrections including Jaw relations
                   All Conservative Treatment
                   All Prosthodontic treatment
                   All Peridontic Treatment
                   Trauma care unit


           o District Hospital
                   All Oral Surgery including Maxillo Facial Surgery
                   All Orthodontic Corrections (Fixed appliances) including Jaw
                    relations
                   All Conservative Treatment
                   All Prosthodontic treatment
                   All Peridontic Treatment



                                            126
          o Taluk Hospital and Taluk Level Hospitals-
                 Minor Oral Surgery
                 Orthodontic Corrections with removable appliances
                 Prosthodontic Treatment


Mental Health Centres / Mental Hospitals


Equipments


    C.T. Scanner
    E.E.G Mapping Equipments (Computerise)
    Computerised network for data storing on HIMS
    Generator
    Fax Machine
    Water Still Stainless steel with storage tank
    Semi Auto analyser
    Spectro calorimeter
    Flame Photometer
    Automatic Micro Pipette
    U.P.S. with constant stabiliser
    Refrigerator
    Electric Centrifuge
    Hot air oven
    Balance Bringers type
    Balance Electronic digital EEG Machine
    Photocopier
    E.C.G. Machine
    Boyles apparatus
    Defibrillator




                                         127
 Cardiac Monitor
 X-ray machine
 Power Laundry
 Photo electric calorimeter
 Voltage Stabiliser
 Gas stove with Cylinder
 Centrifuge Digital with timer and speed control
 Microscope
 Hemoglobinometer
 Incubator
 Flame Photometer
 E.C.T. Machine
 Water bath with thermometer




                                     128
  STANDARDISATION OF LABORATORY SERVICES IN
        KERALA GOVERNMENT HEALTH SERVICES

Introduction


        The Health status and morbidity pattern of the people of Kerala is undergoing
important changes in the past few years. The change will continue to occur in the future
also.   The most important change that has occurred is the emergence of non-
communicable diseases as the number one cause of mortality in the state. Hypertension
and Diabetes Mellitus with their complications is the most important cause of morbidity
and mortality in the state. While the non-communicable diseases pose serious threat to
the health of the people, communicable disease has not declined to any great extent.
Tuberculosis, typhoid and cholera do occupy an important position in the morbidity
scenario of the state. Communicable disease like Leptospirosis and dengue fever has
come to stay. HIV epidemic has hit the state already. Malaria and filarial diseases
though has come down, their re-emergence cannot be ruled out.


        Government health care system should address this situation in the planning for
the future patient care activities.     Another factor to be considered is the cost
effectiveness.   Patient management       should also address the laboratory facilities
available in Government health care delivery system. The standardization suggested
aims at developing a comprehensive Laboratory service system at all levels in the
Government health care delivery.


Objective
        Laboratory investigation services now available in different types of health care
delivery institutions are now vary and not even having primary investigation facilities in
many of the laboratories attached to different types of institutions. Diagnostic facilities
are essential service to help the physician (doctor) to arrive at a definite diagnosis and
there by to deliver quality health care delivery. Here suggest minimum laboratory
investigation facilities that can be provided in each levels; Sub Centres, PHCs, CHC,



                                           129
Taluk hospitals and District Hospitals, General Hospitals and District, Regional and
State Public Health Laboratories to assist the functionaries for the delivery of quality
health care delivery.


LABORATORY SERVICES PROPOSED IN: -

I. SUB CENTRE

        Sub Centre is the peripheral health unit, which delivers the primary health care
and surveillance activities. Minimum level of laboratory investigation such as Blood
Haemoglobin estimation and Urine Sugar, Bile Pigment and Albumin examination are
the services that can be rendered in these units to help the JPHN for Antenatal care and
surveillance activities.
        The instrument & equipment needed are Hemoglobinometer, Test tubes and
Spirit lamp, which have been already supplied with the sub centre kits.
        The re-agents needed are N/10 Hydrochloric Acid, Benedict‟s Qualitative re-
agent, Tincture Iodine and Sulphosalicylic acid.


II.PHC


        PHCs are the primary health care delivery institutions. Preventive, Promotive
and Curative services are the services rendered through the primary health centres. To
deliver quality care services through these institutions there shall have minimum
laboratory investigation services.


