REPORT ON THE PERFORMANCE OF THE PUBLIC PRIVATE PARTNERSHIP OF INTERNATIONAL ISLAMIC MEDICAL COLLEGE TRUST AND RAILWAY HOSPITAL,

RAWALPINDI.

Abstract.
Background. Rawalpindi railway division had a hospital which catered to the basic medical needs of its employees and their families. The department was given an offer by a private party that claimed it would transform RH into an international standard, tertiary care, PMDC recognized hospital with state of the art of facilities that would also enable their newly established medical college to get recognition as per PMDC requirements. IIMCT was to provide specialists and advanced diagnostic and therapeutic equipment. In exchange, IIMCT would get a hospital obviating the need to construct a new hospital ground up. This hospital land area of 9.2 Acre and covered area of 30,000/- sq feet is being utilized by IIIMCT. The commercial value of the land is such that it can generate rent of Rs.99.32 million per year if made available for open auction. Thousands of items of equipment that range from expensive items like auto-clave machine (for sterilization of surgical instruments) and x-ray machines to minor items like beds and tables, were handed over to IIMCT. Railway doctors and staff with a combined salary bill of Rs. 18 million per year are also working on the rolls of IIMCT. Some utilities are shared and deficiencies in the provision of drugs is made up by PR as well. Need of this report. This arrangement had an inherent flaw. A teaching hospitals primary focus is to achieve the benchmarks required of it by the regularity authority i.e. PMDC, meaning that PMDC does not monitor the quality of medical care provided to patients but only focuses on whether students are being taught properly. It is PR itself that has to assess the quality and extent of medical services provided to patients. This has unfortunately never been done despite the passage of thirteen years since the first agreement in 1998, and hence the need of this report. Results and conclusion. Parameters and benchmarks set in the clauses of the agreements signed are the means by which the services and care provided by IIMCT can be assessed. The primary reason for IIMCTs inability to come up to reasonable expectations is the unwillingness of PR to exercise its authority in the protection of the due rights of its employees, and, instead favours the financial interests of a private party. Despite PR honoring all its commitments that have unduly increased over the course of years, this public private partnership has failed.

Glossary of Terms
PR IIMCT PMDC RDF IDF RH MS Pakistan Railways International Islamic Medical Trust Pakistan Medical and Dental Council Railway Drug Formulary IIMCT Drug Formulary IIMCT/Railway General Hospital, Rawalpindi Medical Superintendent, Rawalpindi

Table of Contents
Page No.
1.The nature of the agreement between PR and IIMCT. 1.1 Definition of franchisee in a franchise agreement. 1.2 Revised agreements of 2000 and 2004. 2. What Railways provided and what Railways expects in return 2.1 2.2 2.3 2.4 PMDC rules for teaching hospitals. CT scan Echocardiography with color Doppler 150 bed versus a 450 bed hospital 10 6 5

3. Drugs and reimbursements. 3.1 IIMCT and Railway Drug Formulary 3.2 The Range of Medicines and the effect on patient care. 3.2.1 Mortality benefit drugs. 3.2.2 Other essential drugs. 3.3 How Railway LP makes up for these deficiencies. 3.4 Packing and Labeling of Drugs. 3.5 Reimbursements. 4. Infrastructure development 4.1 4.2 4.3 4.4 4.5 Intensive Care Unit. Increased number of wards by IIMCT : What constitutes a ward ? The TB Ward issue. General sanitary conditions. Yet to be made: Community Health Units, Mobile Primary Health Unit and Flying squad.

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5. Other aspects of Hospital services 5.1 Patient dietary services 5.2 Railway Out Patient Department (OPD) 6. Expansion of IIMCT. 6.1 Congestion 6.2 The expansion proposed 7. Railways check and balance 7.1 The Medical Superintendent 7.2 The Management Committee 8. Financial and other benefits to IIMCT 8.1 Student fee 8.2 Private patient earning 9. Conclusion 10.Appendix

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1.The nature of the agreement between PR and IIMCT. In many of the discussions at different forums regarding Railway/IIMCT Hospital, Rawalpindi (henceforth RH), there is a confusion regarding the nature of the agreement. It has been often called a lease or rental agreement implying that the premises (land, building and equipment) has been handed over to IIMCT for the duration of the agreement. This is a misinterpretation of the agreement. Right at the beginning the following statement is made This franchise agreement shall be for a period of 33 years extendable for another similar term. However, the contract will be renewed after five years (latter sentence later removed). 1 This clause indicates that it is a franchise agreement, not a lease or a rental agreement. In exchange IIMCT is to do the following: to upgrade and develop The Pakistan Railways Hospital Rawalpindi into a Teaching Hospital The agreement never specifies anywhere a payment of lease or rent. The premises were never handed over in the sense it is handed over to a lessee; an indication of which is the fact that the administration of the hospital was initially kept with Railways and was later handed over to IIMCT in a subsequent revised agreement 2. Furthermore, the canteens in the premises of the hospital are auctioned by the divisional Railway authorities. 1.1 Definition of franchisee in a franchise agreement. In this case, IIMCT is the franchisee and can be described as: One who purchases a franchise. The franchisee then runs that location of the purchased business. He or she is responsible for certain decisions, but many other decisions (such as the look, name, and products) are already determined by the franchisor and must be kept the same by the franchisee. The franchisee will pay the franchisor under the terms of the agreement, usually either a flat fee or a percentage of the revenues or profits, from the sales transacted at that location. 3 The flat fee or percentage of the profits mentioned are indicated in clause no. 24 of the 1998 agreement in which one third of fees generated out of private patients will go to the Railway revenue and two third will be paid to the Islamic International Medical College Trust. This excludes indirect payments made in the form of free drugs to a certain limit and reimbursement of medical services provided outside the hospital (due to their non-availability in RH). The agreement is in character and spirit a partnership/joint venture and legally an operating franchise agreement in which IIMCT will run and manage the hospital and its assets and staff, but both will remain that of PR. The territory of the franchisee i.e. of IIMCT, has not been defined and the terms and conditions stated on the agreement legally bind both
1 2

Clause No.1 of original agreement (1998). Clause no.25 of 1998 agreement: The administration of the Railway Hospital will remain exclusively with Pakistan

Railways (the Professional and Administrative control with Medical Superintendent/Divisional Superintendent Pakistan Railways Rawalpindi under Divisional Organization and Professional and Administration Control with the Chief Medical and Health Officer, Pakistan Railways under Headquarters Office, organization)
3

http://www.businessdictionary.com/definition/franchisee.html

parties in different ways, for example, IIMCT has been prohibited by Clause 34 and 35 of Revised Agreement 2000 to sublet or construct any structure within the premises without PRs written permission, however, no such clause prevents PR from doing so. 1.2 Revised agreements of 2000 and 2004. The spirit and purpose of the agreement is inherent in the original agreement of 1998. Subsequent revised agreements in 2000 and 2004 added or modified clauses of the original agreement which changed the balance of authority in the hospital and gave IIMCT the right to manage and operate the hospital. These changes were seemingly done on the basis of give and take. PR obtained incentives like more medicines, reimbursements, mobile primary health units etc. In exchange IIMCT got benefits such as a the right for the agreement not to be reviewed by PR after every five years, the operational control of the hospital, shared utilities, additional accommodation, removal of the one third private patient earning to PR etc. Only after an analysis of the hospital and the services that PR expected in return can it be determined whether PRs policy was mutually beneficial or only to the advantage of one party. 2. What Railways provided. 2.1 Land and buildings. The most valuable asset PR provided was its land. According to present day estimates, the value of the land is such that it can generate Rs. 99.13 million per year. The counter argument to this claim is that the utilization of this land at present is limited to being used for a hospital only. However, if commercialized, the financial value of the land and structures utilized for the medical needs of the division could be converted into revenue allocated to the medical needs of employees. This is a hidden potential and the opportunity cost is incorporated into the arrangements made by PR with IIMCT. The covered area of RH was 30,000 sq feet and at present day value of the average construction of sq feet of covered area is also a hidden benefit to IIMCT. 4 2.2 Equipment and furniture. Thousands of items of equipment that range from expensive items like auto-clave machine (for sterilization of surgical instruments) and x-ray machines to minor items like beds and tables, were handed over to IIMCT. Approximation of the total value of the equipment comes well into the millions. 2.3 Railways Doctors. A large number of staff which included were merged into IIMCT but their salaries were provided by PR with a token amount provided by IIMCT. The counter argument that IIMCT does not need this staff and can do without them is incorrect. IIMCT would need to replace PRs staff even if they were not existent there and would pay their salaries themselves. The total cost of the salaries of PR staff in RH comes to Rs. 18 million per year. This excludes 66 paramedical and other staff.

Source : Land branch, Divisional Superintendent Office, Rawalpindi

2.4 Other benefits. PR has also provides a regular stream of Railway patients and a prestigious departments name and reputation. The location of the hospital is excellent in terms of accessibility, price of land and being on the outskirts of Pindi cantonment and near Islamabad. 2.5 What Railways expects in return? RH itself is part of the large network of hospitals and medical services that PR has established for employee medical care. RH provided basic services as a 100-150 bed hospital and patients needing specialized care were referred to larger hospitals. PR sought to provide more extensive treatment and IIMCT was to provide the same thus minimizing the need for outreferrals and overcoming the budgetary constraints of PR. A certain amount of medicines and reimbursements for patients needing care or laboratory tests which IIMCT could not provide were also to be taken in exchange. However, the agreement and revised agreements lacked specifics and are vague. One term that constantly crops up is teaching hospital with constant references to Pakistan Medical and Dental Council (PMDC). The term teaching hospital means only one thing in this context i.e. a hospital that is recognized by PMDC as fulfilling the prerequisites of an undergraduate or post graduate teaching hospital. The following references are made in the agreements which can illuminate the matter further: In time with the mission, the IIMCT shall upgrade the Railway Hospital to a level of a teaching hospital with state of art facilities 5 Whereas Second Party, a Public Welfare trust, is running a Medical College at Islamabad under the name Islamic International Medical College for the past two years and has offered to improve entirely at its own cost and expense, the status and standard of Pakistan Railways Hospital Rawalpindi to bring it up to the level of an excellent Teaching Hospital for its college. The Pakistan Railways also desire that in the larger interest of Railways and Welfare of its employees, the said Hospital be improved on considerably upgraded to meet the standard and requirement of a teaching hospital, without any financial burden whatsoever on the Pakistan Railways. And whereas, the second party agrees and accept that their shall be no liability at all for all such improvement on the Pakistan Railways 6 AND WHEREAS the first party has accepted the said offer of the second party, the first party shall fully cooperate and allow the second party, in manner laid down hereinafter, to upgrade and develop Pakistan Railways Hospital Rawalpindi into a Teaching Hospital 7 That the Second Party shall undertake the responsibility to raise the said hospital to a teaching hospital and employ professionals and supporting staff according to its own scheme of things and as per PMDC requirements. 8

5 6

Preface of 1998 Agreement (including revised agreements) Ibid 7 Ibid 8 Clause 13 of 1998 agreement

This, however, is an inherent fault of the agreement vis--vis PRs requirements. PMDC prioritizes its rules for the purpose of imparting proper teaching to medical students, not for the delivery of medical services and facilities which is PRs primary interest. Despite this flaw a considerable up-gradation could be achieved if PMDCs rules are adhered to. As shown in the preceding paragraphs, PR has a full right to claim and expect from IIMCT, as per agreement, the adherence to the standards and requirements set by PMDC for a teaching hospital. This right is not PMDCs alone. 2.5.1 PMDC rules for teaching hospitals. The PMDC rules for the recognition are available in the document titled : MINIMUM CRITERIA, REQUIREMENTS AND GUIDELINES INCLUDING FACULTY REQUIREMENT/CHECKLIST OF INFRASTRUCTURE AND EQUIPMENT FOR MEDICAL AND DENTAL INSTITUTIONS TRAINING FOR A MEDICAL OR DENTAL QUALIFICATION AND RULES AND REQUIREMENTS REGARDING THEIR ATTACHED TEACHING HOSPITALS 2009. 9 This document exhaustively explains the requirements of a teaching hospital in order to be recognized. The initial parts are of little relevance to PR and indicate procedures and processes. What is in PRs interest is the checklist of infrastructure and equipment. Compliance to the requirements in this list is needed for recognition as a teaching hospital and in this regard IIMCT is severely lacking. So crucial and capital intensive are these requirements that it has been deemed essential that the whole list be added to this report for detailed examination. 10 IIMCT has not provided 96 out of 436 medical equipment items. It is needless to say that the provision of such equipment would significantly improve the care provided to Railway employees and the lack thereof is a non-compliance to the agreement between IIMCT and PR. Not only is it a non-compliance but a defeat of the purpose of the agreement as far as PR is concerned which clearly envisages a developed and upgraded teaching hospital with advanced diagnostic and therapeutic facilities and equipment. Rather than examining each and every item, two items will be taken to assess the benefits if they had been provided on the premises. 2.5.2 CT scan: A CT scan machine (computerized axial tomography) scan is an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. A CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments. 11 The prime benefit of a CT scan is the ability of a doctor to quickly diagnose and start appropriate treatment immediately. This is critical for patients who have had brain strokes where immediate treatment can save a life or at least minimize damage. If the CT scan is
9

PMDC website Page No. 31 to 34. 11 Internet link : http://www.medicinenet.com/cat_scan/article.htm

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outsourced and provided at a location far away where some patients can be injured on route, or if its usage is restricted on account of it not being available at odd hours, its utility is limited to the treatment of illness which do not need immediate assessments or diagnosis. PR, when it gave RH to a third party was expecting such a facility as IIMCT was to conform to PMDC requirements. In fact, IIMCT did have a CT scan in 2009 on the premises of RH but discontinued it for reasons best known to them. 12 An MRI (Magnetic Resonance Imaging), which is also included in the same checklist, is as useful as a CT scan or more, taking into account the fact it uses harmless magnetic rays rather x-rays/radiation. 2.5.3 Echocardiography with color Doppler. Echocardiography is one of the most widely used diagnostic tests for heart disease. It shows the size and shape of the heart, and the location and extent of any damage to its tissues and assessing diseases of the heart valves. It also detects the presence and assesses the severity of coronary artery disease, as well as help determine whether any chest pain is related to heart disease. The biggest advantage is that it does not involve breaking the skin or entering body cavities and has no known risks or side effects. The counter argument to the obvious fact that such equipment is not available as per contractual obligation in RH is that it is available on request and charges would be reimbursed. This is not an adequate response. IIMCT is under contractual obligation to provide these facilities for free and on the hospital premises. What actually happens in practice is totally different. MRI and CAT scans and all other laboratory tests not available in RH were to be provided to Railway patients for free up to no limit (see para 3.1), but now the cost of these tests have been included in the Rs. 4 million that IIMCT was to give only for out-referred cardio, neuro, dialysis and cancer cases. Above that amount is now being paid by Railways (further detail in para 3.1). At present all these facilities for which PR has the right to expect to be available in RH premises for free (and which IIMCT has tried to provide in the past but unsuccessfully), is now is being paid from PRs own pocket due to non-compliance of the terms of a clause of the agreement. 2.5.4 150 bed versus a 450 bed hospital. As per PMDC requirements, a teaching hospital needs a certain number of beds in order to be recognized. The question that is relevant in this regard is whether such a large increase in the number of beds is in PRs interest or not. From a cursory look at the records of indoor admitted patients it can be seen that no more that 100 to 150 railway patients are admitted at a time. 13 This shows that the increase in the number of beds is a requirement of PMDC, to cater for private patients and does not serve the needs of Railway patients in any significant manner.

12 13

Internet Link : http://pakistanrailways.blogspot.com/2009/04/extension-work-at-railway-hospital.html MS figures obtained in Divisional Officers Meetings at DS Office, Rawalpindi.

3. Drugs and reimbursements. The direct financial benefit PR draws from the agreement is in the form of free medicine and reimbursement of treatment and lab tests obtained outside the hospital (which are not available in RH). This is, however, subject to certain limitations. The first limitation is financial. Initially, the limit of free medicine was up to Rs. 0.5 million (1998) which was later increased in Rs.3 million. By 2011, the amount has increased to Rs 7 million. However, a great flaw exists in this process: no independent check or verification is carried out whether the amount is actually spent or not. The only verification carried out by Medical Superintendent, Rawalpindi is the acknowledgement that IIMCT has purchased such and such medicine from the market and that it is deposited in its store with no verification whether it has been disbursed to Railway patients. It is an unforgivable error to rely on the goodwill of a private party to spend Rs. 7 million without any form of independent verification. This point cannot be stressed enough. 3.1 IIMCT and Railway Drug Formulary. Another lacunae exists in compliance to clause no. 6 of the 2000 revised agreement which states the following: The Second Party shall provide medicines to the extent of Rs. 3.0 million per annum and this amount will be reviewed with mutual consent, if required shall be provided to Railway entitled patients as per Pakistan Railways Drug Formulary. If required IIMT will try to provide medicines, not included in the Formulary, to the deserving patients. The drug formulary of IIMCT was obtained and compared with that of Railway drug formulary and it was found that 475 out of 646 drugs in Railway formulary did not exist in IIMCT lists. IIMCT formulary contained 311 drugs while Railways formulary is of 646 drugs. 171 drugs existed in both formularies but IIMCT drugs are not from the approved brands of Railway drug formulary. Only 30 drugs from the same brands existed in both formularies. In other words, IIMCT conformity to Railway drug formulary as per relevant clause of the agreements is only 10 %. The IIMCT argument for using other brands is that the Railway formulary lacks inexpensive local drugs and in order to increase the quantity of drugs they are using the same. However, a cursory look at the Railway formulary reveals that there are plenty of local companies. This also doesnt explain the absence of many drugs in IIMCTs formulary. The range of medicines available to doctors and specialists in particular is poor. A detailed comparison is available for perusal. 14 IIMCT formulary suffers from a severe lack of range of medicines which defeats the purpose and benefits of the increased number of specialist departments and consultants. Medicines are often prescribed by doctors that are not available in IIMCT formulary at all. Evidence of the same has been collected in the prescriptions of specialist, medical officers and house officers of IIMCT. This can be interpreted as IIMCTs own doctors lack of confidence in the type of drugs or brands available in the hospital. The purpose of this clause was to ensure that railway patients were provided quality medicines that had been screened by PRs medical branch. IIMCT is in clear breach of this clause and
14

Detailed break-up of ratio of number of medicines in IDF and RDF (page no.35-38).

