Final-Report-MHSDP-SC-KPK-2-11-16-accepted-changes-formatted

FINAL REPORT
SECONDARY LEVEL MINIMUM
HEALTH SERVICES DELIVERY
PACKAGE FOR SECONDARY CARE
HOSPITALS (MHSDP)
Dr. Inayat Thaver and Dr. Muhammad Khalid
2nd
of November, 2016

Minimum Health Services Delivery Package for Secondary Care KP
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Contents
1 MHSDP: Background, concepts and principles..............................................................23
1.1 Packaging of health services delivery (HSD) ..........................................................23
1.2 Levels of care and HSD system in Pakistan ...........................................................24
1.3 Experiences of developing and implementing HSD Packages ...............................25
1.3.1 International experience...................................................................................25
1.3.2 National experience .........................................................................................27
2 Background to MHSD Package in KP ............................................................................27
2.1 Current status of health and HSD in KP..................................................................27
2.2 Categorisation of Secondary Care Hospitals in KP.................................................30
2.3 Improving HSD and quality in KP: achievement & work in progress.......................33
2.3.1 Acts related to health service delivery..............................................................33
2.3.2 Health Care Commission .................................................................................34
2.3.3 Standards for secondary care ..........................................................................34
2.4 Government of KP strategic vision and challenges for improving health status......35
3 Objectives, processes followed and Final outcome........................................................36
3.1 MHSDP-for secondary care, but focusing on “Categories of hospitals” in districts .36
4 Process followed for developing MHSDP for secondary care facilities ..........................37
4.1 Participatory consultation ........................................................................................37
4.2 Defining roles & responsibilities of various key stakeholders..................................37
4.2.1 The Technical/Clinical sub-Committee.............................................................37
4.2.2 The administrative/management sub-Committee ............................................37
4.2.3 The Preventive Care sub-Committee...............................................................38
4.3 The final outcome....................................................................................................39
5 MHSDP for Category “A” Secondary Care hospital........................................................39
5.1 Clinical and Supportive Services.............................................................................39
5.2 Human Resource Requirements .............................................................................49
5.3 Essential Equipment................................................................................................49
5.4 Essential Medicines.................................................................................................49
6 MHSDP for Category “B” Secondary Care hospital........................................................49
7 MHSDP for Category “C” Secondary Care hospital .......................................................59

8 MHSDP for Category “D” Secondary Care hospital .......................................................68
9 Preventive and primary health care services for all categories of secondary care
hospitals.................................................................................................................................77
10 Physical Infrastructure guidelines for all secondary care hospitals ................................84
10.1 Factors to be considered in locating a district hospital............................................84
10.2 Size of the Site ........................................................................................................84
10.3 Topography .............................................................................................................85
10.4 Departmental Planning and Design.........................................................................85
10.5 Bed Strength and Specialities across Category A, B, C and D secondary care
hospitals .............................................................................................................................92
11 Financial Resources Required .......................................................................................93
12 Way Forward ..................................................................................................................93
13 Appendices.....................................................................................................................94
13.1 References and Bibliography ..................................................................................94
13.2 Government of Khyber Pakhtunkhwa criterion for categorisation of secondary care
hospitals according to beds distribution for specialities .....................................................95
13.3 TORs (as of contract) ..............................................................................................98
13.4 Experts/Stakeholders met/consulted.....................................................................100
13.5 Composition, Roles and Responsibilities of the Assignment Committees ............101
13.6 Conceptual Understanding of the MHSDP for Secondary Care According To
Categories of Hospitals: ...................................................................................................103
13.7 Human Resource Requirements for Category A, B, C and D Hospitals ...............104
13.8 Equipment requirements for Category A, B, C and D Secondary Care Hospitals.107
13.9 List of Medicines prepared by Medicines Co-Ordination Cell (MCC), 2015-16, Govt.
of KP 117
13.10 Meetings of the Clinical Sub-Committee............................................................126
13.11 Meetings of the Preventive Sub-Committee Meetings.......................................131
13.12 Meeting of the Administrative Sub-Committee Meeting.....................................134

List of Tables
Table 1: Health Facilities by types in Khyber Pakhtunkhwa (Source: DHIS cell) ..................30
Table 2: Speciality wise status across categories of secondary care hospitals in KP ...........31
Table 3: District Wise Approved Categorization of Hospitals ................................................32
Table 4: MHSDP-SC for Category A Secondary Care Hospitals...........................................40
Table 5: MHSDP-SC for Category B Secondary Care Hospitals...........................................50
Table 6: MHSDP-SC for Category C Secondary Care Hospitals ..........................................59
Table 7: MHSDP-SC for Category D Secondary Care Hospitals ..........................................69
Table 8: Preventive Health Care Services at Secondary Level Hospitals .............................78
Table 9: Summary of the Criterion for Categorisation of Secondary Care Hospitals.............92
List of Figures
Figure 1: Overview of the health service delivery in Pakistan ...............................................25
Figure 2: Provincial comparison of Infant and Under 5 mortality rates (Source: PDHS 2012-
13)..........................................................................................................................................28
Figure 3: Percentage distribution of top five illnesses reported by Public sector health
facilities in KP Jan-June, 2016 (Source: DHIS, KP) ..............................................................28
Figure 4: Percentage of women receiving antenatal care from a skilled provider (Source:
PDHS 2012-13) .....................................................................................................................29
Figure 5: Place of delivery by Urban and Rural areas, KP (Source: PDHS 2012-13) ...........29
Figure 6: Process of MHSDP SC –KP development .............................................................38
Figure 7: Topography ............................................................................................................85
Figure 8: Zoning of the district hospital departments.............................................................86
Figure 9: Traffic flow in operating department .......................................................................89

Acronyms
BHUs Basic Health Units
BPHS Basic Package of Health Services
CMWs Community Midwifes
DHIS District Health Information System
DHQH District Headquarter Hospital
EPHS Essential Package of Health Services
HSD Health Service Delivery
IDPs Internally Displaced Persons
KP Khyber Pakhtunkhwa
KPHCC Khyber Pakhtunkhwa Health Care Commission
LHWs Lady Health Workers
MCHCs Maternal and Child Health Centres
MHSDP-SC Minimum Health Service Delivery Secondary Care
PSPU Policy and Strategic Planning Unit
RHCs Rural Health Centres
THQH Tehsil Headquarter Hospital

23
1 MHSDP: Background, concepts and principles
The Government of Pakistan is committed to address the health needs of its population
through efficient quality health care services. The devolution of 17 Federal ministries
including health ministry to the provinces in 2010 led the responsibility of health sector
planning, strategy development and service provision to the provinces. The fiscal and
administrative devolution of powers to the provinces gave them an opportunity to decide on
health priorities specific to the province. In this connection, Punjab, Sindh, KP and
Baluchistan developed their Health Sector Strategies. The implementation of these
strategies require the provinces to develop standardized packages of healthcare to ensure
provision of quality healthcare services to the population equitably. The current assignment
on developing Minimum Health Service Delivery Package for secondary level of care
(MHSDP-SC) in KP is one step towards achieving the objectives of Health Sector Strategy,
Khyber Pakhtunkhwa (2010-17).
1.1 Packaging of health services delivery (HSD)
After the declaration of Alma-Ata in 1978, debate on the merits of a limited package of
interventions versus the notion of comprehensive primary health care started during the late
1970s and 1980s. Essential Health Packages came to prominence when the 1993 World
Development Report posed a practical analysis of how the low-income countries’
governments spend their very limited health budgets. With the help of epidemiological and
costing data, the Report argued that governments should radically shift their health
expenditure towards spending on a minimum package of essential public health and clinical
services. The concept of packages was further reinforced by the Report of the Commission
on Macroeconomics and Health (2001) and the 2006 Disease Control Priorities Project
subsequently1
.
The packaging of the health services delivery at various levels of care facilitate in ensuring
the availability of the requisite services at that particular level and takes into account the
health care needs of the population and the available financial resources. The health service
delivery package primarily includes the list of services along with infrastructure, human
resource, medicines, supplies and equipment requirements to deliver those services. The
standards of service delivery refer to the qualitative aspects of the services that are being
provided and sets out the quality protocols for delivery of each service. The terms “Basic”
and “Minimum” are used interchangeably in relation to the Health Service Delivery Package.
A Basic or Minimum Health Service Delivery Package is defined as a minimum collection of
essential health services to which all the population need to have a guaranteed access. The
term “Essential Health Service Delivery Package” refers to those health services that provide
a maximum gain in health status for the money spent i.e. the services which provide the best
'value for money'. In other words, essential services are those services, which if not
provided, will result in the most negative impact on the health status of the overall
population2
.
1
. Essential Health Packages: What Are They For? What Do They Change? WHO Service Delivery
Seminar Series Technical Brief No. 2, 3 July 2008. Retrieved from
www.who.int/healthsystems/topics/delivery/technical_brief_ehp.pdf on 19
th
July, 2016
2
A Basic Health Services Package for Iraq, Ministry of Health 2009. Retrieved from
www.emro.who.int/dsaf/libcat/EMROPD_2009_109.pdf on 18
th
of July, 2016

24
1.2 Levels of care and HSD system in Pakistan
Pakistani health care system envisages to deliver healthcare through a three-tiered
healthcare delivery system and a range of public health interventions, more than two thirds
through the government. However, there is a parallel non-government, for-profit and not-for-
profit health care system which is highly un-regularized. For description and discussion, the
health systems and services that will be referred would actually be through the government.
The range of services that are being provided through the government include promotive,
preventive, curative and rehabilitative health care services. The three tiers of the health
service delivery system include primary, secondary and tertiary level of care (Figure 1).
Primary Health Care – refers to "essential health care" that is based on practical,
scientifically sound and socially acceptable methods and technology, which make universal
health care accessible to all individuals and families in a community3
. Primary health care in
Pakistan has two components
• Community component of service provision through frontline health workers (Lady
Health Workers – LHWs and Community Midwives – CMWs) that involves primarily
preventive and health promotive services.
• Health facility component including Basic Health Units (BHUs), and Rural Health
Centres (RHCs), Maternal and Child Health Centres (MCHCs) and Civil
Dispensaries. The MCHCs and Civil Dispensaries are often located in urban and
large rural areas.
Secondary Health Care – refers to the medical care that is provided by a specialist or
facility upon referral from primary care and that requires more specialized knowledge, skill,
or equipment than the primary care professional can provide. The Secondary level health
facilities in Pakistan include Tehsil Headquarter Hospital (THQH) and District Headquarter
Hospital (DHQH). The services provided at the health facilities are primarily curative in
nature.
The Primary and Secondary Health Care constitutes the District Health Service system.
Tertiary Health care – refers to state of the art specialised consultative health care that
involves all specialties and sub-specialties supported by availability of required
infrastructure, human resource, supplies, medicines and equipment including Hi-tech
medical equipment. These tertiary care hospitals are generally located in the provincial
capital and ideally expected to receive patients from secondary care hospitals situated in
the districts. With few exceptions, these are also affiliated with the medical teaching
institutions for graduates and post-graduates.
3
Declaration of Alma-Ata, September, 1978. Retrieved from
http://www.who.int/publications/almaata_declaration_en.pdf on 18
th
July, 2016

25
Figure 1: Overview of the health service delivery in Pakistan
1.3 Experiences of developing and implementing HSD Packages
1.3.1 International experience
There is a wealth of experiences with regards to developing and implementing health
services delivery packages in developing countries. The experience of Liberia informs us
that it started from a Basic Package of Health Services (BPHS) for primary and secondary
care and after implementing the basic package for almost four years with considerable
success moved on to develop an Essential Package of Health Services for secondary and
tertiary care with a more comprehensive set of services. The BPHS for Liberia was
developed and made operational in 2007 as a cornerstone of countries National Health
Policy and Plan. The BPHS established basic preventive and curative services needed to
improve access and health care. After being in place for almost four years i.e. by 2011,
BPHS implementation demonstrated significant successes. For the first time in many years,
Liberia’s clinics, health centers and hospitals were given a set of standard services that they
were expected to provide. There has been progressive improvement in coverage of the
BPHS each passing year. In 2009, approximately 35% of Liberia’s government health
facilities were implementing the BPHS, which improved to 80% in 2010, and in 2011, this
number again increased to 84%. The country saw considerable improvement in
standardized medical services, health human resource development and supply chain
management systems to ensure the acceleration of health care for all in Liberia. Liberia
developed its ten-year National Health and Social Welfare Policy and Plan (NHSWPP,
2011–2021) and considered it critical to not only expand the services available to all
Liberians but also continue to improve and standardize health care delivery systems in order
to ensure quality health care for all Liberians. This led to the development of Essential
Package of Health Services (EPHS) for secondary and tertiary care, to serve as a
cornerstone of the new National Health and Social Welfare Policy and Plan, building upon
the successes of the BPHS implementation. The vision behind developing secondary and
tertiary care package was to improve referral networks and raise the availability of services
and quality of care at all Health Centers and Hospitals. The EPHS for secondary and tertiary
care provided a more comprehensive set of services to strengthen key areas that were
performing poorly and added new services necessary to address needs at all levels of the

26
health care system. The EPHS was introduced in two phases; first phase that covered the
period 2011-2013, after which a review and modification was to be done on the basis of the
progress made4
.
The case of Nepal shows similarities with Liberia to the approach in standardising the
package of health care services i.e. to start small and then grow. The first EPHS was
published in 1999 by the government of Nepal, called the “Essential Health Care Services
package,” as part of the Second-Long Term Health Plan, which included 20 broad health
areas. The government’s Health Sector Strategy (2004) acknowledged that the original
EPHS was not affordable for the government to provide, given the available resources and
proposed to focus on delivering four main areas of essential care across all districts: safe
motherhood and family planning, child health, control of communicable disease, and
strengthened outpatient care. The Nepal Health Sector Programme Implementation Plan
2010–2015 updated and expanded the EPHS to include new services under the
reproductive health and child health areas, and new programs on mental health, oral health,
environmental health, and community-based new-born care, and a community-based
nutrition care and support program. In addition, the update adds a non-communicable
disease control component to address changes in demographics and diseases5
.
The EPHS developed for Somalia envisage to implement the package in a phased manner
(two phases). The EPHS has set distinct criteria for phase 1 and phase 2 that covers all tiers
of health service delivery and not only provides the list of services and associated required
inputs at each tier but also sets bare minimum operational standards for the services
proposed. The facilities who attain the criteria set for phase 1 after evaluation shall be
entitled to move to phase 2. The package for Somalia is similar to aforementioned country
examples in that it adopts a phased approach but different with regards to inclusion of
standards for the services that are proposed at level/tier of care6
.
The country examples presented above put forth following key aspects of Minimum Health
Services Package
• The health services package follows the principal of starting small and then growing
up. The packages developed in all three countries started with minimum/essential
package of health services and after its implementation, proceed towards
enhancement/addition of services to the package.
• The packages do take into account the cost associated with the proposed package.
• The packages developed envisage to integrate the primary and secondary levels of
care, rather than seeing the package in isolation for each level of care.
• The packages prioritise the selection of services based on population needs and
epidemiological trends.
4
Essential Package of Health Services (EPHS). Secondary & Tertiary Care: The District, County &
National Health Systems - Liberia, 2011
5
Wright, J., Health Finance & Governance Project. July 2015. Essential Package of Health Services
Country Snapshot: Nepal. Bethesda, MD: Health Finance & Governance Project, Abt Associates Inc.
6
Essential Package of Health Services (EPHS), Somalia, 2009

27
1.3.2 National experience
The experience with regards to standardisation of care at various levels/tiers of care vary
across provinces. The Govt. of Punjab has developed the Essential Package of Health
Services (EPHS) for primary as well as the secondary care. In 2012, the Punjab Health Care
Commission (PHC) developed Minimum Service Delivery Standards (MSDS) for the
secondary care hospitals while the Policy and Strategic Planning Unit (PSPU, Govt. of
Punjab) with support from TRF developed the Minimum Service Delivery Standards (MSDS)
for primary health care. The Minimum Service Delivery Standards provided the protocols for
ensuring qualitative aspects of the health services that were enlisted in the Essential
Package of Health Services (EPHS). The Punjab Devolved Social Services Programme
(PDSSP) also developed the Minimum Service Delivery Standards for Primary and
Secondary Health Care for Primary Health Care.
The Essential Package of Health Services for secondary care hospitals in Punjab (EPHS-
SC, Punjab) sets out the list of services that should be provided at the secondary care
hospitals. The EPHS-SC, Punjab also provides the detail of infrastructure, human resource,
medicines, supplies, and equipment requirements to provide the enlisted services. The
EPHS-SC Punjab provides the list of services and the associated requirements for DHQH
and THQH. It does not provide the list of services and other requirements by the categories
of DHQHs (Category A, B, and C) and THQHs (Category A, B and C). The development of
the EPHS-SC, Punjab involved review of the relevant literature, government documents, as
well as inputs from all the key stakeholders in the government, and a comprehensive
consultative process with the technical committee notified by the Govt. of Punjab7
.
2 Background to MHSD Package in KP
2.1 Current status of health and HSD in KP
Pakistan is the sixth most populous country in the world, with a population of around 184
million8
. The population of Khyber Pakhtunkhwa has increased from 17.7 million in 1998 to
27.9 million in 2014, of which a vast majority (77%) lives in urban areas 9
. Khyber
Pakhtunkhwa has 25 districts with a total area of 74,521 km2
and constitute about 9% of the
total area and 15% of the total population of Pakistan. In addition, it is estimated that there
are more than 1.8 million Afghan refugees living in the province. The average household
size in Khyber Pakhtunkhwa is 7.2 people, second highest in Pakistan after Baluchistan
(7.90 people)10
. High population growth rate, Afghan refugees, Internally Displaced Persons
(IDPs) and volatile security situation are some of the key challenges that the government of
Khyber Pakhtunkhwa is facing.
Khyber Pakhtunkhwa has the lowest infant and under 5 mortality (58 & 70 per 1000 live
births, respectively) compared to other provinces in Pakistan (Figure 2). However, there is
7
Essential Package of Health Services for Secondary Care, Punjab, 2014
8
National Institute of Population Studies. Accessed from http://www.nips.org.pk/Home.htm, on 19
th
July, 2016
9
Bureau of Statistics, Khyber Pakhtunkhwa. Retrieved from
http://kpbos.gov.pk/prd_images/1399372174.pdf on 19
th
July, 2016
10
Household integrated economic survey (HIES), 2013-14. Retrieved from
http://www.pbs.gov.pk/content/household-integrated-economic-survey-hies-2013-14 on 19
th
July,
2016

28
an urban rural disparity in these mortality rates with urban areas faring well (Infant mortality=
53/1000 live births, Under-5 mortality = 58/1000 live births,) compared to rural areas (Infant
mortality=53/1000 live births, Under 5 mortality=72/1000 live births)11
.
Figure 2: Provincial comparison of Infant and Under 5 mortality rates (Source: PDHS 2012-13)
With regards to the type of illnesses that are being reported by the public sector health
facilities through the DHIS system (Jan-June 2016), indicate that the most commonly
reported illnesses are Acute Respiratory Infection (49%) followed by Dysentery in less than
five-year-old (15%), Fever due to other causes (15%), Dysentery in more than five years old
(11%) and Urinary Tract Infection (10%) (Figure 3). A similar pattern of illnesses was
observed in the calendar year 201512
.
Figure 3: Percentage distribution of top five illnesses reported by Public sector health facilities in KP
Jan-June, 2016 (Source: DHIS, KP)
With regards to access to health services, three fifth (60%) of the women in Khyber
Pakhtunkhwa had an antenatal check from a skilled provider. Other provinces fared well in
11
Pakistan Demographic and Health Survey (PDHS), 2012-13
12
District Health Information System (DHIS), Khyber Pakhtunkhwa
PUNJAB
SINDH
KPK
BALOCHISTAN
PUNJAB
SINDH
KPK
BALOCHISTAN
INFANT
MORTALITY
UNDER-FIVE
MORTALITY
88
74
58
97
105
93
70
111
INFANT AND UNDER 5 MORTALITY
(PER 1000 LIVE BIRTHS)
[CATEGORY
NAME]
[PERCENTAGE]
[CATEGORY
NAME]
[PERCENTAGE]
Dysentery in
less than five
years old
[PERCENTAGE]
Dysentery in
more than five
years old
[PERCENTAGE]
[CATEGORY
NAME]
[PERCENTAGE]
Percentage distribuXon of top five diseases, 2016, KP

29
this regard, except Baluchistan where nearly one third (31%) of the women had their
antenatal check-up from a skilled health care provider (Figure 4). More than half of the
women (56%) had their last birth protected against neonatal tetanus with urban areas
performing better (66%) compared to rural areas (54%)13
.
Figure 4: Percentage of women receiving antenatal care from a skilled provider (Source: PDHS 2012-13)
With regards to the place of deliveries, nearly three fifth of the deliveries (60%) in KP are
being conducted at home. The deliveries at home show a stark difference between urban
and rural areas, with rural areas having twice the proportion (64%) of deliveries at home
compared to urban areas (37%). There is also a considerable difference in utilisation of the
public sector health facilities for delivering a child in urban (23%) and rural (15%) areas
(Figure 5)13
.
Figure 5: Place of delivery by Urban and Rural areas, KP (Source: PDHS 2012-13)
The public sector health service delivery in KP is through a three-tiered system involving
primary, secondary and tertiary health care. The primary health care primarily focusses on
the provision of preventive and promotive health care while the secondary and tertiary health
13
Pakistan Demographic and Health Survey (PDHS), 2012-13
87
92
85
53
74
68
56
25
78 78
61
31
0
20
40
60
80
100
Punjab Sindh KPK Balochistan
Antenatal care from a skilled provider
Urban Rural Total
[VALUE] 40
23
64
21
15
0
10
20
30
40
50
60
70
80
90
100
Home Private
sector
Health
Facility
Public
sector
Health
Facility
Home Private
sector
Health
Facility
Public
sector
Health
Facility
Urban Rural
%
Place of Delivery by Urban and Rural areas

30
care primarily provide curative health services. The health facilities operating in the province
are provided in the Table 1.
Table 1: Health Facilities by types in Khyber Pakhtunkhwa (Source: DHIS cell)
S.No Type Number
1. Teaching/Tertiary Hospitals 9
2. Category A Hospitals 8
3. Category B Hospitals 18
4. Category C Hospitals 19
5. Category D Hospitals 56
6. Civil Hospitals 10
7. Women and Children Hospitals 6
8. Police Hospitals 4
9. Jail Hospitals 4
10. Basic Health Units 771
11. Civil Dispensaries 447
12. Rural Health Centers 92
13. Sub Health Facilities 23
14. Mother Child Health Centers 56
15. Leprosy Clinics 24
16. TB Centers 35
17 Other Health Facilities 12
Total 1594
2.2 Categorisation of Secondary Care Hospitals in KP
The secondary level of care as provided in Khyber Pakhtunkhwa has been categorized/
standardized in to four categories of hospitals (Category A, B, C and D) according to the bed
size, the catchment population and of course needs and demands of the local population. All
the four categories of hospitals have both in-patient and outpatient services, in addition to
emergency, diagnostic and other day care facilities. The table below provides the
recommended availability of the clinical specialities across the four categories of secondary
care hospitals. The details about each category can be found in 13.613.2.