        Routine examination of Blood, Urine and Stool, Sputum for AFB, Peripheral
Smear examination for Malaria, Filaria, Urine examination for Bile Salt and Bile
Pigment; and Blood Sugar.


        The equipments required are Microscope, ESR tube with stand, Photo-
calorimeter, Test tubes, Burner with gas connection, Glass slides and cover slip,
Computer and printer with accessories




                                          130
       The re-agents required are: -
                 Benedict‟s Qualitative re-agent,
                 Conc. Carbol fushion,
                 Methylne blue 1 %,
                 25% S2HO4,
                 JSB Stain 1 &2,
                 Leishman‟s Stain,
                 Sulphur Powder,
                 Tr. Iodine,
                 Blood Sugar Kits and
                 Other re-agents according to the additional requirements.
       Infrastructure facilities required are Room with Work area of minimum of 400
Sq.ft. with Electrical and Sanitary fittings – Washbasin, Sink, and Work bench.


STAFF
       1. Lab Technician        –1


III. CHC/GOVT.HOSPITALS


       These institutions are the institutions having inpatient care with limited service
delivery. The health care services delivered through these institutions are Specialities
such as medicine, surgery, Anaesthesiology, paediatrics, Obst. & Gynaecology.


       To deliver quality care services through these institutions there shall have
minimum laboratory investigation services such Blood, Urine & Stool - Routine
examination, Sputum-AFB; Urine-Pregnancy Card Test, Peripheral smear-for Malaria,
Filaria; RBC Count, Platelet Count, Recticulocite Count, PCV, MCV, MCHC, MCH;
Blood grouping, Blood-sugar, Urea, Creatinin, Cholesterol, VDRL; Semen analysis and
collect Cytology and FNAC Specimens and transport these samples near by the Taluk
hospital Laboratory.




                                          131
       The equipments required are Microscope, Photo-calorimeter, Plain Photo meter,
Serological water bath, Centrifuge, Refrigerator, Micropipettes, Haemocytometer, DC
Cell counter, Conical flask, Test tubes, Glass slides Measuring jars, Glass bottles with
stopper of varying capacity and Burner with gas connection Computer and printer with
accessories.


       The reagents required are Benedict‟s Qualitative re-agent, Conc. Carbol fushion,
Methylne blue 1 %, 25% H2SO4, JSB Stain 1 & 2, Leishman‟s Stain, Sulphur Powder,
Tr. Iodine, Blood Sugar, Urea, Creatinin, Cholesterol, RPR and VDRL Kits, Grouping
Anti-sera and other re-agents according to the modification and requirements.


       Infrastructure facilities required are Room with Work area of 800 Sq.ft. with
Electrical and Sanitary fittings – Washbasin, Sink, and Workbench, Toilet facilities
inside and out side.


STAFF
       1. Lab Technician              -2
       2. Lab Assistant / Attender –1


IV. THQ HOSPITALS


       Taluk Head Quarters Hospitals are the first referral hospitals with facilities to
deliver all types of specialities and unit system. The laboratory services required for the
delivery of quality care are clinical, limited biochemical and bacteriological
investigation of Blood, Urine, Stool, sputum and CSF.


       Details of investigations are Blood, Urine and Stool -Routine examination,
Urine- Pregnancy Card Test, Stool examination Hanging drop for Cholera, Peripheral
smear-for Malaria, Filaria, RBC Count, Platelet Count, Recticulocite Count, PCV,
MCV, MCHC, MCH; Sputum-AFB, Blood grouping, Blood-sugar, Urea, Creatinin,
Cholesterol, Triglycerides, VDRL, HIV, HBSAg, Widal test, LFT such as Serum
Bilirubin, SGOT, SGPT, Serum proteins, Alkaline Phosphatase, Prothrombin index,




                                           132
RFT such as Serum urea, Creatinin; Serum Electrolytes- Sodium, Potassium; CSF-
Protein, Sugar and Chloride and Culture and sensitivity tests; .


