Indian Railway is an organization with about 64,500 km of track

covering almost all parts of India and employing about 14 lacs of

employees. The railway has committed to providing comprehensive

health care services to its employees, their families and other

beneficiaries. To cater to the health needs of the beneficiaries of

railway health care, the railway has a huge health organization with

all levels of health care viz Primary, Secondary, Tertiary healthcare

services at field level, divisional level and zonal level respectively

and referral services to outside agencies as well.

Need for the Study:

In 1997, the ministry of railway felt that there is a need for the

reorganization of the railway by forming nine newer zones for

effective administration by decentralization. Two of the nine new

zones have already started functioning from October 2002.

Remaining seven zones start functioning from April 2003. Since the

new zones are being formed, there may be a need for new hospitals at

zonal level for second level referral services.

1
South Western Railway, headquartered at Hubli, Karnataka is one of

the new railway zones to be established. This railway zone is being

organized by taking Bangalore and Mysore divisions of Southern

Railway and Hubli division of South Central railway. The health

services for Wheel and Axle Plant, Bangalore also come under the

administrative control of South Western railway.

This study aims at studying the existing referral health care facilities

in South Western Railway and examining the need for further

enhancing and strengthening the referral services in South Western

Railway.

2
• To study the existing referral health services and examine the

need for further enhancing and strengthening referral health

services in South Western Railway Zone and explore various

options for the same and recommending the best.

1. To study the existing referral services in South Western

Railway.

2. To explore the necessity for further enhancing and

strengthening of referral health services in South Western

Railway

3. To examine various means of enhancing and strengthening the

referral services viz upgrading the in-house facilities,

developing a referral system for out side hospitals (out-

sourcing).

4. To suggest the effective means and quantum of enhancement

and strengthening the referral services with minimum

expenditure.

3
Development of hospital services after independence:

After attaining independence, there was a rapid industrialization in

the country; but at the same time, there was continuous growth of

population, which caused a number of problems in providing

adequate medical and health services. On the eve of independence,

there were 7400 hospitals and dispensaries in India. There were

1,13,000 beds, giving a population bed ratio of 0.2 beds per thousand

population. There were 19 medical colleges and 19 medical schools.

As a consequence of industrialization and population growth, special

medical and health problems cropped up. Special efforts, therefore,

were made by Government of India to solve these problems. The

Government has set up various committees to recommend the

strategies to tackle the problem. Some of the important committees

are Bhore Committee, Mudaliyar Committee, Jain committee,

Shrivastava committee, Sidhu Committee, Rao Committee, Bajaj

Committee, Chhadda committee and so on.

According to Health Information India (1995-96), India had 146

medical colleges, 15,097 hospitals and over 6,23,819 beds, with

population bed ratio of 0.67 per 1000 population, admitting about

thirty million patients in a year. Of all these hospitals, 4,621 were

4
rural hospitals with over 1,22,453 beds and 10,416 were urban

hospitals with 5,01,368 beds. When these hospitals are categorized

according to the ownership, then there are 4,473 Government

hospitals with 3,75,987 beds, 335 local body hospitals with 19,677

beds and 10,289 private and charitable hospitals with 2,28,115 beds.

The population bed ratio at the time of independence was roughly

0.25 per 1,000 population, in 1991, it was 0.75 and in 1995, it was

0.67. Still these figures were far less than the target recommended by

Mudaliyar committee at one bed per 1,000 population. To maintain

the population bed ratio of 1995, it requires adding about 6,000 to

7,000 beds in a year, taking into account the population increase.

On achieving independence, India embarked upon a planned effort for

raising the standard of living of masses and made the health planning

an integral part of the overall socio-economic development.

The recommendations pertaining to the hospital services of the

various committees set up by the Government of India are reviewed.

Bhore Committee (1943-46) recommended a short term plan covering

a period of two to five years for setting a 30 bedded hospital for every

two Primary Health Centers and a long term plan called the three

million plan for setting up a 75 bedded hospital for 10,000 to 20,000

population, secondary units with 650 bedded hospital and a district

5
hospital with 2,500 beds in each district with a population of 5 to 7

lacs.

Mudaliyar committee (1961) recommended a population bed ratio of

one per thousand population.

National Health Policy (1983) recommends that the curative centers

should be related to the populations they serve, keeping in view the

densities of the population, distances, topography, and transportation

facilities. These centers should function within the recommended

referral system, the gamut of general specialties required to deal with

the local disease patterns being provided as near to the community as

possible, at the secondary level of the hierarchal organization. To

maximize the utilization of available resources, new and additional

curative centers should be established only in exceptional cases, basic

attempt being towards upgrading the existing facilities at selected

locations, the guiding principle being to provide the facilities as near

to the beneficiaries as possible. The strategy also is to reduce the

expenditure by utilizing the cheap and locally available resources and

appropriate architectural designs and engineering concepts and

economic investment in equipment.