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has been so for a long time with little or no problems from PR. While working in Rawalpindi division it is commonly known that the largest numbers of complaints are of the quantity and quality of medicines in RH. IIMCT compliance to the Railway drug formulary and proper independent verification during and after the disbursing of medicines will significantly improve the medical care imparted to Railway patients. The expected cost to be incurred by PR in RH in 2011-12 is approximately Rs. 7.2 million (excluding salaries of Railway staff) in contrast to the Rs. 11 million being spent on drugs and reimbursements per year by IIMCT. Rs 2.93 million has been spent by MS/RWP on medicines provided to Railway patients turned back from IIMCT (as the same medicine was not available with IIMCT). Any medicine that is provided by PR to Railway patients raises the question of what is the use of this provision in the agreement if PR is still incurring such heavy costs and that too on medicines that IIMCT is to provide as per Railway drug formulary. 3.2 The Range of Medicines and the effect on patient care. In the treatment of patients doctors need a variety of options and discretion to use any of them according to their professional opinion. When a patients suspected illness presents itself, a doctor must know that he has the tools at his disposal for its diagnosis after which a surgical intervention or drug treatment is necessary. Therefore, a drug formulary or list and its proper preparation is crucial. The IIMCT drug formulary has severe limitations in this regard and although the Railway drug formulary is far from perfect, the following examples will show how the Railway formulary caters to a larger number of diseases than IIMCTs and how IIMCTs non-compliance to the agreement is effecting Railway patients. The comparison that will follow will only between Railway drug formulary medicine vis--vis IIMCT medicines. No other medicine will be mentioned. 3.2.1 Mortality benefit drugs. Mortality drugs are those drugs that are lifesaving drugs. Their administration to patients on the spot and immediately is crucial to save a life or at least to increase chances of survival later. The option of asking a patient to bring such a drug from a pharmacy is not an option in the usage of such drugs. The drug lists have been examined and such drugs that are available in Railway drug lists (henceforth RDF) and not available in IIMCTs list (henceforth IDF) have been mentioned. i.Anaesthetics. Thiopentone Sodium is the first anaesthetic in the Railway drug formulary. It is a standard drug all over the world for giving to a patient who needs to be anaesthetized. IIMCT list does not have it but instead uses an alternative called propofol. Propofol has the effect of lowering blood pressure of the patient therefore it is not an acceptable drug of choice for a patient who has, for example, come from a road accident and has massive bleeding (as the bleeding will lower blood pressure). However, another drug available in RDF i.e. Midazolam is also used as the drug of choice in case of massive bleeding which isnt available in IDF. In such circumstances another mortality drug i.e. Atracurium is used for patients who need to be put on ventilator and sedated and resist the effects of propofol. This too isnt available on IDF.

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ii. Pain Killers. Minor Painkillers or non-steroidal anti-inflammatory agents (NSAIDS) are used in the relief of pain. Next generation drugs such as Piroxicam, Orphanedrin and Naproxen are available in RDF and absent in IDF. IDF only contains Diclofenac Sodium and Ibrufen. In case of patients who are unable to take NSAIDS (due to the effect of NSAIDS on the stomach) such as those who have cancer, after major surgeries, acute heart attack, stomach bleeds, kidney failure and orthopaedic surgeries, arthritis pain etc, the next category of drugs for them are called opioids. RDF has four opioid drugs while IDF has none. A glaring absence is of morphine and its variants which is available in any hospital that conducts any surgery and needs to give pain relief to patients who have diseases such as cancer. iii. Cardio Vascular drugs. These drugs are used in the treatment of patients with heart related illnesses. Three drugs ensure 30 % survival benefit to patients with congestive heart failure i.e. heart attacks. Those are Bisoprolol, Metoprolol and Carvedalol. Standard treatment for ischemic heart disease which means patients with angina and heart attacks is called ABCD: A for antiplatelet medicine (e.g. clopidogrel), B for Beta blockers, C for cholesterol lowering (e.g. statin) and D for Disprin. Out of these four steps only Disprin (Aspirin) is available in IDF while all four exist in RDF. This automatically rules out availability of drugs for patients with heart problems etc. 70% of patients in Medical department are of Type 2 Diabetes and almost all of them are hypertensive (high blood pressure). Controlling blood pressure in these patients is by ACE inhibitors, one of which captopril is available with IDF but it causes chronic dry cough as a side effect. As no other such drug is available patients often quit inevitably unaware that it may lead to their death gradually or serious complications as no alternative to this group is available although mandatory for treating blood pressure in diabetes. Another option for hypertension control in diabetes is ARB, the newest drug used worldwide but not available in IDF. Another drug called warfarin is of crucial importance in patients with the most common cardiac emergencies i.e. atrial fibrillation (fluttering of the heart) in order to the keep the blood thin. It is not available in IDF. The commonest emergencies like atrial fibrillation (mentioned above) and SVT (supra ventricular tachycardias) need a series of medicine which are unavailable in IDF as listed below: Inj Digoxin Inj Amiodarone Inj Verapamil Inj Metoprolol Inj Diltiazem Inj Adenosine

iv. Stomach problems. IDF contains two drugs for stomach related illnesses; Famotidine and Ranitidine. These drugs are not used in patients who have risk of bleeding in their upper gastro-intestinal tract. Such patients include diabetic gastropathy esophageal varices in CLD and chronic use of NSAIDs. Alternatives such as omeprazole (injections/IV) are required which IDF does not 12

have. Domperidone is a drug crucial for diabetic patients who have stomach or digestion related illnesses that doesnt exist in IDF. Children with simple diarrhea which can become life threatening but can be treated by symptomatic drugs like Kaolin Pectin which IDF doesnt have. Medicines for stomach worms etc (anti-helminitics) are absent in IDF. No iron or calcium supplements exist in IDF which are crucial for children who are anemic (one in five in OPD, RH). v. Psychiatric medicine. Medicine for psychiatric patients consist of medicines ranging from those with serious psychiatric illnesses and those with clinical depression. Such medicine is particularly necessary for patients who suffer from chronic or severe diseases as described below: Congestive heart failure Cancer Diabetes Chronic Kidney disease and dialysis Tuberculosis Other severe/chronic illnesses

The probability of surviving such diseases is drastically reduced if patients suffer from depression, which is associated with all of them. A study shows that untreated depression in patients with above mentioned illnesses reduces the prognosis of survival for patients. A single antidepressant is not available in IDF as common as fluoxetine and escitalopram. IIMCT only provides tranquilizers diazepam and bromazepam with the notable absence of the commonest and cheapest of drugs such as haloperidole and risperidone used for psychotic and non-psychotic cases of delirium and agitation in old age. These two medicines are in contrast to the considerable variety of such drugs in RDF. Life threatening attacks of epilepsy (statis epileticus) or asthmatic attacks (statis asthmaticus) have no medicine in IDF. Parkinsons disease has no medicine in IDF and neither is there any for migraines. It is pertinent to mention that depression and migraine constitutes 60-70% of the psychiatry OPD pool. 3.2.2 Other essential drugs. i. Asthma attacks:

As the Rawalpindi/Islamabad region is well known for the severity of Asthmatic problems; very few medicines are available in IIMCT for such diseases. For example, in case of a severe or even life threatening asthmatic attack, a sequence of treatment with drugs is needed: Albuterol nebulizer/inhaler Steroids Ipratropium inhaled (study shows it works best with Albuterol to open airways) Magnesium IV (Drugs no 1 and 4 are not available in IDF.) 1. 2. 3. 4.

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In case a patient doesnt get improved they have to be ventilated immediately to avoid death of the patient. As mentioned before, patients who dont respond to the only anesthesia available i.e. propofol, need atracurium to get intubated and be ventilated. As it is not available in IDF, a short trip to the market isnt feasible in an emergency. In addition to this, a blood gas analyzer (ABG) needed to show the oxygen and other levels of gas in the blood stream in order to fix the settings of the ventilator is needed to use the ventilator. Such a device to test ABG is not available in IIMCT. ii. Antibiotics:

The following antibiotics are available in IDF: Inj Ampicillin Inj Gentacin Inj Cephradin Inj Flagyl Tablet Ciproxin

These medicines are totally inadequate in treating the following bacterial infections: Typhoid (Ciproxin is ineffective in 70% percent of South Asian patients) Drug resistant tuberculosis Meningitis Pneumonias (complicated or resistant cases mainly) Lung abscess Urinary tract infection Chronic liver disease (CLD) with infections

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3.3 How Railway LP makes up for these deficiencies. Healers pharmacy is a private pharmacy shop on the premises of RH that has been allowed on the condition that it provides 5-10% concession to Railway patients in the purchase of medicines. It is a remarkable fact that all the variety of medicines and items that are needed in RH are available in the pharmacy and notably absent in the dispensary. The Medical Superintendent (Railway representative in RH) reimburses Railway patients to the tune of Rs. 3.2 million per year for expenditure on medicine refused by IIMCT in their dispensary. Upon examination of the receipts submitted by the office of the MS to the Accounts Branch of DS office, Rawalpindi, an overwhelming majority of medicine purchased, if not all, are the drugs that are available in RDF and absent in IDF. Almost all the medicine that has been prescribed has been done so by doctors of IIMCT. All the medicines purchased are from the Healers pharmacy and indicate no concessions for Railway patients. A number of conclusions can be taken from this fact: Railways administration in the hospital is subsidizing the absence of medicine in IDF by purchasing them through local purchase from Railway funds sent by Headquarters office, Lahore Healers pharmacy secures its business through a monopoly as no other commercially run pharmacy exist on the premises. IIMCT doctors deliberately and repeatedly prescribe medicines and brands that are not available in the IIMCT dispensary as they simply dont exist in IDF. IIMCT doctors dont have confidence in the brands available in the dispensary indicating their professional differences with IIMCT. PR administration not only provides money from its own pocket thereby assisting IIMCT financially, but helps in the running of a commercial business i.e. Healers Pharmacy. Hepatitis patients receive medicine that are only available in RDF which should be provided by IIMCT, but is bought through local purchase by the Medical Superintendent. This amounted to Rs. 931,000/- last year.

3.4 Packing and Labeling of Drugs. The last aspect of IIMCTs faulty drug policy is that drugs dispensed for patients are not as per the The Drugs (Labeling and Packing) Rules, 1986 of the Government of Pakistan. Syrups or anything containing liquid medicines were packed in unmarked plastic bottles poured in from larger containers. Neither were these bottles sealed or labeled. Upon the insistence of the divisional administration they started to be labeled, however, the information is still insufficient. As per rules the labels are to detail the following: (a) the name and principle place of business of the manufacturer; (b) the drug manufacturing license number; (c) the drug registration number; (d) the date of expiry; (e) Urdu version of the following namely:(i) registered name of drug. (ii) dosage (numerals in English shall be sufficient) : and (iii) Instructions. 15

(f) the distinctive batch number, date of manufacture, and the maximum retail price: The information on liquid container does not mention any date of expiry. The same is for tablets disbursed in strips of paper. The patient is to just to assume that the medicine is what it seems to be and not expired. 3.5 Reimbursements. The term reimbursements means payments given to patients who are referred to other hospitals or doctors for medical care or laboratory tests not available in the hospital. The relevant clause of the agreement pertaining to the same is reproduced below: The Second Party shall be responsible to provide specialized medical cover, free of cost to the serving/retired employees of Pakistan Railways, their families and dependents as admissible and presently available to them in terms of Railways Boards Notification issued from time to time. This shall include :a). Outdoor Laboratory test. treatment including consultation, medical attendance and

b). In-door treatment including medical attendance, consultation, surgery, specialized medical cover including:i). Dialysis ii). Cancer therapy, Chemotherapy and Radiotherapy iii). Cardiac Surgery iv). Neurosurgery v). Provision of orthopedic implants, stents, meshes DCR tubes etc. vi). C.T Scan and MRI vii). Laboratory investigations not available in the hospital and advised by the head of concerned department. The amount being reimbursed by Pakistan Railways currently for Cardio/Chemo/Dialysis/Neurology cases will be taken up by the Second Party upto a total of Rs. 1.0 million per annum (later increased to Rs.4 million). Expenses above this limit will be borne by Pakistan Railways. 15 This clause meant that Cardio/Chemo/Dialysis/Neurology cases were to be referred to outside IIMCT as the same medical care was not available in RH. The last three items i.e. v,vi and vii were to be reimbursed by IIMCT as and when required. In 2006, a meeting of the management committee modified this clause much to the detriment of the interest of Railway patients by including the last three categories as well. Now, the reimbursements are made from the Rs. 4 million for the last three categories as well which was not the case before. Upon the utilization of the Rs. 4 million, over and above expenditure is made by PR which came to Rs. 3.9 million last year and has been increased by a larger budgetary allocation for 2011-2012. This raises the natural question of the limited benefit of IIMCT if it has yet to develop any facilities for patients of heart disease, cancer, kidney disease and neurological problems despite having had

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Clause no. 2 & 3 of 2000 Revised Agreement.

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RH for the last 13 years. Furthermore, no CT or MRI scan facilities and other diagnostic services have evolved, despite PMDC requirements. 4. Infrastructure development. The envisaged development and up-gradation of the hospital logically meant increase in the physical infrastructure of the hospital in the form of better equipped, furnished interior facilities and improved standards of cleanliness and environmental conditions. It also meant better diagnostic facilities available in the wards e.g. ventilators and ECG machines. It is selfevident what constitutes better infrastructure and further elaborate detail is not needed. An examination of each nook and cranny of the hospital would perhaps be too exhaustive and therefore a sample study would suffice to give a decent overall picture. 4.1 Intensive Care Unit. An intensive care unit can be described as a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment. The type of patients in an ICU are as follows: Critically ill patients in a medically unstable state who require an intensive level of care (monitoring and treatment). Patients requiring intensive monitoring who may also require emergency interventions. Patients who are medically unstable or critically ill and who do not have much chance for recovery due to the severity of their illness or traumatic injury. Patients who are generally not expected to survive. 16

The specialized monitoring equipment expected in an ICU is as follows: Common equipment in an ICU includes mechanical ventilators to assist breathing through an endotracheal tube or a tracheotomy; cardiac monitors including those with telemetry; external pacemakers; defibrillators; dialysis equipment for renal problems; equipment for the constant monitoring of bodily functions; a web of intravenous lines (central), feeding tubes, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs to treat the primary condition(s) of hospitalization. Medically induced comas, analgesics, and induced sedation are common ICU tools designed to reduce pain and prevent secondary infections. 17 The nurse to patient ratio is a minimum 1:2, whereas that of a normal ward is 1:4 or 5. In other words, an ICU is the cleanest (due to extreme high risk of infections in patients whose immunity is severely weakened), the most well equipped, well-staffed run on a 24/7 routine. Only doctors and nurses well equipped with expertise and knowledge can work in an ICU. Needless to say, an ICU is the showpiece of a hospital. Besides the inadequate equipment 18, the doctors on duty proved to be the highlight of the visit. Doctors posted in an ICU are specialists and are supposed to have a specialist degree. In
16 17

Internet link: http://www.surgeryencyclopedia.com/Fi-La/Intensive-Care-Unit.html Internet link: http://en.wikipedia.org/wiki/Intensive_care_unit 18 List at Page no. 31-34.

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practice, in most hospitals, a post graduate student after having completed their first two years of a four year training program are post as ICU doctors. Two programs are offered by the College of Physicians and Surgeons, Pakistan namely ATLA (advanced trauma life support program) and ACLS (advanced cardiac life support) which is least that one could expect if a specialist doctor is not available. Instead, in the ICU of RH, two doctors Ms. Rashida and Mr. Tanveer were present. Ms Rashida was a recent graduate of MBBS at IIMCT and had just completed her house job. Mr. Tanveer was a recent graduate qualified in China. This is administratively and professionally intolerable for any hospital that strives to achieve high standards and recognition as a teaching hospital. This situation was reflected in the ER as well which lacked crucial equipment in treating emergency patients. The doctor on duty was a casualty medical officer named Dr. Usman who was also a recent graduate from China. The conclusion drawn is also a reflection of the condition of the wards. The ICU, the most critical of all units of a hospital, has been treated in such a manner and that too after more than ten years of opportunity of time and resources for improvement speaks clearly of the development and up-gradation that has occurred in RH. Moreover, the benefits of the increased number of wards cannot be assessed by their mere existence. A proper assessment would have to be regarding the services provided i.e. whether they are qualitatively adequate, catering to real needs of patients and performing as per medical standards expected of such units. To state that they exist and assume they are perfect is not sufficient.

4.2 Increased number of wards by IIMCT: What constitutes a ward ?

Another aspect which is noticed is the increased number of wards. The number of wards now made available by IIMCT is as follows: a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. Two Medical Units Two Surgical Units Two Gynae & Obstetric Units Paediatrics Department Ear, Nose & Throat Department Eye Department Orthopedics Department Intensive Care Unit (ICU) Neonatal ICU Burn Ward Labour Room Physiotherapy Department Operation Theaters (4) Pain Clinic Skin department

The increased number of departments or wards and their allied facilities and specialists has been contrasted with how RH was before and portrayed as one of the benefits IIMCT has provided to RH. Below is a brief description of how some of these wards have been created. i. The Medical Unit II has 40 beds of which four have been allocated to the dermatological (skin) department. The skin faculty consists of one Associate 18

ii.

iii.

Professor, one medical officer and one house officer. The total number of medicines available to treat the large variety of skin ailments in IDF is two, one being Polyfax, and antibiotic cream and Betnovate, a steroidal cream. The psychiatry department consists of the same beds in Medical Unit II, meaning that skin and psychiatric patients share and use the same beds in Medical Unit II. This is hardly appropriate as one can well understand the needs of both types of patients and why they shouldnt be kept together. Furthermore, IDF has no psychiatric medicines at all. The ENT (Ear, nose and throat) department constitutes of four beds shared in Eye ward for male patients. Female patients have nowhere to go and are usually accommodated in the Medical Units.

4.3 The TB (Tuberculosis) Ward issue. The old Railway set up had a TB ward near Transit Camp chowk, Rawalpindi cantonment. This is a large building specifically made for the peculiar requirements of TB patients. In 2000, the then Administrator, IIMCT sent a letter to Divisional Superintendent, Rawalpindi, which is reproduced partially below: The existing number of patients of open cases of Tuberculosis has increased manifold and gradually increasing day by day. Due to short space in the Medical Ward it is very difficult to admit the patients. Besides this, the isolation for these patients is also essential . In addition to T.B. patients the position of skin diseases patients is also the same and no isolated ward for these patients has so far been provided in the hospital which is an urgent need of the time. it is also pertinent to mention here that orthopedic unit is working fully and a demand of Physio-therapy Unit is increasing day by day. Keeping a circumspect view of the facts narrated above we propose that old T.B Ward (Sanatorium) of P.R. Hospital, Rawalpindi may be developed as a Unit of Chest Diseases, Dermatology and Physio-therapy unit. We would merely like to renovate its present position and not to make major alterations, we will seek your approval before the work is taken in hand. 19 The building was provided to IIMCT for the purpose it was requested for in 2005. In 2011, on the indication of the Divisional administration, Rawalpindi, it was asked as to why the ward building had been used for other purposes for which it was not handed over, the following reply was received: Reference to your above mentioned letter on subjected matter, you are hereby informed that TB Ward(Sanatorium) is the part and parcel of Railway Hospital Rawalpindi clearly mentioned in the letter written by worthy D.S Rawalpindi having Ref No.60-W/734 dated 27.4.2000 ... These references clearly reflects that their no need of any further approval required from any authority for converting the subjected ward into Nursing Hostel 20

IIMCT letter No. IIMCT/RH/C-3 dated 4/4/2000 Subject Renovation of TB Ward (Sanatorium) P.R. Hospital, Rawalpindi. 20 IIMCT letter No. IIMCT/RH/TBW/02 dated 5/7/2011 Development of Pakistan Railway Hospital TB Ward (Sanitorium).