31
Table 2: Speciality wise status across categories of secondary care hospitals in KP
CATEGORY A CATEGORY B CATEGORY C CATEGORY D
SURGERY
MEDICINE
GYNAE/OBS
PAEDIATRICS
DENTISTRY UNIT
EYE
ENT
ORTHOPAEDICS
CARDIOLOGY
PSYCHIATRY
CHEST/TB
DIALYSIS UNIT
DERMATOLOGY
PAEDS SURGERY
NEUROSURGERY
SPECIALTIES
CATEGORY A
CATEGORY
B
CATEGORY
C
CATEGORY D
1 Casualty
2 Labor Room
3 ICU/CCU
4 Nursery Peads/ICU
The number of Category A, B, C and D hospitals across districts in the province of Khyber
Pakhtunkhwa are provided in the table below

32
Table 3: District Wise Approved Categorization of Hospitals
S. No
Name of
District
Category-A Category-B Category-C Category-D
1 D.I Khan 1 1 0 3
2 Tank 0 1 0 1
3 Lakki Marwat 0 1 1 2
4 Bannu 1 1 0 2
5 Karak 0 1 1 3
6 Kohat 1 0 0 1
7 Hungu 0 0 1 2
8 Peshawer 0 0 1 3
9 Nawshera 1 0 0 3
10 Charsadda 0 1 1 1
11 Mardan 1 1 1 5
12 Sawabi 0 1 3 2
13 Malakand 0 1 1 3
14 Lower Dir 0 1 2 4
15 Upper Dir 0 1 0 3
16 Swat 1 0 2 4
17 Bunair 0 1 0 1
18 Batagram 0 1 0 1
19 Kohistan 0 1 0 1
20 Abbot abad 1 1 0 3
21 Chitral 0 1 1 1
22 Haripur 0 1 1 4
23 Shangla 0 1 1 2
24 Mansehra 1 0 2 1
25 Torghar* 0 0 0 0
Total 8 18 19 56
*District Torghar was not included in the approved policy

33
2.3 Improving HSD and quality in KP: achievement & work in progress
The initiatives that had been undertaken by the government of KP in improving the quality of
Health Service Delivery (HSD) with regards to policy reforms/legislation, health services
regulation and standardizing the provision of services are provided below.
2.3.1 Acts related to health service delivery
2.3.1.1 Private Medical Institutions (Regulation of Services) Ordinance, 1984
The Private Medical Institutions (Regulation of Services) Ordinance, 1984, under which the
rules for the registration of the private health care establishments were developed. However,
no dedicated body was constituted to carry out the functions of regulation of health services
in private sector resulting in non-implementation of the ordinance in practice.
2.3.1.2 Medical and Health Institutions Reforms Act, 1999
The Medical and Health Institutions Reforms Ordinance, 1999, which was passed by the
provincial assembly and turned into Medical and Health Institutions Reforms Act, 1999.
Through the Act of 1999 definitions of ‘health institution’ and ‘medical institution’ were given.
A health institution was defined as an institution in public sector or directly under
government, delivering health care services to public at large without having teaching
arrangements. Similarly, a medical institution was defined as an institution in public sector or
directly under government having teaching arrangement in addition to the delivery of health
care services to public at large.
2.3.1.3 Medical and Health Institutions and Regulation of Health Care Services Ordinance,
2002
In 2002, Medical and Health Institutions and Regulation of Health Care Services Ordinance
was introduced. Through that ordinance, the Act of 1999 and the Medical Institutions
(Regulation of Services) Ordinance, 1984 were repealed. The said ordinance was a
comprehensive law regulating affairs of teaching/medical institutions, and health institutions
defined as a hospital, nursing home or maternity home, clinic, including medical, dental and
X-ray clinics, clinical laboratory and a blood bank, delivering health care services to the
public or private sector. The ordinance provided for establishment of a management council
for the teaching/medical institution, whereas there was a management committee for the
public health institution. Under the law, the government had to appoint chief executive for a
teaching/medical institution, whereas a medical superintendent was appointed for each of
the hospitals. The ‘institution-based practice’ was also introduced by the ordinance under
which the doctors serving in public health institutions were asked to practice in the institution
to which they belonged. The Ordinance also provided for the establishment of Health
Regulatory Authority having functions, including registration of private health institutions,
monitoring institutional private practice, setting standard for the practice of medical, dentistry,
nursing and paramedical profession and dealing with malpractice or violation of standards in
the private sector, etc.
Recently, the Ordinance of 2002 and its amendments in 2006 and 2010 were repealed and
instead two laws were introduced, the MTI (Medical Teaching Institutions) law and KP Health

34
Care Commission Act 2015. The latter law led to constitution of KP Health Care Commission
while the former sets out the governing laws for the medical teaching institutions in the
province such as Lady Reading Hospital (LRH), Khyber Teaching Hospital (KTH),
Hayatabad Medical Complex (HMC) and Ayub Teaching Hospital.
2.3.2 Health Care Commission
Khyber Pakhtunkhwa Health Care Commission (KPHCC) is a statutory body constituted
under Khyber Pakhtunkhwa Care Commission Act 2015 to regulate both public and private
Health Care Establishments (HCEs) in Khyber Pakhtunkhwa. The commission as laid down
in the Act and the regulations will comprise of a body of commissioners which includes ten
members, and a provincial/regional/ district setup responsible for the execution and
implementation of the vision, policies and guidelines of the commission under the overall
responsibility of Chief Executive. To carry out the regulatory function, KP Health Care
Commission is in process of establishing following sections under the oversight of the
members of the commission
a) Directorate of Registration and Licensing for registration, licensing, renewal,
cancellation and suspension of registration/license of healthcare establishments. To
carry out the tasks which ensure the healthcare services are rendered in
accordance with the provisions of the Act, Rules and Standards/Reference manuals
of the KPHCC. At the moment, the KPHCC is using a minimum standards checklist
developed for clinics and hospitals for the purpose of assessment of healthcare
establishments for decision on whether to issue them license or not.
b) Directorate of Complaints Management and Patients’ Rights for receiving,
managing and resolving complaints.
c) Sections for business support functions including Finance section led by Chief
Financial Officer for maintaining the books of accounts of the Commission; Human
Resource section; IT section.
2.3.3 Standards for secondary care
The Health Regulatory Authority developed the Standards for Quality Health Services in KP
(at that time NWFP) in 2007 for the primary and secondary care. The secondary care
standards set out the quality protocols for following aspects of health service provision at
secondary care level
• Quality protocols for management of the hospital including protocols for general
management, risk and quality management, financial management and human
resource management
• Standards for Client/Patient’s Rights
• Standards for access to health services, continuity of care, patient assessment,
patient care plans, treatment, documentation of care, patient discharge, transfer and
referral
• Standards for key departments/services including Operation Theatre department,
Casualty department, and Intensive Care Unit; resuscitation services, maternity
services and auxiliary services (Laboratory, Pharmacy and Radiology services)

35
• Standards for Infection Control, Hygiene and Waste Management
2.4 Government of KP strategic vision and challenges for improving
health status
After devolution, Khyber Pakhtunkhwa was the first province to develop a Health Sector
Strategy 2010-2017, entailing a responsive health system to improve the health status of the
population based on prioritised outcomes. The health sector strategy is based on the
strategic directions and priorities of the Comprehensive Development Strategy, Khyber
Pakhtunkhwa (CDC, KP 2010-17). The five key priority areas as identified by the health
sector strategy are
• Enhance coverage/ access to essential health services
• Reduction in morbidity and mortality
• Improve human resource management
• Improve governance and accountability
• Improve regulation and quality assurance
The health sector strategy refers to poverty, inequality, insufficient access to health care
services, the impact of conflict and natural disasters on the access to health services, as key
challenges to overcome. Households out of pocket expenditure is a main source of financing
for health care in Khyber Pakhtunkhwa (61%)14
. A high out of pocket expenditure on health
can be catastrophic for the households living in poverty or below poverty line. In Khyber
Pakhtunkhwa, more than three fifth (61%) of the health services are being accessed from
the private sector15
. The health facility assessment conducted in Khyber Pakhtunkhwa in
2012 indicated that the major issues faced by the facilities were mainly due to the lack of
MNCH-related staff at the facilities such as WMOs at RHCs and specialists (including
gynaecologist, anaesthetist and paediatrician) at DHQ and THQ hospitals. Infrastructure
components required for paediatric care were deficient at most of the THQ hospitals. Major
gaps were also revealed in the availability of required medicines, equipment and supplies16
.
Shortage of staff and partial availability of essential medicines, equipment and supplies
contribute to underutilisation of the public sector health facilities.
Govt. of Khyber Pakhtunkhwa has undertaken a number of initiatives to ensure progress on
the key priority areas identified in the health sector strategy. As a measure to improve the
quality of care and standardisation of the health care services, Minimum Health Services
Delivery Package (MHSDP) for primary health care and the Minimum Health Service
Delivery Standards (MSDS) for primary and secondary care have been developed. For the
purpose of regulation and quality improvement of the health care establishments in the
public and private sector, Health Care Commission was constituted in 2015 and is in
progress towards strengthening of the commission’s institutional structure to implement its
mandate.
The secondary level of health care serves as a central pivot between primary and tertiary
care in the health service delivery system. The health sector strategy for KP, explicitly refers
14
National Health Accounts for Pakistan, 2011-12, Pakistan Bureau of Statistics
15
Pakistan Standard of Living Measurement (PSLM), 2014-15, Pakistan Bureau of Statistics
16
Health Facility Assessment, Khyber Pakhtunkhwa, June 2012

36
to development and implementation of the Minimum Health Service Delivery Package for
secondary health care (MHSDP-SC) with following key considerations/actions17
• The MHSDP-SC should be developed for secondary health care along with costing of
the services and should include necessary staffing levels/skills mix, equipment and
supplies
• Re-designate secondary care facilities in light of MHSDP-SC
• Upgrade health facilities on the basis of the need and according to criteria
established by the DoH, which may include a new design for health facilities
depending upon the services included in the MHSDP SC and quality standards.
• Outline pathways for referral and use of information communication technology to
improve linkages with primary and tertiary health care
• The MHSDP-SC should include dental care, psychiatric services, treatment and
management of non-communicable diseases and rehabilitative services
• Define the management structure and expertise required to ensure provision of high
quality health services outlined in the package at the DHQH and THQH
• Pilot tele-health to support the provision of specialised care to the poor in the remote
areas of the province
• Explore other options to improve health service delivery at secondary level such as
district hospital autonomy and contracting out of hospitals.
3 Objectives, processes followed and Final
outcome
The Department of Health in Khyber Pakhtunkhwa (KP), in collaboration with Technical
Resource Facility (TRF) has developed Minimum Health Service Delivery Package for
Primary health care which is being implemented. Similarly, Minimum Service Delivery
Quality Standards (MSDS) for primary and secondary level of health care have also been
developed by Health Department KP and are under implementation now. The Government
of KP requested Technical Resource Facility Plus (TRF+) for assistance in the development
of Secondary level MHSDP to promote standardization and delivery of equitable health
services, by defining the minimum package of health services for secondary health care
levels, which includes the categorized services i.e. A, B, C and D as explained earlier. It can
also serve as a management tool to guide resource allocation, which responds to local
priorities and needs. The detailed objectives and ToRs are shared in 13.3.
3.1 MHSDP-for secondary care, but focusing on “Categories of
hospitals” in districts
The ToRs for this assignment were carefully designed taking into account all the needs and
requirements for developing the MHSDP for secondary level care facilities. The thinking
behind had been the previous experience by TRF+ for conducting the same exercise for
Department of Health (DoH), Government of Punjab. However, the dynamics and
administrative set up for secondary level services delivery is totally different as compared to
17
Health Sector Strategy, Khyber Pakhtunkhwa, 2010-17

37
that of Punjab. The DoH has undertaken a thorough exercise on standardizing/categorizing
the various secondary level care facilities by applying various criteria (as mentioned above)
so that the services and its various requirements in terms of human resource, equipment,
infrastructure and medicines can be made available to the population. The categorization of
secondary level care facilities necessitated that the four level of packages and its minimum
requirements are identified and documented.
4 Process followed for developing MHSDP for
secondary care facilities
4.1 Participatory consultation
The process for developing the MHSDP had to be participatory and consultative process
with all the stakeholders, as at the end of the day, these stakeholders either have to execute
orimplement, monitor and finance the whole process. This would thus necessitate close
coordination and cooperation among each other. The list of experts/stakeholders that were
met during the course of MHSDP development are provided in 13.4.
4.2 Defining roles & responsibilities of various key stakeholders
This consultative process thus necessitated that roles and responsibilities are defined,
though there were some overlapping areas among the stakeholders.
Three sub-committees were notified by the HSRU, the focal Unit for developing this
package. These were
• The Technical/Clinical sub-Committee
• The administrative/management sub-Committee and
• The preventive care sub-Committee.
Following roles and responsibilities of each of the committees guided the consultative
process:
4.2.1 The Technical/Clinical sub-Committee
This Sub-Committee was to estimate the various MHSDP disease incidence rates and facility
utilization rates for identifying clinical needs. This sub-Committee was made up of seven
officials - experienced clinicians and doctors, who had wide experience of working at all
levels of health care in the Province. The composition and roles and responsibilities of the
Technical/Clinical sub-Committee is provided in the 13.5.
4.2.2 The administrative/management sub-Committee
This sub-committee had the purpose of defining the human resources needs for
implementing the MHSDP at the various levels of health facilities in terms of providing the
basic care in addition to the clinical care according to various specialties in various
categories of the hospital; this among others included, patients’ rights, infection control,
waste management and coordination among various specialties. This sub-committee also
identified the infra-structure requirements for providing the various specialists’ care. The

38
composition and roles and responsibilities of the administrative/management sub-
Committee are provided in the 13.5.
4.2.3 The Preventive Care sub-Committee.
As discussed earlier, the role of preventive and promotive care at the secondary level care
facilities cannot be underscored. The facilities are being utilized for not only basic primary
and preventive care but also to provide outreach care and link with various primary care
programmes. The composition and roles and responsibilities of the Preventive Care Sub-
Committee are provided in the 13.5.
Following is a diagrammatic illustration of the processes followed.
• IniXal MeeXng with Key Stakeholders
• Discussion on the preferred process/methodology of MHSDP-SC development
• Acquired the relevant documents for review
• IncepXon Report and SituaXonal Analysis Report
• Outline of the service package manual, methodology and Dmelines. Based on the
meeDngs with key stakeholders and review of documents an overall situaDonal analysis
report was prepared
• Development of outline of package
•  Prior to the iniDaDon of the consultaDve process an outline of the package including
the services (CuraDve and PrevenDve), Human Resource, Equipment, and infrastructure
requirements was developed to sought the inputs of the assignment commiKees
• ConsultaXve MeeXngs with the MHSDP-SC Commibees
• MHSDP-SC CommiKee meeDngs (Clinical, PrevenDve and AdministraDve sub-commiKee
meeDngs) were conducted to discuss the overall approach, methodology and the details
of the service package manual
• Development of the zero drad MHSDP-SC
• Zero draN was prepared based on the review of the relevant documents and the
consultaDons with the key stakeholders including the three commiKees
• Final reivew under chair of secretary and approval of drad report
• Revision and ﬁnalisaXon of the drad approved report
• Revision and sharing of the ﬁnal report as per the feedback recieved from the key
stakeholders including the three commiKees
Figure 6: Process of MHSDP SC –KP development

39
4.3 The final outcome
The Secondary Health Services Package as shared in the following chapters is thus
developed according to all the 4 categories of hospitals (Category A, B, C and D). It has
been tried to make it as simple and practical as possible. The basis for defining the
minimum services for each of the category is shared in 13.613.6 which explains how the
various categories when once fully furnished and operational should be working in
harmonization with each other and ensure a good referral system. However, the department
feels that till the time all the categories of hospitals are furnished and fully functional, some
internal arrangments of ‘hub-model’ may be considered; “In cases where Category D
hospital doesl not have a theatre, two or three category D hospitals may all be grouped with
a category B/C hospital. This may be based onon one of the models from Saidu group of
hospitals which hasshared administrative set up. It will be more cost effective, for the time-
being. Surgeons/gynaecologists may also share the theatre/diagnostic facilities at category
B hospital as and when needed.”
As regards various other services which are part and parcel of MHSDP will be mainly
dependent on the human and other resources allocations, based on the standards already
defined. Thus, all of them have been combined rather than duplicating it again and again for
each of the services. It should also be noted that the MHSDP will be a living document and
should be improved after undertaking a formal assessment of the progress. In addition, the
optimal functioning of each of the categories of hospitals can be ensured by developing and
implementing a practically applicable referral system.
5 MHSDP for Category “A” Secondary Care hospital
5.1 Clinical and Supportive Services
The Category A secondary care hospitals in KP has 350 inpatient beds, 6 Dialysis Units, 6
Dentistry Units and is intended to serve a population of around one million people. The
category A secondary care hospitals have both in-patient and outpatient services, in addition
to emergency, diagnostic and other day care facilities. The clinical specialities that are
recommended to be available at a category A hospital include Surgery, Medicine,
Gynae/Obs, Paediatrics, Eye, ENT, Orthopaedics, Cardiology, Psychiatry, Chest/Tb, Dialysis
Unit, Dentistry Unit, Paediatric Surgery, Neurosurgery, Dermatology, Accident and
Emergency, Intensive Care Unit and a Paeds Nursery/ICU. The table below provide the
services that are to be provided by the Category A hospitals based on the available clinical
specialities and support services. However, it should be noted that the Clinical Sub-
Committee did not recommend any services for the “Paediatric Surgery and Neurosurgery”.
In addition, it was also noted by the Consultant Team that there will be a definite need of
either a Unit (to start with) or a Department to ensure smooth running of Category A
hospitals. These have been highlighted in the Table below.

40
Table 4: MHSDP-SC FOR CATEGORY A SECONDARY CARE HOSPITALS
S.No Services Department Remarks
Clinical Services
1.
General Medical (Outpatients, In-
patient, Emergency)
Infection:
All uncomplicated bacterial, viral,
fungal and protozoal infections.
Medical Department
GI disorders:
Amoebiasis, Gastroenteritis,
Diarrhea(chronic), Gastritis, Irritable
bowel syndrome, Peptic ulcer
disease, Helminthic infection, GI tract
bleeding
Medical Department
A specialist post for
Gastroenterologist has
been proposed; some
sections of Medical
Department may be
allocated for this
specialist, also
Other Medical conditions
Thyroid dysfunctions, Diabetes
mellitus & other endocrine associated
conditions, Liver cirrhosis & other liver
conditions (abscess, cyst, etc.),
Cerebral palsy, Herpes Zoster
Hepatosplenomegaly, Stroke,
Ischaemic heart disease, Seizure
disorders, Coma
Medical Department
2. Respiratory Problems
Upper and Lower Respiratory Tract
infections, Pneumonia, Chronic
Obstructive Pulmonary Disease
(COPD), Tuberculosis, Asthma,
Allergies, Chronic Bronchitis,
Emphysema, Acute Bronchitis, Cystic
Fibrosis
Chest/TB Department
3. Renal disorders
Acute glomerulonephritis, Acute renal
failure, Hypo/hyperkalemia, Nephrotic
syndrome, Chronic renal failure,
Dialysis Unit
The Nephrologist at the
Dialysis Unit should
manage the patients
4.
General Paediatric (Outpatients, In-
patient, Emergency)
fungal and protozoal infections;
Neonatal care, Neonatal resuscitation;
During delivery: ENC including clean
airway, clean clamp and cord cutting,
weighing baby, avoid hypothermia
and ensure exclusive breast feeding
including colostrum; Identify and
Manage neonatal jaundice and
infections, Phototherapy, Birth
injuries, Incubation, Immunization (all
births in the hospital and all children
<5 visiting hospital to be actively
screened for immunization status),
Infants of diabetic mothers, Asthma
(chronic)
Pediatrics Department

41
Diarrhea (chronic), Failure to thrive
Growth retardation, Malnutrition—
severe or moderate, acute/chronic,
micronutrient deficiency (Vitamin
A/C/D deficiencies, anemia, iodine
deficiency), Manage Neonatal
complications, Congenital anomalies,
Bilirubin encephalopathy (kernicterus),
Thalassemia
Well-baby clinic to be established in
the OPD and to have minimally the
following services available:
EPI plus services, CDD/ARI control
activities, Nutrition counseling, Breast
feeding counseling and support,
Malaria and Dengue control activities,
Growth monitoring and counseling,
Deworming (provision of anti-
helminthic)
Paediatric Outpatient
Department
5.
General Cardiology (Outpatients,
In-patient, Emergency)
Congenital heart disease, Deep-vein
thrombosis, Heart failure,
Hypertension, Pulmonary oedema,
Rheumatic heart disease
Cardiology Department
Myocardial infarction, Ischemic heart
disease
Initial Management and
workup, referral in case of
need for Angiography and
Angioplasty
6.
General Dermatology(Outpatients,
In-patient)
Dermatological therapeutic services
including Moles, acne, hives,
chickenpox, eczema, rosacea,
seborrheic dermatitis, contact
dermatitis, keratosis pilaris, psoriasis,
vitiligo, impetigo, warts, childhood skin
conditions including diaper rash,
seborrheic dermatitis, chickenpox,
measles, fifth disease, hives,
ringworm, rashes from bacterial or
fungal infections, rashes from allergic
reactions; Common skin conditions
caused by pregnancy including stretch
marks, melasma, pemphigoid, pruritic
urticarial papules and plaques,
dermatitis.
Basic Dermatological Diagnostic
services
Dermatology
Department
In case of non-availability
of Dermatologist, Medical
specialist shall be
responsible
Skin Cancer
Dermatology
Department
Initial assessment by
Dertmatologist and
Referral to a Tertiary care
facility
7.
General Psychiatry (Outpatients, In-
patient, Emergency)
of Psychiatrist or clinical

42
staff member from
Psychiatry department,
Medical specialist shall be
responsible
Acute confusion (Acute psychosis),
Depression; Anxiety and stress-
related disorders; Sleep disorders;
Mania, Schizophrenia, Suicidal
ideation, Substance abuse and
dependency, Post-traumatic stress
problems; IQ/Personality assessment
Psychiatry Department
8.
General surgery (Outpatients, In-
patient, Emergency)
Elective Surgery
Thyroidectomy, Mastectomy, Biliary
tract operations, Colon operations,
Proctological operations (perianal
abscess), Hernioraphy, Rectal
prolapse, Superficial abscesses,
Cysts, Cavity abscesses,
Circumcision
Vasectomy, Venous cut down,
Excision of sebaceous cyst, Wedge
resection of IGTN, Excision of
Lipoma, Lymph node Biopsy, Chest
Intubation, Supra pubic
catheterization ( via suprapubic
cystostomy kit), Supra pubic
catheterization (open Technique),
Trucut Biopsy, FNAC D/D
Dressings, Skin lesion Biopsy,
Cauterization of viral warts,
Sigmoidoscopy, Urethral dilatation, DJ
Stent Removal, Lord’s Dilatation, T.
Stich, Polypectomy, Examination
Under Anesthesia (EUA), Excision of
Fibro adenoma Breast, I/D of Breast
Abscess, I/D & D/D under G/A,
Feeding Jejunostomy, Colostomy, DJ
Stenting, Open Appendicectomy,
Haemorrhoidectomy, Lateral Internal
Sphincterotomy, Herniotomy,
Hydrocele surgery, Varicocele
surgery, Undescended Testes (UDT),
Simple Mastectomy, Wide Local
Excision
Varicose Veins Surgery, Perianal
Abscess/ Fistula (Low), Peri Anal
Fistula High/complex, Mesh repair of
inguinal /Ventral Hernias/ Incisional
Hernia, Open Cholecystectomy,
Gastrojejunostomy, Ureterolithotomy,
Vesicolithotomy, Excision of pilonidal
Sinus, Ileostomy/ Colostomy
Reversal, Upper Gastrointestinal
Endoscopy (UGIE) with biopsy, Lower
Surgical Department

43
Gastrointestinal Endoscopy (LGIE)
Colonoscopy with biopsy, Hiatus
hernia, Crohn's disease
9.
Mortuary (Medicolegal)
Surgical Department
Preferably shall be
responsibility of Forensic
Department of Medical
College in the district, If
available
Routine medico-legal,
Specialized medico-legal including re-
examination,
10. A&E Services
The Casualty Medical
Officer (CMO) should
have capacity building in
A&E services. For future
planning, the A&E
department would be
upgraded with a specialist
having post-graduation in
either Trauma or A&E
services. This would
require establishing the
A&E speciality training in
the province
All medical emergencies including
animal/snake bite
Accident and
Emergency
Department
Management by specialist
on-call from relevant
department. For cases
requiring referral, basic
life support and
emergency treatment will
be given
Abdominal trauma (minor), Acute
appendicitis, Perforated peptic ulcer,
Intestinal obstruction, Diverticulitis,
Inflammatory bowel disease,
Mesenteric adenitis, Cholecystitis,
Cholangitis, Cystitis, Urinary Tract
Infection, Ureteric colic, Acute urinary
retention, Peritonitis, Rectus sheet
haematoma, Airways and ambu-bag
breath, Cricothyroidotomy, Fluid and
electrolyte balance and blood
transfusion, Soft Tissue Injuries,
Tendon injuries, Abdominal trauma
(major), Splenic rupture,
Retroperitoneal haemorrhage,
Shock/Septicaemia
Accident and
Emergency
Department
on-call from surgical
department
Advanced acute abdominal conditions
like Vascular, Pancreatic, Urological
and requiring sub-specialised
supervision
Accident and
Emergency
Department
Assessment, Stabilization
and referral by specialist
department
Multiple Injuries
Accident and
Emergency
Department
Initial management and
stabilization along with
referral to specialized unit

44
if required by specialist
department
Pneumothorax and hemothorax –
chest intubation with observation
Accident and
Emergency
Department
Initial management by
specialist on-call from
surgical department if
required referral to
thoracic facilities
Initial Management of burns as per
rule of 9s and referral to a burn centre
in case of
1. Partial-thickness abdomen full-
thickness burns of greater than 10%
of the BSA in patients less than 10
years or over 50 years of age;
2. Partial-thickness and full-thickness
burns on greater than 20% of the BSA
in other age groups;
burns involving the face, eyes, ears,
hands, feet, genitalia, and perineum,
as well as those that involve skin
overlying major joints;
4. Full-thickness burns on greater
than 5% of the BSA in any age group;
5. Significant electrical burns,
including lightning injury (significant
volumes of tissue beneath the surface
can be injured and result in acute
renal failure and other complications);
6. Significant chemical burns;
7. Inhalation injury;
8. Burn injury in patients with pre-
existing illness that could complicate
treatment, prolong recovery, or affect
mortality;
9. Any patient with a burn injury who
has concomitant trauma poses an
increases risk of morbidity or
mortality, and may be treated initially
in a trauma center until stable before
being transferred to a burn center
Accident and
Emergency
Department
Initial Management by
surgical department and
immediate referral as per
the provided criteria
Head injury, Spinal Injuries
Accident and
Emergency
Department
on-call from Neurosurgical
department, refer if
required
Closed Fracture and Dislocation,
Closed Fracture and no dislocation,
Femur fracture, Open fractures, Pelvic
fracture without complication
Accident and
Emergency
Department
on-call from Orthopaedic
required
Major disaster plan TRIAGE and
assessment of trauma patients along
with stabilization of the patient with
referral to the sub-specialty concerned
(if required),
Accident and
Emergency
Department