Special, well-coordinated programs are launched to provide physical

and social rehabilitation of those who are mentally retarded, deaf,

dumb, blind, physically disabled, infirm, and aged.

6
Policy of railway:

True to the ideas of welfare state, the Indian Railway has been

pursuing a policy of progressively improving both the working and

living conditions of staff and providing them with maximum

possible amenities in several spheres including medical facilities.

(IRMM, Para-101)

Mission Statement of Indian Railway Medical Service: Total patient

satisfaction through humane approach and shared commitment of

every single doctor and paramedic to provide quality health care

using modern and cost effective techniques and technologies.

(IRMM, Para-108)

In April 1954, the MOR appointed a one-man commission under

Dr.E.Somasekhar to present a detailed scheme on planned expansion

of medical facilities on Indian railway.

With a view to examine and implement the said scheme, a separate

cell was created at the Railway Board in 1955. There has been a

progressive improvement and expansion of the curative and

promotional services on IR since then, resulting in an appreciation

from the Kunzru Committee (1963) as being second to none in the

country.

All Zonal railways have now a uniform organization of medical

services. The policy in this respect is based on the realization that the

7
expenditure in this direction would pay the dividend in the long run.

The output of a contended and healthy worker who is relieved of

mental and financial worries on an account of his own or some family

member’s sickness will be better and more conductive to the efficient

running of railway.

To meet the primary health care needs of the beneficiaries, the

railway run health units, each catering for the needs of about 2,000 to

7,000 population and the distance between two health units 80 km to

160 km.

The railway has Divisional Hospitals, one each is a division and sub-

divisional hospitals depending upon the requirement, which serve as

first referral centers with services in basic broad specialties viz

medicine, surgery, obstetrics and gynecology, pediatrics and

ophthalmology. The services of other broad specialties are also

available in these hospitals depending upon the availability of doctors

in a particular specialty. The railway also hires the services of the

honorary consultants for the specialties in which the in-house

specialists are not available.

The zonal hospitals, one each in a zone serve as second level referral

centers. These hospitals provide services in all the broad specialties

and in a few super specialties. As far as super specialty services are

concerned, different zonal hospitals provide services in different

8
super specialties for effective and economic utilization of resources.

The zonal hospitals also hire the services of the honorary consultants

of outstanding caliber in both broad specialties and super specialties.

At present, the railway has about 605 health units, 56 sub divisional

hospitals, 55 divisional hospitals and 9 zonal hospitals.

Criteria for opening a railway hospital (IRMM Para 302(2) & (4)):

The bed strength of existing RH may be considered for increasing

suitably when the BOR exceeds 110 percent and where every

available space in the building has already been utilized for indoor

beds.

Building or rooms for ancillary services, such as laboratory, X-ray

department, physiotherapy unit etc, should be provided in those

hospitals where there is justification for the same.

Criteria for increasing bed-strength of a hospital (IRMM, Para 303):

All proposals for increasing the bed-strength of a hospital should be

subjected to the following evaluation.

• For the month preceding the month during which the

evaluation is undertaken a list has to be made-out of all patients

admitted to the hospital giving the following details.

9
 1. Serial number
2. Name
3. Age & Sex
4. Disease
5. Date of Admission
6. Date of Discharge
7. Date of Operation (If Operated)
8. Place from where referred

• Thereafter, about 5% of these cases are randomly (Using

Fischer’s Table) scrutinized minutely and critically by calling

for their complete case papers.

1. If it were really necessary for all those to have come to

the hospital.

2. If they could not be disposed off at the periphery by

developing facilities there.

3. If a few could not have been admitted in a nearer

hospital even if it was necessary for these cases to have

been referred to.

4. If some of them could not have been discharged earlier

with better discharge notes for a good follow up in the

OPD/Health unit.

5. If the stay could not have been made shorter by quicker

investigation, better diagnosis, and active treatment.

10
 • If a systemic appraisal as indicated above, shows a very small

number of cases, which should not have been admitted, the

significance is enormous.

• It may be possible to find out if a certain disease is endemic

and if it is advisable to take special preventive steps or create

suitable facilities to bring down the number of such reference.

The facilities in an hospital is considered to be optimally utilized if

the BOR is between 70 to 85, according to various authorities.