        The equipments required are Microscope, Photo-calorimeter, Plain Photo meter,
Semi Auto Analyser, Incubator, Hot air Oven, Autoclave, Serological water bath,
Centrifuge, Refrigerator, Micropipettes, Haemocytometer, DC Cell counter, Conical
flask, Test tubes, Glass slides Measuring jars, Glass bottles with stopper of varying
capacity and Burner with gas connection; Computer and printer with accessories.


        The reagents required are Benedict‟s Qualitative re-agent, Conc. Carbol fushion,
Methylne blue 1 %, 25% H2SO4, JSB Stain 1 & 2, Leishman‟s Stain, Sulphur Powder,
Tr. Iodine, Blood Sugar, Urea, Creatinin, Cholesterol, RPR and VDRL, HIV, HBSAg,
LFT, RFT, Widal test Kits, Grouping Anti-sera and other re-agents according to the
modification and requirements; and Culture media and Chemicals for Culture and
Sensitivity.


        Infrastructure facilities required are Room with Work area of 2500 Sq.ft. with
proper separation. Instrument room must be Air-conditioned. Stand by Generator is
also required. Electrical and Sanitary fittings – Washbasin, Sink, and Workbench, Toilet
facilities inside and out side are also required.




STAFF
        1. Junior Specialist in Clinical Pathology   -1
        2. Lab Technician                            –3
        3. Lab Attender                              –2


V. District Hospitals / General Hospitals.


        District hospitals are the Secondary/Tertiary level of institutions and referral
centres with specialised health care delivery for all types of specialities and super
specialties. So these institutions shall have a laboratory with facilities for all types of




                                             133
investigation for clinical, Bacteriolocal, Bio-chemical and blood bank and 24 Hour
emergency laboratory investigation facilities.


         Details of investigations are Blood, Urine and Stool -Routine examination,
Urine- Pregnancy Card Test, Stool examination Hanging drop for Cholera, Peripheral
smear-for Malaria, Filaria, RBC Count, Platelet Count, Recticulocite Count, PCV,
MCV, MCHC, MCH, Bleeding Time, Clotting Time; Sputum-AFB, Blood grouping,
Blood-sugar, Urea, Creatinin, Cholesterol, Triglycerides, VDRL, HIV, HBSAg, Widal
test, LFT such as Serum Bilirubin, SGOT, SGPT, Serum proteins, Alkaline
Phosphatase, Prothrombin index, RFT such as Serum urea, Creatinin; Serum
Electrolytes- Sodium, Potassium; CSF-Protein, Sugar and Chloride and Culture and
sensitivity tests; Histo-pathological examinations, Pap‟s smear, FNAC, Semen analysis
& culture. Investigations such as CPK, CKMP, LDH, Troponing T, Platelet Count,
Prothrombin time and Blood Sugar.


         The equipments required are Microscope, Photo-calorimeter, Test tubes, Burner
with gas connection, Glass slides and cover slips, Semi Auto Analyser, Incubator, Hot
air Oven, Autoclave, Refrigerator, Micropipettes and necessary glass wares, Flame
Photo Meter with LI. Filter, Coulter Counter, Coplinagar, Staining dishes, Cotton,
gauze, disposable syringes and needles, Slide rack, Conical flask, Measuring glass
bottles, Computer and printer with accessories


         The re-agents required are Benedict‟s Qualitative re-agent, Conc. Carbol
fushion, Methylne blue 1 %, 25% S2HO4, JSB Stain 1 &2, Leishman‟s Stain, Sulphur
Powder, Tr. Iodine, Blood Sugar Kits and other re-agents according to the modification
and requirements, Grouping Anti-sera, Urea, Creatinin, Cholesterol Kits, RPR Kit for
VDRL, Kits for HIV, HBSAg, LFT, RFT, Widal test, Culture media and Chemicals for
Culture and Sensitivity, Pap stain- Haematoxylin, EA36, OG6, Alcohol, Xylene, DPX,
Ether.


         Infrastructure facilities required are Room with Work area of 3500 Sq.ft. with
proper separation. Instrument room must be Air-conditioned. Stand by Generator is



                                            134
also required. Electrical and Sanitary fittings – Washbasin, Sink, and Workbench,
Toilet facilities inside and out side are also required.


