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2013 Cambridge Business & Economics Conference ISBN : 9780974211428
Possibilities Exploration for Public –Private Partnership (A Study of Social Security Systems Employees)
By
Dr.Muhammad A. Quddus *Dr. Mazhar Ul Haq Baluch**
Khawar Ata***
* Director, Punjab Economic Research Institute, Lahore /Pakistan**Senior Research Fellow, Lahore school of Economics Lahore/Pakistan*** Research Economist, Punjab Economic Research, Lahore/Pakistan
Punjab Economic Research Institute48-Civic Centre, Johar Town, Lahore-Pakistan
Lahore School of Economics, Main Campus Burki Road, Lahore/PakistanJuly 2-3, 2013Cambridge, UK
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2013 Cambridge Business & Economics Conference ISBN : 9780974211428
Possibilities Exploration for Public –Private Partnership(A Study of Social Security System Employees)
Dr.Muhammad A. QuddusDr. Mazhar-Ul-Haq Baluch
Khawar AtaAbstract: The objective of this evaluation exercise was to study the health care facilities provided by these two types of hospitals (one functioning under the control of Government and the other managed by a company under public-private partnership) and to assess their performance and quality of service in terms of patients’ satisfaction. For impact evaluation, two hospitals of PESSI viz Shahdara Hospital, Lahore and Khawaja Farid Social Security Hospital, Multan of 100 beds each were selected. Regarding the hospitals managed by PSSHMC, both the hospitals located at Manga-Riawind Road and Muzaffargarh of 150 beds each were taken in the sample. Total number of patients/beneficiaries interviewed by the PERI’s survey teams for this study was 500 i.e. 125 beneficiaries from each hospital. The necessary information for the study was also collected from the hospitals administration. The Institute’s survey teams interviewed the doctors and paramedical staff/other staff as well in order to know their viewpoint about service delivery and service conditions/job satisfaction. The results of the study provide useful information on functioning of these two categories of hospitals with regard to their organizational structure, staff strength, number of specialists/doctors, paramedical staff/other staff, infrastructural facilities, salaries of doctors/staff, outdoor/indoor patients, lab facilities, facilities available in the operation theaters, income & operational expenditure, patients referred from/to the hospital, patients satisfaction regarding waiting time in the reception area/OPD, availability of doctors/paramedical staff, medical check-up and treatment by the doctors/specialists, behavior of doctors/staff, laboratory tests conducted, operations performed, post operation facilities, and satisfaction of service providers (Doctors, Paramedics and Other Staff) about their salary package, Job security, service conditions & working environment etc. It was observed that PSSHMC hospitals have generally better infrastructure, properly equipped with latest machinery/equipment and laboratory facilities but their performance is not as good as it should have been, when compared to the PESSI hospitals in terms of number of clinical pathology tests performed, number of emergency / outdoor / indoor patients attended, surgical operations conducted, satisfaction of the patients about their medical check up, treatment and behavior of the doctors / other staff, quantity / quality of medicines and satisfaction of the service providers (Doctors, Paramedics and other hospital staff) about their salary package, job security, after retirement benefits, service conditions and working environments etc. It was found that the overall performance of PESSI hospitals was better as compared to PSSHMC hospitals with regard to these indicators.
Introduction
Punjab Social Security Health Management Company (PSSHMC) was established under public
– private partnership, as a non – profit organization, registered under the Companies Ordinance,
1984 and was incorporated on 23rd June, 2004 as a company limited by guarantee having share
capital subscribed by the Government of the Punjab. Authorized Capital was Rs. 150 million
divisible into 15 million ordinary shares. Paid-up capital was Rs. 50 million (Rs. 20 million)
subscribed so far.
The primary purpose of setting up the PSSHMC was the provision of health care through
establishment and management of hospitals and health care facilities. An agreement was signed
between the Punjab Employee’s Social Security Institution (PESSI) and the Pakistan Social
Security Health Management Company (PSSHMC) on 19-7-2004.