11
“Consequent to the reorganization of railway zones, there is a need

for enhancing and strengthening of referral health services in South

Western Railway”.

The author visualizes the following alternatives, which require

individual evaluation for recommending the best one

1. Referring patients to existing zonal hospitals in Secunderabad

and Chennai.

2. Referring the patients to outside recognized hospitals and pay

the hospital bills at agreed rates or by system of reimbursement

– A system of out-sourcing the referral services.

3. Developing an in-house facility.

a. Up-gradation of any of the existing railway hospitals as

zonal hospital

b. Construction of a separate zonal hospital for SWR.

12
The study area comprises of the hospitals situated in geographical

area through which the tracks of SWR run. The South Central

Railway Zonal Hospital at Secunderabad serves as a reference

hospital for comparison and standardization.

The period of study is of two and a half months duration, from

15 October 2002 to 31 December 2002.

The study is a combination of various types of study such as

Exploratory, Problem anticipatory and solving, Designing and

Modifying Systems and Evaluation of Options. In its entirety, the

nature of study does not fit into any defined categories but comprise

the components of different types of study.

Different hospital records such as Annual Narrative reports, Hospital

and Departmental Budget, Financial Statement, various policy

documents of MOR & RB, Referral files, Reimbursement and

payment records of Railway Hospitals at Secunderabad, Hubli,

Bangalore, Mysore, and Wheel and Axle Plant form the basic tools,

which give relevant data for the study.

13
For evaluating the option of utilizing the existing zonal hospital in

Chennai and Secunderabad, the adequacy of referral facilities in SR

and SCR is studied to find out whether they can still accommodate

the patients from SWR.

For evaluating of the option of out-sourcing the referral health

services, the referral system and the pattern of reimbursement (other

than cardiac cases) and bill payment are studied and applied to the

situation, assuming that the patients who were previously referred to

existing railway hospitals will now be referred to outside hospitals.

For evaluating the option of constructing a new zonal hospital for

SWR and of the option of upgrading the facilities at any of the

existing hospitals to zonal hospital, the referral patterns of the four

railway hospitals are studied. This gives the estimate of the size of the

new zonal hospital required or the number of additional beds to be

added to the existing facility. The expenditure incurred for running

the zonal hospital at Secunderabad is taken as reference for evaluating

the cost of running a new zonal hospital for SWR or for upgrading the

existing facility at any of the Railway hospitals. Zonal hospital at

Secunderabad is taken as reference hospital for comparisons because,

it is one of the two zonal hospital till now catering to the referral

needs of a part of a population to come under SWR and it is assumed

14
that the bed strength of the proposed hospital would be approximately

same as that of zonal Hospital Secunderabad.

The location for zonal hospital would be based on study of the

distribution of the population and policies of railway.

The costs involved in all the options are evaluated. Taking into

consideration, the present policy of the MOR, the best possible option

would be recommended.

Limitations of Study:

• The existing hospitals, which will come under SWR are at

present under administrative control of different authorities, as

Southern railway (Bangalore and Mysore), South Central

Railway (Hubli) and Wheel & Axle Plant (Railway Hospital,

Wheel and Axle Plant). Hence, the policies, the procedures,

and the documentation in different hospitals differ.

• Documentation in some railway hospitals is inadequate.

Records of more than one year past in some hospitals are not

available.

• After going through the records of past three to five years, in

hospitals where all the past records are available, the statistical

15
 figures were found to be consistently same with only minor

variations.

• To over come the above mentioned deficiencies, first, the facts

and figures are standardized and then applied in the study. For

example, if the reimbursement particulars of only nine months

are available, then the figures are mathematically upgraded for

one year and then applied to the study.

• Due to the factors mentioned above, it was decided to analyze

the data of year 2001-02 only, instead of taking the averages of

past few years.

16
Study of the present scenario in existing railway hospitals
in SWR:

Due to the vastness of the information to be discussed, it requires a

large amount of space to present the scenario in a descriptive form.

So the scenario is presented in a tabular form.

Human resources:

Table-1 below gives the over-view of the existing human resources in

SWR.