45
Patient referral (using ambulance)
11.
General Ophthalmology
(Outpatients, In-patient,
Emergency)
Emergencies: Trauma (except
intraocular foreign body and orbital
fracture);
Eye Department
Referral in case of
complicated trauma
Common eye conditions; Cataract,
Glaucoma, Refraction, Diabetic eye
complications
Eye Department
12.
General ENT (Outpatients, In-
patient, Emergency)
Epistaxis, Upper respiratory tract
infections, Rhinitis, Acute & Chronic
sinusitis, Granulomatous conditions of
nose & PNS, Nasal polyp
Septal surgeries, Nasal & facial
trauma, Smell disorders, Obstructive
sleep apnoea, Oral lesions,
Pharyngeal infections, Adenoids &
Tonsils & its surgeries, Laryngeal,
infections-paediatrics & adults, Voice
disorders, Deep neck abscesses,
Thyroid masses, Acute management
of laryngo-tracheal & neck trauma,
Tracheostomy, Dysphagia, Otitis
Externa, Wax in ear, Acute otitis
media; Chronic otitis media, Balance
disorders, Otosclerosis, Otological
trauma, Common complications of
otitis media, Otitis media with effusion,
Diagnostic nasendoscopy, Stridor &
airway obstruction with facility for rigid
bronchoscopy
ENT Department
Head & Neck benign & malignant
tumours– primary & metastatic
ENT Department Screen and Refer
Foreign body in the ear/nose ENT Department Stabilise and Refer
Mastoiditis, Deafness, Deaf child
ENT Department Assessment and Referral
(if required)
13.
General Orthopaedic (Outpatients,
Closed fracture and dislocation of all
of minor joints and bones,
Supracondylar displaced fractures,
Volkmann's ischemia and
compartment syndrome, Soft tissue
injuries and crush injuries, Pelvic
fracture without complication, Hip joint
dislocation, Femur neck fracture,
Femur fracture, Knee joint dislocation,
Tibia and fibula closed fracture, Tibia
open fractures, Ankle joint dislocation
and fractures, Ankle bones open
fractures, Tarsal bones fractures and
Orthopaedic
Department

46
dislocations, Tarso-metatarsal joint
dislocation, Skin graft and tendon
injuries, Acute osteomyelitis, Pyogenic
septic arthritis
Tuberculosis of bones and joints,
Gout arthritis, Rheumatoid arthritis,
Bone Cyst, Carpal tunnel lesion, Hand
flexors and extensors injuries,
Amputation (open amputation),
Menopausal osteoporosis, Change of
dressing without anesthesia, Intra
articular injection or joint aspiration,
Injection for tendinitis, In Growing Toe
Nail (IGTN), Below knee and below
elbow POP without anesthesia,
Skeletal traction
COD under GA, TVE POP, Above
knee and above elbow POP,
Manipulation Under Anesthesia
(MUA), Closed reduction of small
joints of fingers or toes, Excision of
bursa, Application of hip spica, Open
muscle biopsy, Trucut biopsy, Closed
reduction and percutaneous fixation of
distal radius, Closed reduction of
knee/hip/below/shoulder, POP under
GA, Open Reduction Internal Fixation
(ORIF) small bones of hand & foot,
Small bone operations of hands/foot
to include, fracture
fixation/arthrodesis/osteotomes,
Forefoot amputation till midtarsal joint,
Amputation of finger or thumb
14.
General Gynae/Obs (Outpatients,
Counseling of Maternal and new-born
health issues including breast feeding,
family planning and personal hygiene
Obstetrics and
Gynaecology
Department
Antenatal care
Management of intestinal worms,
Malnutrition, Malaria, UTI &STI,
Treatment of Vit. A deficiency (if night
blindness appears in last trimester),
Rhesus (Rh) incompatibility,
Management of pre-eclampsia,
Management of, Ectopic pregnancy
Obstetrics and
Gynaecology
Department
Natal Care
Manage complicated labour,
Transfuse safe blood
(haemorrhage/blood loss), Manage
3rd degree vaginal tears,
Management of prolapsed cord,
Management of shoulder dystocia,
Manage prolonged and obstructed
labour, Caesarean section, Manage
Obstetrics and
Gynaecology
Department

47
3rd degree cervical tears
Postnatal care
Management of PPH/shock, Blood
transfusion in case of haemorrhage
Management of puerperal sepsis
(simple)
Obstetrics and
Gynaecology
Department
Gynaecological/obs; care:
Uterus fibromyoma, Infertility,
Ovarian cyst and adnexal masses
(simple), Menstrual disturbances,
Pelvic inflammatory disease (PID),
Abscesses, Prolapse and trans-
vaginal operations, Complications of
puerperium, Puerperium psychosis,
Deep vein thrombosis (DVT),
Incomplete abortion, Malnutrition—
deficiency)
Obstetrics and
Gynaecology
Department
Family Planning:
Implants, Tubal ligation,
Complications of contraceptives
Obstetrics and
Gynaecology
Department
15.
General Dental services
Emergency)
Crowning/ Dentures/ braces, Pulpitis,
Periodontitis, Pericoronitis, Gingivitis,
Cellulitis (oral), Alveolitis (dry socket),
Acute necrotizing ulcerative gingivitis,
Abscess (periapical)
Dentistry Department
A specialist post for
Dental Surgeon has been
created who will be
heading this Department
Support Services
16.
Laboratory (Outpatients, In-patient,
Emergency)
FBC, ESR, LFTs, Blood urea and
electrolytes; CSF/pleural fluid/ascitic
fluid/ pericardial aspirate microscopy;
Biochemistry, gram's and ZN stain;
HBsAg, Anti-HCV; HIV;
Toxoplasm/brucella andtibodies;
Serum amylase, CPK, Blood glucose;
ABGs; Culture and sensitivity testing;
Screening of donor, blood grouping
and cross match; Storage (Blood bank
services)
Pathology
Unit/Department
17.
Radiology (Outpatients, In-patient,
Emergency)
X-ray Chest/abdomen (erect &
Supine)/spine/hands/pelvis/joints/
Sinuses; X-ray for fracture; X-ray for
age estimation; Ultrasound
Radiology
Unit/Department

48
Chest/orbit/Abdomen/ Pelvis; CT
brain/Chest/Abdomen/ Pelvis/Spine;
Barium swallow; Intravenous
Urography (IVU)
18. Anaesthesia services:
Intubation, Manage emergencies and
cardiopulmonary resuscitation,
Manage convulsions, Cardiac life
support, General anaesthesia, Local
anaesthesia, Spinal anaesthesia,
Epidural anaesthesia
Anesthesia
Unit/Department
Services to be provided
by Anesthesiologist
Ventilation
Anesthesia
Unit/Department
Stabilization by
Anesthesiologist and
Refer
19.
Pharmacy (Outpatients, In-patient,
Emergency)
Support prescription of drugs; Manage
main drug store (Inventory/stock,
forecasting etc); Drug utilization
evaluation; Pharmacovigilance; Drug
therapeutic goods information and
poison control center
Pharmacy
Unit/Department
20. Physiotherapy services
Frozen shoulder; Backache therapy;
Post-fracture therapy; Therapy of
joints; Short wave diathermy;
Physiotherapy for chest; Mobilization
(postoperative and post stroke)
Physiotherapy
Unit/Department
21.
IT and Hospital Management
Information System
Maintenance of computers; Closed
Circuit TV; Central speaker
announcement; Health educational
corner at OPDs
Administration
Department
22.
Infection prevention & control, safe
environment, hygiene and safe
waste disposal:
Incinerator should be
available at the Facility
Ensure aseptic sterilized diagnostic &
therapeutic procedures; Notify ORs
and house staff of MRSA/VRSA and
other nosocomial infection when it
occurs; Segregation of sharp and non-
sharp medical waste and local or
contractual arrangement for its safe
disposal
Administration
Department
responsible for
implementation of the
infection control
measures
23.
Emergency Preparedness and
Disaster Management Services:
Plan available to respond to the
emergency/ disaster, Buffer supplies
to address emergencies
Administration
Department
Administration
Department to take lead
in developing a
emergency preparedness
and disaster management
plan, Liasion within the
hospital and with related
departments in the district
24. Ambulance Service: Administration Service shall be run by

49
Department 1122 for transporting
patients and shall not be
used for pick and drop
service of any kind and
transporting dead bodies
5.2 Human Resource Requirements
The human resource in Category A secondary care hospitals mainly consists of
management, clinical and support specialists, general cadre doctors, nursing and paramedic
staff and support staff. This documents provides guidance for determining number staff of
different categories required to provide indicated package of services effectively. However,
government need to develop a comprehensive policy and strategy for human resource
development and management to ensure that adequate number of providers equipped with
required knowledge and skills are available in these hospitals. The specialist staff has been
proposed based on the essential requirement to run the respective hospital as a 24/7
facilities. Proposed essential staff MHSDP-SC listed services for Category A Secondary
Care Hospitals are reflected in Tables at Appendix 13.7
5.3 Essential Equipment
Secondary hospitals deal with a wide range of acute and chronic ailments including
emergencies for which essential and quality diagnostic and care equipment are required. An
essential list of equipment and instruments in line with requirements of MHSDP-SC has
been developed for Category A hospitals. The proposed list of equipment is placed at
Appendix 13.8.
5.4 Essential Medicines
Based on the proposal of the clinical sub-committee, the MHSDP-SC for KP envisage the
approved list of Medicines, Surgical Disposables and other non- Drug Items of Government
prepared by Medicines Co-Ordination Cell (MCC), Khyber Pakhtunkhwa for the year 2015-
16 will serve as drug formulary for the district hospitals; however, the concerned hospital will
have the liberty to choose the medicines/drugs/surgical items from the MCC list to be
procured as per their needs (Appendix 13.9).
6 MHSDP for Category “B” Secondary Care hospital
The Category B secondary care hospitals in KP has 210 inpatient beds, 4 Dialysis Units, 4
Dentistry Units and is intended to serve a population of around half a million people. The
category B secondary care hospitals have both in-patient and outpatient services, in addition
to emergency, diagnostic and other day care facilities. The clinical specialities recommended
to available at a category B hospital include Surgery, Medicine, Gynae/Obs, Paediatrics,
Eye, ENT, Orthopaedics, Cardiology, Psychiatry, Chest/Tb, Dialysis Unit, Dentistry Unit,
Accident and Emergency, Intensive Care Unit and a Nursery Paeds/ICU. The table below
provide the services that are to be provided by the Category B hospitals and the guidelines
for referral (if required) based on the available clinical specialities and support services. In

50
addition, it was also noted by the Consultant Team that there will be a definite need of either
a Unit (to start with) or a Department to ensure smooth running of Category B hospitals.
These have been highlighted in the Table below.
Table 5: MHSDP-SC FOR CATEGORY B SECONDARY CARE HOSPITALS
Clinical Services
1.
patient, Emergency)
If supportive services are
not available, patient shall
be referred to designated
facility for appropriate
management
Infection:
Medical Department
GI disorders:
bowel syndrome, Peptic ulcer
disease, Helminthic infection, GI tract
bleeding,
Medical Department
mellitus & other endocrine
associated conditions, Liver cirrhosis
& other liver conditions (abscess,
cyst, etc.), Cerebral palsy, Herpes
Zoster
Hepatosplenomegaly
Medical Department
Stroke Medical Department
Stabilization and referral to
a facility with CT scan
Ischemic heart disease Medical Department
referral to Category A
hospital for further work up
and management
Seizure disorders Medical Department
referral to referral to a
facility with CT scan (If
required)
2.
General Dermatology
(Outpatients, In-patient)
Basic dermatological diagnostic and
therapeutic services
Medical Department
(Dermatologist)
specialist shall be
responsible
3. Respiratory Problems
Upper and Lower Respiratory Tract
infections, Pneumonia, Chronic
Obstructive Pulmonary Disease
(COPD), Tuberculosis, Asthma,
Allergies, Chronic Bronchitis,
Emphysema, Acute Bronchitis,
Cystic Fibrosis
Chest/TB Department
4. Renal disorders

51
Acute glomerulonephritis, Acute
renal failure, Hypo/hyperkalemia,
Nephrotic syndrome, Chronic renal
failure,
Dialysis Unit
The Nephrologist at the
Dialysis Unit should
manage the patients
5.
General Pediatrics (Outpatients,
management
fungal and protozoal infections,
Neonatal care, Neonatal
resuscitation
weighing baby, Avoid hypothermia
and ensure exclusive breast feeding
including colostrum, Identify and
infections, Phototherapy, Birth
injuries, Incubation, Immunization (all
births in the hospital and all children
<5 visiting hospital to be actively
screened for immunization status),
Infants of diabetic mothers, Asthma
(chronic)
deficiency), Manage Neonatal
complications, Congenital anomalies,
Bilirubin encephalopathy
(kernicterus), Thalassemia
Pediatrics Department
activities, Nutrition counseling,
Breast feeding counseling and
support, Malaria and Dengue control
activities, Growth monitoring and
counseling, Deworming (provision of
anti-helminthic)
Department
6.
General Cardiology (Outpatients,
Congenital heart disease, Deep-vein
thrombosis, Heart failure
Hypertension, Pulmonary oedema,
Rheumatic heart disease
Myocardial infarction, Ischemic heart
disease
referral for further work up
and management including
the assessment of need for
Angiography and

52
Angioplasty
7.
General Psychiatry (Outpatients,
of Psychiatrist or clinical
staff member from
Psychiatry department,
responsible
Depression; Anxiety and stress-
related disorders; Sleep disorders;
problems; IQ/Personality
assessment
8.
patient, Emergency)

management
Elective
Circumcision
resection of IGTN, Excision of
Intubation, Supra pubic
catheterization ( via suprapubic
cystostomy kit), Supra pubic
catheterization (open Technique),
Trucut Biopsy, FNAC D/D
Sigmoidoscopy, Urethral dilatation,
DJ Stent Removal, Lord’s Dilatation,
T. Stich, Polypectomy, Examination
Under Anaesthesia (EUA), Excision
of Fibro adenoma Breast, I/D of
Breast Abscess, I/D & D/D under
G/A, Feeding Jejunostomy,
Colostomy, DJ Stenting, Open
Appendicectomy,
Hydrocele surgery, Varicocele
surgery, Undescended Testes
(UDT), Simple Mastectomy, Wide
Local Excision
Surgical Department

53
Sinus, Ileostomy/ Colostomy
Reversal, Upper Gastrointestinal
Endoscopy (UGIE) with biopsy,
Lower Gastrointestinal Endoscopy
(LGIE) Colonoscopy with biopsy,
Crohn's disease
9. A&E Services
animal/snake bite
Accident and
Emergency
Unit/Department
Previously mentioned as
“Casualty”
requiring referral, basic life
support and emergency
treatment will be given
Infection, Ureteric colic, Acute
urinary retention, Peritonitis, Rectus
sheet haematoma, Airways and
ambu-bag breath, Cricothyroidotomy,
Fluid and electrolyte balance and
blood transfusion, Soft Tissue
Injuries, Tendon injuries, Abdominal
trauma (major), Splenic rupture,
Retroperitoneal haemorrhage,
Shock/Septicaemia
Accident and
Emergency
Unit/Department
department
Advanced acute abdominal
conditions like Vascular, Pancreatic,
Urological and requiring sub-
specialised supervision
Accident and
Emergency
Unit/Department
Assessment, Stabilization
and referral by specialist
department
Multiple Injuries
Accident and
Emergency
Unit/Department
stabilization by specialist
department along with
if required
Accident and
Emergency
Unit/Department
department, if required
referral to thoracic facilities
rule of 9s and referral to a burn
Accident and
Emergency

54
centre in case of
burns on greater than 20% of the
BSA in other age groups;
than 5% of the BSA in any age
group;
volumes of tissue beneath the
surface can be injured and result in
acute renal failure and other
complications);
mortality;
Unit/Department surgical department and
Head injury
Accident and
Emergency
Unit/Department
Initial management by
surgical department,
Based on Glasgow coma
scale) – score 8 or less to
be referred to
neurosurgical facility
Spinal Injuries
Accident and
Emergency
Unit/Department
Initial stabilization by
referral
Femur fracture, Open fractures,
Pelvic fracture without complication
Accident and
Emergency
Unit/Department
required
referral to the sub-specialty
concerned (if required),
Accident and
Emergency
Unit/Department

55
10.
Emergency)
Emergencies: Trauma (except
intraocular foreign body and orbital
fracture)
Eye Department
Stabilize and Refer if
required
Common eye conditions, Cataract,
complications
Eye Department
11.
patient, Emergency)
sinusitis, Granulomatous conditions
of nose & PNS, Nasal polyp
Externa, Wax in ear, Acute otitis
media
Chronic otitis media, Balance
otitis media, Otitis media with
effusion
ENT Department
Foreign body in the ear/nose ENT Department Stabilize and Refer
12.
Closed fracture and dislocation of all
of minor joints and bones,
Supracondylar displaced fractures,
Volkmann's ischemia and
compartment syndrome, Soft tissue
injuries and crush injuries, Pelvic
fracture without complication, Hip
joint dislocation, Femur neck
fracture, Femur fracture, Knee joint
dislocation, Tibia and fibula closed
fracture, Tibia open fractures, Ankle
joint dislocation and fractures, Ankle
bones open fractures, Tarsal bones
fractures and dislocations, Tarso-
metatarsal joint dislocation, Skin
graft and tendon injuries, Acute
osteomyelitis, Pyogenic septic
arthritis
Orthopaedic
Department

56
Tuberculosis of bones and joints,
Gout arthritis, Rheumatoid arthritis,
Bone Cyst, Carpal tunnel lesion,
Hand flexors and extensors injuries,
Menopausal osteoporosis, Change
of dressing without anesthesia, Intra
Injection for tendinitis, In Growing
Toe Nail (IGTN), Below knee and
below elbow POP without
anesthesia, Skeletal traction
Manipulation Under Anaesthesia
muscle biopsy, Trucut biopsy,
Closed reduction and percutaneous
fixation of distal radius, Closed
reduction of
GA, Open Reduction Internal
Fixation (ORIF) small bones of hand
& foot, Small bone operations of
hands/foot to include, fracture
Forefoot amputation till midtarsal
joint, Amputation of finger or thumb
13.
General Gynae/Obs (Outpatients,
Counseling of Maternal and new-
born health issues including breast
feeding, family planning and
personal hygiene
Obstetrics and
Gynaecology
Department
Antenatal care
Treatment of Vit. A deficiency (if
night blindness appears in last
trimester), Rhesus (Rh)
incompatibility, Management of pre-
eclampsia, Management of, Ectopic
pregnancy
Obstetrics and
Gynaecology
Department
Natal Care
3rd degree vaginal tears,
Management of prolapsed cord,
Management of shoulder dystocia,
Manage prolonged and obstructed
labour, Caesarean section, Manage
3rd degree cervical tears
Obstetrics and
Gynaecology
Department

57
Postnatal care
(simple)
Obstetrics and
Gynaecology
Department
deficiency)
Obstetrics and
Gynaecology
Department
Family Planning:
Implants, Tubal ligation,
Complications of contraceptives
Obstetrics and
Gynaecology
Department
14.
Emergency)
Crowning/ Dentures/ braces, Pulpitis,
Periodontitis, Pericoronitis, Gingivitis,
Cellulitis (oral), Alveolitis (dry socket)
Acute necrotizing ulcerative gingivitis
Support Services
15.
Laboratory (Outpatients, In-
patient, Emergency)
electrolytes, CSF/pleural fluid/ascitic
fluid/, Biochemistry, gram's and ZN
stain
HBsAg, Anti-HCV, Serum amylase,
CPK, Blood glucose, ABGs
and cross match, Storage (Blood
bank services)
Pathology
Unit/Department
16.
Emergency)
Sinuses, X-ray for fracture
X-ray for age estimation,
Ultrasound /Abdomen/ Pelvis
Radiology
Unit/Department
Intubation, Manage emergencies and Anaesthesia Services to be provided by

58
anaesthesia
Unit/Department Anaesthesiologist
Ventilation
Anaesthesia
Unit/Department
Stabilization by
Anaesthesiologist and
Refer
18.
Emergency)
Support prescription of drugs;
Manage main drug store
(Inventory/stock, forecasting etc);
Drug utilization evaluation;
Pharmacovigilance; Drug therapeutic
goods information and poison control
center
Pharmacy
Unit/Department
Frozen shoulder; Backache therapy;
Post-fracture therapy; Therapy of
joints; Short wave diathermy;
Physiotherapy for chest; Mobilization
Surgical and Medical
Department
Two Physiotherapist each
in the Surgical and
Medical Department to
provide Physiotherapy
services
20. Routine medico-legal
21.
Information System
Maintenance of computers; Closed
Circuit TV; Central speaker
announcement; Health educational
corner at OPDs
Administration
Department
22.
Infection prevention & control,
safe environment, hygiene and
safe waste disposal:
Ensure aseptic sterilized diagnostic
& therapeutic procedures; Notify
ORs and house staff of MRSA/VRSA
and other nosocomial infection when
it occurs; Segregation of sharp and
non-sharp medical waste and local
or contractual arrangement for its
safe disposal
Administration
Department
responsible for
infection control
measures
23. Ambulance Service:
Administration
Department
Service shall be run by
1122 for transporting
The human resource in Category B secondary care hospitals mainly consists of
staff and support staff. The specialist staff has been proposed based on the essential

59
requirement to run the respective hospital as a 24/7 facilities. Proposed essential staff
MHSDP-SC listed services for Category B Secondary Care Hospitals are reflected in Tables
at Appendix 13.7
An essential list of equipment and instruments in line with requirements of MHSDP-SC has
been developed for Category B hospitals. The proposed list of equipment is placed at
Appendix 13.8.
7 MHSDP for Category “C” Secondary Care hospital
The Category C secondary care hospitals in KP has 110 inpatient beds, 2 Dentistry Units
and is intended to serve a population of around 300,000 people. The category C secondary
care hospitals have both in-patient and outpatient services, in addition to emergency,
diagnostic and other day care facilities. The clinical specialities that are recommended to be
available at a category C hospital include Surgery, Medicine, Gynaecology/obstetrics,
Paediatric Medicine, Eye, ENT, Orthopaedics, Accident and Emergency (A & E) Department
(previously known as “Casualty), and Intensive Care Unit. The table below provide the
services that are to be provided by the Category C hospitals and the guidelines for referral (if
required) based on the available clinical specialities and support services. In addition, it was
also noted by the Consultant Team that it will be a good idea to label some of the services
under a particular “Unit” to make it more visibility and recognition. These have been
highlighted in the Table below
Table 6: MHSDP-SC FOR CATEGORY C SECONDARY CARE HOSPITALS
Clinical Services
1.
patient, Emergency)
management
Infection:
Medical Department
GI disorders:

60
bowel syndrome, Peptic ulcer disease,
Helminthic infection
Medical Department
GI tract bleeding, Medical Department Stabilise and Refer
Renal disorders
Acute glomerulonephritis, Acute renal
failure, Hypo/hyperkalemia, Nephrotic
syndrome
Medical Department
Stabilise and Refer to CAT
B hospital
Hepatosplenomegaly
Medical Department
Stabilisation and referral to
Ischaemic heart disease Medical Department
and management
required)
2.
General Cardiology (Outpatients, In-
patient, Emergency)
of cardiologist, Medical
specialist shall be
responsible
Myocardial infarction Medical Department
Initial Management
(including provision of
Streptokinase, if required)
and referral for further work
up and management
including the assessment
of need for Angiography
and Angioplasty
Deep-vein thrombosis, Hypertension Medical Department
Pulmonary oedema Medical Department
Stabilise and Referral to
CAT B hospital
3.
In-patient)
Medical Department
specialist shall be
responsible
4.
patient, Emergency)
of Psychiatrist, Medical
specialist shall be
responsible
Depression
Medical Department
Referral to a Psychiatrist at
Category B secondary care
hospital

61
Anxiety and stress-related disorders,
Sleep disorders
Medical Department
problems
Medical Department Stabilize and Refer
5.
patient, Emergency)
management
Neonatal care, Neonatal resuscitation
weighing baby, Avoid hypothermia and
ensure exclusive breast feeding
infections, Phototherapy, Birth injuries,
Incubation, Immunization (all births in
the hospital and all children <5 visiting
hospital to be actively screened for
immunization status), Infants of
diabetic mothers, Asthma (chronic)
deficiency)
Paediatric
Department
Manage Neonatal complications
Paediatric
Department
Stabilise and Refer
helminthic)
Department
6.
patient, Emergency)

management
Elective Surgery
Surgical Department

62
Cysts, Cavity abscesses, Circumcision
resection of IGTN, Excision of Lipoma,
Lymph node Biopsy, Chest Intubation,
Supra pubic catheterization ( via
suprapubic cystostomy kit), Supra
pubic catheterization (open
Technique), Trucut Biopsy, FNAC D/D
Sigmoidoscopy, Urethral dilatation, DJ
Stent Removal, Lord’s Dilatation, T.
Stich, Polypectomy, Examination
Under Anaesthesia (EUA), Excision of
Fibro adenoma Breast, I/D of Breast
Abscess, I/D & D/D under G/A,
Feeding Jejunostomy, Colostomy, DJ
Stenting, Open Appendicectomy,
Hydrocele surgery, Varicocele surgery,
Undescended Testes (UDT), Simple
Mastectomy, Wide Local Excision
Sinus, Ileostomy/ Colostomy Reversal,
Upper Gastrointestinal Endoscopy
(UGIE) with biopsy, Lower
Gastrointestinal Endoscopy (LGIE)
Colonoscopy with biopsy
7.
(Outpatients, In-patient, Emergency)
Pulpitis, Pericoronitis, Gingivitis,
Surgical Department
(Dental Surgeon)
Services to be provided by
the dental surgeon with
provision of 2 dental units
8. A&E Services
animal/snake bite
Previously mentioned as
“Casualty”
requiring referral, basic life
support and emergency
treatment will be given
Accident and
Emergency
Unit/Department