According to this agreement, PSSHMC was required to manage and establish hospitals and
provide medical care services in the allocated areas to the secured persons and their dependents
defined in section 2(25) and 2(6) respectively of the Punjab Employees Social Security
Ordinance,1965. The Company was required to provide all kinds of medical care facilities as
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were being provided presently by the institution to the beneficiaries in term of section 38, 38-A,
44 and 45 of the ordinance in the allocated area as mentioned below.
Manga-Riawind Road and from 43 K.M at Lahore- Multan Road up to Iqbal Nagar
including the areas of Phoolnagar, Chunian, Pakpattan and Arifwala.
From Chowk Pir Bahar Shah to G.B Canal i.e., up to 20 KM on Sheikhupura - Faisalabad
Road and from Feroze Wattwoan to 8-K.M up to Warburton.
Muzaffargarh District
According to the aforesaid agreement, the institution is under obligation to transfer to the
company 80 percent of net social security (after deduction of the administrative costs of the
institution) received by it with respect to secured persons of each allocated area. Under the
agreement, the company was required to build, staff, equip and operate three hospitals at:-
Manga – Raiwind Road -------------150 beds
Muzaffargarh ------------------ 150 Beds
Sheikhpura --------------------100 beds.
Hospitals at Manga- Raiwind road and Muzaffargarh were established which started functioning
on July, 4, 2007 and 1st August 2007 respectively. Construction of Sheikhupura hospital could
not be started due to litigation before the Lahore High Court.
The company was managed by the Board of Directors consisting of 26 members, 17 from private
sector, 5 from the government of Punjab and 4 labor representatives. The administrative control
of each hospital was exercised by the Local Hospital Management Committee, Executive and the
Board. The chairman of the Board was from the Private sector. The Chief Executive Officer
(CEO) of the company had control over the affairs of both the hospitals of Mange- Rewind Road
and Muzaffargarh. There was one administrator for each of the hospitals at Manga and
Muzaffargrah.
The total number of industrial units in the area allocated to the PSSHMC Hospital Manga –
Riawind Road was 1295 units. The PSSHMC Hospital Muzaffargrah was located in
Muzaffargrah city and the allocated area for this hospital was the Muzaffargrah district.
According to administration of PSSHMC diet charges, medicines, disposables and all test
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charges were paid by the company. Accounting and financial records were being checked by
Internal Auditors on monthly basis and External Auditors on annual basis.
Overall bed occupancy ratio remained from 60 percent to 80 percent of both the hospitals at
Manga – Riawind Road and Muzaffargrah. This comparative study of assessment of service
delivery of Selected Hospitals of Punjab Employees’ Social Security Institution (PESSI) and
Punjab Social Security Health Management Company (PSSHMC) was conducted on behalf of
the Punjab Social Security Institution. The purpose of this comparative study was to explore
possibilities of practical options for public –private partnership for health service delivery system
to provide better health care facilities to the secured workers and their dependents,
Methodology
Two stage sampling technique was adopted for selecting the representative sample. At the first
stage , a sample of two social security Hospitals of the Punjab Employees Social Security
Institution (PESSI) viz Shahdra Hospital, Lahore & Khawaja Fareed S.S Hospital, Multan were
selected for study. On the other hand, both the hospitals managed by the Punjab Social Security
Health Management Company (PSSHMC), Manga and Muzaffargrah were taken for study
purposes.
At the second stage, a sample of patients of these two types of health providers was selected. For
determining the sample size of patients, the following statistical formula with known population
and guessed variability for maximum sample size was applied:-
n =
= = = 249.63 say ---250
This sample was equally distributed between both the hospitals i.e., 125 from each of Shahdra
and Khawaja Fareed hospital.
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The same formula was applied to determine the sample size for Manga and Muzaffargrah the
Hospitals, controlled by (PSSHMC)
n= = = 249.60-----250
The estimated sample size was also the same250 i.e., 125 from each of the hospitals viz Manga
and Muzaffargrah.