Table -1, Human Resource, Medical Services, SWR

comparision only)SECUNDERABAD* (For

BANGALORE

MYSORE

Job Title
HUBLI

W&AP

1 2 3 4 5 6

Medical Director or equivalent 01 01 01 01 02

Medical Officers of all grades 25 07 21 08 40

Hon. Consultants and contract
04 06 06 04 10
docs
Asst. Nursing officer NIL NIL NIL NIL 01

1 2 3 4 5 6

17
Matron Gr I,II &III 17 05 09 07 34

Nursing sister and Staff Nurse 33 16 22 07 70

Asst. Pharmacy officer 01 NIL 01 NIL 01

Pharmacists, Gr I,II&III 21 08 14 04 32

Lab Suptds. Gr I,II&III 03 02 04 02 06

Physiotherapists Gr I, I & III 01 NIL 01 01 02

Dietician NIL NIL NIL NIL 01

ECG Technician 01 01 02 01 04

Dialysis Technician NIL NIL NIL NIL 06

Radiographer 02 01 04 01 06

OT Assistants and Dressers 15 06 21 07 31

Hospital Attendants & Peons 59 12 42 09 89

Ambulance driver 03 03 05 02 05

Cook 06 04 05 04 12

Other Group C Staff 39 04 14 04 42

Superintending Engineers 01 NIL 01 NIL 02

• For comparative purposes only.

Table-2 below gives the over-view of the utilization of existing

referral hospitals in SWR.

18
Table-2, Overview of referral health services in SWR

19
 Employees + Family (Size of Family=5)
No of Out

Retired + Family (Size of Family=3)

Doctors patients

Number of Retired persons served

Average No of Inpatients per day

Per day

Total in patients in 2001-02

No of employees served

Total Population Served

Section covered in km

Beds/1000 population

Bed Occupancy Ratio

Total No of beds
Serial number

Work load per doctor

Hon.Consul
HOSPITAL
General y
Specialist

Total cases
S

Divisional 2215 11079 11541

Hospital 0 1 9 5 1 5 14 1 4
1 17 04 4620 106 71 617 62
Hubli 8 458 +800 +4000 540 +4000 9 .29 382
(*Zonal HQ) * * *
Divisional
0 1137 1 0 1
2 Hospital 04 06 500 56880 5599 62479 46 25 72 300 27
3 6 998 .73 385
Bangalore

Divisional 2
0 1 1948 1 10085 10 1 1
3 Hospital 18 06 97420 3438 015 65 69 69
3 121 4 146 8 1 .00 446
Mysore 5

Wheel and
0
4 axle Plant 07 04 NA 2213 11065 181 543 11600 36 3.1 1156 14 30 190 25
1
Hospital
S.C.Rly
Zonal The figures of this hospital are only for 2
5 1 30 1
Hospital 30 10 comparative purpose. These columns are 472 180 60 77
* 0 0 400
Secunderaba not relevant to the study. 3
d
Hospital Expenditure 2001-02:

Table-3 below gives the Total Hospital Expenditure in various referral

hospitals in SWR.

Table-3, Hospital Expenditure 2001-02 (in Thousands of Rupees):

Divisional Divisional Divisional Wheel and *Zonal

Hospital Hospital Hospital axle Plant Hospital
Hubli Bangalore Mysore Hospital Secunderabad

20
Salary, wages and
administration
38887 18270 36201 10080 68838
Hospital costs
excluding 941 340 625 127 1575
Medicines

Cost of medicines 16744 5500 13877 3450 49922

Cost of
Equipment
1751 700 1829 725 7606
Repairs and
maintainance of 119 880 205 632 806
equipment
Reimbursement,
payment to other 1378 1598 397 2714 22564
hospital
Welfare
Expenditure
172 270 464 75 672

Misc.
Expenditure
00 00 00 00 00

Total expenditure 81272 27558 53598 17803 109609

No of employees
and retired
23699 13374 20556 2394
Not relevant to
Cost of medical the study.
service on each 2531 2061 2607 7437
beneficiary
* For comparative purpose only.

21
Referrals and payment of bills for referred cases:

Table-4 below gives the details of the referrals and payment of bills
for the referred cases in various divisions of SWR.

Table-4 Referrals and payment of bills for referred cases:

From:-

BANGALORE

MYSORE
HUBLI

W&AP
To
Other railway
hospitals (other 271 154 315 74
than cardiac cases)

Outside hospitals 52 155 159 862

No of cases for
which bills to
44 100 29 102
outside hospitals
are paid
Total amount of
bill payment (in 543576 1598000 397007 2713904
Rupees)

Average amount
per referral (in 12354 15980 13690 26607
Rupees)

22
Evaluation of the option of referring the patients to
existing Zonal hospitals at Chennai and Secunderabad:

At present, south central railway hospital at Secunderabad is the

second referral centre for the patients from Hubli division and

Southern railway hospital Chennai is the second referral centre for

patients from Bangalore and Mysore divisions and Wheel and Axle

plant. Railway hospital Chennai also serves the super-specialty needs

of patients from other zones of Indian railway.