63
Tendon injuries
department
(if required),
Accident and
Emergency
Unit/Department
and requiring sub-specialized
supervision
Accident and
Emergency
Unit/Department
Initial
Management/Stabilization
by specialist on-call from
referral
Multiple Injuries
Accident and
Emergency
Unit/Department
department along with
if required
Accident and
Emergency
Unit/Department
Assessment by specialist
department, if required
referral to thoracic facilities
Shock/Septicemia
Accident and
Emergency
Unit/Department
Initial stabilization by
referral to CAT B hospital
Head injury (based on Glasgow coma
scale) – score 8 or less to be referred
to neurosurgical facility
Spinal Injuries
Accident and
Emergency
Unit/Department
Initial
Management/Stabilization
by specialist on-call from
referral to a facility having
CT scan
in case of
thickness burns of greater than 10% of
the BSA in patients less than 10 years
or over 50 years of age;
4. Full-thickness burns on greater than
Accident and
Emergency
Unit/Department

64
5% of the BSA in any age group;
5. Significant electrical burns, including
lightning injury (significant volumes of
tissue beneath the surface can be
injured and result in acute renal failure
and other complications);
mortality;
increases risk of morbidity or mortality,
and may be treated initially in a trauma
center until stable before being
transferred to a burn center
Femur fracture, Open fractures, Pelvic
fracture without complication
Accident and
Emergency
Unit/Department
Department
9.
management
Emergencies: Trauma Eye Department Stabilize and Refer
Common eye conditions, Cataract,
complications
Eye Department
10.
patient, Emergency)
management
sinusitis, Granulomatous conditions of
nose & PNS, Nasal polyp
Externa, Wax in ear, Acute otitis media
Chronic otitis media, Balance
ENT Department

65
otitis media, Otitis media with effusion
Foreign body in the ear/nose ENT Department Stabilize and Refer
11.
management
Closed fracture and dislocation of all of
minor joints and bones, Supracondylar
displaced fractures, Volkmann's
ischemia and compartment syndrome,
Soft tissue injuries and crush injuries,
Pelvic fracture without complication,
Hip joint dislocation, Femur neck
fracture, Femur fracture, Knee joint
dislocation, Tibia and fibula closed
fracture, Tibia open fractures, Ankle
joint dislocation and fractures, Ankle
bones open fractures, Tarsal bones
fractures and dislocations, Tarso-
metatarsal joint dislocation, Skin graft
and tendon injuries, Acute
osteomyelitis, Pyogenic septic arthritis
Tuberculosis of bones and joints, Gout
arthritis, Rheumatoid arthritis, Bone
Cyst, Carpal tunnel lesion, Hand
dressing without anesthesia, Intra
Injection for tendinitis, In Growing Toe
Nail (IGTN), Below knee and below
elbow POP without anesthesia,
Skeletal traction,
Manipulation Under Anaesthesia
muscle biopsy, Trucut biopsy, Closed
reduction and percutaneous fixation of
distal radius, Closed reduction of
GA, Open Reduction Internal Fixation
(ORIF) small bones of hand & foot,
Small bone operations of hands/foot to
include, fracture
Forefoot amputation till midtarsal joint,
Amputation of finger or thumb
Orthopaedic
Department
12. General Gynae/Obs (Outpatients, In- If supportive services are

66
patient, Emergency) not available, patient shall
management
Obstetrics and
Gynaecology
Department
Antenatal care
Obstetrics and
Gynaecology
Department
Natal Care
3rd degree vaginal tears, Management
of prolapsed cord, Management of
shoulder dystocia, Manage prolonged
and obstructed labour, Caesarean
section
Obstetrics and
Gynaecology
Department
Postnatal care
(simple)
Obstetrics and
Gynaecology
Department
Gynecological/obs; care:
deficiency)
Obstetrics and
Gynaecology
Department
Family Planning:
Implants, Tubal ligation, Complications
of contraceptives
Obstetrics and
Gynaecology
Department
Support Services
13.
Emergency)
electrolytes, CSF/pleural fluid/ascitic
fluid/ , Biochemistry, gram's and ZN
stain, HBsAg, Anti-HCV
Laboratory

67
Serum amylase, CPK, Blood glucose,
ABGs, Screening of donor, blood
grouping and cross match, Storage
(Blood bank services)
14.
Emergency)
Sinuses, X-ray for fracture
X-ray for age estimation,
Ultrasound /Abdomen/ Pelvis
Medical Department
(Radiologist)
Radiologist in the medical
department to provide
radiological diagnostic
services. If any services is
facility
anaesthesia
Surgical and
Orthopaedic
Department
(Anaesthesiologist)
One Anaesthesiologist
each in the Surgical and
Orthopaedic department to
provide Anaesthesia
services. The two
Anaesthesiologist will also
provide services for other
surgeries conducted by
Eye, ENT and Gynae/obs
department
Ventilation Stabilise and Refer
16.
Emergency)
Support prescription of drugs, Manage
forecasting etc), Drug utilization
evaluation, Pharmacovigilance,
Drug therapeutic goods information
and poison control center
Pharmacy
Unit/Department
Frozen shoulder, Backache therapy,
Post-fracture therapy,
Therapy of joints,
Short wave diathermy,
physiotherapy for chest,
Mobilization (postoperative and post
stroke)
Department
One Physiotherapist each
in the Surgical and Medical
Department to provide the
Physiotherapy services
18.
Information System
Maintenance of computers, Closed
Circuit TV,
Central speaker announcement
Health educational corner at OPDs
Administration
Department
19.
waste disposal:
therapeutic procedures, Notify ORs
Administration
Department
responsible for

68
occurs,
Segregation of sharp and non-sharp
medical waste and local or contractual
arrangement for its safe disposal
infection control
measures
Administration
Department
The human resource in Category C secondary care hospitals mainly consists of
staff and support staff. The specialist staff has been proposed based on the essential
requirement to run the respective hospital as a 24/7 facilities. Proposed essential staff
MHSDP-SC listed services for Category C Secondary Care Hospitals are reflected in Tables
at Appendix 13.7
Secondary hospitals deal with a wide range of acute and chronic ailments including
emergencies for which essential and quality diagnostic and care equipment are required. An
essential list of equipment and instruments in line with requirements of MHSDP-SC has
been developed for Category C hospitals. The proposed list of equipment is placed at
Appendix 13.8.
8 MHSDP for Category “D” Secondary Care hospital
The Category D secondary care hospitals in KP has 40 inpatient beds, 1 Dentistry Units and
is intended to serve a population of around 100,000 people. The category D secondary care
hospitals have both in-patient and outpatient services, in addition to emergency, diagnostic
and other day care facilities. The clinical specialities that are available at a category D
hospital include Surgery, Medicine, Gynaecology/obstetrics, Paediatric Medicine, Accident
and Emergency (A & E) Department. The table below provide the services that are to be
provided by the Category D hospitals and the guidelines for referral (if required) based on

69
the available clinical specialities and support services. In addition, it was also noted by the
Consultant Team that it will be a good idea to label some of the services under a particular
“Unit” to make it more visibility and recognition. These have been highlighted in the Table
below
Table 7: MHSDP-SC FOR CATEGORY D SECONDARY CARE HOSPITALS
Clinical Services
1.
patient, Emergency)
management
Infection:
Medical Department
GI disorders:
bowel syndrome, Peptic ulcer disease,
Helminthic infection
Medical Department
GI tract bleeding, Medical Department Stabilise and Refer
Renal disorders
Hypo/hyperkalemia, Medical Department
Referral if required
Acute glomerulonephritis, Nephrotic
syndrome
Medical Department
Patient should be referred
to Category B secondary
care hospital if ICU care or
dialysis is required
Hepatosplenomegaly
Medical Department
Stabilisation and referral to
Ischaemic heart disease Medical Department
and management
required)
2.
General Cardiology (Outpatients, In-
patient, Emergency)
Myocardial infarction Medical Department
referral for further work up
and management including
the assessment of need for
Angiography and

70
Angioplasty
Deep-vein thrombosis Medical Department
Referral
Hypertension Medical Department
Pulmonary oedema Medical Department
Stabilise and Referral to
CAT B hospital
3.
In-patient)
Medical Department
responsible and assess the
need for referral to CAT B
hospital
4.
patient, Emergency)
of Psychiatrist, Medical
specialist shall be
responsible
Depression, Mania, Schizophrenia,
Suicidal ideation, Substance abuse
and dependency, Post-traumatic
stress problems
Medical Department
Referral to a Psychiatrist at
Category B secondary care
hospital
Anxiety and stress-related disorders,
Sleep disorders
Medical Department
5.
patient, Emergency)
management
Epistaxis Medical Department Stabilisation and referral
Upper respiratory tract infections,
Rhinitis, Acute & Chronic sinusitis,
Medical Department
Pharyngeal infections, Laryngeal,
infections-paediatrics & adults, Otitis
Externa, Wax in ear, Acute otitis media
Chronic otitis media,
Medical Department
6.
Emergency)
If any services is not
available, patient shall be
referred to designated
facility
Sinuses, X-ray for fracture, Ultrasound
Abdomen/ Pelvis
Medical Department
(Radiologist)
Radiologist in the medical
department to provide
radiological diagnostic
services. If any services is
facility
7.
management
Emergencies: Trauma
Medicical
Department
Stabilise and Refer
Common eye conditions, Refraction, Medical Department

71
8.
patient, Emergency)
management
Neonatal care, Neonatal resuscitation
weighing baby, Avoid hypothermia and
ensure exclusive breast feeding
infections, Phototherapy, Birth injuries,
Incubation, Immunization (all births in
the hospital and all children <5 visiting
hospital to be actively screened for
immunization status), Infants of
diabetic mothers, Asthma (chronic)
deficiency)
Paediatric
Department
Manage Neonatal complications
Paediatric
Department
Stabilise and Refer
helminthic)
Department
9.
patient, Emergency)

management
Elective
Mastectomy, Biliary tract operations,
perianal abscess, Hernioraphy, Rectal
Circumcision, Vasectomy, Venous cut
down, Excision of sebaceous cyst,
Wedge resection of IGTN, Excision of
Intubation, Supra pubic catheterization
(via suprapubic cystostomy kit), Supra
pubic catheterization (open
Surgical Department

72
Technique), Trucut Biopsy, FNAC D/D
Sigmoidoscopy, Urethral dilatation,
Lord’s Dilatation, T. Stich,
Polypectomy, Examination Under
Anaesthesia (EUA), Excision of Fibro
adenoma Breast, I/D of Breast
Abscess, I/D & D/D under G/A, Open
Appendicectomy, Haemorrhoidectomy,
Lateral Internal Sphincterotomy,
Herniotomy, Hydrocele surgery,
Varicocele surgery, Undescended
Testes (UDT), Simple Mastectomy,
Wide Local Excision, Varicose Veins
Surgery, Perianal Abscess/ Fistula
(Low), Peri Anal Fistula High/complex,
Mesh repair of inguinal /Ventral
Hernias/ Incisional Hernia, Open
Cholecystectomy, Excision of pilonidal
Sinus
Adenoids & Tonsils & its surgeries,
Acute management of laryngo-tracheal
& neck trauma, Tracheostomy,
Surgical Department
Management and
assessment of the need for
referral by Surgical
Specialist
10.
management
Closed fracture and dislocation of all of
minor joints and bones, Volkmann's
ischemia and compartment syndrome,
Bone Cyst, Carpal tunnel lesion, Hand
dressing without anesthesia, Injection
for tendinitis, In Growing Toe Nail
(IGTN), Below knee and below elbow
POP without anesthesia, Above knee
and above elbow POP, Closed
reduction of small joints of fingers or
toes, Excision of bursa, Open muscle
biopsy, Amputation of finger or thumb
Surgical Department
Management and
assessment of the need for
referral by Surgical
Specialist
Manage convulsions General
anaesthesia, Local anaesthesia
Surgical Department
(Anaesthesiologist)
Refer to CAT A or B
hospitals (as appropriate)
for cases requiring ICU
and specialist care
One Anaesthesiologist in
the Surgical department to
provide Anaesthesia
services Surgical and
Gynae/obs department
Ventilation Stabilise and Refer

73
12.
management
Pulpitis, Pericoronitis, Gingivitis,
Surgical Department
(Dental Surgeon)
Services to be provided by
the dental surgeon with
provision of 2 dental units
13. A&E Services
animal/snake bite
Accident and
Emergency
Unit/Department
Previously called as
“Casualty”
Management by the
relevant Department. For
cases requiring referral,
basic life support and
emergency treatment will
be given
Tendon injuries
Accident and
Emergency
Unit/Department
Management by the
Surgery Department and
referral if required
and requiring sub-specialised
supervision
Accident and
Emergency
Unit/Department
Initial Stabilisation by the
referral
Multiple Injuries
Accident and
Emergency
Unit/Department
stabilization by the
if required
Accident and
Emergency
Unit/Department
stabilization by the
referral to CAT B hospital
or thoracic facilities, as
required
Shock/Septicaemia
Accident and
Emergency
Unit/Department
Initial stabilisation by the
referral to a facility with
ICU care
Head injury (based on Glasgow coma Accident and Initial Stabilisation by the

74
scale) – score 8 or less to be referred
to neurosurgical facility
Spinal Injuries
Emergency
Unit/Department
referral to a facility having
CT scan
in case of
than 5% of the BSA in any age group;
volumes of tissue beneath the surface
can be injured and result in acute
renal failure and other complications);
mortality;
Accident and
Emergency
Unit/Department
Initial Management by the
Accident and
Emergency
Unit/Department
Management by the
assess the need for
referral
(if required),
Accident and
Emergency
Unit/Department
14.
General Gynae/Obs (Outpatients, In-
patient, Emergency)

75
management
Obstetrics and
Gynaecology
Department
Antenatal care
Obstetrics and
Gynaecology
Department
Natal Care
3rd degree vaginal tears, Management
of prolapsed cord, Management of
shoulder dystocia, Manage prolonged
and obstructed labour, Caesarean
section
Obstetrics and
Gynaecology
Department
Postnatal care
(simple)
Obstetrics and
Gynaecology
Department
deficiency)
Obstetrics and
Gynaecology
Department
Family Planning:
Implants, Tubal ligation, Complications
of contraceptives
Obstetrics and
Gynaecology
Department
Support Services
15.
Emergency)
electrolytes, Biochemistry, gram's and
ZN stain, HBsAg, Anti-HCV, Serum
amylase, CPK, Blood glucose, ABGs,
Laboratory

76
and cross match, Storage (Blood bank
services)
16.
Emergency)
Support prescription of drugs, Manage
forecasting etc), Drug utilization
evaluation
Pharmacy
Unit/Department
Frozen shoulder, Backache therapy,
physiotherapy for chest, Post-fracture
therapy, Therapy of joints, Mobilization
Department
One Physiotherapist to
provide the Physiotherapy
services to Surgical and
Medical Department
18.
Information System
Maintenance of computers, Closed
Circuit TV, Central speaker
announcement, Health educational
corner at OPDs
Administration
Department
19.
waste disposal:
therapeutic procedures, Notify ORs
occurs, Segregation of sharp and non-
sharp medical waste and local or
contractual arrangement for its safe
disposal
Administration
Department
responsible for
infection control
measures
Administration
Department
The human resource in Category D secondary care hospitals mainly consists of
staff and support staff. This documents provides guidance for determining number staff of
different categories required to provide indicated package of services effectively. The
specialist staff has been proposed based on the essential requirement to run the respective
hospital as a 24/7 facilities. Proposed essential staff MHSDP-SC listed services for Category
D Secondary Care Hospitals are reflected in Tables at Appendix 13.7
An essential list of equipment and instruments in line with requirements of MHSDP-SC has

77
been developed for Category D hospitals. The proposed list of equipment is placed at
Appendix 13.8.
9 Preventive and primary health care services for
all categories of secondary care hospitals
The role of preventive and promotive care at the secondary level care facilities cannot be
underscored. The secondary health care facilities are being utilized for not only basic
primary and preventive care but also to provide outreach care and link with various primary
care programmes. Based on the recommendations of the preventive care sub-committee,
following are proposed for all categories of secondary care hospitals
- There should be a Preventive Care Unit within the hospital which should provide
training/capacity building of the hospital staff on preventive care. The Preventive Care Unit
should have a Nutritionist, Health Education Officer and a hospital Epidemiologist.
- The OPDs should have a prevention room that caters for the preventive health care
services.
- The OPDs should have standardized preventive care videos displayed in local language.
- The secondary care hospitals should be linked/connected through web portals to have
access to standard preventive care messages within and across districts.
It is proposed that Knowledge Management (KM) wing sould be established at the Director
General Health Office. The Knowledge Management wing in addition to its other knowledge
management related responsibilities, will also focus on the IEC (Information Education and
Communication) related to prevention of diseases. With regards to development of IEC
material and identification of priority illnesses, the KM wing should get information on
diseases, which are commonly presented to the district hospitals. The KM wing will identify
those, which can easily be prevented with health education. The KM wing will then classify
diseases which are common across all the hospitals and which are specific to some
hospitals.
The envisaged key role and responsibilities of the KM wing with regards to IEC are
- Obtain HMIS information from all levels of hospitals including secondary and tertiary care
hospitals.
- Identify common and relevant diseases.
- Develop themes for prevention.
- Develop materials IEC materials, TV /Radio Adds, billboards etc.

78
- At the secondary care hospitals level, liaise with heads of the department or nominated
personnel from every unit for identification of diseases that needs to be addressed
- Design and develop IEC materials accordingly with the help of Public Health Department
of Medical Colleges and Medical Consultants
The key preventive health care services for the prevailing health problems, their prevention
and control that should be available across all categories of secondary care hospitals are
provided in the Table 8 below. The Hospital Epidemiologist, Nutritionist and the Health
Education Officers housed at the proposed Preventive Care Unit in the hospital should serve
as the focal point for promotion of the preventive health care services at the hospital and
provide training/capacity building of the hospital staff on preventive care.
Table 8: Preventive Health Care Services at Secondary Level Hospitals
Activities / measures
to be taken
Responsibility
MATERNAL AND REPRODUCTIVE HEALTH
1. Delay the first pregnancy at least up to 19 years of age, practice
birth spacing for at least 3 years, and limit family size.
2. Counselling on family planning methods
• Motivate for family planning
• Remove misconceptions
• Help make informed choice
3. Seek antenatal care at least 4 times during the pregnancy (first as
soon as possible, second 6-month, third 8-month, and fourth 9-
month).
4. Take iron tablets regularly from 3 months onwards in pregnancy.
5. Take calcium tablets regularly from 5 months onwards in pregnancy
6. Seek assistance for delivery only from a Skilled Birth Attendant
(SBA) such as CMW, LHV, and lady doctor.
7. Promotion of healthy maternal diet and hygiene in the post-partum
period
8. Awareness about breast examination for early detection of breast
cancers
Gynaecology and
Obstetrics Department
INFANT AND CHILD FEEDING PRACTICES
1. Initiate breastfeeding with first half to one hour after delivery.
2. Give the first bath to the new-born after 24 hours
3. Breastfeed exclusively for 6 months.
4. From about 6 months, provide appropriate complementary feeding
such as khichri and continue breastfeeding until 24 months.
5. Continue feeding children and increase fluids during illness; increase
feeding immediately after illness.
Paediatrics Department
PREVENTION OF MALNUTRITION
1. Facilitate initiation of early breastfeeding
2. Support and promote exclusive breastfeeding for six months
Paediatrics Department

79
to be taken
Responsibility
3. Deal with breastfeeding problems in early months
4. Promotion of appropriate complementary feeding from 6 months
5. Promotion of maternal nutritional status through counselling
6. Diagnosing malnutrition in pregnant and lactating women
7. Promotion of maternal nutritional status to prevent anaemia and
other micronutrient deficiencies
8. Iron/folic acid/calcium supplementation for pregnant, lactating women
9. Prevention of parasitic infections
10. Vitamin A supplementation: To all children 6 months to 59 months
and to post-partum mothers
11. Promote exposure to sunshine for women and children to avoid
vitamin D deficiency
12. Exclude diagnose and treat vitamin D deficiency
13. Promotion of iodized salt
WATER SANITATION AND HYGIENE PROMOTION
General OPD
1. Availability of clean drinking water
2. Availability of safe tape water for hand washing with soap and
other disinfectant.
3. Availability of wash-room, latrine within the waiting area along
with wash basin and proper drainage system of the used water.
4. Health education on personal and patient hygiene both body and
oral, food intake, cooking, washing of food items, clean clothes
and environment.
5. General cleanliness and cross-ventilation of the room/s and
space for OPD.
6. Dustbins for various used items like linen and food/edible
pouches etc
Hospital administration
& sanitary staff; & MO/
WMO/ Paramedics; etc
on duty
Ward and casualty (Accident & Emergency
Unit/Department) level
1. Availability of all the above protocols, plus
2. Washing and disinfection of the rooms and wards of the hospital.
3. Availability of running water for washing and ante septic dressing
of the wounds.
4. Water availability for the hospital staff after handling of patients,
giving injection, after using toilet, catheterization etc.
5. Separate washrooms/latrine for patients and staff.
6. Clean drinking water available for both patients and hospital staff.
7. Proper flow of used water from ward to main drain.
8. Health education by the staff of the ward
& sanitary staff
Operation theatre level
1. Regular and proper cleanliness with clean water of the OT after
& sanitary staff

80
to be taken
Responsibility
use.
2. Disposal of used items, like dressing pads, towels, tissue papers,
used sutures, linen, disposable/auto-lock syringes,
3. Running water for scrubbing before operating on each and every
patient.
4. Proper drain for used water.
Hospital Kitchen
1. Use of properly washed food materials
2. Safe and clean tape water for cooking to avoid food poisoning
and spread of diseases.
3. Use of plates and cutlery washed with clean water.
& sanitary staff
General clean water and sanitation of hospital
1. Disinfected provision of safe and clean water for use of patients,
clients, attendants and hospital staff
2. Chlorination and use of aquatabs in water reservoirs
3. Hospital administration should clean all places with standing
water both on ground, lawns and drains.
4. Open blocked drains.
5. Avoid piping of clean and safe water through drains.
6. Applying filters and solar disinfection processes for making clean
drinking water available
7. The hospital should keep a monitoring and supervising staff to
look into overall cleanliness, ensuring round the clock running of
clean water,
and public health
engineering Dept.
Patient awareness
1. Promoting safe drinking water measures at home:
• Applying solar disinfection
• Using Aquatabs
• Using boiled water
2. Hygiene Promotion
• Hand washing with soap: after using toilet, after handling baby’s
faeces, before cooking, before feeding
• Toilet use
3. Other Measures such as creating awareness about problems
created by stagnant water, blocked drains, defecating outdoors.
Cross cutting – All
departments to
promote the message
IMMUNISATION PRACTICES
1. Take infants for immunisation even when he or she is sick. Allow sick
infant to be immunised during visit for curative care.
2. For every pregnant women and women of childbearing age, seek
tetanus toxoid vaccine at every opportunity.
3. Take infant for measles immunisation as soon as possible after the
age of 9 months
Immunization services
(Infection control
services) of DoH with
the help of Paediatrics
Department

81
to be taken
Responsibility
4. Motivate families for
• Regular and timely immunisation
• Giving polio drops on all NIDs
CONTROL OF TUBERCULOSIS
1. Health education to:
• Identify suspects
• Get sputum test done
• Educate TB is curable
• Inform treatment is free of costs
• Inform where TB services are available
Infection control
services of DoH with
the help of physician
and TB control program
through Chest/TB
Department
CONTROL OF MALARIA
1. Health education about:
• Cleanliness of the surroundings
• Netting windows and doors
• Use insecticide-treated bed-nets for pregnant women and
children under 5 years of age
Infection control of DoH
with the help of Malaria
control program and
physician from Medical
Department
CONTROL OF HEPATITIS B AND C
1. Health education on transmission of hepatitis B and C
Infection control of DoH
with the help of Malaria
control program and
physician from Medical
Department
CONTROL OF BLOOD PRESSURE AND PREVENTION OF HEART ATTACK AND STROKES
1. Health education for control of BP and prevention of heart attack and
strokes:
• Tobacco cessation
• Regular physical activity 30 minutes a day
• Reduced salt intake <5 gm per day
• Regular use of antihypertensive
• Regular use of Aspirin
• Weight control
Health promotive and
preventive educational
programs of DoH and
Department of Primary,
Secondary and higher
education with the help
of physicians from
Medical and Cardiology
Department
HEALTH EDUCATION ABOUT DIABETES
1. Health Education on diabetes about
• Diet guidance
• Avoiding sugars
• Weight control
• Regular physical activity 30 minutes a day
• Regular use of oral hypoglycaemic agents/ insulin by person
with diabetes meillitus
programs of DoH and
of physicians from
Medical Department
PREVENTION OF IODINE DEFICIENCY

82
to be taken
Responsibility
1. Promotion of the use of iodised salt for prevention of iodine
deficiency
programs of DoH,
Department of food and
of physicians/Medical
Department
HEALTH EDUCATION ON DISABILITIES
1. Health Education on
• Early examination of infants and children
• Dealing with disability at home
• Making life of disabled productive
• Seeking advice on physiotherapy
HEALTH EDUCATION ON ORAL HEALTH
1. Health Education on oral health about
• Brushing the teeth with use of tooth paste at least twice daily,
once in the morning and once before going to sleep
• Mouth washing and dental toileting after meals
• Use of mouth wash
• Harmful effects of naswar/ghutka
programs of DoH with
extended school health
services and extended
Masjid health services
through local health
facility involving
physician, surgeon,
gynaecologist and
CARE-SEEKING PRACTICES
1. Seek appropriate care from trained professionals in the event of
illness
2. Administer treatment and medications according to instruction
(amount and duration).
Cross cutting – All
Departments
HEALTH EDUCATION TO YOUTH
1. Teaching the youth about roles and responsibilities of men and
women in building a healthy family
2. Promoting healthy life style behaviours – exercise, no
smoking/naswar, avoiding violence
3. Imparting knowledge about structure of menstrual cycle to females
4. Educating about risks involved in early age marriages and
pregnancies
programs of DoH with
extended school health
services and extended
Masjid health services
through local health
facility involving
physician, surgeon and
gynaecologist. The
responsibilities will be
cross cuttingfrom all
Departments
PREVENTIVE OPHTHALMIC CARE
Following are some Important Conditions of eye which need to be
addressed at Secondary Health Facilities.
Eye Department