STAFF
        1. Senior Specialist                    -          1
        2. Junior Specialist with DCP           -          1
        3. Junior Scientific Officer            –          1
        4. Lab Technician                       –          4
        5. Lab Attender                         –          2
        6. Data entry Operator                  -          1


VI. Regional Laboratory / District Public Health Laboratory.


        These laboratories are the referral laboratories in the district and shall have the
facilities for all types of laboratory investigations for clinical, biochemical,
bacteriological and pathological investigations.


        Blood- RE, Peripheral smear- for Malaria, Filaria, Platelet Count, BT, CT,
Osmotic fragility test for RBC, PCV, Recticulocite Count, T4 Lymphocyte count,
Coombs test, Urine-sugar, Albumin, Microscopy, Stool-RE, Stool Hanging drop for
Cholera, Stool Culture & Sensitivity, phage typing-for Cholera, Sputum-AFB, Blood
grouping, Blood-sugar, Serum urea, Creatinin, VDRL, HIV, HBSAg, LFT-Serum
Bilirubin, SGOT, SGPT, Serum proteins, Alkaline Phosphatase, Prothrombin index,
RFT-, Serum Electrolytes-Sodium, Potassium, Bicarbonates, Serum Cholesterol, HDL,
Triglycerides, Serum Acid Phosphatase, Serum Amylase, Urinary Amylase, Serum
Calcium, Phosphorous, Serum Protein Electrophoresis, Haemoglobin Electrophoresis,
Lipoprotein Electrophoresis, Serum Ceruloplasmin, RBC Glucose-6- Phosphatase
Dehydrogenase ,      Serum Acetyl Choline esterase Serum Alfa-1 antitrypsin         Serum
iron, Serum copper, Serum Magnesium, Serum Iron binding capacity, Serum Lithium,
Serum Phospholipids, RBC- Glycosylated Haemoglobin, Serum Creatin Kinase, Serum
CKMS, Faetal Haemoglobin estimation, Blood Ammonia, Serum Lead ,                    Serum
Barbiturate in blood Gravindex/ pregnancy test, VMA screening,5 HIAA screening,



                                             135
Arsenic screening-nail/hair, Stone analysis, Bence Jones protein in Urine-Urine uric
acid, Blood Acetone, T3,T4,TSH,TSHRH, Prolactine, LH,FSH,               AFP, CEA, TSS
Neonatal, IG, Elisa Technique,          Ferritin, TEG, ESH, PT4, Digoxine, Insulin,
Proinsuline, Culture and sensitivity tests-Blood, Urine, Sputum, Stool, Widal test, Weil
Felix test, Paul-Bunnel test, Brucella agglutination test, RA factor, ASO, CSF-Protein,
sugar, chloride, Histo-pathological examinations, Bone marrow examination , LE Cells,
Viral markers-for Hepatitis-A,B,C,E


        Histo-pathological Lab in District and Regional Public Health Lab is to be set
up.


Equipments: - Automatic Tissue Processor, Micro tome, Micro tome knife, Knife
sharpener, Tissue floatation bath, Cryostat, Hot air Oven, Incubator, Refrigerator etc.


       The re-agents required are Formaline, Alcohol, Xylene, Ether, Chloroform, Con.
Nitric Acid, Hydrochloric Acid, H&E Stain, Special stains and other Chemicals.


        Infrastructure facilities required are 4000 Sq.ft areas with proper room
separation. Instrument room must be Air-conditioned. Stand by Generator is also
required. Electrical and Sanitary fittings – Washbasin, Sink, and Workbench, Toilet
facilities inside and out side are also to be provided.