Results of the Study
To derive the factual results of comparison of the facilities available at both the sets analyzing
the strengths and weaknesses of both the systems i.e., PESSI and PSSHMC hospitals on the basis
of infrastructural facilities and capacity of the hospitals such as staff strength, number of
functional departments, laboratory facilities available and number of lab tests performed since
the inception of the hospitals. The other considering fact was of patients, referred by PSSHMC
Hospitals, Muzaffargrah and Manga to Social Security Hospitals (Khawaja Fareed in Multan and
Nawaz Sharif Social Security Hospital, Lahore), in case of non-availability of specialists /
facility for the disease or due to other reasons. All the facts considered essential for presentation
were discussed in this section.
The basic information of both PSSHMC and PESSI hospitals are discussed in Table 1. The data
in above table reflected that there were 36 wards in PESSI hospitals and 50 wards in PSSHMC
hospitals. Other facilities such as number of rooms for doctors in OPD, operation theaters, admin
staff, labs, waiting areas, pharmacy store and other stores were reported to be 36, 6, 16, 21, 8 and
7 in PESSI hospital and 23, 10, 21, 14,16,6 and 9 in PSSHMC hospital. Both the PESSI
hospitals were 100 bedded each and the PSSHMC hospitals were 150 each. The existence and
functional status of different wards / departments in both type of hospitals are presented in
Annex-I.
Staff Strength
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Staff strength refers to sanctioned, filled in and the vacant posts of professional and supporting
staff including workers hired on daily wages in an institution. Since the functioning capacity of
an institution depends upon the availability of the required staff, the staff situation was examined
for both types of the hospitals functioning under PESSI and PSSHMC. The data in the table
reflects that about 96.0 percent of the posts in different cadres were reported filled in the
considered hospitals. Consequently, Professional staff strength environment reflected good
situation in both types of the considered hospitals (PESSI and PSSHMC) hospitals. (Table-2)
Laboratory Facilities
To examine functioning pattern, the availability of different laboratory / diagnostic test facilities
and the number of tests performed during the last three years 2007-08 to 2009-10 were assessed.
The results reflected that plain X-rays were performed more than double (25601) in PESSI
hospital as compared with (12562) in PSSHMC hospitals. Only 146 dye-induced x-rays were
performed in PSSHMC hospitals, while the corresponding figure in PESSI hospitals was 1433.
In-brief PESSI hospitals were far ahead in case of about all the laboratory tests performed during
the considered period (2007-08 to 2009-10). This could be assessed that newly initiated system
was not yet common to be availed medical facilities in the areas (Table-3). Ultimately, this
situation might be due to time concerning of establishment of the institution (PSSHMC), since
the health care provision is generally dealt with by the people having past experience of the staff
and the dealing of the lower staff of the institution, which is again time concerning of the
establishment of the relevant institution.
3.5: Number of Patients Referred
As per agreement, the secured person was needed to be referred to other hospitals under situation
of non availability of the department / specialty, some complication or non-availability of
specialist doctors for that particular disease. To assess the performance, the cases of the social
security hospitals, which were referred to other hospitals were verified in this context. The
information provided for these cases were reflected in the table-4.
The total 4,242 patients of cardiology were referred to other hospitals from PESSI hospitals
during 2007-08 to 2009-2010. Furthermore, 397 patients of cardiac surgery were referred to
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other hospitals due to non-availability of cardiac surgeon in these hospitals. At second number
was Neurosurgery / Neurology department, where the number of patients referred was 1258.
This specialty was not available in PESSI
hospitals so they referred the patients to other hospitals. About 913 patients of urology
department of PESSI hospitals were referred to other hospitals. (Table-4)
However, the Chief Executive of PSSHMC reported that most of the patients referred by
PSSHMC hospitals to other hospitals were from Cardiology department (834 patients), and
Orthopedic department (811 patients). It was strange to observe that these hospitals have their
own departments functional and yet they referred the cases to other hospitals. About 692
patients of Eye department were referred to other hospitals by PSSHMC hospitals despite having
their own department being functional.
