Human Resource for Health shows Khyber Pakhtunkhwa significantly deficient
The Pakistan Medical and Dental Council (PMDC) has exclusive regulations namely the “Medical and Dental Institutions (Recognition, eligibility criteria for enhancement in annual admissions and accreditation standards) Regulations, 2012 to set requirements of Medical and Dental Colleges. Link of original regulation is given below.
I will be concentrating on the following Regulations in this writeup for a rough cost estimation:
- Regulation 4 as it says institution will be inspected and scored on the basis of facilities available as set out in Appendix-III of the Regulation.
- Regulation 13 which requires a separate College and Hospital building
- Regulation 16 which gives infrastructure requirement at Appendix-IV of College building including offices for faculty, administrators, support staff, laboratories, classrooms, auditorium etc,
- Regulation 17 regarding Affiliated Teaching Hospital wherein Appendix-V details hospital facilities whereas Appendix-VI details the units
- Regulation 28 wherein number, qualifications and functions of faculty are given at Appendix-VII.
Pertinently, in order to bring out implications, financial, physical, administrative, of setting up of a 100 seat medical college in public sector, while original PMDC regulations attached above contain all Appendixes, for calculation purposes most have been retyped as below:-
Mentioned requirements in Appendixes of PMDC Regulations and their costing
Appendix-III – The PM&DC criterion of 1000 marks for 100 MBBS admissions with break-up is as under:
|Infrastructure of College||200||120|
Appendix-IV: The details of College and Teaching Hospital infrastructure requirements as per the PMDC criterion are as under:
A – College
|Auditorium||15 sq ft/person||1||15 sq ft x 500 students||7500|
|Lecture Hall||15 sq ft/person||5||1500 sq ft each x 5 years classes||7500|
|Library||50 sq ft/ person||1||5000|
|Common Room Girls||At least 50 x 50 sqft||1||2500|
|Common Room boys||Atleast 50 x 50 sqft||1||2500|
|Tutorial (x4)||15 sq ft/person||4||375 sq ft each x 4||1500|
|Labs (x6)||50 sq ft/person||6||1250 sq ft each x 6||7500|
|Skill Lab||Lump sum||1000|
|Museum (x4)||20 sq ft/person||4||500 sq ft each x 4||1000|
|Offices (x7)||500 sq ft each department||7||3500|
|Mortuary & Anatomy Dissection hall||Lumpsum||1500|
|House Officer Hostel Male||Lumpsum||5000|
|House Officer Hostel Female||Lumpsum||5000|
|miscellaneous space (Administration)||2000|
|Circulation & other space||10000|
|Total||134325 sq ft|
B – Hospital
|Hospital Facility||500 beds||250 sq ft per Bed||125,000 |
|Teaching Facilitates and |
|10,000 sq ft|
|Faculty residence |
Total Covered Area as per Criterion:
|College||134,325 sq ft|
|Hospital||210,000 sq ft|
|Total||344,325 sq ft|
D. Other Facilities
|IT laboratories with Wi.Fi connectivity.|
|The library may be well-stocked with at least thirty copies of each and every text books and ten sets of at least five reference books in each subject.|
|That institute must have availability of internet connectivity and at least one computer per ten students on roll.|
Appendix-V – Hospital facilities including OPD, Pharmacy, Emergency Room, OTs, Clinical Care beds, Central Sterile Services Department [CSSD], Radiology Services, Laboratory Services, Food service, Waste disposal (incinerators):-
Equipment for Clinical Departments
Cost PKR Millions
|General Items (AC, CCTV, Networking, |
Computers, Generators, Security etc)
- Source Gajju Khan Medical College & ZAB Medical College
Equipment for Basic Sciences
Cost PKR Millions
|Library (Books + Equipment)||37.0|
|Vehicles (Buses, Coasters etc)||37.0|
|General Items (Generators, CCTV, Wifi connectivity, |
computers, networking, ACs, security etc)
|Furniture / Fixture||24.0|
- Source: Gajju Khan Medical College & ZAB Medical College
Appendix VI – Number of Beds (100 admissions)
|Othopedio / Trauma||40|
|Medicine & allied facilities||80|
|Surgery and Allied Facilities||80 (1 Unit of OMFS)|
Annex-VII – Faculty Requirement for MBBS – Basic Sciences & Clinical (100 admission)
|Associate Professor (BS-19)||Assistant Professor (BS-18)||Demonstrator|
Senior Registrar (for clinical) (BS-17)
|RMO BS-17 (for clinical)|
|Medicine & Allied||2||2||2||2||4|
|Surgery & Allied||2||2||2||2||4|
|Gynae & Obs||2||2||2||2||4|
|Anaesthesia||1||1||1||As per workload (1)|
|Radiology||1||1||1||As per workload (1)|
|A&E||1||CMO (3 per shift) = 9|
|Principal / VP||2|
Please note – Doctors, Paramedic, Nursing & other staff for both College & 500 bedded hospital has not been taken into account. However, ZAB Medical College Peshawar has calculated, grade and designation-wise, full pay which comes to Rs 400.056 Million per year. That calculation is attached in picture mode in the end.