STAFF for District Lab.
       1. Pathologist                  –       1 (MD –3)
       2. Microbiologist               –       1 (MD –1)
       3. Scientific Officer           –       1 (Bio Chemistry –1)
       4. Junior Scientific Officer –          2
       5. Lab Technician               –       5
       6. Lab Attender                 –       2
       7. Hospital Attendant Gr.II –           1
       8. LDC                          -       1
       9. Typist/Data Entry Operator –         1



                                            136
STAFF for Regional Lab.
    Pathologist                         –        2 (MD –3)
    Microbiologist                      –        1 (MD –1)
    Scientific Officer                  –        1 (Bio Chemistry –1)
    Junior Scientific Officer           –        2
    Lab Technician                      –        5
    Lab Attender                        –        3
    Hospital Attendant Gr.II            –        2
    LDC                                 -        2
    Typist/Data Entry Operator          -        1



VII. State Public Health & Clinical Laboratory


          State public health laboratory shall be apex centre for monitoring the quality of
service delivery from the different laboratories attached to various types of government
medical institutions in Kerala. This State Laboratory shall be the training centre for skill
up gradation for the laboratory technicians and other staffs working in the other
laboratories. Also conducts of laboratory technicians‟ courses for human recourse
generation in the field.


          The state public health laboratory has the following functions and are carried out
through Diagnostic Section, Bio Chemistry Section, Serology Section, Microbiology,
Central     Malaria   Lab,    Cytology       Section,   Histo-pathology   Section,   Re-agent
Manufacturing Section, Radio Immuno assay Section, Diploma in MLT Section, Bio
Medical Maintenance Unit, Electrical Maintenance Section, Training Programme,
Media Section.



          All types of laboratory diagnostic services including modern special
investigation are done through the above different sections.




                                                137
1. Diagnostic Section:
        In this section all types of routine and special investigation of Blood, Routine
investigation of Urine, Stool, CSF, Sputum, Cytology of Fluids. Immuno-Histo-
Chemistry, Full Coagulation study, HB Electrophoresis, Foetal HB and Chromosome
study can be done.



2. Bio Chemistry Section:
        All Biochemical investigations of Blood, Enzyme studies, CSF and Urine
analysis. Blood Gas Analysis can be done.


3. Serology Section:
        Widal Test, VDRL, Rubella antibody Test, Paul Bunnel Test, Anti streptolysin
O titre, Rheumatoid factor, HVS Ag, ANA, Infectious mono nucleosis test, Coombs
test, Leptospira IGM.TB, IgG Assay. PCR test such as Hepatitis C Virus – RNA, DNA,
Herpes Virus – DNA and other sophisticated investigations.



4. Re-agent Manufacturing Section:
        Routine reagents like Benedict‟s solution & Leishman‟s stain are prepared to
distribute.

        By modifying and equipping reagent manufacturing section, reagents can be
        manufactured and distributed to various laboratories in the State.



5. Diploma in MLT Section:
        Three post of Tutor Technician are vacant which has to be filled up urgently.



6. Bio Medical Maintenance Unit
    Start equipment-repairing unit under a Bio medical engineer with sufficient
    technical supporting staff. This unit can service all lab instruments. This service
    can be extended to other Laboratory by starting a mobile unit.




                                           138
7. Electrical Maintenance Section:
       Start an electrical maintenance unit in State P.H.Lab with required Staff.



8. Training Programme Section
       Start a permanent orientation-training programme to the lab staff. All the lab
staff must get training once in two years.        In State P.H. Lab, DMLT Course is
conducting. By filling up of the vacant 3 Tutor Technician posts, their service can be
utilized for training and other expert staff service can be utilized for training during off
hours on remuneration basis.       The medical officer and Pathologist must be given
deputation chance to attend seminars and CME Programme. All Laboratories must
provide advanced waste disposal facility. RIA Section waste disposal must be provided
as per BARC specifications.



Equipments
   Spectrophotometer, Cuvette, Micropipette, Haemocytometer, WBC Pipette, Glass
   slides, Microscope, DC Counter, RBC Pipette, ESR Tube, Winthrop‟s Tube,
   Centrifuge, Pasteur- Pipette, Bunsen Burner Semi Auto Analyser Electrophoresis,
   Blood Gas Analyser, Electrophoresis Scanner, Micro Pipettes, Fully auto Analyser,
   Semi auto Analyser, Photo colorimeter, Centrifuge, Refrigerator

   Water bath, Coteroyan Equipments, Incubator, Autoroben, Refrigerator, Media
   Shaker Water bath, ELISA Reader, Centrifuge, Microscope, Kemi incubator,
   Refrigerator, Hot air oven, Microscope, Autoclave,        Refrigerator,    UV     Lamb,
   Common Balance, Tapping tool machine, Chemi-Lumino-meter, Automatic gamma
   counter, Ultra Centrifuge, HPLC Unit, Microtom (Rotary)