Ultimately it was concluded that PESSI hospitals referred those patients to other hospitals for
which they had no facility or specialty for their treatment. However, PSSHMC hospitals referred
patients from almost all departments to other hospitals, even having their own departments
functioning, and this aspect leads towards inefficient performance or intention of improper care
of the patients registered for treatment in PSSHMC hospitals, while PESSI proved relatively
efficient in their performance with respect to reference matters.
Exclusive to the cases referred reflected above the cases of PSSHMC hospitals which were
treated in Nawaz Sharif, Social Security Hospital, Lahore and Khawaja Fareed Social Security
Hospital, Multan have been shown in the table-5.
PSSHMC Hospital Manga referred more than 7 thousand patients (7321 patients) during 2007-08
to 2009-10, while the corresponding figure for PSSHMC Hospital, Muzaffargarh was 3097.
Most of the patients referred were related to Medical (2736 patients), followed by Orthopedic
(1294 patients), General Surgery (876 patients) and Gynae / Obs (815 patients) departments.
The PESSI hospitals treated these referred patients of PSSHMC hospitals without any payment
from PSSHMC. These PSSHMC checked the patients in their hospitals and after giving some
treatment referred them to PESSI hospitals and the Company did not pay even a single penny to
them. Thus PESSI hospitals had to spend a lot of money from their own resources for the
treatment of the patients referred by PSSHMC.
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It was noted that PSSHMC patients have a choice for their treatment. If they want to visit their
registered PSSHMC hospital they may go there, otherwise they can go to PESSI hospital for
their free medical treatment and PESSI hospital will not charge any amount from patients of the
PSSHMC hospital. However, example was not noticed that PESSI patients visited the PSSHMC
hospital for free medical treatment. Table - 6 gives this crucial information regarding those
patients who are registered in PSSHMC hospitals but they have chosen PESSI hospitals for their
medical treatment.
Budget and Expenditure
The performance of the institute mainly depends upon the annual budget allocated for provision
of the necessary matters and materials with exceptional provision of the professional and
supporting staff. Though the employed staff has already been working with the available
resources, yet their performance is basically linked with the yearly sanctioned and provided
funds allocated in the budget, and consequently the staff may pretend of non - availability of the
medicine stuff required for the treatment of some specific patients. The data presented in the
Table-6 elaborates the annual budget of four hospitals under study. It was important to note that
PSSHMC hospitals had no specified sanctioned budget heads (Accumulated Allocation).They
spent the money under different heads during the year according to their needs. On the other
hand, PESSI hospitals were sectioned head-wise budget and they were to spend the amount
considering heads. The data also indicated that total budget of Shahdara Hospital during 2009-10
was Rs. 116,186,447. The expenditure incurred on medicines during the year was 24.2 percent,
while the share of Pay and Allowances was 55.8 percent.
Total annual budget of KFSSH Multan in 2009-10 was Rs. 104,268,392. Total amount spent on
medicines during the year was 15.8 percent, while the budget spent on Pay and Allowances was
62 percent respectively.
Total budget of Manga Hospital managed by PSSHMC for the year 2009-10 was Rs.
113,705,796. The expenditures incurred on medicines during the year were 36.7 percent. The
share of expenditure on Pay and Allowances for the year was 40.8 percent. Total annual
expenditure of PSSHMC hospital, Muzaffargarh was Rs. 85,361,811 for 2009-10. The
expenditure on purchase of medicines during the year was 39.2 percent. However, the July 2-3, 2013Cambridge, UK
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expenditure incurred on Pay and Allowances for the year was 38.1 percent. The situation reflects
that PSSHMC hospitals were spending more on medicines and less on Salary of Staff as
compared to PESSI hospitals. This may be the reason that PSSHMC staff was not satisfied with
their salary package. On the other hand, the patients of PSSHMC hospitals were also not fully
satisfied with the services provided by PSSHMC hospitals.
The situation reflects that PSSHMC hospitals were spending more on medicines and less on
Salary of Staff despite having low allocation as compared to PESSI hospitals. This may be the
reason that PSSHMC staff was not satisfied with their salary package. On the other hand, the
patients of PSSHMC hospitals were also not fully satisfactory.