83
to be taken
Responsibility
Communicable Diseases;
1- Epidemic Kerato-Conjunctivitis and Trachoma;
Counselor, who can be an Optometrist, will educate the people on
importance of face washing and avoidance of contact with the patients.
2- Ophthalmia neonatorum: Educating the mothers and Hospital staff
attending the deliveries in the labour room for early identification of the
problem and prompt treatment to prevent complications.
Non-Communicable diseases;
1- Optometrist/Counselor: Examination of a newborn child for detection
of congenital anomalies of the eye such as Congenital Glaucoma,
Congenital Cataracts and ophthalmia neonatorum to prevent Blindness.
Educating mothers for awareness of such conditions
2- Amblyopia: Optometrist is the key person. Educating people in early
identification of squint and then advising about the refractive errors and
patch therapy.
3- Glaucoma. Optometrist/Counselor: Educating people regarding the
risk factors for development of glaucoma, educating people regarding
the importance of taking regular follow-up and treatment for prevention
of Blindness from glaucoma.
4- Diabetic Retinopathy. Optometrist/ Counselor; Educating people for
regular examination of the eyes in patients suffering from diabetes. Non-
Mydriatic -Fundus photograph. Control of blood sugar Levels.
Importance and benefits of Laser application to the fundus as advised by
ophthalmologists.
PREVENTIVE GERIATRIC CARE
1. All the relevant clinical specialties should provide health education
and screening services for population over the age of 60 with a focus
on following geriatric problems
• Cataract & Visual impairment
• Arthritis & locomotion disorder
• Cerebrovascular disease & Hypertension
• Neurological problems
• Respiratory problems including Chronic bronchitis
• GIT problems
• Psychiatric problems
• Loss of Hearing
All the relevant clinical
specialties
MENTAL HEALTH PREVENTIVE CARE
The psychiatric department should take lead in preventive care related
to mental health. Following measures could be taken to promote mental
health and prevent mental disorders
1. Improve coordination with other specialty departments in the hospital
to have referral of the patients having signs of a mental health problem
2. Orientation and skill enhancement of the clinicians in other specialty
departments to identify the individuals at risk of developing mental health
disorders to facilitate adequate and timely referral
3. Mental health screening sessions at adequate intervals in the OPD
using the recommended tools for early detection of mental health
disorders
with support from other
specialty departments

84
to be taken
Responsibility
4. Counselling sessions for individuals identified as having risk of
developing mental health disorders
10Physical Infrastructure guidelines for all
secondary care hospitals
The importance of an adequate infrastructure for effective and quality health service delivery
cannot be underscored. Adequate infrastructure not only promotes the quality of the services
provided but also helps in better and facilitated access of the patients to the health facilities.
The following guidelines are provided with regards to infrastructure requirements for the
secondary care hospitals based on the recommendations/standards of the World Health
Organisation (WHO) for secondary care hospitals18
. It is well understood that it might not be
possible to implement all the proposed standards/guidelines by the secondary care hospitals
which are already established for practical reasons. However, all the secondary care
hospitals should try to implement the proposed standards to the best possible extent. It is
proposed that the secondary care hospitals that will be established in future or are in pipeline
should consider these standards. In addition to that, quality of care managment standards
as already produced for the services and infrastructure by the Department of Health, KP
should also be followed.
10.1 Factors to be considered in locating a district hospital
Following factors should be considered while identifying a location for a district hospital18
(1) It should be within 15-30 min travelling time and must have metal access road. In a
district with good roads and adequate means of transport, this would mean a service zone
with a radius of about 25 km.
(2) It should be grouped with other institutional facilities, such as educational (school), tribal
(cultural) and commercial (market) centres.
(3) It should be free from dangers of flooding; it must not, therefore, be sited at the lowest
point of the district.
(4) It should be in an area free of pollution of any kind, including air, noise, water and land
pollution.
(5) It must be serviced by public utilities: water, sewage and storm-water disposal, electricity,
gas and telephone. In areas where such utilities are not available, substitutes must be found,
such as a deep well for water, generators for electricity and radio communication for
telephone.
10.2 Size of the Site
The site must be large enough for all the planned functional requirements to be met and for
any expansion envisioned within the coming ten years. Recommended standards vary from
18
District Health Facilities, Guidelines for Development and Operations, WHO Regional Publications,
Western Pacific Series No.22

85
1.25 to 4 ha (25 to 79 Kanals) per 100 beds; the following minimum requirements have been
proposed18
:
a) 25-bed-capacity - 2 ha/40 Kanals (800 m2
/1.6 Kanals per bed)
b) 100-bed capacity - 4 ha/79 Kanals (400 m2
/0.79 Kanal per bed)
c) 200-bed capacity - 7 ha/138 Kanals (350 m2
/0.69 Kanals per bed)
d) 300-bed capacity - 10 ha/198 Kanals (333 m2
/0.65 per bed)
These areas are for the hospital buildings only, excluding the area needed for staff housing.
For smaller hospitals, single-storey construction generally results in effective use of the
building, less reliance on expensive mechanical services and lower running and
maintenance costs. Thus, hospitals up to 150 beds should be single-storey constructions
(with a foundation to support six stories for future needs) unless other parameters dictate
that they be multi-storeyed18
.
10.3 Topography
Topography is a determinant of the distribution of form and space. A flat terrain is the easiest
and least expensive to build on. A rolling or sloping terrain is more difficult and more
expensive to build on, but the solutions can be interesting and innovative; by using the
natural slope of the ground, the drainage and sewage disposal systems can be designed so
as to result in lower construction and maintenance costs18
.
Figure 7: Topography
(Source: District Health Facilities, Guidelines for Development and Operations, WHO Regional Publications,
Western Pacific Series No.22)
10.4 Departmental Planning and Design
The different departments of the hospital should be grouped according to zone, as follows18
(Figure 8)

86
Figure 8: Zoning of the district hospital departments
18Error! Bookmark not defined.
(1) Outermost zone, which is the most community oriented
Primary health care support areas including family planning clinic
Out-patient department; consists of reception and waiting areas, consultation rooms,
examination rooms, treatment rooms, and staff and supply areas.
Emergency department; This fast-paced department requires a large area that is flexible
and can be converted into private areas when necessary, usually by the use of curtains on
tracks around delineated spaces. It is vital that the provisions for movement within the
emergency department allow for fluidity, with rapid access to the operating, X-ray and other
departments. Because of the nature of emergencies, it is recommended that if resources
are available, beds be clustered and dedicated to specific types of emergency cases.
Accident and trauma, fracture and orthopaedic, obstetrics and gynaecology, and paediatrics
cases require different ministrations and emergency procedures.
Administration; the administrative department is orientated to the public but is at the same
time private. Areas for business, accounting, auditing, cashiers and records, which have a
functional relationship with the public, must be located near the entrance of the hospital.
Offices for hospital management, however, can be located in more private areas.
Admitting office, reception
(2) Second zone, which receives workload from (1)
Radiology and imaging department; with X-ray, Ultrasound and CT scan facilities (in a
Category A hospital). The diagnostic imaging area should be on the ground floor of the
hospital, with easy, covered access for wheel-chairs, patient trolleys and beds. Its location
close to the emergency section of the out-patient department is helpful, but easy access for
all patients should be the first consideration. A separate building is not necessary. The X-ray
department should consist of three room; (i) the X-ray room (ii) the dark-room; and (iii) office
and storage space. The ultrasound room should contain a patient couch, firm but
comfortable, a chair and at least 1 m2
for the equipment. The lighting must be dim-bright,
light makes it difficult to examine a patient properly-but the room must not be very dark.

87
Handwashing facilities should be located either in the room or close by. There must be a
toilet close to the ultrasound room.
Laboratories; The laboratory must be located and designed so as to:
• provide suitable, direct access for patients
• allow reception of deliveries of chemicals
• allow for disposal of laboratory materials and specimens.
The basic utilities that are to be provided in the laboratory are water supply, sanitary drains
and drain vents, electricity, compressed air, distilled water, carbon dioxide, steam and gas.
Others may be necessary depending on the types of tests to be performed. A method must
be designed for identifying the different pipes in the laboratory; the following colour code
may be used:
! hot water orange
! cold water blue
! drain brown
! steam gray
! compressed air white
Blood bank; To have blood donation and transfusion services it is important to have
screening carried out for anaemia and infectious agents, including human immunodeficiency
virus (HIV) type 1 (and, where necessary, type 2), the surface antigen of hepatitis B virus,
syphilis, and any other conditions, considered important based on local epidemiological
profile and a standard exclusion criteria. There should also be facility for adequate storage
of the donated blood after screening.
Pharmacy; The pharmacy must be located so that it is:
• accessible to the out-patient department,
• convenient for dispensing, and
• accessible to the central delivery yard.
(3) Middle zone between outer and inner zones
Operating department; the number of operating theatres required is obviously related to the
number of hospital beds. As a general rule, one operating theatre is required for every 50
general inpatient beds and for every 25 surgical beds. The preferred location is on the same
floor as the surgical wards, which may be the ground floor. It should be connected to the
surgical ward by the simplest possible route, It should also:
• be easily accessible from the accident and emergency department;
• be easily accessible for the delivery suite;
• adjoin the intensive care unit;
• adjoin the central sterile supply department;
• be located in a cul-de-sac, so that entry and exit can be controlled; there should
be no through-traffic

88
The overriding principle is that the centre of the theatre suite should be the cleanest
area, the requirement for cleanliness decreasing towards the perimeter of the
department i.e. the concept of progressive asepticism.
The OT department should provide following rooms/areas ( Figure 9)
Transfer area
This area should be large enough to allow for the transfer of a patient from a bed to a
trolley. A line should be clearly marked in red on the floor, beyond which no person from
outside the operating department should be permitted to set foot without obtaining
authority and putting on protective clothing.
Holding bay
This space is required when the corridor system is used and should be located to allow
supervision of patients waiting to go into the theatre. One bed per two theatres should
be foreseen.
Staff changing rooms
Access to staff changing rooms should be made from the entry side of the transfer area.
At both the transfer area and the theatre side of the changing rooms, space must be
provided for the storage, putting on and removal of theatre shoes.
Operating theatres
Each theatre should be no less than 6 x 6 m (36 m2
) in area and should have access
from the 1 anaesthetic room, scrub-up room and supply room. Separate exit doors
should be provided.
Scrub-up room
Scrub-up facilities may be shared by two theatres. A minimum of three scrub up places
is required for one theatre, but five places are adequate for two theatres. A clear area
within the scrub-up room, at least 2.1 x 2.1 m, must be provided for gowning and for
trolley or shelf space for gowns and masks.
Sub-clean-up
In suites of four or more operating theatres, a small utility area is required for each pair
of operating theatres, for the disposal of liquid wastes, for rinsing dropped instruments
and to hold rubbish, linen and tissue temporarily until they are removed to the main
clean-up room.
Sub-sterilizing
An area for sterilizing dropped instruments should be provided to serve two theatres.
Recovery room
The recovery room should be located on the hospital corridor near the entrance to the
operating department. The number of patients to be held, until they come out of
anaesthesia, depends on the theatre throughput; two beds per theatre is usually
satisfactory. In hospitals where there is an intensive care unit, additional room and
facilities will be needed.

89
Figure 9: Traffic flow in operating department
Intensive Care Unit; The intensive care unit is for critically ill patients who need constant
medical attention and highly specialized equipment, to control bleeding, to support
breathing, to control toxaemia and to prevent shock. They come either from the recovery
room of the operating theatre, from wards or from the admitting section of the hospital. This
unit requires many engineering services, in the form of controlled environment, medical
gases, compressed air and power sources. As these requirements are very similar to those
in the operating department, it is advisable to locate the intensive care unit adjacent to the
recovery room of the operating department. The number of beds in this unit should
correspond to approximately 1-2% of the total beds in the hospital.
Obstetrics and Gynaecology department; Proximity to the operating department is desirable,
as transfer of delivery patients may be necessary. The Obstetrics and Gynaecology
department is a useful one for primary health care activities. Education and training
materials on maternal and child health and on family planning can be effectively transmitted
to receptive fathers in the waiting room. An area should be provided for this purpose.
Paediatrics Unit/Nursery; the nursery should be located adjacent to the delivery department
to ensure protected transport of newborns. Areas must be provided for cribs for both well
and ill babies and for support services that include formula and preparation rooms.
(4) Inner zone, in the interior but with direct access for the public
Inpatient wards; the wards in a hospital are usually classified according to specialties:
medicine, paediatrics, obstetrics-gynaecology and surgery, which are the basic services
offered by a district hospital. There are no radical differences between the requirements of
medical and surgical wards and only minor differences between those of the other
specialties.
(5) Service zone, disposed around a service yard
Dietary services/Kitchen; Apart from parenteral feeding (not considered here), hospitals
should provide dietary services for those in special need of them (i.e., infants and other
patients unable to eat normal meals). These services should be provided whether or not the
local custom is for the family to provide regular meals for the patient.

90
The dietary department of the hospital should advise staff and patients about special diets
(that include or exclude specific ingredients), modified diets (containing increased or
reduced amounts of certain components, such as carbohydrate or fat), and normal diets. All
meals should be composed with the aim of achieving appropriate nutrition, within the limits
of the hospital budget, local food habits, and cultural and religious restrictions.
The hospital should provide patients and relatives information on proper nutrition and well-
balanced diets. Dietary education should be provided not only during therapeutic care, but
on all suitable occasions, and should deal with normal nutrition as well as special diets. A
list of food choices may help to illustrate nutritional principles.
The dietary department should be located next to the kitchen or anywhere on the ground
floor, directly accessible from the service court to receive daily deliveries of meat, vegetables
and dairy products. Direct deliveries to the refrigerated section eliminate traffic through
corridors and cooking areas. The direction of the prevailing wind must also be considered.
The location of the dietitians depends on the main activities. In case that the dietitian is
involved in clinical nutrition, it can be convenient to locate the dietitian in the kitchen or next
to the kitchen. When a kitchen is designed, not only the location and the type of the kitchen
should be taken into account but also the hygienic rules and regulations should be
considered from the start. Kitchens must be located such that heat and odours are not
directed towards areas of high population. They should also not be located under wards,
especially those for non- ambulant patients, as a fire safety precaution.
Laundry and housekeeping; (a) The housekeeper's office should be on the lowest floor,
adjacent to the central linen room.
(b) The central linen room supplies linen for the whole hospital. It must have shelves
and spaces for sewing, mending and marking new linen. If laundry is to be handled in
the hospital, the central linen room must be adjacent to the "clean" end of the laundry
room.
(c) The soiled linen area is for sorting and checking all soiled laundry from the
hospital. It must be next to the "dirty" end of the laundry area and provided with
sorting bins.
(d) Laundry can either be done in-house or contracted to an outside enterprise. If it is
to be done in-house, proper washing and drying equipment must be installed. If it is
to be contracted out, areas must be provided for receiving clean and dispatching dirty
linen and for sorting.
The facilities must thus include:
! a soiled linen room;
! a clean linen and mending room;
! a laundry-cart storage room;
! a laundry processing room, with equipment sufficient to take care of 7 days'
linen;
! janitor's closet, with storage space for housekeeping supplies and equipment
and a service sink;
! storage space for laundry supplies.
The last three are not needed if laundry is to be contracted out.

91
Storage; The standard for central storage space is 2 m2
per bed; in smaller hospitals, this
value is usually increased.
The following compartments must be provided in the hospital storage area:
! pharmacy storeroom,
! furniture room,
! anaesthesia storeroom,
! records storage and
! central storeroom.
The risks of fire and explosion in a medical supplies storeroom and storage of dangerous
substances such as nitric and picric acids and inflammable materials such 'as alcohol,
oxygen and other gas cylinders merit special attention.
For smooth, rapid flow of materials both to and from the central store, sufficient space
and ramps should be provided for handling, unpacking, loading, unloading and
inspection. In a hospital planned with a functional central supply and delivery system,
many of the traditional ancillary rooms could be eliminated from some departments and
be replaced by systems of lifts, with sufficient parking space in the wards for trolleys.
Maintenance and engineering; (a) Boiler room: The boiler plant must be designed by a
qualified engineer to ensure the safety of patients and staff.
(b) Fuel storage: The space will vary according to the fuel used.
(c) Groundkeeper's tool room: Space must be provided for working and for the storage of
equipment and tools for the staff in charge of landscaping and general upkeep of the
garden and grounds.
(d) Garage: The garage is best located in a shed or building separated from the hospital
itself. If the hospital is to maintain 24-hour ambulance service, additional facilities must
be provided for drivers' sleeping quarters.
(e) Maintenance workshop: A carefully planned and organized maintenance programme
for general repair of medical and nonmedical equipment is necessary for ensuring
reliable hospital service. A mechanical workshop with an electric shop, well equipped
with tools, equipment and supplies, is conducive to preventive maintenance and is most
important in emergencies. Failure of lights or essential equipment in an operating
theatre, such as respirators, can have serious consequences. Adequate space for
equipment like lathes, welding materials and wood- and metal-working machines should
be provided, and there should be storage space for damaged material, such as
stretchers, beds, wheelchairs, portable machines and food trolleys. As most repair work
is done outside of normal working hours, space should be provided for workers,
maintenance staff, supervisory personnel and biomedical engineers.
Mortuary; the mortuary should be in a special service yard, with a discreet entrance; it
should be away from the out-patient department, ward block and nursery.
Staff facilities/Residential block; The residential block for the doctors, paramedics and
support staff should be located on the periphery near roads and public transport: staff
dormitories, quarters or housing.

92
10.5 Bed Strength and Specialities across Category A, B, C and D
secondary care hospitals
The secondary levels of care as provided in Khyber Pakhtunkhwa has been categorized in to
Category A, B, C, and D hospitals (as mentioned earlier) according to the bed size, the
catchment population and of course needs and demands of the local population. All the four
categories of hospitals have both in-patient and outpatient services, in addition to
emergency, diagnostic and other day care facilities. Category “A” secondary care hospital
has the highest number of specialties and the number of inpatient beds. The number of
specialties and the inpatient beds decreases across category “A” to category “D” hospitals19
.
The bed strength and the available specialities by the four hospital categories are provided
in the Table 9.
Table 9: Summary of the Criterion for Categorisation of Secondary Care Hospitals
CATEGORY
A
CATEGORY
B
CATEGORY
C
CATEGORY
D
SURGERY 40 beds 30 beds 20 beds 8 beds
MEDICINE 40 beds 30 beds 20 beds 8 beds
GYNAE/OBS 40 beds 20 beds 15 beds ;10 beds
PAEDIATRICS 40 beds 20 beds 10 beds 10 beds
EYE 30 beds 20 beds 10 beds 0
ENT 30 beds 20 beds 10 beds 0
ORTHOPAEDICS 20 beds 10 beds 10 beds 0
CARDIOLOGY 15 beds 10 beds 0 0
PSYCHIATRY 15 beds 10 beds 0 0
CHEST/TB 10 beds 10 beds 0 0
DIALYSIS UNIT 6 U 4 U 0 0
DENTISTRY UNIT 6 U 4 U 2 U 1 U
PAEDS SURGERY 10 beds 0 0 0
NEUROSURGERY 10 beds 0 0 0
DERMATOLOGY 10 beds 0 0 0
ACCIDENT AND
EMERGENCY (Casualty)
10 beds 10 beds 5 beds 4 beds
LABOR ROOM 10 beds 5 beds 5 beds 2
ICU/CCU 10 beds 10 beds 5 beds 0
INPATIENT
BEDS
NURSERY PEADS/ICU 10 beds 5 beds 0 0
TOTAL BEDS
350 Beds
+
6 Dialysis
Units
+
6 Dentistry
210 Beds
+
6 Dialysis
Units
+
6 Dentistry
110 Beds
+
2
Dentistry
Units
42 Beds
+
1 Dentistry
Unit
19
It should be noted that these estimations have been made on Population Census made in 1998; it
was recommended that updated projections for each district be made and bed strength also
calculated on that projections ensure that populatons need match the services.

93
CATEGORY
A
CATEGORY
B
CATEGORY
C
CATEGORY
D
Units Units
11Financial Resources Required
In order to estimate the overall cost implications of implementing the MHSDP-SC at
Category A, B, C, and D Secondary Care Hospitals, a financial assessment will be done
based on the standards agreed in the MHSDP-SC20
.
12 Way Forward
• In order to ensure smooth implementation of MHSDP KP concerted planning with
allocation of resources would be required. The key steps to be followed for
implementation of the MHSDP KP are provided belowCosting of the MHSDP SC
Package – The costing of the MHSDP SC should be conducted for each category of
secondary care hospital and take in to account the envisaged services along with
the required infrastructure, human resource, medcines, supplies and equipment.
• Developing a strategy and plan for orientation of health care providers followed by
the process for its implementation focussing on a “change management” approach.
• Development of materials for conducting orientation of health care providers for
implementation of MHSDP.
• Develop an implementation plan based on the priorities/needs and in line with other
structural changes being recommended in the KP
• Ensuring allocation of resources for implementation of MHSDP SC for DoH, KP
through the approval of Planning and Development Department and Finance
Department.
• A simultaneous exercise should also be considered in terms of developing the “Job
description” for sound Human Resources management; there are some duplications
and ambiguities in various categories of services.
• An appraisal followed by development of a “Referral system” at all the three levels of
services i.e Primary, Secondary and Tertiary level and within the categories of
Secondary level be undertaken for optimum utilization of various levels of services.
20
This is not part of the ToRs assigned to the current team

94
13Appendices
13.1 References and Bibliography
1 Essential Health Packages: What Are They For? What Do They Change? WHO Service
Delivery Seminar Series Technical Brief No. 2, 3 July 2008. Retrieved from
www.who.int/healthsystems/topics/delivery/technical_brief_ehp.pdf on 19th
July, 2016
2 A Basic Health Services Package for Iraq, Ministry of Health 2009. Retrieved from
www.emro.who.int/dsaf/libcat/EMROPD_2009_109.pdf on 18th
of July, 2016
3 Declaration of Alma-Ata, September, 1978. Retrieved from
http://www.who.int/publications/almaata_declaration_en.pdf on 18th
July, 2016
4 Essential Package of Health Services (EPHS). Secondary & Tertiary Care: The District,
County & National Health Systems - Liberia, 2011
5 Wright, J., Health Finance & Governance Project. July 2015. Essential Package of
Health Services Country Snapshot: Nepal. Bethesda, MD: Health Finance &
Governance Project, Abt Associates Inc.
6 Essential Package of Health Services (EPHS), Somalia, 2009
7 Essential Package of Health Services for Secondary Care, Punjab, 2014
8 National Institute of Population Studies. Accessed from
http://www.nips.org.pk/Home.htm, on 19th
July, 2016
9 Bureau of Statistics, Khyber Pakhtunkhwa. Retrieved from
http://kpbos.gov.pk/prd_images/1399372174.pdf on 19th
July, 2016
10 Household integrated economic survey (HIES), 2013-14. Retrieved from
http://www.pbs.gov.pk/content/household-integrated-economic-survey-hies-2013-14 on
19th
July, 2016
11 Pakistan Demographic and Health Survey (PDHS), 2012-13
12 District Health Information System (DHIS), Khyber Pakhtunkhwa
13 National Health Accounts for Pakistan, 2011-12, Pakistan Bureau of Statistics
14 Pakistan Standard of Living Measurement (PSLM), 2014-15, Pakistan Bureau of
Statistics
15 Health Facility Assessment, Khyber Pakhtunkhwa, June 2012
16 Health Sector Strategy, Khyber Pakhtunkhwa, 2010-17

95
13.2 Government of Khyber Pakhtunkhwa criterion for categorisation of
secondary care hospitals according to beds distribution for
specialities
SPECIALITY AND SUPPORT DEPARTMENTS IN THE “CATEGORY A”
SECONDARY CARE HOSPITAL
SPECIALTY DEPARTMENTS
S.NO SPECIALTIES
Beds
Distribution
1 Surgical 40
2 Medical 40
3 Gynaecology/obstetrics 40
4 Labour room 10
5 Paediatric Medicine 40
6 Nursery paediatrics/ICU 10
7 Paediatric surgery 10
8 Eye 30
9 ENT 30
10 Orthopaedics 20
11 Chest/TB 10
12 Cardiology 15
13 Neurosurgery 10
14 Psychiatry 15
15 Dialysis Unit
21
6 U
16 Dentistry Unit 6 U
17 Dermatology 10
18 Accident and Emergency (A & E) Department 10
ICU/CCU 10
Total
350 beds
+
6 Dialysis Units
+
6 Dentistry Units
SUPPORT UNITS/DEPARTMENTS
1 Anaesthesia
2 Radiology
3 Pharmacy
4 Pathology
5 Physiotherapy
22
6 Administration
STAFFING
1 Clinical 348
2 Support staff 204
Total 552
21
This should be developed in to a Nephrology Department with time
22
This is recommended Unit

96
SPECIALITY AND SUPPORT DEPARTMENTS IN THE “CATEGORY B”
S.NO SPECIALTIES
Beds
Distribution
1 Surgical 30
2 Medical 30
4 Labour room 5
6 Nursery paediatrics/ICU 5
7 Eye 20
8 ENT 20
9 Orthopaedics 10
10 Chest/TB 10
11 Cardiology 10
12 Psychiatry 10
13 Dialysis Unit
23
4 U
16 ICU/CCU 10
Total
210 beds
+
4 Dentistry Units
+
4 Dialysis Units
1 Anaesthesia
2 Radiology
3 Pharmacy
4 Pathology
5 Administration
STAFFING
1 Clinical 218
2 Support staff 151
Total 369
SPECIALITY AND SUPPORT DEPARTMENTS IN THE “CATEGORY C”
S.NO SPECIALTIES Beds Distribution
1 Surgical 20
2 Medical 20
23
This should be developed in to a Nephrology Department with time