    The lab and instrument room must air-conditioned



STAFF

       MD Biochemistry Medical Officer                -       1

       Senior Scientific Officer                      -       1

       Scientific Officer                             -       2



                                            139
      Junior Scientific Officer               -   3

      Lab Technician                          -   4

      Lab Attender                            –   3

      Attendant Grade II                      -   2

      Veterinary Surgeon                      –   1

      Lab Technician                          –   2

      Stable Attender                         –   2

      An animal house is necessary



9.    RIA Section

      Medical Officer (MD Nuclear Medicine)   –   1

      Chief Scientific Officer                –   1

      Senior Scientific Officer               –   1

      Scientific Officer                      –   1

      Junior Scientific Officer               –   2

      Lab Technician                          –   5

      Lab Attender                            –   4

      Attendant Grade II                      –   2



10.   Reagent manufacturing section

      Medical Officer (MD, Bio Chemistry)     –   1

      Project Officer                         –   1

      Senior Scientific Officer               –   2

      Scientific Officer                      –   2

      Junior Scientific Officer               –   4

      Lab Technician                          –   3




                                      140
       Lab Attender                                 –       3

       Attendant Grade II                           –       6

       Packer                                       –       3

       Glass Blower                                 –       1

       Driver                                       –       1

       Data Entry Operator                          –       1



11.Office Section:

       Post of LDC, Data Entry Operator, Head Clerk and Lay Secretary is essential to
       handle the Office work.



12.Histopathology section

       Medical officer (MD, Pathology)              -       2

       Scientific Officer                           -       1

       Junior Scientific Officer                    -       1

       Lab. Technician

       (With Cyto Histopathology training)          –       2

       Junior Lab. Assistant                        -       2

       Health Assistant Gr.II                       -        2.


Conclusion
                The committee for standardisation has been entrusted with the task of
       setting up of a standard norm for different levels/ types of health institutions
       under Kerala Health Services. The committee tried to classify the health
       institutions and set up a standard norm from sub centre to the General hospital in
       terms of service delivery, infrastructure, equipment and man power. This
       requires revision according to the change/ modernisation of treatment facilities.




                                          141
                                        Annexure-1
            PROCEEDINGS OF THE DIRECTOR OF HEALTH SERVICES,
                               THIRUVANANTHAPURAM.
        Sub: - H.S.Dept. – Standardisation of Govt. Medical Institutions under
             Kerala Health Services Department – Constitution of an Expert
             Committee – Orders issued –
        Read: - 1. Govt. D.O.Lr.No.43236/M1/01/H&FWD. Dated; 31-12-2001.
                2. This Office Lr.No.PLB3-74500/97/DHS. Dated: 4-05-2002.


                     ORDER NO.PLB3-74500/97/DHS. DT; 13-5-2002
        Standardisation of Government Medical Institutions under Health Services Department
and Constitution of an Expert Committee to look into the various points in were discussed with
Additional Chief secretary. Additional Chief Secretary has directed the Director of Health
Services to constitute Committee and expenditure may be met from European Commission
Fund.
        A Committee is therefore constituted with the following external experts as members to
work out a detailed plan for standardisation of Government Medical Institutions including
management and referral Protocol.
   1. Addl. Director of Health Services (Planning) as Chairman.
   2. Dr.Thankappan, Associate Professor, Achutha Menon Centre, Sree Chithira Thirunal
        Institute of Science & Technology, Thiruvananthapuram.
   3. Dr.Ramankutty, Health System Specialist.
   4. Dr.Vijayakumar, Associate professor, Community Medicine, Medical College Hospital,
        Alappuzha.
   5. Mr.Joseph Gregory, Retired Senior Administrative Asst. from Health Services
        Department.
   The Committee shall submit the report within two months positively.
   The expenditure required for the Committee comes to Rupees One Lakh and the same may
   be met from the current year‟s budget allotment under EC – PMC Fund.
        The Additional Director (FW) will draw the amount and disburse to the Additional
   Director (Planning) immediately.
                                                                     Sd/-
                                                                 Dr.V.K.RAJAN,
                                                       DIRECTOR OF HEALTH SERVICES.