19

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At present, TB (tuberculosis) department is now four beds located in the Medical Unit II ward. This is particularly interesting considering the large number of TB patients in the surrounding regions with TB resistant to the strongest antibiotics. TB patients are usually placed in isolation due to the risk of infections to other patients in a hospital whose immune systems have already been weakened and thereby susceptible to infection. The Skin/dermatology and Physiotherapy units were also to be accommodated in the TB building given by PR. Furthermore, the range of antibiotics and medicine needed for TB patients is glaringly absent from the drugs list provided by IIMCT. Lastly, no pulmonologist or Chest physician exists to cater to TB patients or the large number of patients with chest problems in the Rawalpindi/Islamabad (due to allergies). It can be seen from the above, that serious reservations exist on the manner which IIMCT has improved the infrastructure in terms in terms of staff, medicine provided and buildings to accommodate patients. 4.4 General sanitary conditions. A survey report conducted by the Welfare branch which was necessitated after numerous complaints is attached with this report for ready reference. 21 It is self-explanatory and shows the general condition of washrooms, wards and grounds of the hospital. Since the report has been forwarded to higher authorities, IIMCT has improved the conditions on the directives of the Ministry of Railways. Nevertheless, it defies belief that a hospital could tolerate such conditions in the first place. Interestingly, the areas that were identified have been renovated in the hospital after being pointed out in the survey report. However, areas that were not identified due to limited access remain the same, a good example of which is the Gynae Ward. A number of pictures have been taken which shows that unless shown by means of photographic evidence by others, IIMCT is least bothered to keep the hospital clean and in a proper condition. 22 4.5 Yet to be made: Community Health Units, Mobile Primary Health Unit and Flying squad. Community health units were to be established utilizing the Child Welfare centers and operated by IIMCT. This has yet to take place. A mobile primary health unit was also to be established but has yet to be made. Instead IIMCT forwarded the proposal to up-grade a medical van of a relief train. A relief train is used to proceed to accident sites and contains a special carriage adapted as a medical van. It is restricted to travelling on rails alone and is very expensive to operate on account of fuel costs and availability of locomotives. A mobile primary health unit means something else that could be set up in a Railway colony in relatively far flung area of the division which does not have easy access to health care. Lastly, a flying squad i.e. The Second Party will also render emergency services in the Hospital and also establish a flying squad to provide emergency aid at the site to any injured/casualties as a result of Railway accident in Rawalpindi area was also a part of the agreement. At present, till the writing of this report, IIMCT has one Suzuki van converted into an ambulance and an old, decrepit Toyota Hiace van that was originally of the division and handed over to IIMCT which has since been returned to the division in a dilapidated condition. A donated American
Survey committee report of Welfare Branch, DS Office, Rawalpindi with photographs included attached separately with this report (Appendices) 22 Pictures of Gynae ward (Page 39-51)
21

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ambulance that is not in running condition and not practical to use on account of its size, operating cost and width is rarely seen or used. This amounts to the flying squad now employed. 5. Other aspects of Hospital services. A complete analytical study of the performance of a hospital and the medical services given to patients is beyond the scope of this report, however, they are aspects to a hospital that can be logically observed by anyone and inferences can be made. 5.1 Patient dietary services. One such observable is the diet given to patients. The diet chart provided by Cairns Railway Hospital, Lahore and Railway Hospital, Rawalpindi prior to being taken over by IIMCT are reproduced as table A and B below: Table A
SCHEDULE OF UN-COOKED DIET OF A PATIENT IN RAILWAY CAIRNS HOSPITAL, LAHORE. S. No. 1 2 3 4 5 1 2 3 4 5 6 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 'A' Genl.Diet 'B' Diet 'C' Diet 1 No. 2 (50 Gm) 25 Gm 1 1/2 Ltr. 60 Gm 'D' T.B.Diet 1 No. 2 (50 Gm) 25 Gm 1/2 Ltr. 30 Gm 250 Gm 125 Gm 125 Gm 25 Gm 250 Gm 125 Gm 125 Gm 60 Gm 25 Gm. 25 Gm 25 Gm 4 Gm 1 Gm 4 Gm 2 Gm 3 Gm 5 Gm

Description of diet items

EGG BREAD SLICE BUTTER MILK (TETRA PACK) SUGAR ATTA MEAT/CHICKEN VEGETABLE RICE DAL MOONG COOKING OIL ATTA MEAT VEGETABLE DAL RICE DAL MOONG COOKING OIL TOMATOS ONION CHILLIES HALDI DH1NNIA DRY GINGAR LEHSAN SALT

BREAKFAST 1 No. 2 (50 Gm) 2 (50 Gm) 25 Gm 1/2 Ltr 30 Gm LUNCH 250 Gm 125 Gm 125 Gm 25 Gm DINNER 250 Gm 125 Gm 125 Gm 60 Gm 25 Gm 1 Ltr. 60 Gm

125 Gm 30 Gm 12.5 Gm

125 Gm 30 Gm 25 Gm 12.5 Gm MISCELLANEOUS (Each Diet) 25 Gm 25 Gm 25 Gm 4 Gm 1 Gm 4 Gm 2 Gm 3 Gm 5 Gm 5 Gm

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Table B DIET SCHEDULE OF PAKISTAN RAILWAY HOSPITAL RAWALPINDI PER PATIENT PER DAY FROM 01/07/1996 TO 30/06/1997 No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Description of items of diet Milk Bread Butter Sugar Egg (Large Size) Atta Rice Basmati a) Matton or Keema, chicken/ Fish Rohu only substitute b) Dal Dal (Masoor, Moong) Ghee Vegitable Vegitables (Seasonal in rotation) Onion Fruit (as per note below) Curd of Milk Salt Masala including chillies Haldi, Dhania etc Tomatos (good quality) A 1 Litre 50 gm 25 gm 60 gm 1 No. 500 gm 250 gm 125 gm on meat less days 120 gm 50 gm 250 gm 25 gm 200 gm 15 gm 20 gm 25 gm B 1 Litre 50 gm 25 gm 60 gm 1 No. 360 gm 60 gm 50 gm 25 gm 200 gm 250 gm or 1/4 litre 10 gm C 1 Litre 50 gm 25 gm 60 gm 1 No. -

A hospital diet is different from normal diets in the sense that the types of food available in a chart are for patients whose requirements vary from each other on the basis of their sickness. For example, a patient who has severe stomach illness and advised soft food can be seriously harmed if fed any solid, hard food, even a toast or boiled egg. Similarly, patients with heart disease, kidney problems have their own specific requirements that are assessed by a professional nutritionist. In Railway hospitals, foods are generally categorized into four groups, i.e. A, B, C and D. Doctors prescribe a particular category, or if something advised is not available for a patient at the hospital, it is purchased by the patient himself. 23 Generally, the simplest classification is as under: Liquid Diets Sodium Restricted Diets Diets for Diabetics Diets for Heart Patients

22

Two charts have been perused. The diet chart provided by IIMCT is reproduced below:

Diet Menu As Per Doctor Advise

Date 5/1/2011 5/2/2011 5/3/2011 5/4/2011 5/5/2011 5/6/2011 5/7/2011 5/8/2011 5/9/2011 5/10/2011 5/11/2011 5/12/2011 5/13/2011 5/14/2011 5/15/2011 5/16/2011 5/17/2011 5/18/2011 5/19/2011 5/20/2011 5/21/2011 Break Fast Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Milk+Bread+Suger Lunch Aaloo+Chicken Aaloo+Chicken Aaloo+Chicken Aaloo+Chicken Aaloo+Chicken Gobi+Ghosht Tinda+Ghosht Aaloo+Chicken Aaloo+Ghosht Aaloo+Chicken Aaloo+Chicken Kaddoo+Ghosht Tinda+Ghosht Bengan+Ghosht/Daal Ghosht Palack+Ghosht Kaddoo+Ghosht Aaloo+Chicken Aaloo+Chicken Gobi+Ghost Kaddoo+Ghost Bhindi+Ghost Dinner Daal-Chana+Palak Caal+Mash Kadoo+Daal+Chana Daal+Chana+Palak Daal+Lobia Bengan+Tinda Daal+Moong Daai+Chana+Kaddo Daal+Chana Daal+Mash Aalco+Gobi+Bengan Daal+Channa Aaloo+Gobi Daal+Channa Daal+Moong Aallo+Gobi Daal+Channa+Kaddo Daal+Mash Daal+Lobia Shimla+Mirch+Gobi Daal+Moong

As seen above, there is no categorization of food. No indication that certain foods cater to patients with certain groups of disease. Charts obtained from RH indicate that all patients receive only one type of diet i.e. category B though the chart provided by Administrator IIMCT indicates no categorization of food 24. In short it is not the type of diet that is given to patients in a hospital and a deterioration in the diet that was provided before RH was handed over to IIMCT. Pictures of IIMCT kitchen are an indication of the sanitary conditions before improvement on the directives of the Ministry of Railways 25. Issues like food handling, personnel involved in dietary services, entitlement, procurement and transportation of food articles, storage, preparation and quality of food have not been explored in this report although it is hoped that all dietary services will be examined in detail as a result of what has been shown above. 5.2 Railway Out Patient Department (OPD). Railway patients who visit RH can be categorized into two categories: those that get admitted and become indoor patients in wards and those that get medical advice or care in the OPD and are sent home. The large majority of patients are those that only need OPD care and dont need to be admitted. On average, 80-100 beds of the hospital are occupied by admitted Railway patients. In the hospital processes, the service provided to Railway patients in the OPD is crucial, therefore, a step by step understanding is necessary as described below:
24 25

Food consumption charts provided by RH. Pictures of kitchen and food (95-97)

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A Railway patient enters the hospital and goes to the OPD immediately to the reception window inside the reception hall. Next the patient goes to the Railway OPD which is actually a room in the main hall which is a general OPD containing all the relevant OPDs of different functional specialties in different rooms. Two Railway doctors screen patients and they are sent to the relevant OPD e.g. ENT, eye or orthopaedics. This process, according to the Railway doctors posted there takes two hours. There is no bed for patients to lie down and be examined. Only one BP apparatus for two or three doctors are provided and only one blood pressure apparatus. On reaching the relevant OPD, another hour is used up. The doctor sitting there is usually a house officer i.e. a medical college student trainee who is supposed to be under the supervision of a medical officer. It is often reported that the doctor attending is only a H.O. A Railway OPD chit showing the signature of a HO and the stamp of a consultant is indicative of the laxness in the conducting of the OPD. 26 After attending the OPD, the patients then proceeds to the IIMCT dispensary where he waits on average of one hour.

This information has been received from doctors and patients alike. It proves that a patients with a common complaint like a bad throat or upset stomach waits on average for four hours from his arrival at the hospital till he receives medicine. The care he receives is from an MO or HO. Some patients are referred to the consultant OPD where specialists attend from 9am to 2pm. On average very few patients are sent to the consultant OPD. Another aspect of OPD patient is the number of patients with specific diseases. A cursory look at the type of diseases prevalent indicate that almost 50% of OPD patients suffer from cardiac diseases and hyper tension (blood pressure). RH has no cardiac facilities or cardiologist. Moreover, the drugs available in IIMCT formulary are insufficient to cater to the needs of cardiac and hypertensive patients. A list of commonly used drugs below which are not available is at 3.2.1(iii). Most significantly, are the large number of Railway patients who are sufferers of chronic diseases and need medicine all the time. They make up at least one third of OPD patients and are usually pensioners. The reason why they are so many is that they receive only three days of medicine whereas standard practice is to give such patients two weeks of medicine e.g. CMH/Rawalpindi. The provision of cardiac care, adequate drugs in type and quantity would significantly address the problems OPD patients face. The time consumed in OPD can be significantly reduced by at least 50 % initially by eliminating the Railway OPD. In discussions with Railway doctors it has been revealed that it has no significant function as the screening process is needless and can be done by the front reception by the attendance of a nurse. The waiting time would be cut by half to two hours. The time at pharmacy can be cut down by having more window attendants or dispensers. This is important as patients often wait for an hour to be told that such and such medicine is not available.

26

See Page 52.

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6. Expansion of IIMCT. One of the arguments that has been put forward to account for the deficiencies in the working of the hospital is that a physical expansion would assist IIMCT in resolving the problems that are highlighted from time to time. It would, therefore, need to be examined whether such an expansion would be a panacea for the problems of RH or not. 6.1 Congestion. The first argument put forward is that RH workload has expanded manifold over the years and that due to these increasing numbers it is necessary to increase the covered area of the hospital. Taking the figures provided by MS/RWP, the average number of patients is 80 for Railway patients and 70 private patients coming to a total of 130 bed occupancy out of a total of 400 beds. There is no indication that the hospital has been bursting at its seams. The number of OPD patients per month comes to an average of 12,000 per month with 13,319 at the highest during the last year. This shows that the average number of OPD patients per day is 200. The above figures indicate that the existing infrastructure in terms of catering for the influx of indoor and outdoor (OPD) patients is quite adequate. In fact, half of the hospital lies underutilized to a large extent for most of the year, and the 100-150 figure in terms of numbers of beds is adequate to cater to the requirements of Railway patients as RH has been established and handed over for the needs of Railway patients, not revenue generating private patients. 6.2 The expansion proposed. Out of the total covered area of 50,595/- sq/feet proposed in the expansion plan submitted by IIMCT, 42643/- sq feet is occupied by academic areas, private rooms, consultant rooms. The rest of the total i.e. 7952/- i.e. 16.13% of the total is occupied by medical facilities i.e. physiotherapy, intensive care unit and 9 bedded wards. If the rest of the hospital is an idea to go by, the facilities will not be to the standard as expected by PR. The other argument posed is that the area freed up in the main buildings by the shifting of academic facilities will be utilized in another manner. What has been proposed so far is an emergency trauma centre. This is, however, superfluous for Railway patients requirements which do not need an extensive trauma centre. Facilities like a simple cardiology ward, chemotherapy unit or a better ICU etc are not included despite being a clear need. The absence from the plan of how the existing infrastructure of the hospital could be improved and the freed up space would be utilized is a glaring fact that would leave any expansion plan incomplete. Moreover, if the existing problems are anything to go by, generalized statements e.g. a CCU or Neurosurgery unit without clear cut parameters or specifications in terms of equipment or staff should not be accepted and further details should be provided as per practice in the medical field. A newspaper report of IIMCT 27 citing statements of the Administrator IIMCT shows that the primary purpose of the expansion is to create an academic block. However, an expansion that does so for Railway patients after an objective assessment should be welcomed and encouraged if and whenever proposed.
3rd June, 2011 edition of the The New International. Internet Link http://www.thenews.com.pk/TodaysPrintDetail.aspx?ID=50542&Cat=6
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7. Railways check and balance. The hospital is situated in Rawalpindi division which is under the administration control of the Divisional Superintendent (Grade 20 officer). The end users and patients of RH are the Railway employees of the whole of Rawalpindi division with the bulk of the employees in Rawalpindi itself. RH does not cater to the whole of PRs network. Consequently, Rawalpindi divisions concerns regarding the services of RH are the concerns of PR. 7.1 The Medical Superintendent. The Medical Superintendent of RH is a representative of PR who plays a role of coordinator, facilitator and exercises check on IIMCT regarding compliance to the provisions of the agreement. The MS informs higher ups of the situation on the ground and of the concerns and interests of Railway patients. In other words, the role of the MS is pivotal in ensuring that patients rights are being adequately catered to. One prevailing situation that severely compromises the neutrality and objectivity of the MS is that the present and previous MS were also faculty members of IIMCT - the present MS being part of the Radiology faculty as an Assistant Professor. The previous MS was not only a faculty member but held her evening clinic in the sister concern of IIMCT i.e. Hearts International Medical Centre, Rawalpindi. The post of MS belongs to the administrator cadre for which administrative degree holders exist. To employ doctors so intimately related to IIMCT and taking remuneration in the form of an honorarium or other benefits is a clear cut conflict of interest and must be done away with forthwith to maintain some semblance of neutrality and administrative cohesion. A clause of the agreement also states that the coordinator who will also process the disciplinary cases against hospital employees (which is by function the MS) will be from the General Cadre i.e. the management cadre of medical doctors in Railways, not specialist. The administrative control of the hospital will be with the 2nd Party. However, senior most Doctor of the 1st Party (in General Cadre) shall act as coordinator in order to work as a cohesive team for the smooth functioning of the hospital. He/She will also process the disciplinary cases against hospital employees 28. 7.2 The Management Committee. The Chief Medical Officer is the overall in-charge of the medical department who works under the supervision of the General Manager/Development. These two officers play a role according to a clause of the agreement as reproduced below: Management Committee comprising General Manager (M&S), Director Health and Medical Services, Divisional Superintendent, Rawalpindi and Medical Superintendent, P.R, Rawalpindi, Managing Trustee and three nominees from Islamic International Medical College Trust will meet at least once a year. Decisions of Important nature, pertaining to this agreement or not covered by this agreement shall be referred to and decided by the Managing Committee. 29
28 29

Clause No.22 of Revised Agreement of 2000. Clause No.23 of Revised Agreement of 2000.