97
4 Labour room 5
6 Eye 10
7 ENT 10
8 Orthopaedics 10
10 ICU/CCU 5
Total
110 beds
+
2 Dentistry Units
1 Pharmacy
2 Laboratory
3 Administration
STAFFING
1 Clinical 117
2 Support staff 69
Total 186
SPECIALITY AND SUPPORT DEPARTMENTS IN THE “CATEGORY D”
S.NO SPECIALTIES
Beds
Distribution
1 Surgical 8
2 Medical 8
4 Labour room 2
6 Accident and Emergency (A & E) Unit/Department
24
4
Total
42 Beds
+
1 Dentistry Unit
1 Pharmacy
2 Laboratory
3 Administration
STAFFING
1 Clinical 117
2 Support staff 69
Total 186
24
This is the recommended Unit

98
13.3 TORs (as of contract)
Development of Secondary Level Minimum Health Service Delivery Package
(MHSDP) for Health Department, Khyber Pakhtunkhwa25
Background:
The Department of Health in Khyber Pakhtunkhwa, in collaboration with Technical Resource
Facility (TRF) has developed Minimum Health Service Delivery Package for Primary health care
which is being implemented. Similarly, Minimum Service Delivery Quality Standards (MSDS) for
primary and secondary level of health care have also been developed by Health Department KP
and are under implementation now. The Governments of KP has now requested Technical
Resource Facility Plus (TRF+) for assistance in the development of Secondary level MHSDP to
promote standardization and delivery of equitable health services, by defining the minimum
essential standards for each service at secondary health care levels. It can also serve as a
management tool to guide resource allocation, which responds to local priorities and needs.
TRF+ is a four years’ project, funded by the UK’s Department for International Development (DfID).
The TRF+ is managed by Mott MacDonald Group, in partnership with Acasus. The objectives of the
TRF+ include the provision of technical assistance to the government for improving health systems
and services.
Objective:
The overall aim of the TA is to prepare costed MHSDP for secondary level of public sector health
care facilities in KP.
Specific objectives:
1. Developing an MHSDP for each type of public sector secondary care health facility;
2. Spell out required resources (including infrastructure, human resources, supplies and equipment)
for each type of facility for implementing the suggested package ofservices;
3. Prepare a cost estimate for implementing the service package for each type of facility and put a
price tag for each service;
4. Support the Government in capacity development for implementation of this secondary level
MHSDP.
Scope of Work:
1. Review relevant documents of the DoH, KP. These will include recent legal documents, Acts
related to Hospitals, Health Care Commission etc.; besides international/national literature review on
MHSDP and Quality Standards will be carried out.
2. Review and analyze the available standards and yardsticks of the health department (planning cell)
about the infrastructure, medicines & equipment lists, standard human resource for each level of
secondary health care facility etc. Meet with relevant stakeholders in KP, seeking their inputs on
preferred processes and ultimate outcome of the assignment;
3. Meet with relevant stakeholders in KP, seeking their inputs on preferred processes and ultimate
outcome of the assignment;
4. Develop, share and finalize inception report, outlining methodology, work plan and timelines for
implementing the assignment;
5. Based on the above review, provide a situation analysis report before moving further on the
assignment.
25
The elements of scope of work and deliverables highlighted in yellow are not part of the current
assignment

99
6. Develop draft packages including:
• Functions/ services of each type of secondary level facility, including referral
services and responses (service package)
• Details of infrastructure, type and number of human resource, supplies & equipment
and availability of standard operating procedures.
7. Share packages in consultative process with relevant technical experts and stakeholders;
8. Finalize the packages based on given inputs;
9. Based on identified specific package, work out cost for implementing the package and the cost for
each type of facility; based on given assumptions.
10. Based on the package, develop training material for training of health care providers for
implementation of MHSDP.
11. Develop training strategy and plan for training of health care providers in consultation with
Provincial Health Services Academy (PHSA).
12. Conduct training of master trainers in appropriate number of batches.
13. Develop an implementation plan and suggest next steps for the provincial health department to
implement the package.
26
Deliverables:
1. Inception plan including suggested outlines for service package manual, methodology, deliverables
and timelines;
2. Situation Analysis report
3. Draft package of MHSDP for each type of secondary level facilities of Khyber Pakhtunkhwa;
4. Final package of MHSDP for each type of secondary level facilities in Khyber Pakhtunkhwa;
5. Training strategy and plan for training of health care providers;
6. Training material for training of health care providers;
7. Training of master trainers.
8. Implementation strategy for MHSDP with recommendations for next steps.
Timeline:
The TA will last for a period of three months from signing of contract.
Expertise Required:
National Team Leader/ Health Systems Specialist:
! PhD or a Master’s in Public Health or equivalent,
! Have a medical background with at least a postgraduate degree in public health or related
field;
! 8 – 10 years’ experience of working in the health sector and having complete
understanding of health care delivery systems and structures are desirable.
! Have experience of developing professionally sound project documents such as project
proposals and review report is a must.
! Have proven experience of designing and implementing technical meetings for senior
government officials/technical experts.
! Preferably having previous experience in developing such packages.
Public Health Specialist (Mid - level):
! Master in Public Health with clinical experience;
26
All highlighted areas not the assignment of current team

100
! Strong analytical and report writing skills;
! Clinical experience specifically at secondary level is considered to be an asset.
Costing Specialist:
! Have a post graduate qualification in accounting/ costing/ financial analysis;
! Proven experience in developing costs for various projects/ services for social sector;
! Candidates with experience in health sector will be preferred.
Research Associate:
! Medical graduate with clinical experience or a postgraduate having worked in the health
department at the planning and policy level; a degree in public health will be an additional
preference;
! Have the ability to conduct literature review, develop draft reports;
! Previous experience in facilitating technical meetings and coordinating with senior officials
is desirable.
Specialists Team:
A team comprising of following specialists will be constituted and notified by the Health
Department: Medicine, Surgery, Gynecology/Obstetrics, Pediatrics, Orthopedics and
Trauma, ENT, Eye, Psychiatry, Dental Surgery, Radiology, Any other
This team will assist and guide the consultant’s team during development of MHSDP.
Required LOE
Tasks TL/ HSS PHS CS RA
Collecting & reviewing documents and
earlier workdone 4 4 0
Situation analysis report 3 2 2
Initial meeting with relevant stakeholders/
visit to facilities 5 5 3
Inception Plan 3 3 0
Drafting package 7 7 0
Preparation for consultative
meetings/workshops 1 1 0
Consultative workshops with DoH
Specialist Team (3) 3 3 0
Costing of facilities and pricing of services 0 0 10
Debriefing to relevant stakeholders 4 4 4
Finalizing package 5 5 3
Development of training strategy and plan
Development of Training Material
Training of Master Trainers
Total number of person days 35 34 22 40
13.4 Experts/Stakeholders met/consulted
1. Mr. Muhammad Abid Majid, Secretary Health, DoH, KP
2. Dr. Ali Ahmad, Director General Health DoH, KP

101
3. Dr. Shaheen Afridi Deputy Director Public Health
4. Dr. Shahid Younas Chief HSRU, KP
5. Dr. Ijaz Ahmed Deputy Chief HSRU, KP
6. Dr. Shahzad Faisal Coordinator, HSRU
7. Dr. Muhammad Khalil Akhter Coordinator, HSRU
8. Dr Uzma Alam Zeb Coordinator, HSRU
9. Dr. Azmat DD DHIS cell
10. Prof. Noor-ul-Iman Professor of Medicine
11. Dr. Zubair Ahmad Khan Surgical Specialist
12. Professor Dr. Parhaizgar Professor of Anesthesiology
13. Dr. Muhammad Ibrar Professor of Ophthalmology
14. Dr. Ghareeb Nawaz Associate Professor ENT
15. Dr. Gul Naz Syed Gynaecology and Obstetrics
16. Dr. Bawar Shah Child Specialist
17. Dr. Nasir Saeed Professor of Ophthalmology, Dean PICO
18. Dr. M. Ayub Rose Program Director HIV/AIDS
19. Dr. Malik Niaz Program Director TB control Program
20. Dr. Sahib Gul Provincial Coordinator MNCH program
21. Dr. Zafeer Hussain Health Integrated Program
22. Dr. Riaz Mohammad MS DHQ Mardan
23. Dr. Muhammad Niaz DHO Swabi
24. Dr. Naeem Awan MS GM & GH
25. Dr Samia Naz PICO /HMC
26. Dr. Nasreen Akbar AD EPI-DGHS Office
27. Dr. Haroon Khan Deputy Director (Nutrition)
13.5 Composition, Roles and Responsibilities of the Assignment
Committees
A. Clinical Sub-Committee

102
Committee Members:
Prof. Noor-ul-Iman: Chair
Dr. Zubair Ahmad Khan: Member
Dr. Ibrar Member
Dr. Ghareeb Nawaz Member
Dr. Gul Naz Syed Member
Dr. Bawar Shah Member
Roles and responsibilities:
The work of the Technical/clinical Sub-Committee was to define/discuss an epidemiological
profile (as much as possible) of the province as well as an estimate of utilization rates at
each level of care and propose the services that are to be included at the secondary care
level hospitals.
Wherever possible, this was based on empirical evidence such as estimates obtained from
any health surveys undertaken in the Province or from the DHIS.
In many instances, such evidence was weak or lacking, in which case the committee
members, through discussion, used their experience, as seasoned clinicians within the
Province, to identify and propose the need of services at the secondary care level hospitals.
B. The administrative/management sub-Committee
Committee Members:
Dr. Zafeer Hussain Chair of the committee, Health Integrated Program
Dr. Riaz Mohammad MS DHQ Mardan
Dr. Muhammad Niaz DHO Swabi
Dr. Naeem Awan MS GM & GH
The work of the Administrative/Management Sub-Committee was to define the staffing
allocation by cadre and anticipated utilization, the infra-structure requirements and other
basic care needs for each facility type and unit delivering the MHSDP.
This was based on best practice sites and other HRH.
Development trends for developing countries; the recommended norms and governmental
allocations as permissible within the rules
The Sub-Committee members used their experience, as seasoned professionals within the
Province, to make recommendation on staff utilization, skills requirements and post mixes.
The sub-committee members based all considerations on Accessibility, Equitable
Distribution and Affordability.
C. The Preventive Care sub-Committee.
Committee Members:
Dr. Nasir Saeed Chair of the committee, Dean PICO

103
Dr. M. Ayub Rose PM/PD HIV/AIDS
Dr. Malik Niaz PD TB control Program
Dr. Sahib Gul PC MNCH Health Department
Dr. Azmat ullah/ Hamid Iqbal DD (DHIS)/D/A (DHIS)
The work of this Sub-Committee was to define/discuss what the dimensions of preventive
are and promotive care based on the epidemiological profile (as much as possible) of the
province as well as an estimate of utilization rates various preventive care services at each
level of care.
Wherever possible, this was based on empirical evidence such as might be obtained from
any health surveys undertaken in the Province or from the DHIS.
These evidence/estimates were used in the MHSDP to provide the required preventive care
services. However, it should be mentioned here that these services are just mentioned here
and mostly referred to the MHSDP at primary level, already prepared.
13.6 Conceptual Understanding of the MHSDP for Secondary Care
According To Categories of Hospitals:
The definitions:
1. MHSDP:
The terms “Basic” and “Minimum” are used interchangeably in relation to the Health Service
Delivery Package. A Basic or Minimum Health Service Delivery Package is defined as a
minimum collection of essential health services to which all the population need to have a
guaranteed access. The term “Essential Health Service Delivery Package” refers to those
health services that provide a maximum gain in health status for the money spent i.e. the
services which provide the best 'value for money'. In other words, essential services are
those services, which if not provided, will result in the most negative impact on the health
status of the overall population27
.
2. The categories of hospitals at secondary level care in the entire district:
The categorization of hospitals at secondary level of care has been carefully developed and
being practiced; the premise being that within a district a strong referral system exists and
according to population as well as capacity of beds, human resources and infrastructure all
the basic as well as many of the specialists’ care is available and people would not have to
rush to the Peshawar for the specialist care. The rational of developing this MHSDP is to
produce a blue-print which can then be used to negotiate the budgeting for various
categories of hospitals with some proper justification.
Having all said, the ideal situation would be to what the Sub-clinical Committee for this
exercise is proposing; however this may actually kill the whole purpose for negotiating extra
27
A Basic Health Services Package for Iraq, Ministry of Health 2009. Retrieved from
www.emro.who.int/dsaf/libcat/EMROPD_2009_109.pdf on 18
th
of July, 2016

104
budget for furnishing the categories of hospitals beyond the “Category D”. The assumption
over here is that, all the categories would definitely be providing the basic/minimum care as
has been identified below in the figure as ‘1’. Thus it is illustrated that a step-ladder
approach for having various services in various categories identified from ‘2 to 4’ are also
expected to be there in addition to ‘1’ also.
Considering this conceptual understanding the category ‘A’ will be expected to provide not
only the MHSDP (which is true for all the categories of hospital), it will have to provide as
part of ‘essential’ health services the 2, 3 and 4 services. Now, whether you call it as
MHSDP for category or the Essential services, it does not make a difference. The reason
will be that the Hospital Incharge (MS or Director) will then be indebted to ensure that s/he
has to provide all the 1,2,3, and 4 services. And, once this is implemented and operational,
the referral systems can work as illustrated by “step-ladder” phenomenon.
The team feels that putting altogether in one package is a good idea, but since there are
categories of hospital beyond ‘D’ which need to offer other essential health services as
explained earlier. Thus, The Consultant Team recommends to have one package, but
demarcate each category separately by giving various colors to pages or by having
‘dividers’. The advantage may be that everyone will be knowing who is supposed to do what
and can refer the patients as and when needed. The disadvantage will be that it may
become a bit thick package and sometimes even confusing etc.
13.7 Human Resource Requirements for Category A, B, C and D
Hospitals
A. Management
S.No. Name of Post CAT
A
CAT
B
CAT
C
CAT
D
Remarks

105
A
CAT
B
CAT
C
CAT
D
Remarks
1. Medical Superintendent 1 1 1 1
2.
Deputy Medical
Superintendent, DMS
(Admin)
2 2 1 1
DMS (Admin) will look after
administration and will report to
MS.
3.
Deputy Medical
Superintendent, DMS
(Services)
1 1 1 1
DMS(Services) will be
responsible for the patient care;
4.
Budget and Accounts
Officer going towards
managerial post
1 1 1 1
Maintains/manages record of
accounts and budgeting
5. Finance Manager 1 1 0 0
6. Director Administration. 1 1 1 1
Maintains records of
employees and administrative
orders
7.
Head Clerk moving towards
Administrative Officer
1 1 1 1
8. Accountant 1 1 1 1
9.
Sr. Clerk moving to Assitant
Adminstrative Officer
1 1 1 1
10. Cashier 1 1 1 1
11.
Store Keeper moving to
Warehouse Warden
1 1 1 1
12. Driver 5 5 3 2
13.
Naib Qasid moving to
Office Assitant
8 6 3 2
B. Clinical Staffing
A
CAT
B
CAT
C
CAT
D
Remarks
1.
Principal Dental
Surgeon
1 1 0 0
2. Senior Dental Surgeon 1* 1 0 0
*A specialist post for Category
A has been approved
3. Dental Surgeon 1* 1 1 1
*A specialist post for Category
A has been approved
4. Physician 2 2 1 1
5. Gastroenterologist 1 0 0 0
This is a new post that has
been approved for Category A
hospitals
6.
Eye Specialist /
Ophthalmologist
2 2 1 0
7. Radiologist 2 2 1 1
8. Surgeon 2 2 1 1
9. Orthopaedic Surgeon 2 2 1 0
10. Cardiologist 2 1 0 0
11. Neurosurgeon 1 1 0 0
12. Nehprologist 1 1 0 0
13. TB / Chest Specialist 1 1 0 0

106
A
CAT
B
CAT
C
CAT
D
Remarks
14. Gynecologist 2 1 1 1
15. Pathologist 1 1 0 0
16. ENT Specialist 2 2 1 0
17. Pediatrician 2 2 1 1
18. Anesthetist 2 1 1 1
19. Psychiatrist 2 1 0 0
20. Dermatologist 2 1 0 0
21. Medical Officer / WMO 108 84 32 16
For CAT A and CAT B following
criteria should be followed
3 (MO) + 1(WMO) per unit. This
arrangements will only be for
Clinical purpose out of these
posts of M.Os no one will be
posted for administrative duty
C. Support Services
S.No. Name of Post CAT A CAT B CAT C CAT
D
Remarks
1. Physiotherapist 6 4 2 1
2.
Nursing
Superintendent
1 1 0 0
3. Chief Paramedic 1 1 0 0
This is a new position
that has been proposed
4. Pharmacist 3 2 1 1
5.
Deputy Nursing
Superintendent
2 1 0 0
6. Head Nurse
As per
criteria
As per
criteria
As per
criteria
As per
criteria
One Head Nurse at 10-
Charge Nurses
7.
8. Nutritionist 2 1 0 0
9.
Hospital
Epidemiologist
1 1 0 0
10.
Health Education
Officer
1 1 0 0
11.
Data Entry/Computer
Operators
10 8 0 0
12.
Bio-medical
technician
1 1 0 0
13. Lab. Technician 6 3 2 1
14. Dental Technician 3 2 1 1
15. ECG Technician 6 4 2 1
16. EEG Technician 1 1 0 0
17. Echo Technician 1 1 0 0
18.
Pharmacy
Technician
(Dispenser)
2 2 1 1
19. Dialysis Technician 2 1 0 0

107
S.No. Name of Post CAT A CAT B CAT C CAT
D
Remarks
20.
Anaesthesia
Technician
2 1 1 1
21.
Sterilisation
Technician
2 1 1 1
22. Projectionist 1 0 0 0
23. CT Scan technician 3 0 0 0
24. Radiographer 4 3 2 1
25. X-Ray Technician 6 3 2 1
26. Optometrist 4 3 2 0
27.
Operation Theater
Assistant
20 10 4 2
28.
Operation Theater
Technician
4 2 1 1
29. Lab Assistant 12 6 3 2
30. Plumber 3 2 1 1
31. Electrician 3 2 1 1
32. Security guards 12 6 3 2
33. Tailor Master 2 1 0 0
34. Lab. Attendant 6 3 1 1
35. Ward Servant/Bearer 118 83 47 16
36. Tube well operator As per need
37. Ward Aya 6 4 2 2
38. Sweeper 43 26 13 6
39. Mali 10 5 4 2
40. Dhobi 8 6 4 2
41. Chowkidar 18 12 10 6
42. Stretcher Bearer 10 6 4 2
13.8 Equipment requirements for Category A, B, C and D Secondary
Care Hospitals
S.NO Infrastructure and equipment
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Out-Patient facilities
1. General provisions (for all OPDs)
Consultation room, Waiting area
Token system, Health education corners
in all OPDs with posters.
TV and DVD player in OPDs for showing
health education related programmes in
local languages; Stretcher/wheel chair
ramp
Yes Yes Yes Yes
Furniture:

108
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Examination couch, Screen, Chair for
the consultant, 3 Chairs for the patient
and attendant
Yes Yes Yes Yes
Items to be available
in each OPD room
Equipment:
Stethoscope, BP apparatus stand type,
Tendon hammer, Measuring tap, Torch,
Cotton wool, Spatula,
Tuning fork 128 cycles/second, weighing
machine, examination gloves,
ophthalmoscope, X-ray illuminator
double table type
Yes Yes Yes Yes
One of each items to
be available in each
OPD room
Defibrillator with ECG monitor Yes Yes Yes Yes
One in the whole
Outpatient
Department
Resuscitation Unit Yes Yes Yes Yes
3 for CAT A, 2 for
CAT B, 1 each for
CAT C and CAT D
Outpatient
Department
Oxygen cylinder with trolley stand,
Oxygen flow meter without humidifier,
Oxygen masks all sizes
Yes Yes Yes Yes
Quantities to be
ascertained based
on patient load
Electric water cooler with filter Yes Yes Yes Yes
4 for CAT A, 3 for
CAT B, 2 for CAT C
and 1 for CAT D
Outpatient
Department
Portable emergency light with battery
backup
Yes Yes Yes Yes
One for each OPD
room
Wheel chair Yes Yes Yes Yes
10 for CAT A, 6 for
CAT B, 4 for CAT C
and 2 for CAT D
hospital OPD
Stretcher Yes Yes Yes Yes
10 for CAT A, 6 for
CAT B, 4 for CAT C
and 2 for CAT D
hospital OPD
Box for proper disposal of sharps, Yes Yes Yes Yes
Quantities as per
need
Desktop computer with printer and UPS Yes Yes Yes Yes
One for the whole
OPD department
Specialty dependent additional
equipment
2. Cardiology:
ECG machine (for all OPD patients), Yes Yes Yes Yes
One in the whole
Outpatient
Department
Echocardiography +/- ETT Yes Yes No No
One in the whole
Outpatient
Department
3.
General Medical:
Pulmonary function unit,
Yes Yes Yes No
One in the whole
Outpatient
Department
4. Paediatric:

109
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Paediatric stethoscope, Paediatric
weighing machine, BP Apparatus with
small cuff, Nebulizer
Yes Yes Yes Yes
One of each items to
be available in each
Paediatric OPD room
5. Dermatology:
Magnifying glass, Woods lamp,
Glass slides
Yes Yes No No
One for each
Dermatology OPD
room
(Though CAT B does
not have
Dermatology
department but it has
dermatologist)
6. Psychiatry:
EEG machine, Wechsler intelligence test
with key adult/Children, Progressive
matrices with key, Wilconsin cord sorting
test with key, International personality
disorder examination - full version with
interpretation,
Yes Yes No No
One of each item for
each Psychiatry OPD
room
7. General Surgery
Proctoscope, Foley’s Catheter with bag,
kidney tray along with a set of dissecting
forceps artery clips and needle holders
Yes Yes Yes Yes
each Psychiatry OPD
room
8. Ophthalmology
Refraction System
Autorefractometer with K-reading,
Retinoscope, Ophthalmoscope,
Refraction box, Vision drum, UPS
Yes Yes Yes No
each Eye OPD room
Consultant OPD
Slit lamp, Applanation, Tonometer,
A-B scan, YAG-Laser, Argon
laser,Torches
Yes Yes Yes No
each Consultant
Ophthalmologist
OPD room
9. ENT
ENT examination unit/ENT mirror and
light source, Rechargeable autoscope,
Tuning forks 512 cycles/second,
Audiometer
Yes Yes Yes No
each ENT OPD room
10. Gynae/Obs;
Antenatal clinic Yes Yes Yes Yes
Gynae examination kit, Fetoscope/sonic
aid, Kit for insertion/removal of IUCD,
Delivery kit, Ultrasound
Yes Yes Yes Yes
One of each items in
each Gynae OPD
room
11. Orthopaedic:
POP cutter, Cotton roll, Crepe bandage,
Local anesthetic,
Injectable analgesic
Yes Yes Yes No
Items to be available
in each Orthopaedic
OPD room as per
requirement
12. Dental
Complete dental unit with X-Ray with
accessories, Dental Lab, Instruments
Yes Yes Yes Yes

110
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Sets, Root Canal Instruments,
Instrument tray/kidney tray Bowls
In-patient facilities
13. General provision (for all wards)
Infrastructure
Ward, Consultant office with bath room,
Doctors duty room with bath room,
Doctors changing room, Nurses
changing room with bath room, Bath
Rooms for patients (one bath room/6
patients), Neonatal Cots
Yes Yes Yes Yes
To be available in
each inpatient ward
High Dependency Beds
Beds for thalassemia patients
Yes Yes No No
4 High Dependency
Beds /ward
1 thalassemia bed
per twenty inpatient
beds
Equipment
Stethoscope, BP apparatus stand type,
Tendon hammer, Measuring tap, Torch,
Cotton wool, Spatula
Tuning fork 128 cycles/second, weighing
machine, examination gloves,
ophthalmoscope, Portable Defibrillator
with ECG monitor, Resuscitation unit,
Ambu bag, Endotracheal tubes various
sizes,
Nursing station, ECG monitored beds,
Pulse oxymeter
Glucometer, Nasogastric tubes,
Foleys/Celestic urinary catheter, I.V
cannula various sizes, Central line, Drip
stands, Instrument tray/Kidney
tray/Bowls, Laryngoscope adult straight
& curved, Oxygen cylinder with trolley
stand, Oxygen flow meter with
humidifier, Oxygen flow meter without
humidifier, Oxygen masks all sizes, SS
urinal/bed pans, Electric water cooler
with filter, Heavy duty suction machine,
Light duty nebulizer, Light duty suction
units, Refrigerator 12 cf., Spirometer,
X-ray illuminator double wall type,
Sterilizing drums, Meigle forceps,
backup, General Surgery Dressing
Instruments Sets, Desktop computer
with printer, UPS
Yes Yes Yes Yes
Each item should be
available in each
inpatient ward in
quantities
ascertained by ward
size/need
Specialty dependent additional
equipment
14. Medicine and Allied ward
Chest drain with under water seal, Three
way pleural tape needle, Ascitic tap
needle, Pleural/liver biopsy needle, Bone
marrow aspiration needle,
Yes Yes Yes Yes
All items to be
available in Medicine
and Allied ward in
quantities