                                             142
    To
         1.   Addl. Director of Health Services (planning).
         2.   Dr.Thankappan, Associate Professor, Achutha Menon Centre, Sree Chithira Thirunal
              Institute of Science & Technology, Thiruvananthapuram.
         3.   Dr.Ramankutty, Health System Specialist.
         4.   Dr.Vijayakumar, Associate Professor, Community Medicine, Medical College Hospital,
              Alappuzha.
         5.   Mr.Joseph Gregory, Retired Senior Administrative Asst. from Health Services Department.
Copy to:- Addl. Director of Health Services (FW) / A.A(Plg.).
              Superintendent, MC, PLA, PLB, FW.
              File/Stock File/Spare.
                                                                                         //Forwarded//


                                                                                     Superintendent.




                                                   143
                                        Annexure-2


        PROCEEDINGS OF THE DIRECTOR OF HEALTH SERVICES,
                           THIRUVANANTHAPURAM


       Sub: -         H.S.Dept. – Standardisation of Government Medical Institution
                      under Kerala Health Services Department – Constitution of an
                      Expert Committee – Orders issued.
       Read: -        This Office Order No.PLB3-74500/97/DHS. Dt: 13.5.2002.


                 ORDER NO.PLB3-74500/97/DHS. DT: 28.5.2002


       As per this Office Order cited, a Committee was constituted with 5 external
experts as members to work at a detailed plan for Standardisation of Government
Medical institutions including management and referral protocol.


       Dr.Mohanan Nair, Faculty, A.M.C.H.S.S., S.C.T.I.M.S, Trivandrum is included
as 6th member in the Committee.
       The order read above stands modified to the above extent.




                                                       Dr.V.K.RAJAN,
                                                DIRECTOR OF HEALTH SERVICES.


To
       1. Addl.DHS (Plg.).
       2. Dr.Thankappan, Associate Professor.
       3. Dr.Ramankutty, Health System Specialist.
       4. Dr.Vijayakumar, Associate Professor, MCH, Alappuzha.
       5. Dr.Mohanan Nair, Faculty, AMCHSS.




                                         144
Copy to: - Addl.DHS (FW) / AA (Plg./Supndt. MC, PLA, PLB /File.


                                             //Forwarded//


                                             Superintendent.




                                      145
                                          Annexure-3
     PROCEEDINGS OF THE DIRECTOR OF HEALTH SERVICES,
                           THIRUVANANTHAPURAM


       Sub: -         H.S.Dept. – Standardisation of Government Medical Institutions
                      under Kerala Health Services Department – Extension of the time
                      limit of the Committee – Orders issued.
       Read:          1. This Office Order No. {LB3-74500/97/DHS. DT: 13.5.02 &
                      28.5.02.
                      2. Request DT: 1.8.02 of the Chairman, Committee for
                      Standardisation of Govt. Medical Institutions.


                 ORDER NO.PLB3-74500/97/DHS. DT:03-08-2002


       The Chairman, Committee for Standardisation of Medical institutions
constituted as per these office proceedings cited Ist has reported that the Committee was
entrusted to submit the report on the Standardisation of institutions including referral
and management protocol.         It has also reported that preparation of referral and
management protocol requires detailed study incorporating experts for which the limited
time and resources will not be sufficient. The Chairman of the Committee therefore
requested sanction to limit the report only to Standardisation of Medical institutions
exempting referral and management protocol.


       The Chairman has further reported that the members of the Committee are
working in addition to their official duty in respective areas and departments and it
involves considerable effort to complete the entrusted task to a final report. It has also
informed that the duration of the Committee requires extension by at least two more
months for completion of the task and requested to extend the period of committee up to
30.9.2002.




                                           146
       In the circumstances explained above the period of Committee is extended up to
30.9.2002. The Committee shall submit the final report on the Standardisation of
Institutions within the extended period exempting referral and management protocol.


                                                             Sd/=
                                                           Dr.V.K.RAJAN,
                                                  DIRECTOR HEALTH SERVICES.
To
       The Chairman and all Members of the Committee.