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The management committee can amend and modify the agreement. A number of problems exist in the functioning of the management committee which are enumerated below: a) The membership is faulty in the sense that it includes only one representative i.e. Divisional Superintendent who represents the interests of the employees of Rawalpindi Railway division. The M.S. is a doctor working under the administrative control of the CMO and ultimately GM/D. b) The minutes of the last Management Committee meetings (8th and 9th) were signed many months after the meetings were held due to disputes as to whether the draft minutes are a true reflection of what was discussed and decided upon during the meetings. c) The authority to amend the agreement places too much power in the hands of the committee. Substantial change has occurred since the original agreement since 1998 in the form of revised agreements and management committee meetings that have changed the character of the original agreement. d) In case of disagreement and gridlock, the matter of dispute is referred to an arbitration council which is nothing but a reconstitution of the management committee with the provision that the matter by consensus will be referred to the Secretary/Chairman (if unresolved) whose decision will be final on both parties. e) The convener of the meeting is GM/D, yet the minutes of the meeting are drafted by IIMCT. f) A reflection and measure of the effectiveness of the management committee is this report itself. The management committee or its members, especially from PRs side, have yet to analyze the genuine problems of Railway patients and cannot hold meetings frequently enough, solve problems or even agree amongst each other how the minutes should be drafted! 8. Financial and other benefits to IIMCT IIMCT was formed after it took over RH from PR in 1998. It was only after two to three years it was recognized as a teaching hospital by PMDC. Its recognition coincided with the Revised Agreement 2000 in which it was handed over the administration of the hospital too. By obtaining RH, IIMCT gained a number of things as listed below: A reliable patient inflow of outdoor and indoor patients which is not always ensured in any teaching hospital. Buildings and a substantive amount of hospital equipment. Location was excellent in terms of accessibility, price of land, in the city limits and on the outskirts of Rawalpindi cantonment and near Islamabad. The name and reputation of a prestigious government department. No direct payment in terms of lease or rental money but in the form of drugs medicine, reimbursements. No upfront payment. Instead electricity, gas and water supply was partially paid by PR (and still is). A number of Railway doctors paid by Railways (Rs 18 million per year)

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8.1 Student fee At present each MBBS student has to pay tuition fees of Rs. 500,000/- per year for a period of five years. As there are five hundred students who have to pay fees for five years, the present approximate earning per year comes to Rs. 250 million. The cost of running the hospital would have existed no matter which hospital would have been obtained or constructed by IIMCT. The direct benefit to PR is in the form of Rs. 7 million of medicines and Rs. 4 million of reimbursement with the former not verified properly. Above all this, PR still spends Rs. 7.2 million as per the allocation to the medical branch in Rawalpindi division for 2010-11 i.e. more than half of the amount IIMCT has to pay. This raises the question of the marginal benefit to PR and the substantive benefits to IIMCT accruing from the hospital. As it cannot be said that Rs. 250 million has been earned by IIMCT from the very beginning i.e. 1998, Rs. 250 million per year has been the regular earning since 2005 when the yearly fees were Rs. 500,000/- and there existed five hundred students. This comes to Rs.1.25 billion since 2005 and a maximum of 2.25 billion and a minimum of Rs. 1.75 billion since 1998 can be safely assumed. Giving them further benefit of doubt, the earning can be squeezed to Rs. 1.5 billion but not less. Furthermore, the earnings from private patients and other earnings cannot be assessed as although IIMCT often highlights its expenditure on RH often, it fails to give an accurate assessment of its earnings. These earnings must be mentally juxtaposed with the image of the dilapidated washrooms, poor diet, drug problems, lack of diagnostic facilities upgradation and compliance to PMDC regulations, and the general overall conditions depicted and described in this report. The washrooms alone would have not cost more than Rs. 100,000/- to construct and maintain in 2003 (at prices at that time) by which IIMCT had earned tens of crores. In 2011, the same washrooms could have been constructed for Rs. 600,000/- out of a confirmed earning is Rs. 250 million, yet they failed to do so. If IIMCT evidently failed to maintain even the barest minimum of sanitation and cleanliness in their busiest and important wards despite earning hundreds of millions, it raises the all too obvious question whether the public private partnership has achieved what was expected of it. 8.2 Private patient earning. Below is a statement indicating the number of private vis-a-vis Railway patients treated in RH from 2008 to 2011 (figures provided by MS/RWPs monthly divisional officers meetings)
Statement showing the position of Indoor and Outdoor Patients of Railway Hospital, Rawalpindi for the period from Jan 2008 to Jun 2011 X-Rays OPD Indoor Ultrasound ECG Operations Confinements Lab 200274 13835 21744 18796 8382 6265 3138 385982

28

Earnings (in million)

Ultrasound Xray ECG Operations Confinements Lab investigations OPD Indoor (admissions) Total 6.5 4.3 (unknown but on higher side) 10.9 (5-10) (exact figure unknown) 5.0 5 to 20 (exact figure unknown) 36.7 (min) 66 (max)

The access to information on how much IIMCT earns per year is extremely limited. Despite being a trust, IIMCT gives no financial information at all. Although it may seem irrelevant, the fact that it can earn from private patients earning alone to the tune of millions per year raises another question whether the benefits provided to PR are adequate enough compared to the earning IIMCT generates through this partnership.

29

9. Conclusion.
The parameters and benchmarks of a teaching hospital are clear as to what constitutes a developed, state of the art hospital. The preceding pages should be evidence enough that the main objective of the handing over the hospital has not been achieved. The tangible benefits that were expected by PR were better consultant care, wider variety of surgery, free drugs and diagnostics and better infrastructure. After thirteen years of running the hospital, IIMCT has lagged behind in providing these benefits. The number of consultants and their availability and frequency of seeing patients, quality, variety and quantity of medicines have been brought into question. Increased infrastructure does not mean four beds in another ward thereby constituting another ward and an addition in a list of achievements. The poor conditions witnessed and lack of proper equipment in the entire hospital is indicative of the fact that little investment has occurred. The posting of fresh graduates in emergency and ICU does not mean that a larger number of doctors of any sort provides tangible benefits. A proper TB ward converted into a nursing hostel and instead now four beds in a room in a ward does not mean that the needs of TB patients have been catered for. The absence of crucial medicine in a drug formulary duly compensated enthusiastically to the tune of millions by a PR administration does not mean that the availability of drugs has been ensured. It is still quite reasonable to say that the handing over the hospital has not been without benefits, but this would be to close ones eyes to the many benefits that have been denied despite being due and expected under the terms and conditions of the agreement signed. Ultimately what decides the failure and success of a public private partnership (PPP) is the public part of the union. The partnership is always in a context and certain conditions must prevail for it to be successful. The first and foremost of those conditions is an objective, neutral and unbiased monitoring body or individual. This is where PR fails miserably. The very fact that this report has been written after so many years with so many violations and discrepancies going unnoticed is a damning indictment on the success of this particular public private partnership. The opinion that the partnership works smoothly is undeniable as the parties involved sync quite well with one another, but unfortunately this harmony does not ensure better services to Railway patients, but rather the opposite is achieved. In addition to this, sham, stage managed visits by the concerned Railway officers who give a clean chit despite acknowledging the criticism heaped on the hospital merely adds insult to injury. It indicates either a naivet or deliberate culpability by those who make such decisions. Lastly and most importantly, committees and inquiries that are manned by officers of dubious reputation and with links to private parties or by those who are unable to fearlessly give their opinions due to excessive pressure exerted by others, political or otherwise is also a reason why no progress is made. An inquiry report in the appendices of this report is 2+an ideal example of the inadequacy of the type of inquiries conducted that ignore substantive evidence. This report can be viewed as a simple criticism but that would be incorrect. Only after the identification of inadequacies can work be started to improve a situation. If one is blind to the reality of things, no further progress can be achieved. It is hoped that ultimately the medical care delivered to the poor employees of PR can reach the targeted standards of this faulty public private partnership.

30

LIST OF EQUIPMENT NOT AVAILABLE AT RAILWAY HOSPITAL S.No. Description PHARMACOLOLGY & THERAPEUTICS 1 Deep freezer -40 c 2 Deep freezer -20 c 3 Microscope multie head(5 place) 4 Microcope Fluoresent 5 Differential lecucocyte counter electronic 6 Automatic pipette 5ul fixed 7 Automatic pipette 50-500 ul adjustable Apparatus electrophoresis complete with accessories, 8 densitometry and UPS 9 Centrifuges microhaematocrit with reader. Blood bank medium with temperature control, alarm 10 and record graph 11 Plasma extractor 12 PH meter clinical Automated coagulation analyzer complete with 13 accessories and UPS 14 Rota Mixer 15 Magnetic mixer/stirrer 16 Blood bag centrifuge refrigerated 17 Platelet incubator with mixer 18 Glass beaker (Pyrex) 100 ml graduated 19 ELISA washer and reader automated with UPS 20 Hot plate 21 Automatic media 22 Shaker 23 Incubator 37 c large 24 Incubator Co2 25 Incubator cold 22-29 c 26 Laminar flow cabinet 27 Inspissator 28 Automatic stainer 29 Cytotech centrifuge 30 Freezing microtome 31 32 33 34 Personal computer Vacuum pump Incubator large Photomicrography microscope Suggested 1 1 Availability not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available not available

1 1 1 1 1

4 1

1 1 1

I each staff Member 1 1 1.

31

35

RADIOLOGY X-ray apparatus radiographic and fluoroscopic 500 mA (50 KW Generator or more)with image intensifier two tube system with vertical bucky stand X-ray App(65 KW Generator) with radiographic, image intensifier fluoroscopy, tomography and vertical bucky stand and accessories Conventional mammography x-ray unit Magnetic resonance imaging unit(1.5 Tesla/permanent magnet system) Mount radiographic film dental 16 film size Brush camel hair Caliper patient thickness Goggles darkness adaptation X-ray photocopier machine Grid refine(stationary) Emergency oxygen cylinder with ventilator support and endotracheal tubes Drier x-ray film fixed type Image Intensifier Fluoroscopy Echocardography with color Doppler OPHTHALMOLOGY. Autorefracto/ Keratometer Ultrasound A-scan bio-meter Hess screen ELECTRO DIAGNOSTIC EQUIPMENTS NCS/EMG machine Urodynamic unit SPEECH THERAPY Speech trainers Sound indicators for all nasal and back sound +fricatives Fundamental frequency indicator Nasality indicator Spirometer Software for voice therapy PSYCHOTHERAPY Manifest anxiety scates Beck Depressive inventory Wechsia intelligence scale for children(wise-R) Wechcles Adult intelligence scale for memory Wechcles memory scale intelligence perception O week eye fight CAT (children appreciation test) 32

not available

36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

not available not available not available ? 1 2 1 1 1 1. 1. 1. 1 1 1 1. not available not available not available not available not available not available not in working condition not available not available not available not available not available not available not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available

67 68 69 70 71 72 73 74 75 76 77

78 79 80 81 82 83

Childhood autism rating scale Luria nebraskes neuropsychological battery Colonies maturity scale 16 PF. SURGERY Thoracic surgical set Plastic surg set Fibreoptic colonoscope (diagnostic & therapeutic) Flexible sigmoidoscope with biopsy and Cautery set. Cystoscope(Diagnostic & Therapeutic) Fibreoptic oesophagoscope Portable x-ray machine, operation table and radiographic film cassette facilities e.g for per operative cholangiogram. Image intensifier with CArm and double monitors ORTHOPAEDICS CO2 Laser Echo Cardiography 2D with color doppler PAEDIATRICS Ultrasonic Nebulizer Dinamap Transport Incubators Otoscope, with infant diagnostic head OBS &GYNAE Hysteroscope Spring dressing forceps(stainless steel) Surgeon's hand bush with white nylon bristles Ventilatory Bag(1) Infant laryngoscope with spare bulb and batteries (1) Sharp and blunt uterine curettes, size o or 00(1) Flexible cannulae ,size 4 to 12 mm Vaccum aspiration with electric pump basic uterine evacuation + hand pump Vacuum pump with extra glass bottles Connecting tubing Cannulae (any of the following) Flexible, 5,6,7,8,9,10 mm. Curved rigid 7,8,9,10,11,12,14 mm Straight right, 7.8.9.10.11.12. mm Equipment for insertions and removals of contraceptive sub dermal implants Trocar with plunger No 10 33

Not available Not available Not available Not available 1 1 1 1 1. 1 Not available Not available Not flexible Not available Not available Not available patient referred to PIMS through lot of difficulties Not available Not available Not available Not available Not available Not available V.Imp, not available from beginning Not available Not available Not available Not available no Uterine curettes is available not available not available not available not available not available not available not available

1. 2

84 85 86 87 88 89 90 91 92 93 94 95 96

6 6 1 2+2

SUMMARY Total No. of equipment as per PMDC Available at Railway Hospital Not available Not known

463 260 96 107

SUMMARY OF COMPARISON BETWEEN IDF AND RDF Total no. of medicines/items in Railway Formulary Total no. of medicines/items in IIMCT Formulary Number of medicines listed in both Formularies Number of medicines listed in both formularies with same company Number of medicines listed in both formularies with different company No. of medicines/items not listed in Railway Formulary No. of medicines/items not listed in IIMCT Formulary 646

311

171

30

141

140

475

34

COMPARISON OF RATIO OF MEDICINES IN RDF AND IDF FORMULARIES

S.No. Type ANESTHETICS 1 GENERAL 2 3 LOCAL ANAESTHETICS NOM-NEUROMUSCULAR BLOCKING AGENTS. ANALGESICS. 4 NON-OPIATES 5 6 7 OPOID ANALGESICS NON-STEROIDAL ANTI INFLAMMATORY AGENTS. URICOSURIC AGENTS ANTS/ANTIEPILEPTICS/PSYCHOTHERAPEUTICS 8 HYPNOTICS 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ANTI CONVULSANTS. NEURO MUSCULAR RELAXANT & ANTI CURARE DRUGS ANTI DEPRESSIVES SEDATIVES & TRANQUILUZERS ALIMENTARY SYSTEM ANTI CHOLINERGICS H2 RECEPTOR ANTAGONISTS PROTON PUMP INHIBITOR DIGESTIVE ENZYMES ANTI-DIARRHOEALS, ANTIHELMINITICS LAXATIVES/PURGATIVES DRUGS ACTING LOCALLY ONN RECTUM ANTI-EMETICS/ANTI NAUSEANTS ANTIHISTAMINES ANTI ALERGICS/DRUGS USED IN ANAPHYLAXSIS ANTI DOTES. 9 5 5 6 5 3 5 12 2 4 5 4 1 8 12 1 3 4 0 0 0 1 1 2 1 0 0 0 3 0 1 1 0 1 18 3 6 9 1 0 2 1 9 2 7 6 3 2 8 3 Railway (RDF) IIMCT(IDF)

35

CARDIOVSCULAR SYSTEM 26 CARDIAC REACTANTS. ANTI-ARRHYTMIC AGENT/BETA BLOCKER 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 BETA 1 RECEPTOR AGONIST SELECTIVE A BLOCKER ANTI HYPER TENSIVE ANGIOTENSIN ll ANTAGONISTS ACE INHIBITORS CALCIUM ANTAGONIST/CALCIUM CHANNEL BLOCKER. CENTRAL ALPHA ANTAGONIST HYPOLIPIDEMICS ANTI ANGINAL VASODILATORS/NITRATE DIURETICS. ANTI-COACULANTS CLOTTING AGENTS ANTI INFECTIVES SEMI SYNTHETIC PENICILLINS BETA LACTAMASE INHIBITOR PENICILLINASE REISTANT PENICILLIN PENICILLINASE REISTANT PENICILLIN TETRACYCLINE Cephalosporins MACROLIDES QUINOLONES SUSPHONAMIDES/ Trimethoprim AMINOGLYCOSIES AMOEBICIDES ANTI MALARIALS ANTI TUBERCULOUS 3 1 2 2 5 5 1 3 4 2 8 5 3 1 6 3 3 1 2 5 5 3 3 3 4 4 7 1 0 0 0 1 2 0 0 0 0 4 2 3 0 3 0 1 0 0 2 0 1 0 0 2 2 3 7 4

36

54 55 56 57 58 59 60

ANTI FUNGAL ENDOCRINES THYROID/ANTITHYROID INSULIN, ORAL HYPOGLYCAEMICS DRUGS AFFECTING IMMUNE RESPONSE ANTIVIRAL FEMALE SEX HARMONES GENITOURINARY SYSTEM

3 6 2 8 3 4 9

1 2 0 3 1 0 1

61 URINARY ANTI SEPTICS/ANTI SPASMODICS 62 BLOOD ALKALIZERS RESPIRATORY SYSTEM 63 EXPECTORANTS 64 65 66 ANTI TUSSIVE COUGH SUPPRESSANTS DECONGESTANTS BRONCHIAL SPASAM RELAXANTS. 67 BRONCHODILATORS B2 AGONISTS 68 Respiratory Stimulants EAR, NOSE AND ORAPHARYNX 69 AURAL PREPARATIONS 70 LOCAL REACTANTS ON NASOPHARYNX DRUGS AFFECTING NUTRITION AND METABOLISM. 71 HAEMATINICS 72 73 74 75 76 77 78 VITAMINS DERMATOLOGICALS PREPARATIONS. Antiparasitic/Anti Mycotic MULTIVITAMINS MINERAL PREPARATIONS. SOLUTIONS CORRECTING WATER, ELECTROLYTE AND ACID BASE DISTURBANCES. OPTHALMOLOGICAL PREPARATIONS SURGICAL DISPOSABLES

1 3 5

0 0 0

6 4 14 8 10 40 51

2 0 2 0 4 9 29

37

79 80 81 82 83 84 85 86 87

DIAGNOSTIC AGENTS SERA, VACCINES. ANTISEPTICS AND DIS-INFECTANTS DENTAL ITEMS BLOOD BANK. LABORATORY ITEMS DISPENSARY ITEMS X-RAY ITEMS LABORATORY ITEMS

1 5 3 25 11 110 6 5 21

0 2 1 0 0 5 5 0 2

Total

648

142

38

Bucket lying in washroom in Gynae Ward

39

Picture of Sink in bathroom of Gynae Ward

40

Commode in washroom of Gynae Ward

41

Picture of scrub tank in Gynae Ward in which doctors and staff clean up before performing procedures. Below picture is of a the interior showing blood in a pan from a procdure performed. The tank can be seen to be unclean and not used frequently. It is an example of the lack of general hygiene.

42

Picture of laundry right beside scrub tank.

43

This machine is to sterilize equipment used in the labour room to deliver new born children. IT was dysfunctional and not in use for a long time according to staff there.

44

This container was used to sterilize equipment used in the labour room. As it can be seen it is insifficient and one of the reasons of increased infection in

the Gynae ward. What is most notable is the fact that a disposable catheter is
being sterilized. Such catheters are supposed to thrown away after first use but it is being sterilized and that too in an incorrect manner. It can cause serious injury to patients.

45

This is the sterilization equipment placed together alongwith a dirty apron.

46

This is a picture of a reusable apron which cannot be cleaned and sterilized as per medical practise. It is just a plastic sheet worn by staff and unnaceptable.

47

Dirty linen placed in linen room of ward

48

This is one the sinks used by staff and patients alike in the ward. As shown it is in a state of
disrepair and dirty.

49

Following three pictures are of unhygenic equipment that were in need of repair. The last picture is of an obsolete ultra sound machine that is rarely used.

50

51

Verified evidence also used in an malpractice enquiry in RH. Original available in DS office, Rawalpindi.

52

Appendixes
Appendix I

AGREEMENT BETWEEN IIMCT AND PAKISTAN RAILWAYS 1998.

AGREEMENT BETWEEN PAKISTAN RAILWAYS 2000 AGREEMENT BETWEEN PAKISTAN RAILWAYS 2004 IIMCT IIMCT AND AND

Page 57-62 Page 63-68 Page 69-74 Page 75-78 Page 79-123 Page 124-128

Appendix II
Appendix III Appendix IV Appendix V Appendix VI

COMPARISON OF RATIO OF MEDICINES IN RDF AND IDF FORMULARIES REPORT OF THE SURVEY COMMITTEE OF RAILWAY HOSPITAL RAWALPINDI SAMPLES OF PRESS IIMCTS RUNNING HOSPITAL COVERAGE OF OF RAILWAY

Appendix VII

INQUIRY INTO THE GRIEVANCES ON THE ORDERS OF MINISTRY OF RAILWAYS IN RESPONSE TO SURVEY REPORT AT APPENDIX V.