The BOR at Zonal hospital Secunderabad is 60.3. The facility at

Secunderabad appears to be underutilized. The reasons for this

phenomenon is beyond the scope of this study.

The Table-5 gives the clear picture of the health facilities in

reorganized South Central railway.

Table-5, Health facilities in reorganized South Central railway.

Population
No of Beds/1000
Hospital including BOR
Beds population
retired
Secunderabad 300 60

Vijayawada 203 64
650065 1.06
Guntakal 131 70
Other Sub-
divisional 60 60
hospitals
Total 650065 694 63.5 1.06

23
The BOR at Zonal hospital Chennai is 84 and it is optimally utilized.

The table-6 gives the overview of health services in the reorganized

southern railway.

Table-6, Health facilities at reorganized Southern railway

Population
Beds/1000
Hospital Including No of beds BOR
population
the retired
Zonal Railway
hospital, 505 84
Chennai
Total of all other
1600926 1.08
Railway 1224 65.1
hospitals

Total 1600926 1729 1.08

Following inferences may be made by studying the Tables 5 & 6.

• The referral health facility at Secunderabad is slightly under

utilized and the facility at Chennai is optimally utilized.

• Due to the increasing cost of medical care in the open market,

there is a possibility in the near future that the facility at

Secunderabad may also be optimally utilized.

24
• This option of referring the patients to the existing facility is

the most cost effective as no fresh investment or expenditure is

involved.

• The population bed ratios in both the reorganized South central

and southern railways would be around unity, and is in

consistent with the Bhore committee recommendations, but

still less than the one recommended in National health policy

1983, of having around 4,000 beds in a district of 10 lacks

population.

• Because of the factors mentioned above, this option may be

considered as a short-term measure, until the other facility is

developed in SWR.

25
Evaluation of the option of Out-sourcing the referral
services:
Assuming that the patients who are at present referred to zonal

hospitals at Secunderabad and Chennai, are referred to out side

hospitals, the projections as in Table-7 may be made. These

projections are purely mathematical in nature. The data of one

scenario is applied to an other scenario

Table-7, (Projections of referrals and referral costs per annum)

Hubli Bangalore Mysore W & AP

Projected No
of referrals to
outside 279 209 445 834
hospitals
(Non cardiac)
Average
cost of each
12354 15980 13600 26607
referral in
Rs.
Total cost
of referral 3446766 3339820 6052000 22190238
in Rs.
Total cost of referrals = Rs. 3,48,28,824 per annum.

(See Table-4 for source of figures)

26
Evaluation of option of developing an in-house facility:
a) By upgrading any of the existing hospitals.
b) By constructing a new hospital.

Deciding the location of the new facility:

Various parameters for deciding the location of new facility

for SWR are considered as under.

• Distribution of the population: The majority of the population

is around Hubli (Table-2).
• Length of the section: Hubli division has the lengthiest tracks
on SWR (Table-2).
• Transportation facility: This factor does not make much
difference as all the divisions of the railway are interconnected
similarly.
• Presence of outside facility: Bangalore and Mysore have very
good outside facilities compared to Hubli so Hubli gets priority
in having a zonal facility over other two locations.
• Economy: The hospital presently at Hubli has the highest
number of beds compared to other three hospitals. Up-
gradation of the facility, if recommended would be economical.
• Policy: Railway has a conventional policy of having a Zonal
hospital at zonal headquarters
Due to the factors mentioned above, Hubli is the ideal place for

having new facility.

Estimation of the additional Beds Required for SWR

27
A detailed calculation for the estimation of the additional

beds required for SWR is done in table-8.

Table-8, Estimation of additional beds for SWR

Total Population of SWR 294352

Total No of bed at present in SWR 308

Beds/1000 population 1.04

Estimated increase in Population to be served 4000

Estimated number of referrals to Zonal hospital at Hubli
per month, excluding super-specialties (Table -2 & 4)
148

Estimated length of stay for such referred cases 18 days

Estimated additional beds to meet the increased
70
demands.
Additional 20% beds for external paying
patients.(Optional) (Expected as Hubli has only few 40
hospitals)

Since the estimated number of additional beds required for SWR is

only 70 or 130 (Optional, for external paying patients), it is not

advisable to construct a new hospital. It is advisable to upgrade

the existing divisional hospital at Hubli as a Zonal Hospital.

Railway has a policy to develop a few super-specialty departments

or exclusive departments in broad specialties in each zonal

hospital. An additional 25 beds would be required for developing

each super-specialty.