COST CALCULATION – ONE TIME COST
|Buildings (covered area)||344,325 sq ft x Rs 3200 per sq ft as per CSR 2017 = Rs 1,101.840 million||Taken on lesser side as fixtures especially for medical equipment etc will escalate the cost|
|Equipment for basic sciences||Rs 352.62 Million||Taken at minimun requirement of PMDC|
|Equipment for Clinical Departments||Rs 1401.50 Million||Taken at minimum requirement of PMDC, otherwise tertiary care equipment required is much more|
|Total||Rs 2855.96 Million||Land cost not included|
COST CALCULATION – RUNNING COST (YEARLY)
|Human Resource (College faculty & anxilliary)||Rs 400.056 Million||Taken as per PMDC Criteria. Its calculation with yearly increase in pay [for next 5 years] is at end of this document|
|Human Resource (Doctors, Nurses, Paramedics & other staff), utilities, other expenses||Rs 654.880 Million||Taken from DHQ Hospital Mardan budget estimates for FY 2018-19, which is 400 bedded, but closest to a 500 bedded Hospital. Cost would go up when it is tertiary care|
|Total||1054.936 Million||On lower side due to Hospital calculation being on a secondary care 400 bedded one|
PLEASE NOTE: BOTH ABOVE COSTS DO NOT INCLUDE LAND COST WHICH IS PRESUMED TO BE FREE
So one time cost for a 100 student per year medical college, less land cost, is Rs 2855.96 Million [on minimum side] and its running cost alongwith 500 bedded teaching hospital is atleast Rs 1054.936 Million.
One can also gestimate one student cost based on above calculations. for that purpose
(1) Expenses on staff and running the 500 bedded hospital per se is not being taken as the Hospital benefits patients through provision of services
(2) Moreover in equipment too, the clinical side of equipment is not being taken – again on the supposition that it benefits the patients too
(3) Moreover, cost of infrastructure and equipment is presumed to take a depreciative value over 30 & 10 years respectively, while faculty and ancilliary staff pay is taken for 5 years with raise but divided in good term by 5 for the 5 years classes
(4) Cost of infrastructure again does not include the hospital side
(5) Their stipend in House Job is also not being taken as its in healthcare delivery service.
Hence only cost of infrastructure, equipment for basic sciences is being taken [less land cost] and the cost of faculty and its ancilliary staff only. That comes out to [Infrastructure (Rs 429.840 Million/30= 14.328) + (Basic Sciences Equipment Rs 352.62 Million/10= 35.26) + 5 years pay for faculty Rs 2,442.383/5= 488.47] Rs 538.058 for 100 students and comes out to Rs 5.380 million per Graduate. This ofcourse is on lower side.
The standards on Human Resource of Health scale the health workforce requirement based on population. Latest document, less the merged Districts of FATA, indicates requirement of Physicians (Graduates) at 21,241 and Physicians (Specialists) at 5,722. In contrast around 15,000 or less doctors are available in the public and private sector in Khyber Pakhtunkhwa at the moment.
By 2030, population of erstwhile Khyber Pakhtunkhwa alone is to cross the 50 million mark, and the human resource for health requirement only for doctors would be 55,877 physicians. HRH vision paper quotes “by end of 2017, [sic 19 medical colleges in KP] capacity to produce graduates was 2,050 [sic per year] indicating that 24,600 graduates can be produced in next 12 years [sic by 2030].
But actual requirement is 55,877 and considering all positive outcomes, retention of doctors in public and/or private sector here there will be a gap of around 15,000 doctors – not to say the expenditure of Rs 132,348.0 Million for producing 24,600 over the next 12 years, inflation not counting especially in pay of HR. This in itself is an investment of Rs 11,029.0 Million per year on MBBS education alone.
To conclude, it is mostly a catch-22 situation. Medical Education is an expensive proposition, both for the government to bear from its annual budget in shape of establishing new Colleges, especially in periphery as well as subsidizing education in existing ones. It is at discretion of government to keep on establishing new Colleges in peripheral districts at great cost in monetary terms where faculty & other facilities are extended with quite an effort, or to strengthen and increase capacity of its existing medical colleges in Peshawar or near about and encouraging “regulated” private sector towards this effort.
Pertinently, the Out Of Pocket expenditure, so to say, of the medical student has not been calculated, especially including hostel expenses. Further, this costing does not include posts creation in public sector for these graduates, nor does it include a sitrep on the availability of faculty in existing public sector colleges especially those in the peripheral districts of Bannu, DI Khan, Swabi and also finally it does not taken into account the quality of education in these medical colleges. That may become part of a furtherance to this writeup.