Expenses & Requirements of Medical Colleges & Graduates in Khyber Pakhtunkhwa

Human Resource for Health shows Khyber Pakhtunkhwa significantly deficient in doctors, nurses and paramedics. On the other hand, existing capacity of medical colleges in public and private sector may not be able to cope with this and coming demand. To top it, whenever a new Medical College or a Dental College is established, whether in public or private sector, or seats are enhanced in an existing one, there is considerable one time and yearly cost attached to it. This is accentuated by public sector’s desire, for whatever reasons, to build colleges in peripheral districts where faculty and teaching hospitals are arguably much harder to make available.

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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.

http://www.pmdc.org.pk/Portals/0/GuidelinesAndCriteria/CRITERIA.pdf

I will be concentrating on the following Regulations in this writeup for a rough cost estimation:

1. 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.
2. Regulation 13 which requires a separate College and Hospital building
3. Regulation 16 which gives infrastructure requirement at Appendix-IV of College building including offices for faculty, administrators, support staff, laboratories, classrooms, auditorium etc,
4. Regulation 17 regarding Affiliated Teaching Hospital wherein Appendix-V details hospital facilities whereas Appendix-VI details the units
5. 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:

Spot	Scoring points	Minimum requirement
Legal	75	75
Financial	75	75
Infrastructure of  College	200	120
Hospital	250	180
Academics Faculty	100	80
Faculty	300	220
Total	1000	750

Appendix-IV: The details of College and Teaching Hospital infrastructure requirements as per the PMDC criterion are as under:

A – College

Item	Unit	Nos	Multiplicable	Total Sq Ft
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
Cafeteria	Lump sum	1		1000
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
Hostel Male	Lumpsum	25		10000
Hostel Female	Lumpsum	25		10000
House Officer Hostel Male	Lumpsum			5000
House Officer Hostel Female	Lumpsum			5000
Faculty Residences				50000
Animal House				225
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 sq ft
Teaching Facilitates and Staff Offices			10,000 sq ft
Faculty residence (clinical sciences)			75,000 sqft
Total	210,000 sq ft

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

Description	Estimated Cost PKR Millions
Diagnostic Centre	58.0
CCU	125.0
Surgical ICU	170.0
Surgical OT	45.0
General Surgery	98.0
General Items (AC, CCTV, Networking, Computers, Generators, Security etc)	85.0
Pulmonology	4.5
Ophthalmology	27.0
Paediatrics	81.0
Gynae Obs	13.0
Orthopaedic	52.0
Psychiatry	10.0
Urology	43.0
Internal Medicine	82.0
ENT	80.0
Dermatology	15.0
Radiology	413.0
Total	1401.50

• Source Gajju Khan Medical College & ZAB Medical College

Equipment for Basic Sciences

description	Estimated Cost PKR Millions
Anatomy	36.0
Physiology	19.99
Biochemistry	16.0
Community Medicine	8.0
Forensic Medicine	29.0
Pharmacology	9.5
Pathology Lab	28.0
Hematology Lab	2.0
Microbiology Lab	6.0
Histopathology Lab	15.14
Library (Books + Equipment)	37.0
Vehicles (Buses, Coasters etc)	37.0
General Items (Generators, CCTV, Wifi connectivity, computers, networking, ACs, security etc)	85.0
Furniture / Fixture	24.0
Total	352.62

• Source: Gajju Khan Medical College & ZAB Medical College

Appendix VI – Number of Beds (100 admissions)

Department	Beds required
Medicine	75
Surgery	75
Gynae Obs	80
Paeds	40
Eye	15
ENT	15
Othopedio / Trauma	40
Medicine & allied facilities	80
Surgery and Allied Facilities	80 (1 Unit of OMFS)
Total	500 beds

Annex-VII – Faculty Requirement for MBBS – Basic Sciences & Clinical (100 admission)

Subject	Professor (BS-20)	Associate Professor (BS-19)	Assistant Professor (BS-18)	Demonstrator (for basic) Senior Registrar (for clinical) (BS-17)	RMO BS-17 (for clinical)
Anatomy	1	1	2	8
Physiology	1	1	2	8
Biochemistry	1	1	1	4
Pharmacology	1	1	1	6
Pathology	2	2	4	8
Forensic Medicine		1	1	4
Community Medicine	1	1	1	4
Medicine & Allied	2	2	2	2	4
Surgery & Allied	2	2	2	2	4
Gynae & Obs	2	2	2	2	4
Eye	1	1	0	1	3
ENT	1	1	0	1	3
Paeds	1	1	1	1	4
Orthopaedics	1	1	1	1	2
Psychiatry	1			1	2
Dermatology	1			1	2
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
total	24	20	20	56	39

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

Item	Cost Calculated	Remarks
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)

Item	Cost calculated	Remarks
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.

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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.

Ends