Projections of BOR in an up-graded hospital at Hubli:

28
Table-9 gives the detailed calculations for the projections of BOR in

an up-graded railway hospital at Hubli.

Table-9 Projections of BOR in an upgraded RH-Hubli

A No of Beds at present 149

B Present BOR 70

C Population to be served increase by 4000

D No of referrals expected per month 148

E Average length of stay for referred cases 18

(in number of days)
F Given the No of beds same, BOR expected 126

G No of beds planned in up-graded hospital 220

H For external paying patients (Optional) +40

I Projection of BOR in upgraded hospital. 79

J If 25 beds per super-specialty is added, 80

then BOR

It is assumed that , the external paying patients get admitted to up-

graded railway hospital Hubli, as there are very few other hospitals.

It is also assumed that the patients requiring the super-specialty

services would be referred to Hubli from other zonal railways, as the

railway has the policy of developing one super-specialty service in

only one zonal Hospital.

29
At present following super-specialties, services are provided in

different railway zonal hospitals as below:

J.R. Hospital, W.Rly, Mumbai Gastro-enterology

Nephrology
Ambedkar Hospital, C.Rly, Mumbai Plastic Surgery
Burns
Northern Railway Central Hospital Orthopaedics
ENT
Cancer research Institute, Lucknow Oncology
Southern Railway Hospital, Chennai Cardiology
Cardio-thoracic
surgery
Eastern Railway Hospital, Calcutta Orthopaedics

It would be commendable if a few super-specialty services are started

at SWR zonal hospital in due course. The services so developed
should be different from the ones already existing in other railway
hospitals. The identifiable services are in Neurology, Neuro-surgery,
Mental Health, Respiratory medicine, Pediatrics and Neonatology etc.

30
Computation of current costs of Up-graded hospital at
Hubli:

A detailed estimation of the current costs of running an upgraded

railway hospital at Hubli is done in Table-10.

Table-10, Computation of current costs of Up-graded

hospital at Hubli:
Present cost of running Divisional Rs8,12,72,000
A
hospital at Hubli
B Cost of running 300 bedded Zonal Rs.10,96,09,000

hospital, Secunderabad
C Deduced cost of running a 220 bedded Rs.8,90,25,000

Zonal hospital at Secunderabad (By

using Various mathematical

applications)
D Additional current cost of running an Rs.77,53,000

upgraded zonal hospital at Hubli, (C-A)

Table-11, Deduction of the costs of running a 220 Bed Zonal

Hospital. (Explanation to item C of Table 10)

31
 Cost of
Deduction
running 300
of running
bed Zonal Explanation or procedure adopted
a 220 bed
Hospital for calculation
Zonal
Secunderab
hospital
ad
Equivalent to the expenditure of
Salary, wages and Divisional Hospital Vijayawada,
administration
68838 47572 having same staff strength and
beds of proposed hospital
Hospital costs
Mathematical computation of costs
excluding 1575 1300 by standard tables
Medicines
16744 incurred presently at Hubli
+ 8644 costs on expected increase
Cost of medicines 49922 25400 in referred cases from other
divisions.
Cost of No major change is anticipated as
Equipment
7606 7606 the equipment required is similar.
Repairs and
No major change is anticipated as
maintainance of 806 806 the equipment required is similar.
equipment
Reimbursement, Reimbursement to patients at UBL,
payment to other 22564 6087 SBC, MYS and W&AP at present
hospital rates. See Table-4
Welfare !72 incurred presently at Hubli +
Expenditure
672 246 74 for increase in Staff

Misc. Unexpected expenditure of still to

Expenditure
00 08 be organized hospital.

Final deduced cost of running a

Total expenditure 109609 89025 220 bed Zonal Hospital.

32
After the study of the present referral services scenario in SWR, it

was found that the services were inadequate and an additional 70 beds

were required for SWR. For enhancing and strengthening the

referral health services of new SWR, the four options assumed by the

author were analyzed systematically.

The option of utilizing the existing zonal hospitals at Secunderabad

and Chennai was studied and found that the referral facilities at

Secunderabad and Chennai are just adequate for the reorganized

South Central and Southern railways and it would be difficult to

accommodate the patients from other zones.

The option of having the system of referring the patients to the

outside hospitals and paying the bills at agreed rates or by a system of

reimbursement is also studied and found that the cost of opting for

such a system would be Rs. 3,48,28,824 per annum for cases till now

referred to zonal hospitals.