Copy to: - File / Stock File.




                                        147
List of Officials, Experts and other dignitaries who contributed and participated in
the discussions.


1.   Dr. A.K.Radhakrishnan
2.   Dr. Amar.S.Fettle
3.   Dr. Aysha Beegom.A
4.   Dr. B.Ekbal
5.   Dr. B.Mahilamoni
6.   Dr K Sandeep
7.   Dr. B.S.Saraswathi Amma
8.   Dr. B.Sreenath
9.   Dr. Chandrasenan
10. Dr. D.Radhakrishnan
11. Dr. D.Thankam
12. Dr. G.Chandradas
13. Dr. J.Radha Bai
14. Dr. J.Vijayabhanu
15. Dr. Jean Padma.C
16. Dr. Jeevan
17. Dr. K.Dinesh
18. Dr. K.Hemachandran
19. Dr. K.K.Sulekha
20. Dr. K.Lali
21. Dr. K.N.Prasad
22. Dr. K.P.Pradeep kumar
23. Dr. K.R.Prabhakaran Nair
24. Dr. K.T.Sreelatha
25. Dr. Kalpana
26. Dr. Kumari.G.Prema
27. Dr. Lali.K.Rajan
28. Dr. Lizy Mathew




                                        148
29. Dr. M.K.C.Nair
30. Dr. M.K.Kamalamma
31. Dr. M.Thampi
32. Dr. Mohanadas.B
33. Dr. P.Ayyappan
34. Dr. P.E.Krishnan Namboothiri
35. Dr. P.J.Leena
36. Dr. Prathapan
37. Dr. R.Sreekumar
38. Dr. R.Venugopalan
39. Dr. Radhika Rani
40. Dr. Rajeswari Gopalan
41. Dr. S.Jayaram
42. Dr. Sasikumar
43. Dr. Sunija.S
44. Dr. Sunny.P.Orathal
45. Dr. T.Jacob John
46. Dr. V.G.Abraham
47. Dr. V.Pavithran
48. Dr. V.Reghuraj
49. Dr. V.Surarajmoni
50. Dr. Velayudhan
51. Dr. Zainaba.B
52. Dr.Kuttamani
53. Dr.M.V.Vijayan
54. Dr.Omana
55. Dr.Prathapan
56. Dr.Raghavan
57. Dr.Shylaja
58. Dr.Vimal raj
59. Abida Beevi
60. Beena.K.V




                                   149
61. Bindu.I
62. Chitra devi.T
63. G.Chandrasenan
64. Hayarin Pereira
65. Jalaja kumari
66. Jyothi kumari
67. K.Kamala
68. K.L.Bindu
69. M.C.Lillykutty
70. M.Saphiya Beevi
71. Mary Jacob.
72. R.Jalaja kumari
73. R.Suresh kumar
74. Remani Devi
75. S.Rajeev
76. S.Sasikumar
77. S.Usha
78. Sakeena Beevi.S
79. Santhakumari.C.G
80. Saroja.P
81. Sreeharshadev.V
82. Sundararajan
83. Sushama.B
84. Sushama.S
85. T.M.Annamma
86. Usha.S
87. V. Prakash
88. V.Rajendran
89. V.Reghuraj




                       150
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      1. Work Study Report of P&ARD.
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            Dr. K.N. Pai (Pai Committee Report)
      3. Report of the One Man Commission by Dr. C.V. Prathapan
      4. Govt. of Kerala XIIth         report of the Kerala Administrative Reforms
            Committee- Report on Health Services Delivery- May 2001..
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      6. Indian Standards - Basic Requirements for Hospital Planning.
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      10. V Raman Kutty. A Primer of Health Systems Economics. New Delhi: Allied
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                                           151
   Hospitals and State Health Secretaries in National Institute of Mental Health
   and Neuro Sciences (Deemed University) Bangalore – dt 5 - 6 - feb. 99
16. Census of India 2001.
17. Managing a Modern Hospital Edited by A.V. Srinivasan
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   Rajeev Sadanandan, K.R. Thankappan, V. Mohanan Nair, Achuthamenon
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   Science & Technology and Dept of H & FWD, Government of Kerala.




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