111
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
ascertained by need
ECG machine (for all in-patients in the
facility)
Yes Yes Yes Yes
One in each
Medicine and Allied
ward
15.
Surgery and Allied ward
Dressing kit, Drains Different Types,
Foley’s Catheter, Drainage Bags,
Airways, Chest Drains, Blood
Transfusion sets, Gloves, proctoscopes,
Naso-Gastric Tubes,
Yes Yes Yes Yes
All items to be
available in Surgery
and Allied ward in
quantities
ascertained by need
16. Orthpaedic ward
Fracture bed with frame beam and
pulley,
Yes Yes Yes No
POP cutter, Yes Yes Yes Yes
Though there is no
Orthopaedic ward in
CAT D hospital, POP
cutter should be
available in Surgical
ward
17. ENT ward
Rechargeable Autoscope self-
illuminating, ENT dressing,
Nasal polypus complete set, Head light
electric, Diagnostic Set ENT,
Tracheotomy set, Minor procedure room:
Light source, items for nasal packing/
ear packing and foreign body ear/nose.
Yes Yes Yes No
All items to be
available in ENT
ward in quantities
ascertained by need
18. EYE ward
Direct Ophthalmoscope & retinoscope
with charger, Refraction box, Boiler, Eye
dressing instruments, Torches, Vision
drum,
Perkin tonometer, Desktop computer
with UPS for data entry, Laptop &
overhead projector
Yes Yes Yes No
All items to be
available in ENT
ward in quantities
ascertained by need
19. Mother and Child ward
Ultrasound, Butter fly various sizes
Paediatric urinary catheters, Intensive
baby incubator, Oxygen tent paediatric, ,
BP Apparatus with small cuff,
Phototherapy machine, Stethoscope
paediatrics, Infant Warmer, Gynae
Table, Stethoscopes foetal (aluminium),
Gynae examination kit, Female metal
catheter F201, F 203, F204, F28,
Ultrasound machine, Nebulizers, Suction
Machines- Neonatal, Pediatric;
Ophthalmoscope;
Neonatal/Pediatric Laryngoscopes with
straight and Curved blades;
Different sizes endotracheal tubes
(premature, term, neonatal, Child),
Auroscopes

112
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Paediatric resuscitation unit Yes Yes No No
Incubators Yes Yes No No
Oxygen Concentrators Yes Yes No No
Cardiac Monitors/DC Cardioversion, Yes Yes No No
Infusion pumps Yes Yes No No
20. Psychiatry ward
Wechsler intelligence test with key
adult/Children, Progressive matrices with
key, Wilconsin cord sorting test with key,
International personality disorder
examination - full version with
interpretation
Yes Yes No No
21. CCU/ICU Yes Yes Yes No
10% of total bed strength of the facility
with monitors
Yes Yes Yes No
Ventilator Yes Yes No No
3 for CAT A, 2 for
CAT B hospital
Temporary Pace Maker Yes Yes No No
4 for CAT A and 2 for
CAT B hospital
22. Operation Rooms (ORs)
Infrastructure
Anaesthetist office with bath room,
Anaesthesia technicians changing room
with bath room, Nursing staff changing
room with bath room, Pre-med room,
central Sterilization room (for the whole
hospital), Scrub room,
Recovery room, Patient pre-operative,
waiting room
Yes Yes Yes Yes
Operation Rooms with H-VEC facility Yes Yes Yes Yes
4 for CAT A, 3 for
CAT B, 2 for CAT C
and 1 for CAT D
hospital
Operation Rooms (ORs) Equipment
General Provision
Stethoscope, Stethoscope Paediatric,
BP Apparatus mercury stand type,
Instrument tray/Kidney tray/Bowls,
Laryngoscope adult straight & curved,
Laryngoscope paediatric straight &
curved, Meigle forceps, Diathermy with
appliances, Catheter, Miscellaneous
instruments sets, Nitrous oxide cylinder,
Oxygen flow meter with humidifier,
Oxygen masks all sizes, SS Basin with
stand,
SS Urinals/Bed pans, Sterilizing drums,
Tracheotomy set, Wt. machine adult, Wt.
machine children, X-ray illuminator
double wall type, Anaesthesia machine,
Yes Yes Yes Yes
Each item should be
available in each OR
in quantities
ascertained by OR
size/need

113
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Automatic operation table, Defibrillator
on trolley,
Electric water cooler, Heavy duty suction
machine, Infusion pumps,
Light duty nebulizer, Mobile OT light with
battery, Operation table hydraulic
semiautomatic, OT ceiling light LED type
with satellite and backup power supply,
Pulse oximeter, Refrigerator 12 cb. Ft.,
Resuscitation unit, Fine Diathermy, NIBP
(Non Invasive Monitors Devices)
Mobile x-ray 30 Yes Yes Yes No
Craniotomy set with pneumatic drill with
air
Yes Yes No No
Sterilization room:
Autoclave vertical automatic, Autoclave
horizontal Hot air oven
Yes Yes Yes Yes
Specialty dependent ORs equipment
23. General Surgery
General Surgery Set, Vascular Repair
Set, Proctoscope electric (set),
Sigmoidoscope (fibroptic), Paediatric
surgery minor, Paediatric surgery major,
General surgery sets major,
General surgery sets minor
Yes Yes Yes Yes
24. Eye
Operation Theatre
Binocular loup(2.5 x), Operating
microscope, Phacoemulsifier, Bipolar
cautery, Autoclave, Hot air oven,
Boiler, OT tables-2, Cataract sets-4,
DCR sets-2, Glaucoma sets-2, Squint
sets-2, Entropion/ectropion sets-2,
Chalasion sets-2, Instrument trolleys-
6,drums-4, Cheital foreceps with
container-2, Desktop computer with UPS
for data entry
Yes Yes Yes No
25. ENT
Binocular Operating microscope, loops,
Head light, ENT surgery instruments
major
Yes Yes Yes No
26. Gynae
Gynaecology Sets, Delivery set normal,
Obstructed labour set, Obstetric surgery
set minor, Obstetric surgery set major,
E&C set
Yes Yes Yes Yes
27. Orthopaedic
Orthopaedic Sets, Set for plating,
Orthopaedic surgery set, Orthopaedic
Operation Table with Traction,
Bone drill, 3.5 mm Ortho Set,
4.5 mm Ortho Set, DHS Set, Vascular
Yes Yes Yes No

114
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Repair Set, Pneumatic Tourniquets,
28. Labor room
Infrastructure
Doctors duty room with bath room,
Doctors changing room, Nurses
changing room with bath room, rooms
for patient with a bath room and Delivery
tables, Baby warmer, Wheel chair,
Stretcher
Yes Yes Yes No
Intensive Baby Incubator Yes Yes No No
Equipment
Nitrous oxide Cylinder, Nitrous oxide
cylinder flow meter, Stethoscope, BP
apparatus stand type, Measuring tap,
Torch, Cotton wool, weighing
machine,examination gloves, Portable
Defibrillator with ECG monitor,
Resuscitation unit, Ambu bag,
Endotracheal tubes various sizes,
Nursing station, Pulse oxymeter,
Glucometer, Foleys urinary catheter,
I.V cannula various sizes, Drip stands
Instrument tray/Kidney tray/Bowls,
Oxygen flow meter with humidifier,
Oxygen masks all sizes, Electric water
cooler with filter, Heavy duty suction
machine, Light duty nebuliser, Light duty
suction units, Refrigerator 12 cf. ft., X-ray
illuminator double wall type,
Sterilizing drums, Meigle forceps,
backup, Delivery set normal, Obstructed
labour set, Mobile OT Light, Vacuum
Extractor, CTG Machine, Sonic/Doppler
Sonic aid,
DNC Set, Infant Trolley with Warmer,
Infant Sucker Machine, Female metal
catheter F201, F203, F204, F28,
Stethoscopes foetal (aluminium),
Hysteroscope
Yes Yes No No
29. A&E
Infrastructure
Doctor duty room with bath room,
Nursing dressing room with a bath room,
Patients waiting area, Patient short term
stay area, Day care facility (monitored
care for upto 12 hours by house staff),
Minor procedure room
Yes Yes Yes Yes
Equipment
Emergency assessment:
Stethoscope, BP apparatus stand type, Yes Yes Yes Yes

115
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Tendon hammer, Measuring tap,
Torch, Cotton wool, Spatula, Tuning fork
128 cycles/second, weighing machine,
examination gloves, ophthalmoscope,
Portable Defibrillator with ECG monitor,
Resuscitation unit, Ambu bag,
Endotracheal tubes various sizes,
Nursing station, Pulse oxymeter,
Glucometer, Nasogastric tubes,
Foleys/Celestic urinary catheter, I.V
cannula various sizes, Central line,
Drip stands, Instrument tray/Kidney
tray/Bowls, Laryngoscope adult straight
& curved, Oxygen cylinder with trolley
stand, Oxygen flowmeter with humidifier,
Oxygen masks all sizes, SS urinal/bed
pans, Heavy duty suction machine, Light
duty nebuliser,
Light duty suction units, Refrigerator 12
cf. ft., Spirometer, ray illuminator double
wall type, X-ray illuminator double table
type, Sterilizing drums,
Meigle forceps, Instrument tray/Kidney
tray/Bowls, Portable emergency light
with battery backup, General Surgery
Dressing Instruments Sets, Electric
water cooler with filter, Glucometer,
Oxygen tent, TV 28 Inch, Nitrous oxide
cylinder 240 cft., Nitrous oxide cylinder
flow meter, Desktop computer with UPS
and printer
ECG monitored beds Yes Yes Yes Yes
4 for CAT A, 2 for
CAT B, 1 each for
CAT C and CAT D
hospital
X-Ray Unit 500-MA with accessories
(mobile),
Yes Yes Yes No
Emergency OR/Minor procedure
room:
Autoclave horizontal, ECG machine,
Diathermy, Mobile OT light, Operation
table hydraulic, OT ceiling light with
satellite
Yes Yes Yes Yes
Cardiac monitor with defibrillator on
trolley
Yes Yes Yes No
30. Support Services
Electric Water Cooler, Stretchers, wheel
chairs
Yes Yes Yes Yes
31. Laboratory
Refrigerator 12 cb. Ft.,
Spectrophotometer with U/V, LPG
cylinder with burner, Microscope
binocular electric, Urine analyser,
Haematology Lab. Analyser (Large),
Yes Yes Yes Yes

116
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
Fed 20 for ESR, Finn Pipette-(Jouster)
05-----100mq/L, Finn Pipette-(Jouster)
100-----1000mq/L, Finn Pipette-(Jouster)
0.05-----20mq/L, Haemoglobin meter
(sahli), Urinometer with glass cylinder for
specific gravity, Sprit lamp,
Haemocytometer (complete), Aseptic
hood, Autoclave vertical automatic,
Automatic lab, Pipettes set, Blood
analyser, Blood bank refrigerator,
Blood gas analyser, Centrifuge machine,
Blood Chemistry Analyser,
Lab. Incubator, Lab. Weight
Machine/Digital Scale, Glucometer,
Hot Air Oven, Desktop computer with
UPS and printer
32. Radiology
CT scan Yes No No No
Colour doppler/Ultrasound Machine, Yes Yes No No
Radiation densitometer, X-Ray
Cassettes all sizes, Lead gowns,
Gloves, Goggles,
Shield set, Hangers x-ray, Ultrasound
Machine with double probe (vaginal and
abdominal), X-Ray Illuminator double
wall type, X-Ray Illuminator double table
type, Desktop computer with UPS and
printer
Yes Yes Yes Yes
33. Pharmacy
Maintenance of stock and inventory,
Drugs mentioned in formulary,
Refrigerator 12 cb. Ft, Desktop computer
with UPS and printer
Yes Yes Yes Yes
34.
IT Services
Computerization of hospital services,
Computers and networking items
Yes Yes Yes Yes
35.
Safe Waste disposal
Collection and segregation at the facility
Yes Yes Yes Yes
Transportation and
disposal at
incinerator at CAT A
hospital
36.
Mortuary
Electric skull cutter, Mortuary table,
Name plates, Mortuary instruments sets
Yes No No No
37.
Laundry
Washer, dryer
Yes Yes Yes Yes
38.
Canteen
Food available for patients, personnel
and attendants
Yes Yes Yes Yes
39. Administration Block
Infrastructure
Office Medical Superintendent, Office
Deputy Nursing superintendent, Office
Superintendent with Sr and Jr clerk,
Yes Yes Yes Yes

117
CAT
A
CAT
B
CAT
C
CAT
D
Remarks
IT office, All offices including A&E,
consultant offices and ORs, connected
through internal telephone from internal
exchange
Equipment
Computer Desktop with UPS and Printer,
Scanner, Sound system with speakers to
cover all essential areas for internal
announcement,
DVD Player connected to TV in OPD,
A&E, wards and ORs for patient
education on common illnesses with
emphasis on primary and secondary
prevention, Close Circuit TV System,
Laptop, Multimedia with overhead
project & screen, Electric Water Cooler
with filter, Refrigerator 12 cu ft,
TV LCD 46 inches, Photocopier
Yes Yes Yes Yes
40. Sets of basic gardening equipment Yes Yes Yes Yes
To be available in
quantities as per
need
41. Fire extinguishers Yes Yes Yes Yes
To be available in
quantities as per
need
42. Stretcher trolley Yes Yes Yes Yes
To be available in
quantities as per
need
43. Wheel chairs Yes Yes Yes Yes
To be available in
quantities as per
need
13.9 List of Medicines prepared by Medicines Co-Ordination Cell (MCC),
2015-16, Govt. of KP
ANAESTHETICS
S.No Name of Medicine
1. Isoflurane liquid for inhalation
2. Sevoflurane liquid for inhalation
3. Inj. Propofol 10mg/ml
4. Inj. Bupivacaine Spinal 7.5%
5. Inj. Lignocaine 2%
6. Sol: Lignocaine 4%
7. Inj. Lignocaine HCl + Adrenaline
8. Inj Glycopyrolate
9. Inj. Atracuriurn Besylate 30 mg
10. Inj.Atracuriurn Besylate 50 mg
ANTI-HISTAMINES
S. No Name of Medicine
11. Tab. Cetirizine 10 mg
12. Syp. Cetirizine 5 mg/5 ml
13. Tab Chlorpheniramine 4mg
ANTI-INFECTIVES
14. Cap Amoxicillin 250 mg

118
15. Cap Amoxicillin 500 mg
16. Susp Amoxicillin 125 mg / 5 ml
17. Susp Amoxicillin 250 mg / 5 ml
18. Tab Amoxicillin + Clavulanic Acid 375 mg
19. Tab Amoxicillin + Clavulanic Acid 625 mg
20. Tab Amoxicillin + Clavulanic Acid 1gm.
21. Syp.Amoxicillin + Clavulanic Acid 125 mg +31.5mg /5 ml
22. Inj Amoxicillin + Clavulanic Acid 1.2 gm
23. Cap: Cephradine 500mg
24. Inj: Cephradine 1gm
25. Inj: Cefotaxime Sodium 500mg
26. Inj: Cefotaxime Sodium 1gm
27. Inj: Ceftriaxone 500mg
28. Inj: Ceftriaxone 1gm
29. Inj: Ceftriaxone 2gm
30. Inj Ceftazidime 500mg
31. Inj Ceftazidime 1 gm
32. Cap Cefixim 400 mg
33. Susp. Cefixim 100 mg /5 ml
34. Susp. Cefixim 200 mg /5 ml
35. Inj Cefoperazone + Salbactum 1gm
36. Inj Cefoperazone + Salbactum 2gm
37. Cap. Doxycycline 100 mg
38. Inj.Gentamicin Sulphate 80 mg
39. Inj Amikacin Sulphate 100 mg
40. Inj Amikacin Sulphate 500 mg
41. Tab: Clarithromycin 250mg
42. Tab: Clarithromycin 500mg
43. Syp: Clarithromycin
44. Cap Azithromycin 250mg
45. Tab Azithromycin 500mg,
46. Syp: Azithromycin 200mg,
47. Tab: Co-Trimoxazole 80 mg + 400 mg
48. Tab: Co-Trimoxazole 160 mg + 800 mg
49. Susp Co-Trimoxazole 40 mg + 200 mg /5ml
50. Susp Co-Trimoxazole 80 mg +400 mg /5ml
51. Tab: Ciprofloxacin 500mg
52. Tab: Ciprofloxacin 500mg
53. Inf: Ciprofloxacin 100ml
54. Cap: Levofloxacin 250mg
55. Cap: Levofloxacin 500mg
56. Inf: Levofloxacin 100ml
57. Inj: Vancomycin 500mg
58. Inj: Vancomycin 1gm
59.
Inj.Piperacillin + Tazobactam
4.5 gm
60. Tab: Rifampicin + INH 150 mg + 75 mg
61. Tab: Rifampicin + INH + Ethambutol (150 mg + 75 mg + 300mg)
62.
Tab: Rifampicin + INH + Pyrazinamide + Ethambutol (150 mg + 75 mg + 400 mg + 275
mg)
ANTI-FUNGALS/ANTI-VIRALS
63. Cap Fluconazole 50mg
64. Cap Fluconazole 150mg
65. Nystatin Oral Drops
66. Tab Clotrimazole 500 mg Vaginal + Applicator
67.
Clotrimazole 1% Vaginal Cream
+ Applicator

119
68. Tab Acyclovir 200mg
69. Inj. Acyclovir 250mg
70. Acyclovir Cream
71. Tab Entacavir 0.5mg
72. Tab: Telbivudine 600mg
ANTI-MALARIALS
73. Tab: Artemether + Lumefantarine Tablets (40mg + 240mg)
74. Sulphadoxine + Pyrimethamine (500 mg + 25 mg) Susp
75. Tab: Amodiaquine Base 150mg
AMOEBICIDES
76. Tab .Metronidazole 400 mg
77. Susp Metronidazole 200 mg / 5 ml
78. Inf: Metronidazole 100ml
ANTHELMINTICS
79. Tab:Albendazole 200 mg
80. Susp: Albendazole 100 mg / 5 ml
BLOOD FORMATION / COAGULANTS / ANTICOAGULANTS & ANTI ANAEMIC
81. Tab Ferrous Sulphate + Vit. C + Vit-B. Complex + Folic Acid
82. Syp. Ferrous Sulphate + Vit. C + Vit-B. Complex + Folic Acid
83. Inj Heparin Sodium 5000 i.u
84. Inj: Enoxaparin 40mg
87. Tab: warfarin sodium 1mg
88. Cap.Tranexaminic Acid 250 mg
89. Cap. Tranexaminic Acid 500 mg
90. Inj Tranexaminic Acid 250 mg
ANTIDOTES
91. Inj: Neostigmine 2.5mg
92. Inj.Desferoxamine 500mg
93. Tab Deferasirox 100mg
94. Tab Deferasirox 400mg
CARDIOVASCULAR
95. Tab Atenolol 50 mg
96. Tab Atenolol 100 mg
97. Tab Bisoprolol 5mg
98. Tab Captopril 25mg
99. Tab Lisinopril 5 mg
100. Tab Lisinopril 10 mg
101. Tab Verapamil 80mg
102. Tab: Amlodipine Besylate 5mg
103. Cap Glyceryl Trinitrate 2.6 mg
104. Tab.Isosorbide Mononitrate 20 mg
105. Inj Isosorbide Di Nitrate
106. Tab Amiodarone HCl 200 mg.
107. Inj: Amiodarone HCl 200 mg.
108. Inj.Dobutamine HCl 250 mg
109. Inj: Dopamine HCI 200mg
110. Inj.Streptokinase 1.5 miu
111. Resovuastatin 10mg Tab
112. Tab Furosemide 20 mg
113. Tab Furosemide 40 mg

120
114. Inj Furosemide 10 mg
115. Tab: Spironolactone 100 mg
116. Inj Nitoprusside 50mg
117. Tab Valsartan 80mg
PSYCHOTHERAPEUTICS
118. Tab. Bromazepam 3 mg
119. Tab Alprazolam 0.5 mg
120. Inj Midazolam 5 mg
121. Inj.Fluphenazine Decanoate 25 mg
122. Tab. Haloperidol 5 mg
123. Tab Amitriptyline HCl 25mg
124. Tab. Dothiepin HCl 25 mg
125. Fluoxetine HCl 20 mg Cap
126. Tab Clozapine 25mg,
127. Tab Clozapine 100mg,
128. Tab Escitalopram 10 mg
129. Tab.Risperidone 2mg
130. Syp. Risperidone
131. Tab.Lamotrigine 50 mg
ANALGESICS & ANTIPYRETICS
132. Tab Acetyl Salicylic Acid 75 mg
133. Tab Acetyl Salicylic Acid 300 mg
134. Tab: Diclofenic 50mg
135. Inj: Diclofenic 75mg
136. Tab Ibuprofen 400 mg
137. Susp Ibuprofen 100 mg / 5 ml
138. Tab Mefenamic Acid 250mg
139. Tab Mefenamic Acid 500mg
140. Inj. Nalbuphine HCl 20 mg
141. Tab Paracetamol 500 mg
142. Syp: Paracetamol 120mg/5ml
143. Inj Paracetamol 2ml
144. Inj Tramadol HCI
145. Inj Katorolac 30mg
ANTICONVULSANTS
146. Tab Carbamazepine 200 mg
147. Syp Carbamazepine
148. Tab Divalporex Sodium 250 mg
149. Tab Divalporex Sodium 500 mg
150. Syp: Divalporex Sodium
ENT PREPARATIONS
152. Betamethasone + Neomycin Drops
153. Betamethasone + Neomycin Ointment
154. Nasal Drops Xylometazoline HCl 0.05%
DRUGS ACTING ON ENDOCRINE SYSTEM
155. Tab Glibenclamide 5 mg
156. Tab Metformin HCl 500 mg
157. Tab: Glimipride 2mg
158. Insulin Regular (Human) 100 IU vial
159. Insulin Premixed (Human) 30/70 100 IU vial
160. Inj Hydrocortisone 100 mg
161. Inj Hydrocortisone 250 mg
162. Inj.Dexamethasone 4mg

121
I.V FLUIDS AND ELECTROLYTES
163. Inj. Sodium Bicarbonate 0.7% iv Solution 20ml
164. Inj. Potassium Chloride 7.4% iv solution 20ml
165. Normal Saline 0.9% 100ml
168. Dextrose 5%100ml
169. Dextrose 5% 500ml
171. Dextrose + Saline 5% 500ml
172. Dextrose + Saline 5% 1000ml
173. Ringer Lactate 500ml
174. Ringer Lactate 1000ml
175. Ringer Lactate + Dextrose 500ml
176. Ringer Lactate + Dextrose 1000ml
177. Dextrose 5% + 0.45% NaCl 500ml
178. Dextrose 4.3%+NaCl 0.18% 500ml
179. Infusion Mannitol 20%
180. Gelatin Polypeptide 500ml
181. Amino Acids Infusion 5%+10%
182. Sterile water for injection 5ml
184. Glycine 1.5% Infusion with TSD set
185. Oral Re-hydration Salt. (ORS)
GASTROINTESTINAL DRUGS
186. Aluminium Hydroxide + Magnesium Hydroxide + Semithicone Susp:
187. Aluminium Hydroxide + Magnesium Hydroxide + Semithicone Susp:
188. Tab Dimenhydrinate 50mg
189. Inj: Dimenhydrinate
190. Syp Dimenhydrinate
191. Inj: Metoclopramide HCL 10mg
192. Tab. Domperidone 10 mg
193. Inj Ranitidine HCl
194. Cap: Omeprazole 20mg
195. Inj. Omeprazole 40mg
196. Tab Drotavarine Hcl 40mg
197. Inj Drotravarine Hcl 40mg
198. Inj Octreotied 0.1mg
199. Inj Terlipressin 1mg
IMMUNOLOGICALS / IMMUNOMODULATORS
200 Inj: Rabies Immunoglobulin
201
Inj. Rabies Vaccine
(Supply order is subject to NOC from NIH Islamabad regarding non- availability
of vaccine)
202 Inj Anti – Venom Sera
203 Inj Hepatitis B Vaccine. 20 mcg with DRAP registered disposable syringe
204 Inj.Tetanus Toxoid
205
Inj. Pegylated Interferon 180mcg, 40Kda + Cap/Tab Ribavarin 400mg + with DRAP
registered disposable syringe 3CC (Package rate).
206
Inj. Anti.-D (Rho)
Immunoglobulin
OPHTHALMIC PREPARATIONS

122
207. Eye Drops Chloramphenicol 0.5
208. Eye Drops Ciprofloxacin 0.3%
209. Eye Drops Dexamethasone 1%
210. Eye Drops Pilocarpine HCL 2 %
211. Eye Drops.Timolol Maleate
0.5%
212. Eye Drops Tropicamide 1 %
213. Eye drop Tobramycin
214. Eye drop Tobramycin + Dexa
215. Eye Oint Polymixin + Zinc
Bacitracin
216. Eye Oint Acyclovir
217. Eye Drop Polymixin + Neomycine+Dexamethasone
DRUGS USED IN RESPIRATORY DISORDERS
218. Tab Salbutamol 4mg
219. Solution Salbutamol
220. Salbutamol 100 mcg/dose aerosol
221.
Spray / Inhaler.Beclomethasone
+ Salbutamol
222. Syp Acefyline
TOPICAL PREPARATIONS
223
Polymyxin + Zinc Bacitracin
Skin Ointment
224. Silver Sulphadiazine 1% Cream Jar pack
225. Clotrimazole 1% Cream
226. Betamethasone 0.1% Ointment 15gm
227. Betamethasone 0.1% Cream: 15gm
228. Betamethasone + Gentamicin Ointment
229. Lignocaine HCl Gel 2%
230. Permethrine Cream 5% w/w
231. Permethrine Lotion 5% w/w
DISINFECTANTS & ANTISEPTICS
232. Solution Povidone- Iodine 60ml 10%
233. Solution Povidone- Iodine 450ml 10%
234. Scrub Povidone- Iodine 7.5% 60ml
235. Scrub Povidone- Iodine 7.5% 450ml
236. Solution Chloroxylenol 4.8 %
VITAMINS / MINERALS
237. Tab. Vitamin B-Complex
238. Syp Vitamin B-Complex
239. Tab Pyridoxine HCl 50 mg
240. Tab Ascorbic Acid 550 mg
241. Tab Calcium Carbonate
MISCELLANEOUS THERAPEUTIC AGENTS
242. Inj Oxytocin 5 i.u
243. Tab. Misoprostol 200mcg
244. Megulmine diatrizoate
245. Iopromide Inj 300/370mg
246. Tab Alfacalcidol 0.5 mcg /ml
247. Inj. Epoetin Alpha
248. Inj. Epoetin Beta
249. Inj. Methoxy Polyvthlene Glycol-Epoetin beta
250. Solution Hemodialysis