The option of establishing a separate new zonal hospital is unviable

as the number of additional beds required to strengthen the referral

services of SWR is only around 70.

After studying the option of upgrading any of the existing facility at

SWR as a zonal hospital, it was logically found that the location of

such up-gradation would be Hubli. The current cost of opting for

such a system would be Rs.7,75,300.

33
The option of upgrading the existing facility at Hubli is more

economical compared to the option of out-sourcing the referral

services. The capital cost of upgrading railway hospital Hubli as

zonal hospital (Appendix-I to III), is around 1.3 crores, including the

physical facilities and equipment.

The option of upgrading the existing railway hospital at Hubli as

zonal hospital is more economical and viable.

It is also preferred to start in due course, a few super-specialty

services, not available in other railway hospitals.

SHORT TERM PLAN:

34
 As a short term measure, for a period of about one year,

the existing facilities at Secunderabad and Chennai

may be utilized for referring the patients for specialized

care, till the in-house facility for SWR is developed.

MID-RANGE PLAN:

About 50-75 beds should be added to the existing

hospital at Hubli in first years. The services in all the

broad specialties should be started by the completion of

one year of organization of SWR.

LONG TERM PLAN:

About 20 to 25 beds should be added each year after

the completion of one year of organization of SWR, to

attain bed strength of 275 to 300. The services in one

or two super-specialties should be started each year

during this plan.

The study, “ Referral Health Services for South Western Railway”

was necessitated due to the reorganization of Indian railways.

35
In this study, the present situation of the referral health services is
studied. It was found that the referral services at present were
inadequate. Various options for strengthening and enhancing the
referral services, such as utilizing the facilities in other zonal
railways, adopting a system of out-sourcing the referral services,
upgrading existing hospitals in SWR and construction of new zonal
hospital, were studied.
After analyzing all the options, it was found that construction of a
new zonal hospital unviable. The existing facilities at other zones are
just sufficient for the population in the respective zones. The system
of referral to outside hospitals and reimbursement of bills works out
to be costlier than upgrading an existing hospital at Hubli to a Zonal
hospital.
It is recommended, after study and analysis of the situation, that as a
short-term measure for one year, the patients from SWR may be
referred to other zonal hospitals at Secunderabad and Chennai as at
present. A medium range measure of adding 50 to 75 beds to railway
hospital Hubli in one year and start services in all broad medical
specialties is recommended. A long term recommendation of adding
about 25 bed each year to make the effective bed strength of 275 to
300 and starting services in few broad specialties is also
recommended.

Appendix-I
Additional physical facilities required for upgrading Divisional

Railway Hospital, Hubli as Zonal hospital- A gross estimate:

36
• A new Out Patient Block has to be constructed.

• The ICU presently situated in the first floor of the Hospital

should be brought to the ground floor, constructing a new ICU

block.

• Construction of four special rooms adjacent to new ICU.

• Setting up new Casualty department with attached exclusive X-

ray unit, mini operation theatre.

• Construction of wards to accommodate additional beds.

• Computerization of Hospital Management with LAN

networking.

• Public announcement system.

• Hospital Pager system.

• Rebuilding of all toilets in the hospital

• Centralised medical gas and vacuum supply.

• Construction of accommodation for House-Surgeons Trainee

nurses.

• Replacement of all furniture used in patient care.

• Provision of head-side reading lamps, call bells for all beds.

37
• One centralized pharmacy department with five dispensing

counters, to be constructed adjacent to the OP block.

• One centralized laundry and linen blocks.

• Centralised Sterile Supply Department.

Estimated cost: 50 lacs.

Appendix-II

38
Estimation of additional staff requirements for an upgraded
hospital:

Table-12, Additional Staff Requirement for Up-graded Hospital

SECUNDERABAD 300

Deduced requirement for

225-250 bedded hospital
bed hospital(For

Extra Staff required

HUBLI
Job Title

comparison)
1 2 3 4 5

Medical Director or equivalent 01 02 02 01

Medical Officers of all grades 25 40 35 10

Hon. Consultants and contract
04 10 10 06
docs
Asst. Nursing officer NIL 01 01 01

Matron Gr I, I &III 17 34 30 13

Nursing sister and Staff Nurse 33 70 60 27

Asst. Pharmacy officer 01 01 01 Nil

Pharmacists, Gr I,II&III 21 32 28 07

Lab Suptds. Gr I,II&III 03 06 05 02

Physiotherapists Gr I, I & III 01 02 02 01

Dietician NIL 01 01 01

ECG Technician 01 04 04 03

1 2 3 4 5

Dialysis Technician NIL 06 04 04

39
Radiographer 02 06 05 03

OT Assistants and Dressers 15 31 28 13

Hospital Attendants & Peons 59 89 75 26

Ambulance driver 03 05 05 02

Cook 06 12 10 04

Other Group C Staff 39 42 40 01

Superintending Engineers 01 02 02 01

Appendix-3

40
Additional basic equipment required to be procured for

upgradation of Divisional Hospital Hubli. (With out super-

specialty services)

(As per RB letter No: 99/H-I/7/85, Dated:08-07-1997.)