Page 129-132

53

Appendix I AGREEMENT BETWEEN IIMCT AND PAKISTAN RAILWAYS 1998

PREFACE Considering the urgent need for improvement in the medical/technical education, moral, and ethical standards and to build sound character of Pakistan youth, the Islamic International Medical College Trust (IIMCT) was established. IIMCT is public welfare registered trust, a non-political, non-sectarian and non-commercial organization with no profit motives. IIMCT has established its first medical college in 1996 and heading towards a multi faculty University for which necessary approval has been granted at the level of University Grants Commission. This University will focus on provision of scientific and technological excellence with the judicious blend of Islamic values. In time with the mission, the IIMCT shall upgrade the Railway Hospital to a level of a teaching hospital with state of art facilities. It will augment the medical and paramedical care and will arrange specialized facilities for the welfare of Railway employees and deserving populace. I owe a deep debt of gratitude to Mr. Nasir Alvi, General Manger, Dr. Mrs. Shameem Hyder, CM & HO, Railway Board, and their staff. They have my gratitude for their vision, humanitarian approach, courtesy and cooperation. This working arrangements they provided were a great boon to me and my staff. PAKISTAN RAILWAYS Headquarters Office, Lahore This agreement made and entered into this 17th day of August, 1998, between the President of Islamic Republic of Pakistan through Pakistan Railways Administration (hereinafter called immediately the Railway Administration) of the First Party and Islamic International Medical College Trust a Public Welfare Trust registered under the Registration Act (hereinafter called the Islamic International Medical College Trust) of the Second Party. Whereas Second Party, a Public Welfare trust, is running a Medical College at Islamabad under the name Islamic International Medical College for the past two years and has offered to improve entirely at its own cost and expense, the status and standard of Pakistan Railways Hospital Rawalpindi to bring it up to the level of an excellent Teaching Hospital for its college. The Pakistan Railways also desire that in the larger interest of Railways and Welfare of its employees, the said Hospital be improved on considerably upgraded to meet the standard and requirement of a teaching hospital, without any financial burden whatsoever on the Pakistan Railways. And whereas, the second party agrees and accept that their shall be no liability at all for all such improvement on the Pakistan Railways, and it is also explicitly mentioned herein that the franchise proposed by the Islamic International Medical College Trust with the Pakistan Railways is not a commercial Enterprise Agreement but purely an academic venture.

54

AND WHEREAS the first party has accepted the said offer of the second party, the first party shall fully cooperate and allow the second party, in manner laid down hereinafter, to upgrade and develop. The Pakistan Railways Hospital Rawalpindi into a Teaching Hospital The term of this agreement are given below:1. 2. This franchise agreement shall be for a period of 33 years extendable for another similar term. However, the contract will be renewed after five years. The Second Party shall, within 3 months, be responsible to provide specialized medical cover free of cost to the serving/retired employees of the Pakistan Railways and the families and dependents as admissible and presently available to them in terms of Railways Boards Notification issued from time to time. This shall include :-

a). Additional outdoor treatment including consultation, medical attendance, Laboratory test (If any) etc. b). In-door treatment including medical attendance, consultation, surgery, specialized medical cover tests such as E.T.T, E.C.G, ECHO, Ultrasound and X.rays etc. c). Medical and Surgical Units as per PMDCs requirements shall be created for outdoor in-door services such as ENT, Eye, Psychiatry, Orthopedic surgery, Gynae, Urology etc. d). Pathology Labs, Operation Theatre shall be upgraded to state of the art standards.

e). The Second Party will also render emergency services in the Hospital and also establish a flying squad to provide emergency aid at the site to any injured/casualties as a result of Railway accident in Rawalpindi area. 3. The Second Party shall provide high level repair and maintenance services for its own medical equipments, through its specialized Bio-medical Engineering Unit with prior approval of the Medical Superintendent. The Second Party with the approval of the Pakistan Railways Authorities may at its own expense, provide additional facilities and sophisticated equipments in the hospital but no compensation whatsoever, will be claim by the Second Party for the same. However, the Second Party shall have the right to remove/replace the equipment brought by it after approval of the Hospital Administration. The Second Party shall provide medicine/test to the extent of Rs. 500,000/(Rupees Five Hundred Thousand Only) per annum at the disposal of its Head of Department/Professor in the Hospital. In case of breach of any of this agreement by the Second Party, the Second Party shall be given a notice of 3 months to rectify the breach and the Second Party shall be bound to do so within the Second Party. Cropping up of a dispute or difference or reference in any matter for arbitration, to management committee defined in Para-18 shall not result in stoppage of activities of either of the parties and their programmes shall continue uninterrupted. Additional staff (Doctors/Para-medical) required to raise the said hospital to the level of a teaching hospital shall be provided by the Second Party at its own 55

4.

5.

6.

7.

8.

cost and expense. However, in recruitment of such staff preference shall be given to the Railway employees sons/daughters and their dependents who possess requisite qualifications and experience and also bear the recommendations of the Railway Authorities. Reasonable compensation/incentives may be given by the second party to the existing Railway Hospital staff for any extra/special services rendered by them for teaching purposes. However, payment of any such honorarium to Railway doctors or medical/Para-medical staff by the second party will be governed by the Railway Rules on the subject. The Second Party shall arrange suitable training on their expense to Paramedical, Nursing staff, Lab. Technicians etc. already working I the hospital for upgrading and improving their knowledge and skill to match the similar staff of the Trust proposed for augmentation. The Second Party shall provide medical cover and allied services from the date of signing of this contract and shall continue to do so till the expiry/termination of the contract. (i) The Second Party shall be responsible for day-to-day repairs and maintenance of the building and shall undertake, at its own cost, all works necessary to keep the said premises in good order during the contract period. No compensation, whatsoever, shall be claimed by Second Party in this regard.

9.

10.

11.

(ii) The Second Party shall be responsible for up keep of all fittings in the premises (as provided by Medical Superintendent, Rawalpindi) 12. No changes, additions, alterations, whatsoever will be made I the existing structures of Railways Hospital by the Second Party without express approval of the First Party, and at the time of expiry/termination of contract any such structure will be handed over to the First Party by Second Party without any claim. That the Second Party shall undertake the responsibility to raise the said hospital to a teaching hospital and employ professionals and supporting staff according to its own scheme of things and as per PMDC requirements. The Second Party may establish Nursing and Para Medical School in due course of time in the same premises with teaching faculty of Islamic International Medical College Trust to improve the Nursing care. However, the students to such courses shall be admitted on the basis of 40-60 ratio of Railway employees sons/daughters and general public purely on merit as laid down by PMDC to be decided by the Management Committee. Entire equipment and set up presently installed in the hospital are and shall remain exclusive property of the Railways. An inventory of all the equipments of the hospital belonging to First Party shall be taken at the time of franchise being operative by Medical Superintendent, Rawalpindi.

13.

14.

15.

56

16.

The Second Party shall not have any claim to any part of the Budget allocations of the First Party for the hospital but the technical and expert advice of the Second Party shall always be readily available, whenever needed by First Party. The Second Party shall appoint and depute its heads of various departments for the hospital who shall also make sure that all departments of the hospital render best possible services in the interest of the hospital, the Railways and its employees. The Railway staff (Doctors/Para-medical) possessing suitable qualification and experience equivalent to various posts of teaching Institutes, and selected by Islamic International Medical College Trust to perform the duties of teaching/demonstration will be paid suitable honorarium/teaching allowance by the Second Party which will be disbursed in accordance with the rules laid down by the Railway Administration for this purpose. Chief Executive (General Manager) Zonal Manager Infrastructure/DS Rawalpindi CM & HO and M.S/Railway Hospital, Rawalpindi, Managing Trustee and two members from Islamic International Medical College Trust & Heads of Teaching Departments of the Hospital shall be ex-officio members of the Management Committee. Decisions of Important nature, pertaining to this agreement or not covered by this agreement shall be referred to and decided by the Management Committee. In case any of the parties wish to terminate the contract before the expiry of the contractual period, a written notice in advance of three years shall be served by that party on the other in order to allow the students already admitted to complete their academic/clinical years. Land and building of the said Hospital are and shall remain the exclusive property of Pakistan Railways. The Second Party shall not assign or sublet the said premises or any part thereof to any third party. Any structural addition/improvement on the existing vacant land within the Hospital premises or alteration to the existing structure, equipment, and utilities of hospital if carried out by the Second Party, shall be subject to the agreed terms and conditions and at the cost and risk of the Second Party. Railway Doctors and staff employed in the hospital shall be governed by their own Service Rules. They shall, however, conduct themselves in close cooperation and liaison with the Second Party. They shall, in the discharge of their duties and functions, make sure that the functioning of the hospital is carried out and run by the parties in a smooth manner. Any Railways Staff Member( Doctor or Para Medical Staff) performing duties for the purpose of teaching/demonstration shall be given teaching allowance by Islamic International Medical College Trust and will deposit one third of such amount in the Railway Treasury as provided in the Rules. General Manager or Chief Executive or Managing Director by whatever designation he is called, enjoying the authority on the Administration of Hospital will exercise the powers of Sole Attributor in case of any dispute between the parties and his decision will be binding on the parties. The 57

17.

18.

19.

20.

21.

22.

23.

arbitration proceedings shall, however, not cause any hindrance in the smooth and efficient running of the hospital or teaching faculties therein. 24. The Specialists/Consultants employed by the Second Party, when admitting their private patients in the hospital(Special or General Wards), shall follow the rules and regulations of Railway viz, out of full amount realized from the patients one third will go to the Railway revenue and two third will be paid to the Islamic International Medical College Trust. For the purpose of rates of fee and other usual charges the private patients admitted by Railway Hospital Authorities will be charged according to the Railway Rules and the private patients of Islamic International Medical College Trust be charged according to their own regulations. The administration of the Railway Hospital will remain exclusively with Pakistan Railways (the Professional and Administrative control with Medical Superintendent/Divisional Superintendent Pakistan Railways Rawalpindi under Divisional Organization and Professional and Administration Control with the Chief Medical and Health Officer, Pakistan Railways under Headquarters Office, organization). The First party will constitute a Committee comprising General manager/Chief Executive, CM&HO, FA&CAO and DS/Zonal Manager, Infrastructure/Rawalpindi to supervise/monitor the performance of the institution. The Committee or any of its members will inspect the hospital from time to time to see the institution is functioning smoothly. The Second Party may, at their own convenience, establish a Dispensary, at their own expense, in Hospital premises for dispensing/issuance of medicines prescribed by their Specialists/Consultants, which shall ultimately become the property of Railways. Approached road of the hospital will be renovated/repaired by the Second Party. The Second Party will also improve the existing premises of the hospital. When the Second Party leaves the hospital at the expiry of the term or termination of the contract, the Second Party will have no claim on the investment made in the shape of immovable property on the Railways remises. Increase in the incidence and cost of utilities( Electricity, Sui Gas, Telephone etc) due to increase use of improve facilities and additional staff will be borne by the Second Party either through sub metering or fixed charge mutually agreed by the parties. The First Party shall not be responsible for any loss or damage to any person or the property of the Second Party or any other person on the said premises arising out of any defect in or for want of any repair or accident to the said premises.

25.

26.

27.

28.

29. 30.

31.

32.

58

33.

On expiry/termination of the contract, the said premises along with structures erected by the Second Party shall revert to the excusive use of First Party. The First Party shall not be liable to pay any cost or compensation for such structures even if constructed with the express approval of the First Party. The ownership of the Hospital and its entire premises shall all the time remain with the First Party. In case of any damage to the buildings premises and fittings, the First Party shall have the right to get the building/fittings repaired and restored in the original condition at the cost of Second Party. Any problem(s) faced by the parties in the day to day functioning of the hospital, which may arise by the passage of time and is/are not covered by this agreement, shall be decided mutually by parties as laid in clause 18.

34.

35.

Signed for and on behalf of President of Islamic Republic of Pakistan by Mr. Nasir Alive, The General Manager at Lahore on the 17th day of August 1998.

(NASIR ALVI) GENERAL MANAGER

Signed for and on behalf of Islamic International Medical College Trust by Maj. Gen (R) Dr. Muhammad Zulfiqar Ali Khan, Principal and Managing Trustee at Lahore on 17th day of August 1998.

(MAJ. GEN. (R) DR. MUHAMMAD ZULFIQAR ALI KHAN) Principal & Managing Trustee

Witness No. 1

Witness No. 2

____________________ ____________________ ____________________

____________________ ____________________ ____________________

59

Appendix II AGREEMENT BETWEEN IIMCT AND PAKISTAN RAILWAYS 2000 AGREEMENT An agreement was made and entered into on 17 Aug 1998 between the President of Islamic Republic of Pakistan through Pakistan Railways Administration( hereinafter called the Railway Administration) of the 1st Party and Islamic International Medical College Trust, a Public Welfare Trust, registered under the Registration Act, (hereinafter called the Islamic International Medical College Trust) of the 2nd Party. Whereas the 2nd Party is running a Medical College at Rawalpindi under the name Islamic International Medical College for the past seven years and has improved, entirely at its own cost and expense, the status and standard of PR Hospital, Rawalpindi to a considerable extent. Pakistan Railways desired that, in the larger interest of Railways and welfare of its employees, the said Hospital be further improved and upgraded to meet the standard and requirement of an excellent teaching hospital. The initial agreement drawn on 17th August, 1998 included 35 clauses. November, 2000, nine clauses were amended and two new clauses were added. It was felt that a agreement needs to be drawn between the parties to further upgrade the facilities at PR Hospital, Rawalpindi to provide better medical cover to entitled patients and to meet the standards of a teaching hospital as per PMDC rules. This agreement is in addition and continuation of the previous agreement dated 17 August, 1998 and all its amendments notified vide notification No. C-199/RH-1 dated 29 November, 2000. AND WHEREAS the first party has accepted the said offer of the second party. The first party shall fully cooperate and allow the second party to function in the manner laid down hereinafter, to upgrade and develop PR Hospital, Rawalpindi into a Teaching Hospital The terms of the agreement are given below:1. 2. This franchise agreement shall be for a period of 33 years w.e.f 17th August, 1998, extendable for another similar term. The Second Party shall be responsible to provide specialized medical cover, free of cost to the serving/retired employees of Pakistan Railways, their families and dependents as admissible and presently available to them in terms of Railways Boards Notification issued from time to time. This shall include :

a).

Outdoor treatment including consultation, medical attendance and Laboratory test.

b). In-door treatment including medical attendance, consultation, surgery, specialized medical cover including:i). Dialysis ii). Cancer therapy, Chemotherapy and Radiotherapy iii). Cardiac Surgery iv). Neurosurgery v). Provision of orthopedic implants, stents, meshes DCR tubes etc. vi). C.T Scan and MRI vii). Laboratory investigations not available in the hospital and advised by the head of concerned department.

60

3.

The amount being reimbursed by Pakistan Railways currently for Cardio/Chemo/Dialysis/Neurology cases will be taken up by the Second Party upto a total of Rs. 1.0 million per annum. Expenses above this limit will be borne by Pakistan Railways. A two-bedded Burns Unit will be provided by Second Party. Fifty percent of indoor beds shall be reserved for Railway employees, their families and dependents. The Railway patients as defined above, however, shall not be refused admission in case of emergency or Railway accident when 50% of the bed strength has already be utilized. The Second Party shall provide medicines to the extent of Rs. 3.0 million per annum and this amount will be reviewed with mutual consent, if required shall be provided to Railway entitled patients as per Pakistan Railways Drug Formulary. If required IIMT will try to provide medicines, not included in the Formulary, to the deserving patients. Mobile Primary Health Care Units may be provided by the Second Party at various Railway facilities within Rawalpindi. Community Health Units may also be established by the Second Party in various Railway colonies within Rawalpindi/Islamabad by utilizing the existing Pakistan Railways Child Welfare Centers. The Second Party shall provide free diet to those categories of Railway employees and their dependents who are at present entitled for the same. That the Second Party shall undertake the responsibility to raise the said hospital to a teaching hospital and employ professional and supporting staff according to its own scheme of things as per PMDC requirements. Additional staff (Doctors/Para-medical) required to raise the standard of the hospital shall be provided by the Second Party at its own cost and expense. However, in recruitment of such staff preference shall be given to the Railway employees sons/daughters and their dependents who possess the requisite qualifications and experience and also bear the recommendations of the Railway Authorities. The Second Party shall appoint and depute heads of various departments for the hospital who shall also make sure that all departments render the best possible services in the interest of the hospital, the Railways and its employees. The Second Party may establish Nursing and Para Medical School in due course of time with teaching faculty of IIMCT, to improve the Nursing care. However, the students to such courses shall be admitted on the basis of 40-60 ratio of Railway employees sons/daughters and general public respectively, purely on merit, as laid down by PMDC and Pakistan Nursing Council. The Second Party shall arrange suitable training at their expense to Nursing/Paramedical staff and Lab technicians working in the hospital to upgrade and improve their knowledge and skill

4. 5.

6.

7. 8.

9. 10.

11.

12.

13.

14.

61

15.

In order to provide better specialized medical services, the Second Party will ensure availability of consultants/specialists round the clock. The Consultants/Specialists of Second Party will admit and treat private patients and out the total income accrued on this account a sum of Rs. 0.6 million per annum will be deposited in Railway Treasury and the rest will be paid to Islamic International Medical College Trust. This will applicable from February 2004. BUDGET

16.

17.

a). The 1st Party reduced the budget allocation for the hospital to fifty percent for the financial year 2001-2002. This allocation will be maintained for five years (upto 2006-2007) and will be revised further beyond 2006-2007 with mutual consent of the parties. b). Proposals for expenditure will be initiated by Director Hospital IIMCT appointed by the 2nd Party, verified by the Medical Superintendent and concurred by Divisional Accounts Officer, P.R, Rawalpindi. The sanction shall be granted by Divisional Superintendent, Pakistan Railways, Rawalpindi. c). Salary/allowances of Railway employees shall be the liability of Pakistan Railways. 18. The Second Party with the approval of the Railways Authorities may at its own expense, provide additional facilities and sophisticated equipments in the hospital but no compensation whatsoever, will be claim by the Second Party for the same. However, the Second Party shall have the right to remove/replace the equipment with the consent of the Hospital Administration. The 2nd Party shall provide high-level repair and maintenance of all Electro Medical equipments available in the hospital through its specialized Biomedical Engineering Unit. An inventory of the entire equipment, tools and plants installed in the hospital was prepared and the same was handed over to the 2nd Party in March, 2001. The 2nd Party shall be fully responsible for its maintenance. Medical equipment not in use are under-utilized in any other Railway facility may be transferred to PR. Hospital, Rawalpindi. The administrative control of the hospital will be with the 2nd Party. However, senior most Doctor of the 1st Party (in General Cadre) shall act as coordinator in order to work as a cohesive team for the smooth functioning of the hospital. He/She will also process the disciplinary cases against hospital employees. Management Committee comprising General Manager (M&S), Director Health and Medical Services, Divisional Superintendent, Rawalpindi and Medical Superintendent, P.R, Rawalpindi, Managing Trustee and three nominees from Islamic International Medical College Trust will meet at least once a year. Decisions of Important nature, pertaining to this agreement or not covered by this agreement shall be referred to and decided by the Managing Committee. Any dispute unresolved by the Management Committee shall be referred to the Arbitration Council, which shall comprise General Manager (M&S), Director 62

19.

20.

21. 22.

23.

24.