123
251. Tab: Mycophenolate Sodium 180mg
252. Tab: Mycophenolate Sodium 360mg
253. Tab: Mycophenolate Mofetil 500mg
254. Cap: Cyclosporine 25mg
255. Cap: Cyclosporine 100mg
256. Inj: Basiliximab
257. Tab: Everolimus
SURGICAL DISPOSABLES
1. Adhesive Tapes (paper/plastic) Non woven surgical tape
2. Adhesive surgical tape PE
3. Zinc Oxide Adhesive Plaster different sizes
4. Cotton Bandages (Surgical)
7. Absorbent Cotton Wool 100 gm
8. Absorbent Cotton Wool 200 gm
9.
Absorbent Cotton
Wool 200 gm
10.
Absorbent Cotton
Wool 400 gm
11.
Absorbent Cotton
Wool 400 gm
12. Crepe Bandages
13. Gauze Cloth Roll
14. Gauze Cloth Roll
15. Medicated Dressing Different Sizes
16. Knitted paraffin Gauze with 5% Chlorohexidine (Different sizes roll)
17. Knitted paraffin Gauze with 5% Chlorohexidine (Different sizes roll)
18. 1CC Disposable Syringe blister pack (Regular)
19. Insulin 1CC Disposable Syringe blister pack
20. 3CC Disposable Syringe blister pack
24. 50CC Disposable Syringes blister pack
25. 60CC Disposable Syringes blister pack
26. Foleys Catheter (Plain & Silicon) Different Sizes.
27. I.V Cannula Different Sizes
28. I.V infusion Set (Sterilized) blister pack
29. POP Bandages Different Sizes
30. Urine Bag
31.
Spinal needle 23 & 24 (Disposable)
(with and without introducer)
32. Surgical Blade
33. Surgical Gloves Sterilized
34. X-ray film
35. X-ray film
36. X-ray film
37. X-ray film
38. X-ray film
39. Auto developer 20 litre
40. Auto fixer 20 litre
41. X-ray films
42. Manual developer
43. Manual fixer
44. Mamography HDR/ADM
45. Mamography ADM

124
SUTURE MATERIAL
CHROMIC CAT GUT
46. 20mm ½ CRB Needle 4/0
50. 30mm ½ CRB Needle 0
S.No BLACK BRAIDED SILK
56. 16mm 3/8 cutting curved 4/0
57. 24mm 3/8 CRV Cutting 4/0
59. 16mm ½ RB Needle (Non cutting) 3/0
60. 26mm 3/8 rev: Cutting 2/0
61. 30mm ½ RB Needle (Reverse cutting) 2/0
62. 30mm cutting needle (RB) 0
63. 30mm ½ RB Needle 0
64. 25mm ½ Curved cutting 0
66. 30mm ½ Curved cutting 1
67. 30mm cutting needle ½ RB 1
68. 40mm ½ RB Needle 1
69. 40mm ½ RB Cutting 1
S.No. POLYGLYCOLIC
71. Polyglyctin Braided with Double Needle 6/0
72. 17mm ½ CRB 5/0
73. 16mm 3/8 cutting RB 4/0
74. 20mm ½ round body 4/0
75. 16mm Cutting RB 4/0
76. 17mm non cutting 4/0
77. 16mm 3/8 cutting RB 3/0
78. 20mm ½ round body non cutting 3/0
79. 26mm 3/8 rev: C 2/0
80. 30mm ½ round body non cutting 2/0
81. 30mm ½ CRB 2/0
82. 35mm taper cut ½ C 90cm 2/0
83. 48mm ½ RB non cutting 2
84. 45mm ½ round body non cutting 2
88. 40mm ½ CRB non cutting 0
90. 35mm taper cut ½ C 90cm 1
S.No. POLYGLYCOLIC
91. 2x8mm ½ CRB 8/0
92. 8mm 3/8 fine double 6/0
93. 12mm 3/8rev: cutting 6/0
94. 13mm ½ CRB fine double 5/0
95. Polypropylene with Double Needle, RB db end 5/0
96. 15mm CC fine 5/0
97. 16mm ½ CRB double
98. 15mm CC fine 4/0

125
99. 16mm ½ CRB double ended 4/0
100. 19mm cutting curved 4/0
101. 17mm RB Double ended 3/0
103. 24mm 3/8 C R Cutting curved 3/0
105. 16mm CC 3/0
106. 25mm ½ CRB Db ended 3/0
107. 26mm RB double ended 3/0
108. 30mm ½ RB 2/0
109. 25mm ½ RB 2/0
110. 75mm 3/8 Rev: C 2/0
111. 25mm taper cut 2/0
112. 75mm ST Cutting Needle 2/0
113. 75mm St Ct 2/0
114. 36mm 3/8 C Rv Cutting 0
115. 30mm ½ RB 0
116. 30mm ½ RB 1
117. 40mm ½ RB 1
118. 30mm ½ CRB 1
POLYPROPYLENE MESH
S. No Size
119. 30cm x 30cm
120. 6cm x 11cm
121. 15 cm x 15cm
STEEL WIRE
S. No Size
122. 48mm ½ Trocar Point Heavy 5
BONE WAX
S. No Size
123. Bone wax

126
13.10 Meetings of the Clinical Sub-Committee
A. Minutes of the First Clinical Sub-committee Meeting
Consultative Meeting with Technical Sub-Committee for Developing MHSDP for
Secondary Care Level.
Date: August 12, 2016
Place: TRF+ office at PC Hotel, Peshawar
Participants:
COMMITTEE MEMBERS:
Dr. Ibrar Member
TRF+ Representatives:
Dr. Shabina Raza: Team Leader
Dr. Mohammad. Naeem Health Specialist
HSRU Representative
Dr. Shahzad Faisal: Focal person MHSDP assignment
Consultants’’ Team:
Dr. Inayat Thaver Team Leader
Dr. Muhammad Khalid Public Health Specialist
Mr. Qabil Shah Khattak: Research Associate
AGENDA:
1. Introduction of the assignment and role definition of various stakeholders
2. Background update on the assignment
3. Discussions on the MHSDP for secondary level
4. Way forward and further consultations
MEETING DETAILS
1. Introduction of the assignment and role definition of various stakeholders

127
The meeting was chaired by Prof. Noor-ul-Iman. He emphasized the need for having a
practical package of services which can be applicable and easily implementable. He shared
his experiences as regards lack or ineffective services resulting in lot of sufferings of
patients. He also appraised the participants that as part of 20 years future planning, it is
envisaged that all the districts should have a medical college along with the teaching
hospital; thus the need for improving health services at district level.
2. Background update on the assignment
Dr. Thaver briefly explained the purpose and expected outcome for developing the MHSDP
for secondary level care facilities, explaining the need and expected outcome and
expectations from the participants of this committee. He also emphasized the need for
ensuring that in addition to including the major specialties in the Package, we should have
the preventive and promotive care as had already been identified in the MHSDP- for Primary
level. The need for inclusion of some support services such waste management, infection
control, patients’ rights support services may also be included as part of this package.
This was followed by the discussion on MHSDP; Dr. Khalid shared the draft format for the
package prepared by the team
3. Discussions on the MHSDP for secondary level
Following are the key highlights of the discussion and agreement:
a. Categories of facilities at secondary level or just secondary care level
Debate was held on the need to have categories and notification as had been issued on
this matter. The categories divided as Type A to D are based on the local catchment
population and the bed strength, the assumption appears to be the fact that the more the
population the more the need for hospitalization and need for more specialties and
higher level of care. HSRU made a case for having the package according to various
categories, including all the types.
However, it was noted by Chair and other members that though it’s a good concept, but
considering the fact that we are talking about the “Minimum” possible services, all the
facilities disregard of the types should have at least all these services as part of MHSDP.
This might be also necessary considering the fact there is no operational referral system
within the province and within even districts. It was suggested by the chair that for the
time being, the group should pick 6-8 major specialties (which are also recommended by
PMDC) and identify various requirements, i.e. function, HR, equipment, medicines etc.
so that on can have standardized access to these secondary level care services,
disregard to the type of facility.
b. Appreciation of lack of referral system among various level of facilities and short-
term solutions
As mentioned earlier, the fact that currently, there is no operational and functional
Referral System; thus the rationale for have some standardized package of ‘minimum’
services by all the secondary level care facilities should be ensured. This should also be
further added with the basic preventive and promotive services as had been identified in

128
the MHSDP for Primary level. Thus the package to be prepared will just mention about
the necessity of including these services and referred to the Primary Package.
c. Cross-cutting services for improving secondary level care facilities
It was noted and endorsed by most participants that the package should also identify and
briefly mention about the services which are not directly the “health services”, but
important for smooth running of various services and supplement its effectiveness.
These have been grouped as:
• Infection Control services including Waste management
• Patients’’ rights and facilitation services
• Reception/facilitation area for the patients
• Nursing counters
• Guidance for patients to reach a particular unit/department, by colour coding
• Patient information board
• Waiting areas having basic utilities such as public toilets
• Wheel chairs and trolley to shift patients
• Laundry services
• Infrastructure supportive services
• Types of floor (no unevenness) and ramps
• Back up electricity and generator etc.
• Emergency supportive facilities
• Triage facilities
• Ambulance services
d. Implementation of package as a follow up
It was emphasized that package should not only be practical and easily implementable.
In that context, it was noted that some follow up exercise in terms of SOPs, clinical
guidelines and District/provincial Formulary can also be developed and notified. It was
also noted that, this Package will be a living document and can be updated/revised after
2-3 years to include other services. In addition, this Package can also serve as
prompting to establishing a functional referral system.
It was agreed by the participants, that the technical committee members will get the soft
copies of the detailed functions/services, equipment and medicine lists for respective
specialties; all will identify/fill the minimum package and various requirements and share it
with the consultants’ team by 20th
of August.
A follow up meeting will be held on 23rd
of August to discuss it further and finalize it so that
meetings with the a) Administrative committee and b) Preventive committees be also held as
a follow up.
The meeting ended with a vote of thanks to the worthy chair.

129
B. Minutes of the Second Clinical Sub-committee meeting
Consultative Meeting with Technical Sub-Committee for Developing MHSDP for
Date: August 23, 2016
Participants:
COMMITTEE MEMBERS:
Dr. Ibrar Member
HSRU Representative
Dr. Shahid Younas Chief Health Sector Reform Unit
AGENDA:
1. Discussion on the proposed draft MHSDP package presented in first clinical sub-
committee meeting
2. Specialty wise inputs from the committee members
MEETING DETAILS
1. Discussion on the proposed draft MHSDP package presented in first clinical sub-
committee meeting
The meeting was chaired by Prof. Noor-ul-Iman. He initiated the discussion on the proposed
draft with emphasis that there should be a minimum services package that is applicable to all
tiers of the secondary care. Debate was held on the need to have categories and notification
as had been issued on this matter. The categories divided as Type A to D are based on the
local catchment population and the bed strength, the assumption appears to be the fact that
the more the population the more the need for hospitalization and need for more specialties

130
and higher level of care. HSRU made a case for having the package according to various
categories, including all the types. Dr. Shahid Younas appraised the committee members
that there is a need for identifying the minimum package of services specific to each tier of
the secondary care as the scale and scope of each tier vary and the same set of services
cannot be expected from Category D hospital and Category A hospital e.g. the specialties
required at the Category D hospital will not be the same as required in Category A hospital
and so as the HR and equipment requirements for them. Dr. Shahid further clarified that the
activity is to enlist the services that will be expected to be present at each tier rather than
having standards for these services. The criterion for the categorization of the secondary
care hospitals including the specialty, bed strength and HR details were shared with the
committee members. Dr. Noor ul Iman shared his point of view that as it is a set of minimum
services, the committee would develop a list of minimum services irrespective of the tier of
care, however the HSRU and the consultant team can then decide on which tier to provide
which services.
2. Specialty wise inputs from the committee members
Dr. Noor ul Iman led the process of discussion and incorporation of the inputs from the
committee members. Item wise discussion was carried out and consensus was built around
the need for each service to be included in the package. Along the course of discussion,
comments were recorded against each service/HR/Equipment item with regards to its
applicability across all tiers or a consideration of the type of the hospital for specifying the
details of service. It was also proposed that the approved list of Medicines, Surgical
Disposables and other non- Drug Items of Government prepared by Medicines Co-
Ordination Cell (MCC), Khyber Pakhtunkhwa for the year 2015-16 will serve as drug
formulary for the district hospitals; however the concerned hospital will have the liberty to
choose the medicines/drugs/surgical items from the MCC list to be procured as per their
needs. The revisions to the proposed draft were made along the course of discussion. Dr.
Noor ul Iman informed that the revised package after incorporation of specialty wise inputs
from the members will be shared with the committee members.
It was agreed by the participants, that the HSRU team and the consultants will hold meetings
with the Administrative and Preventive sub-committees and after having their inputs a joint
meeting of all the three sub-committees will be held to have consensus on the developed
package.

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13.11 Meetings of the Preventive Sub-Committee Meetings
A. Minutes of the First Preventive Sub-Committee Meeting
Consultative Meeting with Preventive Sub-Committee for Developing MHSDP for
Date: September 2, 2016
Participants:
COMMITTEE MEMBERS:
Dr. Nasir Saeed Chair of the committee, Dean PICO
Dr. M. Ayub Rose PM/PD HIV/AIDS
Dr. Malik Niaz PD TB control Program
Dr. Sahib Gul PC MNCH Health Department
Dr. Azmat ullah/ Hamid Iqbal DD (DHIS)/D/A (DHIS)
HSRU Representative
Dr. Shahid Younas Chief Health Sector Reform Unit
TRF+ Team
Dr. Shabina Raza TRF+ Team Leader
Dr. Shabnam RMNCH TRF+
Ms. Shazia Khalid M&E Specialist TRF+
AGENDA:
1. To define/review dimensions of preventive and promotive care based on the
epidemiological profile (as much as possible) of the province

132
2. To estimate utilization rates of various preventive care services at each level of care
based on empirical evidence such as might be obtained from any health surveys undertaken
in the province or from the DHIS
MEETING DETAILS
1. Discussion on the approach to develop preventive care package for the secondary care
as part of the MHSDP SC
The meeting was chaired by Prof. Nair Saeed. The discussion was initiated on whether there
should be same preventive care package across all types of secondary care hospitals or the
package should specify the type of secondary care hospital for each preventive service
being offered. Dr. Shahzad Faisal informed that the secondary care hospitals are
categorized as Type A to D based on the local catchment population and the bed strength,
the assumption appears to be the fact that the more the population the more the need for
hospitalization and need for more specialties and higher level of care. Dr. Shahid Younas
appraised the committee members that there is a need for identifying the minimum package
of services specific to each tier of the secondary care as the scale and scope of each tier
vary and the same set of services cannot be expected from Category D hospital and
Category A hospital e.g. the specialties required at the Category D hospital will not be the
same as required in Category A hospital and so as the HR and equipment requirements for
them. Dr. Shahid further clarified that the activity is to enlist the services that will be expected
to be present at each tier rather than having standards for these services. Dr. Ayub Rose,
Dr. Inayat Thaver and other members of the committee agreed that the preventive care
package should be drafted across the four categories of secondary care hospitals (A,B,C,D).
2. Preventive care Theme wise discussion
The proposed draft themes for the preventive care were shared with the committee
members. The discussion was initiated on whether to structure the “Preventive Care
Themes” according to continuum of care or specialty/ward specific package. Dr. Ayub Rose
suggested and other committee members agreed that the themes may be re-structured
according to continuum of care. Dr. Ayub Rose suggested that there should be a preventive
care unit within the hospital which could provide training/capacity building of the hospital staff
on preventive care. The committee members also suggested that there should be a
Nutritionist, Health Education Officer and a hospital Epidemiologist in the Preventive Care
Unit. Dr. Azmat suggested that a statistical assistant may also be added to the preventive
care team. Dr. Ayub Rose proposed that the OPDs should have a prevention room that
caters for the preventive health care services. It was also proposed that the OPDs should
have standardized preventive care videos displayed in local language. Dr. Azmat suggested
that the secondary care hospitals should be linked/connected through web portals to have
access to standard preventive care messages within and across districts. Dr. Nasir Saeed
proposed that there should be a mechanism for linkage (where possible) between the
hospital and the community medicine department of a medical college that may facilitate in
the community outreach services. It was also suggested that the District Health Officer
(DHO) should serve as a pivot for linkage between various programs (MNCH, LHW, EPI,
DHIS) in the district. Dr. Nasir Saeed suggested that the preventive Eye/Ophthalmic care

133
should be added as a theme while Dr. Thaver proposed to include the preventive Geriatric
care and mental health in the proposed themes. Dr. Azmat proposed that a specialist advice
may be sought for finalizing the contents of each team, to which all the committee members
agreed. Consequently, it was unanimously decided to sort advice from the following entities
finalizing the contents of preventive care themes.
- Maternal and Reproductive Health; Advice from Dr. Sahib Gul, PC MNCH Health Dept.
- Infant and Child Feeding Practices; and Prevention of Malnutrition - Advice from Nutrition
section/Program
- Promotion of Safe Water and Basic Sanitation; Advice from Dr. Ayub Rose, PM/PD
HIV/AIDS
- Immunization Practices; Advice from Dr. Hameed Afridi, DD EPI Program
- Control of Tuberculosis; Advise from Dr. Malik Niaz, PD TB control Program
- Control of Malaria; Advice from Malaria Program
- Control of Hepatitis; Advice from Hepatitis Control Program KP
- Control of blood pressure and prevention of heart attack and strokes; Health education
about diabetes; and other Non-Communicable Diseases (NCDs); Advise from Dr. Sabina
- Preventive Eye/Ophthalmic Care; Advise from Dr. Nasir Saeed, Dean PICO
Following action points were identified at the conclusion of the meeting
- The proposed draft of the preventive care themes will be shared with all the committee
members
- The committee members and the aforementioned key specialist will provide feedback on
the proposed draft by 9th
of September, 2016
- Dr. Khalid will incorporate the feedback received
- The committee will discuss the revised draft and its distribution across all tiers of secondary
care in the next meeting which is planned on 23rd
September, 2016

134
13.12 Meeting of the Administrative Sub-Committee Meeting
Participants
Dr. Zafeer Hussain Chair of the committee, Health Integrated Program
Dr. Riaz Mohammad MS DHQ Mardan
Dr. Muhammad Niaz DHO Swabi
Dr. Naeem Awan MS GM & GH
Dr Inayat Thaver TRF Consultant
Dr. Jamal Afridi Consultant
Chaired by: Dr. Zafeer, Director, Integrated Health Programme.
This meeting was among the last of the series of meeting for developing the MHSDP-SC for
KP. The participants discussed and recommended a number on number of suggestions as
regards various categories of hospitals, Human Resources, infrastructure standards and the
medicines, surgical items and non-medical materials. The details are as follows:
1. Introduction, ‘category’ definition, criteria and current status
Dr Faisal Shahzad, the focal person from HSRU for this assignment welcomed the
participant’s followed by formal introduction of all members. He briefed the participants about
the MHSDP-SC, its objectives and the process so far held. He informed that the formal
categorization of the secondary car hospitals has been formally approved since early 2000s.
The members noted that many of the Category -D hospitals have excellent buildings, but
there is lack of required HR, especially the specialists. In that context, it was suggested that
the PG training of various specialties may consider rotating the trainees in various lower
level categories of hospitals. In addition, the members appreciated the fact that, when once
the MHSDP-SC is implemented fully, then “referral system” can also be functional because
of the variety and need of services in various categories. A number of the ‘departments’
identified in the documents for various categories were noted which were either not properly
represented or not identified; these need to be corrected. Some of them are Dialysis to be
changed to the Nephrology and there is no provision for Physiotherapy department.
2. Human Resource recommendations
The HR list with the consultant team (provided by HSRU) was then discussed. It was
updated by the Chair that since currently lot of recruitments is being done, it will be good
idea to have the latest list and then show it as comparison and the percentage of what has
been filled. In that context, Dr. Shahzad has agreed to get the latest list of HR position at the
secondary level of care.
" A detailed discussion was held the need to have centralized computerization system for
patients recording and for collecting the fees for diagnostics, such as X-ray and
laboratory tests; this was to ensure time management of both patient and hospital staff
as well as minimizing the pilferage of money. Following has been recommended for
category A and B, because of the larger number of beds and more turn-over of patients.

135
o Instead the position of the Junior Clerk, it should be changed to either “Data
Entry Operator (DEO) or Key Punch Operator (KPO) who is of the Grade 8 and
can be easily available.
! 6 DEO/KPO to be distributed as follows
! For OPD: 1 male; 1 Female
! For Emergency having 3 shifts 3
! For working as reliever 1
! For centralized fees collection and issuing the hospital receipt:
• 3 for 3 shifts and
• For working as reliever 1
o Finally, it was recommended that for category A, one needs to have 10 and
Category B Hospitals at least 8 KPO/DEO.
" It was also noted by all the participants that there is no JD for any of the HR and even if
it’s available, it is not known to all and it also needs to be improved. In that context, this
committee felt that rather having a designated “Public Health” person in the hospitals,
the JDs of the DMS should include all those aspects; this may include, quality
assurance, epidemic surveillance, disaster management, crowd management and even
disease control planning and training. etc.
" It was noted by the experts of this committee that lot of working of the hospitals gets
suffered because of the little number of DMS, especially at night and evening. Thus it
was recommended that all the hospitals having the strength of more than 200 beds,
there should be two more positions for the DMS which will apply for Category A and B
Hospitals. It was also recommended strongly that there should be a designated vehicle
and other associated facilities for the MS at least in Category A and B Hospitals.
" The issues related to procurement were also discussed. It was agreed that
recommended laws for procurement of medicines should be followed. However, the
Committee felt that there should be procurement Office of Grade 16, who should be
designated for this assignment at least for Category A and B Hospitals.
" It was recommended that HR should be calculated on the basis of expected/current
workload in terms of utilization of services and the current/future population increases.
However, some indicative number can be recommended for each category.
3. Expected Infrastructure for Hospitals
" It was noted by the Committee that the internationally recommended infrastructure
could be only applied to those hospitals which may be built in future. However,
some acceptable changes may be done. However, there were also some
reservations and practical recommendations in terms of the infrastructure which
should be based on the local situation and environment, geographical terrain and
availability of the of the space. Tus, for example it was recommended that instead of
having several big houses for staff accommodation, especially in far off places,
building of multistoried flats will be more practical.

136
" Standards for accessing the facilities usually suggests the ‘x’ Kms. Away. However,
in KPcontext, the more practical approach could be how much it takes to access the
services.
" The standards for theatre including the number should be based on the following
criteria:
o # of specialty in each Category
o # of OT days
o Per day workload for operations
o # of OT tables in one OT.
" It was nevertheless noted that the OT which have already been built can’t be
changed, so the recommendation that have already been made in the category
document can be considered.
" It was strongly recommended that there should be at least a “Emergency Theatre”
for Categories A and B.
" The need for sterilization system for OTs was also discussed. The number would
vary according operation Theatres (OTs) i.e. # of OTs and # of operations.
" The need for incinerator was also emphasized and recommended for having it at
least at DHQs or mostly the Category A hospitals. Thus in each districts, there
should be a centralized waste management approach. It was noted the wastage
collected has been found to be 2.5 Kg./bed/day. However, at the need, as illustrated
below it was recommended it should ideally be contracted out, because of the cost
implications and its follow up management.
" Within the infrastructure and various services, it was recommended that following
services should actually be contracted to the private sector:
o Laundry
o Electricity and plumbing
o Genitory/cleaning and washing services
o Sterilization of waste materials (as mentioned earlier)
o Parking space, if there is one or for future.
" The importance of having a triage area was again emphasized and should be
available in the Accident and Emergency Department/unit. It was also recommended
that a provision for simultaneously handling of 20-30 emergencies in Category A and
B should also be considered. The need for having an Emergency Theatre has also
been mentioned earlier.
" Some provisions for easy accessibility of the disabled and old age people should
also be ensured in all the hospitals by having ramps, trolleys, wheel chairs and any
other relevant provision.
4. Medicines, surgical items and non-medical materials

137
The list of Essential Medicines as well as MCC recommended lists were shared to the
committee. All the members unanimously agreed to follow the MCC list as has also been
recommended by The Clinical Sub-Committee. Some more suggestion have been made
which are highlighted as follows:
" Liberty should be given to each hospitals to procure the medicine according to their
needs. However, it was recommended that there can be a centralized procurement
system at the district level which should have representative for m all the categories
of hospitals of that district and then distribution be done according to workload and
disease trends. In that context, some budgetary provisions may be made for
unforeseen circumstances.
" The issue of testing all the drugs by the “Drug Testing Laboratory” (DTL) was raised
which had previously caused the delays upto 4-6 months for getting an approval for
its use. However, it was noted that recently, it has improved a lot. In that context,
some suggested to have DTL at the district or divisional level also.

138

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