For ENT Department:

1. Rigid Bronchoscope 01 set

2. Full set Sinoscope 01 set

3. Audiometer 01Set Approx cost---Rs.6 lacs.

For Radiology department:

1. Ultrasonogram equipment with colour Doppler. 01 No.

Approx cost---Rs.8 lacs.

For Surgery Department:

1. Orthopaedic fracture table 01 No. Approx cost---Rs.1

lacs.

2. Electric power drill 01 No. Approx cost--Rs.60,000

3. Suction Apparatus 02 Nos. Approx cost--Rs.50,000

4. C-Arm image intensifier 01 No Approx cost--Rs.12lacs

For Anaesthesiology Department:

1. Monitor with Defibrillator 01 Nos Approx cost---Rs.1 lacs

2. Central medical gas

and vacuum unit. Approx cost--Rs.13 lacs

3. Ultraviolet disinfection system Approx cost--Rs.75,000

41
 4. Shadowless lamps OT 02 Nos Approx cost---Rs.2 lacs

5. Boyles Ultima 01 Nos Approx cost---Rs.5lacs

6. OT Table 01 Nos Approx cost---Rs.10lac

For Gynaec Department:

1. Ultrasonogram machine 01 No Approx cost---Rs.8lacs

2. Double puncture laparoscope 01 set Approx cost---Rs.2lacs

Ophthalmology Department:

1. Auto refractometer with computerized vision tests 01 Nos

2. B-Scan keratotomy to test power of IOL 01 Nos

3. Auto field analyzer 01 Nos

Approx cost---Rs.5lacs

Medical and Surgical wards:

1. Pulse oxymetres 04 Nos

2. High and low ICU metal beds 08 Nos

3. Water beds 04 Nos

4. Bed side monitors for ICU 04 Nos

5. Defibrillators 04 Nos

6. Spirometers 02 Nos

Approx cost---Rs.7lacs

42
1. “Annual Narrative Report-Medical Department”: (2001-02),

South Central Railway, Rail Nilayam, Secunderabad.

2. “Annual Narrative Report-Medical Department”: (2001-02),

Southern Railway, Chennai

3. “Annual Narrative Report”: (2001-02), Divisional Railway

Hospital, Bangalore, India.

4. “Annual Narrative Report”: (2001-02), Divisional Railway

Hospital, Hubli, India.

5. “Annual Narrative Report”: (2001-02), Divisional Railway

Hospital, Mysore, India.

6. “Annual Narrative Report”: (2001-02), Railway Hospital,

Wheel and Axle Plant, Bangalore, India.

7. Financial Advisor and Chief Accounts Officer, South Central

Railway: (April 2002) “Distribution of Final Grant For The

Year 2001-02-Medical Department” South Central Railway,

Secunderabad.

8. Financial Advisor and Chief Accounts Officer, Southern

Railway: (April 2002) “Distribution of Final Grant For The

Year 2001-02-Medical Department” Southern Railway,

Chennai.

43
9. Financial Advisor and Chief Accounts Officer, Wheel and Axle

Plant: (April 2002) “Distribution of Final Grant For The Year

2001-02-Medical Department” Wheel and Axle Plant,

Bangalore.

10. “Health System Management”: (2001), Vol-02: Indira Gandhi

National Open University, New Delhi .Pp 1-30.

11. “Indian Railway Medical Manual”: (2000), Vol-01: Railway

Board, New Delhi. Para 101, 108, 302(2) and 302(4).

12. “Health System Management”: (2001), Vol-04: Indira Gandhi

National Open University, New Delhi. Pp 21-34.

13. “Organization and Management of Hospitals”: (2001), Vol-03:

Indira Gandhi National Open University, New Delhi. .Pp 65-

82

14. Park.K, :(2001), Text Book Of preventive And social

medicine,16 Ed: M/S Banarsidas Publications:Jabalpur, India.

Pp. 613-631

15. “Standardization of Hospital Equipment”: Railway Board,

Policy Letter No: 99/H-I/7/85, Dated 08-07-1997.

44