Health and Medical Services, Divisional Superintendent, Rawalpindi, Managing Trustee and two nominees of the 2nd Party. The recommendations of the Arbitration Council shall be referred to Secretary/Chairman, Railways whose decision will be final and binding on the parties. 25. An Inspection Committee comprising Director Health and Medical Services, FA&CAO/M&S and Divisional Superintendent, Pakistan Railways, Rawalpindi will be constituted by the 1st Party. The committee or any one of its members will inspect the hospital from time to time to see that the institution is functioning smoothly. Any shortcoming/breach of the agreement observed shall be reported to the Management Committee who will notify the 2nd Party with a notice period of three months to rectify the shortcoming/breach. The 2nd Party shall be bound to do so within the said period. If the performance f the second Party is not up to the mark and it fails to improve or rectify the shortcomings as observed by the Inspection Committee and notified to Second Party through Management Committee, this agreement shall become liable to termination. For the purpose of termination the 1st party shall serve a written notice in advance of five years on the second party in order to allow the students already admitted to complete their academic/clinical sessions and to avoid hardship to the second party. Cropping up of a dispute or difference or reference of any matter to Arbitration Council for rectification of the shortcomings/breach or arbitration, shall not result in stoppage of activities of either party and their programs shall continue uninterrupted. Railway Doctors and staff employed in the hospital shall be governed by their own Service Rules. They shall, however, conduct themselves in close cooperation and liaison with the Second Party. They shall, in the discharge of their duties and functions, make sure that the functioning of the hospital is carried out and run by the parties in a smooth manner. Reasonable compensation/incentives in the shape of monthly honorarium/teaching allowance may be given by the second party to the existing Hospital staff (Doctor/Para Medical) possessing suitable qualification and experience equivalent to various posts of teaching Institution and selected by Islamic International Medical College Trust to perform duties pertaining to teaching purpose one third of the honorarium/teaching allowance paid to the Railway Staff will be deposited in Railway treasury. Medical Superintendent, Railway Hospital, Rawalpindi shall seek performance review of employees working in the hospital from the Director Hospital IIMCT before initiating the annual Performance Evaluation Report. Land and building of the said Hospital are and shall remain the exclusive property of Pakistan Railways. The Second Party shall not assign or sublet the said premises or any part thereof to any third party. However the second party can allow utilization of land and building or any part of the said premises for creation of medical ancillary services for the hospital with express approval of Divisional Superintendent. The Second Party shall be responsible for day-to-day repairs and maintenance of the building and shall undertake, at its own cost, all works necessary to keep 63

26.

27.

28.

29.

30.

31.

the said premises in good condition during the contract period and shall not claim any compensation, whatsoever in this regard. 32. The Second Party shall be responsible for up keep of all fittings in the premises. In case of any damage to the building premises and fittings, the 1st Party shall have the right to get the building/fittings repaired and restored in the original condition at the cost of 2nd Party. Any structural addition/improvement on the existing vacant land within the Hospital premises or alteration to the existing structure, equipment, and utilities of hospital, carried out by the Second Party, shall be subject to the agreed terms and conditions and at the cost and risk of the Second Party. The 2nd Party will not make any changes, additions, alterations, whatsoever in the existing structures of Railways Hospital without express approval of the First Party. At the time of expiry/termination of contract the 2nd Party will hand over any such structure to the First Party without any claim. When the Second Party leaves the hospital at the expiry of the term or termination of the contract, the Second Party will have no claim on the investment made in the shape of immovable property on the Railways remises. On expiry/termination of the contract, the said premises alongwith structures erected by the Second Party shall revert to the excusive use of First Party. The First Party shall not be liable to pay any cost or compensation for such structures even if constructed with the express approval of the First Party. The ownership of the Hospital and its entire premises shall all the time remain with the First Party. The cost of utilities, electricity and Sui Gas shall be shared by both parties according to the following ratios:Share of 1st Party 8000 units/per month 40 Units Share of 2nd Party Remaining Units Remaining Units

33.

34.

35.

36.

37.

i). ii).

Electricity Sui Gas 38. 39.

Audit of the hospital record (including Accounts) shall be conducted in the liaison with 2nd Party. Public Relation Department shall be established by the Send Party to improve public relations with Railway patients. Information Guides will be provided by the 2nd Party in the hospital to facilitate the patients. Five percent Medical College Seats will be reserved for Railway employees (serving/retired) sons/daughters on merit. The candidates shall appear in entry test of Islamic International Medical College Trust. Schedule of entry test will be intimated well in advance to Director Health & Medical Services. A list of candidates selected on merit shall be prepared by the second party and sent to Director Health & Medical Services, Lahore. The Railways Administration shall nominate the candidates from amongst the said list on their merit and priority. Finally selected nominees shall be give 50% concession in admission and tuition fee. If more than 5% candidates get selected then railway

40.

64

administration shall have to right to nominate from within the list of selected candidates. 41. Director Health and Medical Services, Lahore and Divisional Superintendent, Rawalpindi shall assist the Second Party in getting donations from national and international donors for expansion of the hospital. All expenses on this account shall be borne by the Second Party. Pakistan Railways shall try to provide accommodation for on-call and emergency staff of the second party in the vicinity of the hospital. Standing Enquiry Committee comprising Medical Superintendent, Rawalpindi, Divisional Medical Officer, Rawalpindi, Director Hospital, IIMCT and one Senior Consultant of IIMCT shall be constituted. This committee shall investigate the cases of alleged professional negligence as and when required. Signed for and on behalf of the of Islamic International Medical College Trust at Islamabad on the 10th day of June 2004.

42. 43.

Signed for and on behalf of the President of Islamic Republic of Pakistan at Islamabad on the 10th day of June 2004.

Sd xxxxxxx Maj Gen Hamid Hassan Butt General Manager (M&S) Pakistan Railways, Islamabad

Sd xxxxxxx Maj Gen Muhammad Zulfiqar Ali Khan Managing Trustee and Principal, IIMCT, Rawalpindi

Witness No. 1

Witness No. 3

Sd xxxxxxx Brig. Muhammad Saleem, Director Health & Medical Services, Pakistan Railways, Lahore

Sd xxxxxxx Mr. Hassan M. Khan, Dy: Managing Trustee IIMCT, Rawalpindi

Witness No. 2 Sdxxxxxxx Mr. Muhammad Ishfaque Khattak Divisional Superintendent, Pakistan Railways, Rawalpindi Explanation
PR = Hospital = Pakistan Railways PR Hospital Rawalpindi

Witness No. 4 Sdxxxxxxx Mr. Asad Ullah Khan Executive Director, IIMCT, Rawalpindi

65

Appendix III AGREEMENT BETWEEN IIMCT AND PAKISTAN RAILWAYS 2004 AGREEMENT An agreement was made and entered into on 17 Aug 1998 between the President of Islamic Republic of Pakistan through Pakistan Railways Administration( hereinafter called the Railway Administration) of the 1st Party and Islamic International Medical College Trust, a Public Welfare Trust, registered under the Registration Act, (hereinafter called the Islamic International Medical College Trust) of the 2nd Party. Whereas the 2nd Party is running a Medical College at Rawalpindi under the name Islamic International Medical College for the past seven years and has improved, entirely at its own cost and expense, the status and standard of PR Hospital, Rawalpindi to a considerable extent. Pakistan Railways desired that, in the larger interest of Railways and welfare of its employees, the said Hospital be further improved and upgraded to meet the standard and requirement of an excellent teaching hospital. The initial agreement drawn on 17th August, 1998 included 35 clauses. November, 2000, nine clauses were amended and two new clauses were added. It was felt that a agreement needs to be drawn between the parties to further upgrade the facilities at PR Hospital, Rawalpindi to provide better medical cover to entitled patients and to meet the standards of a teaching hospital as per PMDC rules. This agreement is in addition and continuation of the previous agreement dated 17 August, 1998 and all its amendments notified vide notification No. C-199/RH-1 dated 29 November, 2000. AND WHEREAS the first party has accepted the said offer of the second party. The first party shall fully cooperate and allow the second party to function in the manner laid down hereinafter, to upgrade and develop PR Hospital, Rawalpindi into a Teaching Hospital The terms of the agreement are given below:1. 2. This franchise agreement shall be for a period of 33 years w.e.f 17th August, 1998, extendable for another similar term. The Second Party shall be responsible to provide specialized medical cover, free of cost to the serving/retired employees of Pakistan Railways, their families and dependents as admissible and presently available to them in terms of Railways Boards Notification issued from time to time. This shall include :

a).

Outdoor treatment including consultation, medical attendance and Laboratory test.

b). In-door treatment including medical attendance, consultation, surgery, specialized medical cover including:i). Dialysis ii). Cancer therapy, Chemotherapy and Radiotherapy iii). Cardiac Surgery iv). Neurosurgery v). Provision of orthopedic implants, stents, meshes DCR tubes etc. vi). C.T Scan and MRI vii). Laboratory investigations not available in the hospital and advised by the head of concerned department. 66

3.

The amount being reimbursed by Pakistan Railways currently for Cardio/Chemo/Dialysis/Neurology cases will be taken up by the Second Party upto a total of Rs. 1.0 million per annum. Expenses above this limit will be borne by Pakistan Railways. A two-bedded Burns Unit will be provided by Second Party. Fifty percent of indoor beds shall be reserved for Railway employees, their families and dependents. The Railway patients as defined above, however, shall not be refused admission in case of emergency or Railway accident when 50% of the bed strength has already be utilized. The Second Party shall provide medicines to the extent of Rs. 3.0 million per annum and this amount will be reviewed with mutual consent, if required shall be provided to Railway entitled patients as per Pakistan Railways Drug Formulary. If required IIMT will try to provide medicines, not included in the Formulary, to the deserving patients. Mobile Primary Health Care Units may be provided by the Second Party at various Railway facilities within Rawalpindi. Community Health Units may also be established by the Second Party in various Railway colonies within Rawalpindi/Islamabad by utilizing the existing Pakistan Railways Child Welfare Centers. The Second Party shall provide free diet to those categories of Railway employees and their dependents who are at present entitled for the same. That the Second Party shall undertake the responsibility to raise the said hospital to a teaching hospital and employ professional and supporting staff according to its own scheme of things as per PMDC requirements. Additional staff (Doctors/Para-medical) required to raise the standard of the hospital shall be provided by the Second Party at its own cost and expense. However, in recruitment of such staff preference shall be given to the Railway employees sons/daughters and their dependents who possess the requisite qualifications and experience and also bear the recommendations of the Railway Authorities. The Second Party shall appoint and depute heads of various departments for the hospital who shall also make sure that all departments render the best possible services in the interest of the hospital, the Railways and its employees. The Second Party may establish Nursing and Para Medical School in due course of time with teaching faculty of IIMCT, to improve the Nursing care. However, the students to such courses shall be admitted on the basis of 40-60 ratio of Railway employees sons/daughters and general public respectively, purely on merit, as laid down by PMDC and Pakistan Nursing Council. The Second Party shall arrange suitable training at their expense to Nursing/Paramedical staff and Lab technicians working in the hospital to upgrade and improve their knowledge and skill In order to provide better specialized medical services, the Second Party will ensure availability of consultants/specialists round the clock. 67

4. 5.

6.

7. 8.

9. 10.

11.

12.

13.

14.

15.

16.

The Consultants/Specialists of Second Party will admit and treat private patients and out the total income accrued on this account a sum of Rs. 0.6 million per annum will be deposited in Railway Treasury and the rest will be paid to Islamic International Medical College Trust. This will applicable from February 2004. BUDGET

17.

a). The 1st Party reduced the budget allocation for the hospital to fifty percent for the financial year 2001-2002. This allocation will be maintained for five years (upto 2006-2007) and will be revised further beyond 2006-2007 with mutual consent of the parties. b). Proposals for expenditure will be initiated by Director Hospital IIMCT appointed by nd the 2 Party, verified by the Medical Superintendent and concurred by Divisional Accounts Officer, P.R, Rawalpindi. The sanction shall be granted by Divisional Superintendent, Pakistan Railways, Rawalpindi. c). Salary/allowances of Railway employees shall be the liability of Pakistan Railways. 18. The Second Party with the approval of the Railways Authorities may at its own expense, provide additional facilities and sophisticated equipments in the hospital but no compensation whatsoever, will be claim by the Second Party for the same. However, the Second Party shall have the right to remove/replace the equipment with the consent of the Hospital Administration. The 2nd Party shall provide high-level repair and maintenance of all Electro Medical equipments available in the hospital through its specialized Biomedical Engineering Unit. An inventory of the entire equipment, tools and plants installed in the hospital was prepared and the same was handed over to the 2nd Party in March, 2001. The 2nd Party shall be fully responsible for its maintenance. Medical equipment not in use are under-utilized in any other Railway facility may be transferred to PR. Hospital, Rawalpindi. The administrative control of the hospital will be with the 2nd Party. However, senior most Doctor of the 1st Party (in General Cadre) shall act as coordinator in order to work as a cohesive team for the smooth functioning of the hospital. He/She will also process the disciplinary cases against hospital employees. Management Committee comprising General Manager (M&S), Director Health and Medical Services, Divisional Superintendent, Rawalpindi and Medical Superintendent, P.R, Rawalpindi, Managing Trustee and three nominees from Islamic International Medical College Trust will meet at least once a year. Decisions of Important nature, pertaining to this agreement or not covered by this agreement shall be referred to and decided by the Managing Committee. Any dispute unresolved by the Management Committee shall be referred to the Arbitration Council, which shall comprise General Manager (M&S), Director Health and Medical Services, Divisional Superintendent, Rawalpindi, Managing Trustee and two nominees of the 2nd Party. The recommendations of the Arbitration Council shall be referred to Secretary/Chairman, Railways whose decision will be final and binding on the parties. 68

19.

20.

21. 22.

23.

24.

25.

An Inspection Committee comprising Director Health and Medical Services, FA&CAO/M&S and Divisional Superintendent, Pakistan Railways, Rawalpindi will be constituted by the 1st Party. The committee or any one of its members will inspect the hospital from time to time to see that the institution is functioning smoothly. Any shortcoming/breach of the agreement observed shall be reported to the Management Committee who will notify the 2nd Party with a notice period of three months to rectify the shortcoming/breach. The 2nd Party shall be bound to do so within the said period. If the performance f the second Party is not up to the mark and it fails to improve or rectify the shortcomings as observed by the Inspection Committee and notified to Second Party through Management Committee, this agreement shall become liable to termination. For the purpose of termination the 1st party shall serve a written notice in advance of five years on the second party in order to allow the students already admitted to complete their academic/clinical sessions and to avoid hardship to the second party. Cropping up of a dispute or difference or reference of any matter to Arbitration Council for rectification of the shortcomings/breach or arbitration, shall not result in stoppage of activities of either party and their programs shall continue uninterrupted. Railway Doctors and staff employed in the hospital shall be governed by their own Service Rules. They shall, however, conduct themselves in close cooperation and liaison with the Second Party. They shall, in the discharge of their duties and functions, make sure that the functioning of the hospital is carried out and run by the parties in a smooth manner. Reasonable compensation/incentives in the shape of monthly honorarium/teaching allowance may be given by the second party to the existing Hospital staff (Doctor/Para Medical) possessing suitable qualification and experience equivalent to various posts of teaching Institution and selected by Islamic International Medical College Trust to perform duties pertaining to teaching purpose one third of the honorarium/teaching allowance paid to the Railway Staff will be deposited in Railway treasury. Medical Superintendent, Railway Hospital, Rawalpindi shall seek performance review of employees working in the hospital from the Director Hospital IIMCT before initiating the annual Performance Evaluation Report. Land and building of the said Hospital are and shall remain the exclusive property of Pakistan Railways. The Second Party shall not assign or sublet the said premises or any part thereof to any third party. However the second party can allow utilization of land and building or any part of the said premises for creation of medical ancillary services for the hospital with express approval of Divisional Superintendent. The Second Party shall be responsible for day-to-day repairs and maintenance of the building and shall undertake, at its own cost, all works necessary to keep the said premises in good condition during the contract period and shall not claim any compensation, whatsoever in this regard.

26.

27.

28.

29.

30.

31.

32.

69

33.

The Second Party shall be responsible for up keep of all fittings in the premises. In case of any damage to the building premises and fittings, the 1st Party shall have the right to get the building/fittings repaired and restored in the original condition at the cost of 2nd Party. Any structural addition/improvement on the existing vacant land within the Hospital premises or alteration to the existing structure, equipment, and utilities of hospital, carried out by the Second Party, shall be subject to the agreed terms and conditions and at the cost and risk of the Second Party. The 2nd Party will not make any changes, additions, alterations, whatsoever in the existing structures of Railways Hospital without express approval of the First Party. At the time of expiry/termination of contract the 2nd Party will hand over any such structure to the First Party without any claim. When the Second Party leaves the hospital at the expiry of the term or termination of the contract, the Second Party will have no claim on the investment made in the shape of immovable property on the Railways remises. On expiry/termination of the contract, the said premises alongwith structures erected by the Second Party shall revert to the exclusive use of First Party. The First Party shall not be liable to pay any cost or compensation for such structures even if constructed with the express approval of the First Party. The ownership of the Hospital and its entire premises shall all the time remain with the First Party. The cost of utilities, electricity and Sui Gas shall be shared by both parties according to the following ratios:Share of 1st Party 8000 units/per month 40 Units Share of 2nd Party Remaining Units Remaining Units

34.

35.

36.

37.

38.

i). ii).

Electricity Sui Gas 39. 40.

Audit of the hospital record (including Accounts) shall be conducted in the liaison with 2nd Party. Public Relation Department shall be established by the Send Party to improve public relations with Railway patients. Information Guides will be provided by the 2nd Party in the hospital to facilitate the patients. Five percent Medical College Seats will be reserved for Railway employees (serving/retired) sons/daughters on merit. The candidates shall appear in entry test of Islamic International Medical College Trust. Schedule of entry test will be intimated well in advance to Director Health & Medical Services. A list of candidates selected on merit shall be prepared by the second party and sent to Director Health & Medical Services, Lahore. The Railways Administration shall nominate the candidates from amongst the said list on their merit and priority. Finally selected nominees shall be give 50% concession in admission and tuition fee. If more than 5% candidates get selected then railway administration shall have to right to nominate from within the list of selected candidates.

41.

70

42.

Director Health and Medical Services, Lahore and Divisional Superintendent, Rawalpindi shall assist the Second Party in getting donations from national and international donors for expansion of the hospital. All expenses on this account shall be borne by the Second Party. Pakistan Railways shall try to provide accommodation for on-call and emergency staff of the second party in the vicinity of the hospital. Standing Enquiry Committee comprising Medical Superintendent, Rawalpindi, Divisional Medical Officer, Rawalpindi, Director Hospital, IIMCT and one Senior Consultant of IIMCT shall be constituted. This committee shall investigate the cases of alleged professional negligence as and when required. Signed for and on behalf of the of Islamic International Medical College Trust at Islamabad on the 10th day of June 2004.

43. 44.

Signed for and on behalf of the President of Islamic Republic of Pakistan at Islamabad on the 10th day of June 2004.

Sd xxxxxxx Maj Gen Hamid Hassan Butt General Manager (M&S) Pakistan Railways, Islamabad

Sd xxxxxxx Maj Gen Muhammad Zulfiqar Ali Khan Managing Trustee and Principal, IIMCT, Rawalpindi

Witness No. 1

Witness No. 3

Sd xxxxxxx Brig. Muhammad Saleem, Director Health & Medical Services, Pakistan Railways, Lahore

Sd xxxxxxx Mr. Hassan M. Khan, Dy: Managing Trustee IIMCT, Rawalpindi

Witness No. 2 Sdxxxxxxx Mr. Muhammad Ishfaque Khattak Divisional Superintendent, Pakistan Railways, Rawalpindi Explanation
PR = Hospital = Pakistan Railways PR Hospital Rawalpindi

Witness No. 4 Sdxxxxxxx Mr. Asad Ullah Khan Executive Director, IIMCT, Rawalpindi

71

Appendix IV COMPARISON OF RATIO OF MEDICINES IN RDF AND IDF FORMULARIES

S.No. Type ANESTHETICS 1 GENERAL 2 3 LOCAL ANAESTHETICS NOM-NEUROMUSCULAR BLOCKING AGENTS. ANALGESICS. 4 NON-OPIATES 5 6 7 OPOID ANALGESICS NON-STEROIDAL ANTI INFLAMMATORY AGENTS. URICOSURIC AGENTS ANTS/ANTIEPILEPTICS/PSYCHOTHERAPEUTICS 8 HYPNOTICS 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ANTI CONVULSANTS. NEURO MUSCULAR RELAXANT & ANTI CURARE DRUGS ANTI DEPRESSIVES SEDATIVES & TRANQUILUZERS ALIMENTARY SYSTEM ANTI CHOLINERGICS H2 RECEPTOR ANTAGONISTS PROTON PUMP INHIBITOR DIGESTIVE ENZYMES ANTI-DIARRHOEALS, ANTIHELMINITICS LAXATIVES/PURGATIVES DRUGS ACTING LOCALLY ONN RECTUM ANTI-EMETICS/ANTI NAUSEANTS ANTIHISTAMINES 9 5 5 6 5 3 5 12 2 4 5 4 1 8 12 4 0 0 0 1 1 2 1 0 0 0 3 0 1 1 18 3 6 9 1 0 2 1 9 2 7 6 3 2 8 3 Railway (RDF) IIMCT(IDF)

72

24 25

ANTI ALERGICS/DRUGS USED IN ANAPHYLAXSIS ANTI DOTES. CARDIOVSCULAR SYSTEM

1 3

0 1

26

CARDIAC REACTANTS. ANTI-ARRHYTMIC AGENT/BETA BLOCKER

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

BETA 1 RECEPTOR AGONIST SELECTIVE A BLOCKER ANTI HYPER TENSIVE ANGIOTENSIN ll ANTAGONISTS ACE INHIBITORS CALCIUM ANTAGONIST/CALCIUM CHANNEL BLOCKER. CENTRAL ALPHA ANTAGONIST HYPOLIPIDEMICS ANTI ANGINAL VASODILATORS/NITRATE DIURETICS. ANTI-COACULANTS CLOTTING AGENTS ANTI INFECTIVES SEMI SYNTHETIC PENICILLINS BETA LACTAMASE INHIBITOR PENICILLINASE REISTANT PENICILLIN PENICILLINASE REISTANT PENICILLIN TETRACYCLINE Cephalosporins MACROLIDES QUINOLONES SUSPHONAMIDES/ Trimethoprim AMINOGLYCOSIES AMOEBICIDES

3 1 2 2 5 5 1 3 4 2 8 5 3 1 6 3 3 1 2 5 5 3 3 3 4

1 0 0 0 1 2 0 0 0 0 4 2 3 0 3 0 1 0 0 2 0 1 0 0 2

73

52 53 54 55 56 57 58 59 60

ANTI MALARIALS ANTI TUBERCULOUS ANTI FUNGAL ENDOCRINES THYROID/ANTITHYROID INSULIN, ORAL HYPOGLYCAEMICS DRUGS AFFECTING IMMUNE RESPONSE ANTIVIRAL FEMALE SEX HARMONES GENITOURINARY SYSTEM

4 7 3 6 2 8 3 4 9

2 3 1 2 0 3 1 0 1

61 URINARY ANTI SEPTICS/ANTI SPASMODICS 62 BLOOD ALKALIZERS RESPIRATORY SYSTEM 63 EXPECTORANTS 64 65 66 ANTI TUSSIVE COUGH SUPPRESSANTS DECONGESTANTS BRONCHIAL SPASAM RELAXANTS. 67 BRONCHODILATORS B2 AGONISTS 68 Respiratory Stimulants EAR, NOSE AND ORAPHARYNX 69 AURAL PREPARATIONS 70 LOCAL REACTANTS ON NASOPHARYNX DRUGS AFFECTING NUTRITION AND METABOLISM. 71 HAEMATINICS 72 73 74 75 76 VITAMINS DERMATOLOGICALS PREPARATIONS. Antiparasitic/Anti Mycotic MULTIVITAMINS MINERAL PREPARATIONS. SOLUTIONS CORRECTING WATER, ELECTROLYTE AND ACID BASE DISTURBANCES.

1 3 5

0 0 0

6 4 14 8 10

2 0 2 0 4

74

77 78 79 80 81 82 83 84 85 86 87

OPTHALMOLOGICAL PREPARATIONS SURGICAL DISPOSABLES DIAGNOSTIC AGENTS SERA, VACCINES. ANTISEPTICS AND DIS-INFECTANTS DENTAL ITEMS BLOOD BANK. LABORATORY ITEMS DISPENSARY ITEMS X-RAY ITEMS LABORATORY ITEMS

40 51 1 5 3 25 11 110 6 5 21

9 29 0 2 1 0 0 5 5 0 2

Total

648 SUMMARY OF COMPARISON BETWEEN IDF AND RDF Total no. of medicines/items in Railway Formulary Total no. of medicines/items in IIMCT Formulary Number of medicines listed in both Formularies Number of medicines listed in both formularies with same company Number of medicines listed in both formularies with different company No. of medicines/items not listed in Railway Formulary No. of medicines/items not listed in IIMCT Formulary 646 311 171 30 141 140 475

142

75

Appendix V REPORT OF THE SURVEY COMMITTEE OF RAILWAY HOSPITAL RAWALPINDI. Consequent upon receipt of complaints over the conditions in Railway Hospital, Rawalpindi, Mr. Fiaz Ahmed Khan, DPO/RWP constituted a survey committee comprising of Senior Welfare Inspector Mr. Mukhtar Ahmed, Head Welfare Branch Mr. Naveed Ahmed, Mr. Javed Iqbal JAT, Muhammad Yar Khan Staff Car Driver, Nimat Ullah UDC, Mr. Sajid Hussain Shah Niab Qasid and ex-Head Welfare Chaudhary Muhammad Rafique to survey the conditions at the hospital and inquire into the problems of patients first hand.at A letter no. Misc/DPL-2 dated 13/5/2011 "Grievances of Railway Employees regarding Railway Hospital" was sent to MS/RWP and copy to Administrator, IIMCT informing them that a survey committee comprising the above members would come to the hospital to inquire into the matters first hand and that MS/RWP should coordinate with them closely. This letter was sent beforehand in order to ensure that no confusion should occur and that the hospital should be informed that the survey committee would be starting their work. The survey report is being furnished for kind perusal and further disposal please: SURVEY REPORT DATED 17.05.2011: Members of the committee carried out a survey from 6.30 pm to 9.00 pm and the observations are as under: Findings of visit to Medical Ward-2: 1. Hygiene and physical condition of bath room inside the ward including its door was a miserable condition. Image 1 attached herewith may be seen as evidence. Sinks were provided in a verandah at the back of the ward for washing utensils but were out of service as well extremely dirty (Image 2 placed for evidence). Patients admitted in the ward have recorded their complaints in shape of statements. These statements are available with the committee for presentation Copied are attached at Serial No. 1 for perusal. IIMCT administration started providing of meals to the patients when survey was going on. The committee collected a few CHAPATIES, which were later on presented to the DPO/RWP for examination. The CHAPATIES which were being provided to the patients were of very poor quality with little glutein protein. Worthy D.S called M.S/PR Rly. Hospital and inquired as to why such a poor quality meal is being provided to the patients. The M.S remarked that the matter relates to IIMCT. Worthy D.S advised the M.S to take up the matter suitably with the IIMCT in collaboration with the Survey Committee of the Hospital. M.S/RWP and the survey committee met with the Administrator IIMCT to discus and inquire the situation. The administrator admitted the fact that CHAPATIES do 76

2.

3.

4.

5.

6.

not meet the required standard. The Administrator also directed his assistant to ensure improvement of its standard, so that it may not harm the human life. Mr. Zafarullah, Administrator IIMCT also kindly gave the survey committee his assurance that it would be facilitated in inspecting the hospital facilities any time. SURVEY REPORT DATED 18.05.2011: The survey committee started their survey from 6 pm to 8 pm and observations are as under: Findings of Eye Ward: Ward was checked at 6.25 pm and the following are the observations: 1. Ward was checked and it was observed none of the staff was available at the counters (Image No.3). The condition of its bath room was very poor and its door was lacking a tower bolt to lock the door inside (Image No.4). A brick was placed instead to avoid opening of door while in use. Findings of Medical Ward-1: 1. Only one male member was available at the counters of Medical Ward-I. No other staff was found in the ward. 2. At male side of the Medical ward there are 14 beds. Six beds were occupied by the patients and rests of the beds were lying vacant. 3. At female side of the ward there are 17 beds. Four beds were occupied by Railway patients, two by non-railway patients and others were lying vacant. . Beds & patient situation is the same in Medical-II, Surgical-I & II wards and Eye Ward. Findings of Orthopedic Ward: 1. There is no nursing counter in this Ward. Patients of this ward are usually temporary disabled and in case of need they have to travel a long distance to reach female ward for seeking help as staff are only available in the adjacent female orthopedic ward. It is most congested ward and hygienically it was in a miserable condition. Patients admitted there have recorded their complaints which are available with the committee for presentation. There were lot of cockroaches in wards over floors and walls and patients made a complaint that these cockroaches often comes over the beds and enter in their clothes. Thus causing a very difficult situation for them who already in situation of agony. The committee when checked a bench lying along the beds was found full of cockroaches, snaps of which were taken. (Images at 4,5,6,7) Upon a complaint of Muhammad Aslam (Patient at bed No.7), CHAPATIES being distributed amongst the patients were checked and again noticed that there has been no improvement in the standard and the quality was the same poor as it was found during the previous inspection. The attitude and behavior of the person deployed to provide CHAPATIES was also hateful not only towards patients but to the members of the committee as well. Most probably due to his ulterior motives.

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3.

4.

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5.

IIMCT's Cafeteria was checked. It consists upon Book Stall, Tea Stall, Pakora & Samosa stall, General Store and a Ladies Canteen. These installations are established over the Railway land and a handsome source of revenue generation. Status of the grant of lease/contract to establish and run these things is not clear. In order to avoid losses to the Railway and complaints on this account regarding unauthorized running of these stalls, it is imperative to check and scrutinize the status of these installation through a duly nominated committee. Contract for a Railway Canteen is awarded yet instead the lessee has established the following additional installation over the extended portion of Railway land:

6.

(i). Tea stall in place of old cycle stand. (ii). A Khokah stall of Pakora/Samosas. (iii) NAAN/CHAPATI shop at the backside of the Railway canteen. Legal status of these installations is ambiguous. In order to avoid losses to the Railway and complaints on this account regarding unauthorized running of these stalls, it is imperative to check and scrutinize the admissibility of these installation through a duly nominated committee. 7. Main gate of the hospital at Railway colony side remains closed round the clock. It is only opened for MS/RWP and IIMCT staff. Patients are not allowed to use gate. They are instead directed to use 2nd gate at Dhoke Mangtal side (An easy approach for the Civilians rather than the Railway employees). The situation is painful for the Railway employees. Snap shots are taken which makes the situation clear. It is strongly recommended that the main gate of the hospital at Railway side should also be opened as door on civilian side is kept opened.

SURVEY REPORT DATED 19.05.2011: Members of the Survey Team started their survey early in the morning from 5.00 to 6.15 a.m and observations are as under: 1. Only 4-5 guards were sitting outside the hospital. Not a single guard was found deployed elsewhere inside the entire hospital. Admn. Office and M.S Office was also unguarded. Medical staff was sleeping in their rooms. After completing survey of the hospital the committee members conducted survey of the entire Path Labs. The members, when they were at the gate of the lab saw a security guard (Mr. Javed) who told them he was coming in to check the lights; otherwise he is posted at the gate. The committee has observed that despite the alarming security threats, the security of the Railway Hospital is horribly ignored. Samples of milk (good milk), and bread being provided to the patients are obtained today. Both the items are of inferior quality. Sample from the flour for making CHAPATIES is also obtained and available with the committee for presentation.

2.

3.

Members of the Survey Team carried out 2nd tour of the railway hospital on the same day at 11.00 hours and observations are as under:

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1.

Railway Pharmacy for the Railway employees is checked. All the medians were lying in bottles of ordinary type with incorrect and improper labeling e.g not indicating date of expiry etc as per Drug Act 1986.. None of the medicine was of branded or multinational companies. The medicines were of unfamiliar companies. It is feared that sub-standard medicines are being provided to the Railway patients. It is therefore extremely needed to constitute a committee that could check the approved brand of medicines and those being provided to the Railway employee. Surgical Ward-1 & 2 was checked. Hygiene condition of the ward was still very poor. Bath rooms were still in a miserable condition (Image at _ and __) Kitchen was checked and meals being prepared were of extremely inferior quality. Cooks were wearing dirty clothes. Utensils were also dirty. Snap shots were taken and available with the committee for presentation (Images at __, __,__ and __). During visit a young doctor came and started checking a patient, named Muhamma Razzaq S/O Muhammad Hayat Carpenter Washing Line RWP. That young man was wearing a white coat which did not contained his name from which his identity could be proved. He also using rough language which does match with the grace & worthiness of a doctor. Need is felt that doctor should be wearing proper uniform with names at their coats, so that it could be made known to everyone that they are under treatment of proper doctors and not being treated by trainees. It is also pertinent to note that a letter was received in the Administrator's Office, IIMCT for the provision of Diet menu, approved list of medicines, position of doctors with status of their posting/responsibilities in the hospital and their duty list. Till date no information was received despite verbal reminders as well. It was also observed that certain clauses of the agreement were not complied with e.g. the creation of Child Welfare Centre, mobile primary health units etc. This issue needs to taken up in detail by the administration with IIMCT. It was also observed that the Railway doctors in charge of monitoring and evaluation of IIMCT performance were staff members of IIMCT as well, making them unsuitable on objectively judging IIMCT performance. An enclosed computer CD contains all the pictures and videos taken by the survey committee which the survey committee undertook to see the problems of admitted railway patients first hand. The scenes witnessed were highly disturbing to say the least. It also provides sufficient evidence that the committee for examining such issues constituted by the agreement is either dysfunctional or unable to probably check matters relating to the welfare of Railway patients in Railway Hospital. Another report which will be a summary of the information received from admitted patients will follow.

2.

3.

4.

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Figure 1 Above is of a chapatti made in the kitchen of Railway Hospital.

Figure 2 wall of the bathroom of Medic al I ward which is badly damaged.

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Figure 3 wall of the bathroom of Medic al I ward which is badly damaged.

Figure 4 wall of the bathroom of Medic al I ward which is badly damaged.

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Figure 5 Mr. M. Zafar , Assistant Examiner RTL, Rawalpindi in Orthopedic Ward

Figure 6 Foreman Mr. Waheed, CDL Workshop, Rawalpindi.

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Figure 7 Floor of Orthopedic Ward right beside the bed of a patient Image B at Page 3). As seen it is full of cockroaches. This was observed frequently in different wards and is indicative of the general hygiene condition of the hospital

Figure 8 gate of the hospital to Railway Colony side. This gate has been closed to Employees though used by hospital staff. The gate at Dhoke Mangtial side is convenient for railway patients and was the old gate used by patients as well. This gate has been sugg

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Figure 9 Shows hospital staff asleep in front of the ICU ward

Figure 10 Front door of ICU

84

Figure 11 entrance to Surgery Unit/Ward 2.

85

Figure 12

Figure 13 floor right beside the water cooler available in the corridor from which the wards at Image A is entered into.

86

Figure 14 Procedure Room in Lab

Figure 15 Dispensary which unhygienic conditions

87

Figure 16

Figure 17 pictures of the Railway pharmacy in which bulk medicine are stored

88

Figure 18

Figure 19 Railway dispensary is of the bulk medicine being distributed.

89

Figure 20

Figure 21 packets of tablet distributed.

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Figure 22 syrup being distributed and packed. It may be noted that the quality of the bottles in which the medicine syrup is distributed is not as per Drug Act which states that proper labeling is needed mentioning expiry dates, name of medicines and manufacturing

Figure 23 Front of the pharmacy.

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Figure 24 Image is of the bathroom of staff and doctors.

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Figure 25 Figure 24 Image is of the bathroom of staff and doctors.

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Figure 26 Figure 24 Image is of the bathroom of staff and doctors.

Figure 27 Figure 24 Image is of the bathroom of staff and doctors.

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Figure 28kitchen of Railway hospital along with of cooks.

Figure 29 kitchen of Railway hospital along with of cooks.

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Figure 30 office of supervisor of Kitchen

Figure 31 counter and floor of kitchen. Kettle at bottom right is for heating water and making tea. The dust bin is also right beside it.

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Figure 32 Kitchen

Figure 33 dressing/bandage room of orthopedic ward.

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Figure 34 another picture of dressing/bandage room of orthopedic ward.

Figure 35 Orthopedic Ward

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Figure 36 entrance to Surgery Unit I (misspelled on board)

Figure 37 bathroom inside Surgical I ward.

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Figure 38 Bathroom of Eye ward

Figure 39 bathrooms of Female Ward.

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Figure 40 entrance to Surgical Unit II.

Figure 41 interior of same ward indicating rubbish room at right. No staff were present when the team visited the ward.

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Figure 42 Washrooms of Eye Ward. Image A shows the broken door of a bathroom.

Figure 43 Female Washroom of Eye Ward (broken Lock or without chatkhani)

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Figure 44 Shows the chapati and low quality of flour used.

Figure 45 cafeteria sub-letted.

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Figure 46 sub-letted canteen

Figure 47 sub-letted canteen

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Figure 48 IIMCT pharmacy which has been unlawfully sub-letted to an outside party i.e. Healers Pharmacy.

Figure 49 As Above

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Figure 50 Sub-letted canteen.

Figure 51 Sub-letted canteen.

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Figure 52 book shop sub-letted unlawfully.

Figure 53 Sub-letted canteen.

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Figure 54 gate to Railway colony closed to Railway patients but opened for hospital staff during opening and closing hours.

Figure 55 Canteen Sub-letted

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Figure 56 Canteen Sub-letted

Figure 57 Canteen Sub-letted

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Figure 58 Orthopedic Ward in which a bench was shaken and cockroaches spilled from them.

Figure 59 Wall and electric switch of Orthopedic Ward

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Figure 60 Rubbish Bathroon

Figure 61 Mr. Rabnawaz S/O Khawaj Muhmmad, Gangman Sangjani being interviewed. The condition of the mattress which has no bedding may be noted.

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Figure 62 door of the kitchen which was locked at 6.30 pm on 18/5/2011.

Figure 63 Eye Ward where no staff was present at the time observed in the clock i.e. around 6.30 pm (18/5/2011).

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Figure 64 Bathroom of the female ward. The door could only be closed by a brick underneath and the interior bolt was broken.

Figure 65 As Above

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Figure 66 Dishwashing Sink at Medical II ward

Figure 67 Patient in Medical II ward. The wall and electric switch above the patient may be observed.

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Figure 68 Sink and Wash basin in the Medical II ward.

Figure 69 Sink and Wash basin in the Medical II ward.

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Figure 70 tap in the bathroom in Medical II ward.

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Figure 71 Bathroom of Medical II ward.

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Figure 72 Bathrooms of Medical II ward.

Figure 73 Bathrooms of Medical II ward.

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Figure 74 Rubbish Store in Medical II ward near entrance.

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Figure 75 Medical II ward rubbish room

Figure 76 Medical II ward.

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Appendix VI Samples of Press Coverage of IIMCT running of Railway Hospital Enquiry committee deplores IIMCT performance (The News International) Thursday, June 02, 2011 The enquiry committee of Pakistan Railways has deplored the performance and services of International Islamic Medical College Trust (IIMCT) and its failure to develop and upgrade the Railway Hospital, condition of which is in shambles. Well informed sources providing evidences, to this scribe, including films and snaps taken during enquiry by the committee members said that the failure of IIMCT in upgrading and developing the over all state of the Railway Hospital, Rawalpindi, is violation of the agreement made between the two parties some thirteen years ago. Under the agreement, Pakistan Railways handed over the charge of the hospital to IIMCT for its upgradation and development, which was to be made in all terms during the thirteen years lease period. In return, the IIMCT was asked to utilise the institution as teaching hospital for the medical students. The committee members in their five-page report has pointed out that though the IIMCT achieved its interests fully by providing teaching to its medical students, yet in return no welfare or development measure has been taken over the last 13 years due to which the condition of hospital including male and female wards, ICU, bathrooms, cafeteria and kitchen have worsened creating bad image among the patients as well as people visiting this institution. The report of the committee forwarded to the Railway Headquarters and the Railway Ministry states that the hygienic and physical condition of bathrooms inside the wards is miserable. Sinks stalled in veranda at the back of the wards were out of service as well as extremely dirty. Patients admitted in wards recorded their complaints to the committee members. The committee members also observed that chapaties (bread) provided by the IIMCT administration to the patients were of very poor quality. During survey by the members, none of the staff was available at the counters in wards. Images were also taken in this regard. Similarly, in another Ward No.1 only one staff member was found while the other staff remained absent. During the survey the conditions of laboratory, cafeteria, bathrooms and kitchen were also found dirty and miserable. Only four guards were sitting outside the hospital and not a single guard was found deployed inside the hospital. Admin office and MS office remained unguarded. Medical staff was sleeping in their respective rooms during working hours. The report states that the security condition at the hospital is horribly ignored. Sample taken of milk that is provided to patients was found to be of inferior quality. On checking of Railway pharmacy for the railway employees, all the medians were found lying in the bottles of ordinary type with incorrect and improper labelling which also did not indicate expiry dates of the medicines. None of the medicines was of branded or of multi-national companies. The report fears that sub-standard medicines are being provided to the Railway 121

patients. The report stressed the need for constitution of committee for checking the approved brand of medicines and those being provided to the Railway employees. Similarly, the report alleges that the IIMCT did not comply with certain clauses of the agreement including the creation of Child Welfare Centre, mobile primary health units etc. The committee members also provided CD containing all pictures and videos taken by the members during survey of the hospital. The scenes witnessed were highly disturbing to say the least. Official spokesman to Pakistan Railways confirmed that enquiry committee set up for the purpose has found the performance of the IIMCT below the mark and inefficient in terms of maintenance, upgradation and development of the hospital. The Railway Headquarters has now formed a high-powered committee to make fresh enquiry into the matter. After our enquiry, the IIMCT started making improvement and maintenance work in the hospital just to save its skin, the spokesman claimed. When approached for comments in this regards, the IIMCT officials including Muhammad Naseer, Assistant Manager and member of Dental Medical Council and Dr. M. Zaffarullah Khattak, Administrator, defended their position. They said that the management is carrying out maintenance and improvement work in phases. More steps would be taken to further improve the over all condition of the hospital, they assured. As far as the matter of failing to upgrade and develop the hospital is concerned, they said they had prepared a project of extending academic block in the hospital but none of the Railway high officials met us for approving it. Under these circumstances how could we upgrade and develop the condition of the hospital, they asked. Inquiry against IIMCT put into cold storage (The News International) Friday, June 17, 2011 The decision of former Pakistan Railways (PR) chairman Shahid Hussain Raja regarding constitution of a high-powered inquiry committee to probe into the alleged failure of International Islamic Medical College Trust (IIMCT) to improve and upgrade the Railway Hospital has been put into cold storage, claim sources while talking to The News here on Wednesday. Sources said that an inquiry committee constituted by the Divisional Office of Pakistan Railways, Rawalpindi, submitted a report to its headquarters with regard to the alleged poor working of the IIMCT. Former Pakistan Railways chairman Shahid Hussain Raja, after going through the report, decided to constitute a high-powered inquiry committee for reinvestigating into the matter. He also sought explanation from the medical superintendent on the poor working of the IIMCT in the affairs of Railway Hospital. However during this period Javed Iqbal replaced Shahid Hussain Raja as chairman, said sources. According to sources, after the departure of Shahid Hussain Raja the decision to reinvestigate into the matter through the high-powered committee was not taken up. As a result, the IIMCT did not take any measures to upgrade and develop the Railway Hospital, Rawalpindi. They

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claimed that patients are suffering badly at the hands of IIMCT staff due to poor medical facilities at the Railway Hospital. The official spokesman, when contacted, said that the IIMCT invited the high-powered committee to probe into the matter regarding allegations by the Divisional Office of Pakistan Railways against it. We are discharging our duties efficiently to the satisfaction of patients. Effective measures are being implemented to upgrade and develop the condition of the Railway Hospital. Some Divisional Office officials, having vested interests, are creating complications and confusion by making false allegations against the IIMCT to achieve their designs, said the spokesman. He said otherwise the situation in the hospital is altogether different. When approached, new Pakistan Railways chairman Javed Iqbal expressed his unawareness about formation of a high-powered inquiry committee by his predecessor to probe into the affairs of the Railway Hospital. Let me check its status first. If any committee has been constituted by the outgoing chairman, we would go ahead with the task, Javed Iqbal assured. It may be mentioned that according to an agreement made in 1998 between Pakistan Railways and IIMCT, the latter had to upgrade and develop the Railway Hospital in 33 years lease period. However, according to sources, 13 years have elapsed but no improvement has been witnessed in the hospital. However, IIMCT is achieving benefits by imparting teaching to its medical students, said sources.

IIMCT directed to improve condition of Railways Hospital (The News International) Saturday, July 02, 2011 Pakistan Railways Chairman and Federal Secretary Javaid Khan has directed the International Islamic Medical College Trust (IIMCT) to improve the condition of the Railway Hospital in Rawalpindi within next three weeks. According to the sources, the railways inquiry committee briefed the chairman about the poor condition of the hospital with the help of photos and films taken by it. The Divisional Office of the Railways had formed the committee for inspection of the hospital. The chairman expressed dissatisfaction on the poor condition of the hospital and issued necessary directions to the general manager development to direct the IIMCT authorities to improve the condition of the hospital in terms of up-gradation. The chairman took the notice on a news item appeared in daily The News relating to IIMCTs poor working at its allied hospital, Railways Hospital. Railway Boards Secretary Shafiqullah while confirming the report said that the IIMCT officials have been directed to take practical measures for improvement as well as upgradation of the hospital to the satisfaction of the patients. Upon submission of the report, Pakistan Railways would take the decision if the situation remains unchanged. However, he ruled out cancellation of the agreement regarding affiliation of the hospital with the IIMCT. Pakistan Railways general manager development also confirmed the news saying that on the directions of the chairman railways a committee at divisional level was formed. He said their 123

team is working on the inspection of the hospital and would submit its report within next two to three days. However, Railway Hospital Medical Superintendent Fehmida Akhter denied receiving any kind of notice relating to the poor condition of the hospital. At the same time she said, steps are being taken to improve the condition of the hospital. Whenever the patients comments were sought they always expressed their satisfaction on the condition of the hospital, she claimed. IIMCTs Manager Naseer Ahmed said that the trust has not received any type of letter or notice from Pakistan Railways regarding poor condition of the hospital. We are working properly according to the agreement made back in 1998, he added.

IIMCT given 14 days to vacate railway building (The News International) Tuesday, July 05, 2011 The Pakistan Railways (PR) has directed the International Islamic Medical College Trust (IIMCT) to vacate its building within 14 days and pay an amount of Rs9.5 million for its commercial use. Well-placed sources in the Ministry of Railways told The News here on Monday that the IIMCT has been asked to vacate the Railway Building close to the Railway Hospital because it is violating the clause 44 of the rules and regulations. The IIMCT had demanded occupation of the building back in 2005 for converting it into a nursing and postgraduate hostel for girls. The audit team of the Pakistan Railways has detected that the building instead of being converted into a nursing and postgraduate hostel for girls is being used by the administrator of the IIMCT for the last six years. After this detection, the Pakistan Railways has directed the IIMCT administrator to vacate the building within 14 days and pay a sum of Rs9.5 million to the railways as commercial charges. In another case, the audit team detected ill use of another building of the railways by the IIMCT near Karbela Gate, Rawalpindi. The Pakistan Railways again on the demand of the IIMCT had given its five-kanal building for opening a tuberculosis centre and skin patients centre in 2005. However the IIMCT did not abide by the rules and regulations and converted it into a hostel for nursing students the same year. The Pakistan Railways sought explanation from the IIMCT management over the violation being made and directed it to pay Rs25 million as commercial charges of the building. The Pakistan Railways has been suffering a loss of Rs30 million because of ill use of the two buildings by the IIMCT, sources added. The Pakistan Railways spokesman, confirming the report, said that the IIMCT, which has failed to upgrade and develop the Railway Hospital, Rawalpindi, has also violated the rules and regulations of clause 44 and making ill use of the two buildings. It would have to vacate the Railway House, which has been occupied by the IIMCT administrator and pay Rs30 million to the Pakistan Railways as commercial charges of two buildings. 124

On the other hand, IIMCT Administrator Umar Awab confirmed receipt of notices from the Pakistan Railways to vacate the Railway House within 14 days. However I have got stay against the orders of the railway authorities. The matter is in the court, which will give its verdict, he said. Secondly as far as charges by railways about the ill use of its building at Karbela Gate, Rawalpindi, is concerned, he said that it has become a part of the hospital, which is under the charge of the IIMCT. We could use it for any purpose. We had opened an eye treatment centre in the building measuring 5 kanals, he said. Expressing his concern, he asked the railway authorities to discuss all such issues in the meeting of the management committee instead of highlighting the matter in the print media. He alleged that some vested interests were trying to tarnish the image of the IIMCT to achieve their designs for which print media is being used.

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Appendix VII INQUIRY INTO THE GRIEVANCES ON THE ORDERS OF MINISTRY OF RAILWAYS IN RESPONSE TO SURVEY REPORT AT APPENDIX V. Subject: GRIEVANCES OF RAILWAY EMPLOYEE AGAINST IIMC-T, RAILWAY HOSPITAL, RAWALPINDI. CM & HO/LHRs letter No: 14-Med/M/IIMC-T/2011 dated: 13/07/2011

Reference:Methodology.

Detail Examination of Survey Committee Report. Study of the Agreement between Pakistan Railways and IIMC-T. Inspection of the Hospital. Meeting with IIMC-T Administration (Administrator, Asstt: Administratior/Medical, Asstt: Administrator/Operation) 5) Hospital information data from IIMC-T regarding Survey committee Report. 6) Securitization of Reply and data provided by IIMC-T. A Divisional level committee was constituted as per instructions of Secretary Railway Board to probe into above subject matter conveyed through CM & HO/LHRs letter No: 14Med/M/IIMC-T/2011, dated: 13/07/2011. Proceedings of the Committee. Committee convened the first meeting on 06/08/2011 a. Detailed examination of Survey Committee Report was carried out. The issues have been highlighted in the said report. Poor condition of bath rooms in MU-I & II, SU-II and Eye Ward. Absence of staff in Eye Ward. Absence of Nursing Counter in Male Ortho Ward. Presence of cockroaches in Ortho Ward. Medicines provided to patients from Railway Hospital. Diet being provided to patients from Railway Hospital. Status of IIMC-T cafeteria established in the Hospital. Status of additional installation with the Railway Canteen in the hospital. Security Measures in the Hospital. Sanitation Services of Hospital.

1) 2) 3) 4)

i). ii). iii). iv). v). vi). vii). viii). ix). x).

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To find out the facts Administration of IIMC-T was called for discussion and they were further asked to provide information regarding system / SOPs for procurement mechanism of medicines, system of complaints registration, fumigation and sanitation services and utilization of hospital cafeteria. b. Study of the revised agreement 2004 between Pakistan Railways and IIMC-T. Following clauses have been reviewed by committee Members.

Clause No.22 The Administrative control of the hospital will be with the 2nd Party. However, senior most doctor of the 1st Party (in General Cadre) shall act as coordinator in order to work as a cohesive team for the smooth functioning of the hospital. He / She will also process the disciplinary cases against hospital employees. Clause No.6 The 2nd Party shall provide medicines to the extent of Rs.3.0 million per annum and this amount will be reviewed with mutual consent, if required medicines shall be provided to Railway Entitled Patients as per Pakistan Railway Drug Formulary. If required. IIMCT will try to provide medicines, not included in the Formulary, to the deserving patients. Clause No.9 The 2nd Party shall provide free diet to those categories of Railway employees and their dependents who arc at present entitled for the same. Clause No.23 A Management Committee comprising General Manager (M&S), Director Health & Medical Services, Divisional Superintendent. Pakistan Railways. Rawalpindi and Medical Superintendent, PR Hospital, Rawalpindi, Managing Trustee and three nominees from Islamic International Medical College Trust will meet at least once a year. Decisions of important nature, pertaining to or not covered by this agreement shall be referred to and decided by the Managing Committee. Clause No.25 An Inspection Committee comprising Director Health & Medical Services, FA&CAO/M&S and Divisional Superintendent. Pakistan Railways, Rawalpindi will be constituted by the 1st Party. The Committee or any one of its members will inspect the hospital from time to time to see that the institution is functioning smoothly. Any shortcomings / breach of the agreement observed shall be reported to the Management Committee who will notify the 2nd Party with a notice period of three months to rectify the shortcoming/breach. The 2nd Party shall be bound to do so within the said period. Clause No.29 Reasonable compensation/incentive in the shape of monthly honorarium /teaching allowance may be given by the 2nd Party to the existing hospital staff (Doctors/Paramedical) possessing suitable qualifications and Experience equivalent to various posts of teaching institutions and selected by IIMCT to perform duties pertaining to teaching purposes. One third of such honorarium/teaching allowance paid to the Railway Staff will be deposited in Railway Treasury. Clause No.32 The 2nd Party shall be responsible for day-to-day repair and maintenance of the building and shall undertake, at its own cost, all works necessary to keep the s a i d premises in good condition during the contract period and shall not claim any compensation whatsoever, in this regard.

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Committee convened the 2 nd Meeting on 10-08-2011. IIMCT Administration (Administrator, Asstt. Administrator/Medical and Asstt. Administrator/Operation) were called. They provided the requisite information including comments regarding survey report and measures taken for their rectification. (Annex- )
a)

b) Inspection of the Hospital Wards was conducted by committee Members. Points noted by the Survey Team and rectifications claimed by IIMCT were physically examined. c) Information provided by IIMCT was scrutinized.

Findings
i) Physical inspection of the Hospital. Renovation of wash rooms of MU-II, SU-II have been completed. Maintenance of Eye Ward wash rooms earned out. Two wash rooms of female sides MU-II and SU-II are in working order but yet to be renovated. According to Duty Roster Nursing staff remains present in the eye ward round the clock. Duty Roster of Eye Ward and Statement of Duty Nurse is attached. (Annex- ) Nursing Station of Ortho Ward is in the Female portion of ward. There is 10 separate counter on male side. Fumigation is done once a week as per routine. However, in the month of July 2011 fumigation is carried out daily and now cockroaches have been finished in the wards.
(Annex- )

ii) iii) iv)

v)

According to Clause 6 of Revised Agreement between Pakistan Railway and IIMCT, Budget for provision of medicines was 3.000 million per annum which was enhanced to 7.000 million in the 7lh Management Committee Meeting held on 09th July 2008 (Reference Agenda Point 2. C). Medicines are being provided to Railway patients by IIMCT according to IIMCT Drug Formulary. (Annex- ) Diet is being provided to Railway patients by IIMCT. Cooked diet and kitchen hygiene is being checked. Diet was inspected. Quality of flour is good. Cooking quality of chapatti has now been improved. Haleeb milk is being provided instead of Good Milk. Menu of diet (Annex- ) Cafeteria Railway Canteen Security services are provided by IIMCT Administration under the control of Asstt: Administrator/Operation. 18 Security Guards are present in the hospital premises round the clock. Issue of closure of main gate colony side has been examined. This gate was closed considering the law & order situation in accordance with the orders of the CM & HO/LHR's letter No.l4-Med/S/2009 dated. 11-04-2009 (Annex- ) attached. However the small passersby gate remains open round the clock for the convenience of Railway patients. If main gate is opened this will provide short cut to general public during traffic jam which become security risk and traffic hazard. 128

vi)

vii) viii) ix)

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Sanitation and up keep of the hospital premises is the responsibility of IIMCT. They have appointed 35 sanitation staff. General Cleanliness of the hospital premises has been checked and found satisfactory. (Annex- ) Recommendations After gone through the whole inspection of the Hospital, examination of matters and information provided by IIMCT, following recommendations are provided by Committee Members. 1. Repair/maintenance of building infrastructure of Hospital and its premises should be a regular feature. IIMC'T should provide/communicate their plans projects in this regard to Railway authorities in black and white so that its schedule can be monitored. IIMCT must take input from Railway authorities regarding needs of Railway patients and Railway staff. Hygiene/sanitation being day to day matter should be more effectively dealt and vigilantly supervised by IIMCT administration. Sanitation staff strength and measures adopted must be boasted on required basis. Fumigation with good quality insecticide/sprays should be a regular feature as per SOP. If it is felt insufficient/ineffective, or due to seasoned variation, its frequency be increased as required. IIMCT Budget for medicines be sufficiently increased to meet the requirements of Railway patients. Pharmacy/Hospital formulary should follow the Railway drug formulary and it should cover all the medicines/Items required by the Railway entitled patients as suggested by the treating doctors. 5. Diet quality/menu should be strictly supervised. A qualified nutritionist may be employed by IIMCT to cater the requirements of patients. A nursing counter should be provided in male ortho ward, which has bed and it is always fully occupied. Induction of more Nursing & Paramedical staff to effectively cope with reliever problem.

2.

3.

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7.

In the light of the findings and recommendations of the enquiry committee, it is evident that some points raised in the survey report are based on facts. These points had also been previously taken up by Railway co-ordinator with IIMCT administration in the Hospital from time to time but these were not timely addressed, it is therefore, recommended that the Managing Trustees of IIMCT be conveyed the findings of the enquiry committee report so that they can take necessary action on their end as regard to Hospital Management and Budget.

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