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Job Experience and Salary Structure
Since the PESSI hospitals were the older, all the staff working in the PESSI hospitals has more
experience except lab technicians than PSSHMC hospitals. In PSSHMC hospitals nurses were
only with 3 years job experience. (Table-7)
The table also reflected the average salary of the staff. The average reported salary of all the
professional staff was relatively higher in PESSI hospitals as compared with PSSHMC hospitals.
This could be justifiable on the basis of relevant job experience, since increase in salary mostly
depends upon the length of service or experience of the staff. The PESSI staff was more
experienced with better salary package and, therefore, they might be expected to perform better
in service delivery.
Along job security and higher salaries, PESSI staff has also pension benefits and medical facility
up to one month basic pay, while in case of PSSHMC hospitals the staff has only medical facility
up to Rs. 1000/- only.
About all of the consultants working in PESSI were satisfied, while 42.9 percent performing job
in PSSHMC were reported dissatisfied with their monthly remuneration. Only a small proportion
(12.5%) of MOs and WMOs working in PESSI expressed dissatisfaction with respect to their
monthly remuneration. All other staff in PESSI reported satisfaction with respect to
remuneration. However the staff working in PSSHMC, except DMO, reported dissatisfaction
regarding monthly salary was 42.9 percent of Consultants, 55.6 percent of MOs/WMOs, 66.7
percent of Laboratory Technicians and 50.0 of nurses. (Table-7)
Work Performance Satisfaction Status
Work performance was assessed by considering daily work load of the doctors through checking
the patients, nursing staff competency satisfaction level, and satisfaction status of the staff with
respect to administration behavioral attitude. In PESSI hospitals about 84.8 percent and 9.1
percent of the doctors reported complete satisfaction and satisfaction to some extent respectively
regarding daily workload of checking of the patients. In PSSHMC hospitals the complete
satisfied level and satisfied to some extent level of doctors were 44.1 percent and 20 6 percent July 2-3, 2013Cambridge, UK
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respectively. However about 35.3 percent of the doctors of PSSHMC reported dissatisfaction
regarding daily work load of checking the patient as against 9.0 percent of the doctors of PESSI
hospitals.
Majority (88.6%) of the doctors of PESSI expressed complete satisfaction about performance /
competency of their nursing staff, while the proportion of the doctor with similar response in
PSSHMC was 48.5 percent. The doctors, satisfied to some extent about performance
/competency of nursing staff, were 11.4 percent and 39.4 percent in PESSI and PSSHMC
hospitals respectively. However the dis-satisfied doctors with respect to performance of the
nursing staff were 12.1 percent in PSSHMC hospitals. In PESSI hospitals all the staff i.e., 97.4
percent and 2.6 percent were complete satisfied and satisfied to some extent with respect to
working performance of the hospital administration. No person reported dissatisfaction in this
regard. In case of PSSHMC hospitals complete satisfied behavior of the administration staff
was reported by 75.7 percent, satisfied to some extent (8.1 percent) and dissatisfied (16.2
percent). (Table-8)
*Ranking of Hospital by Hospital Staff
Hospitals under both systems i.e., PESSI and PSSHMC were ranked by the respective staff
on the basis of working/performance considering ‘Very Good’, ‘Good’, ‘Average’, and ‘Poor’.
The data in table-9 reflected that 73.8 percent of PESSI staff ranked their hospitals as ‘Very
Good, The remaining 26.2 percent of the staff of PESSI ranked their hospitals as ‘Good’. About
44.4 percent and 47.2 percent of the staff belonging to PSSHMC ranked their hospitals as ‘Very
Good,’ and ‘Good’ respectively. However about 6.0 percent and 3.0 percent of PSSHMC staff
ranked their hospitals ‘Average’ and ‘Poor’ respectively. No such ranking ‘Average’ and ‘Poor’
was suggested by PESSI staff. This situation reflected better performance of the hospitals of
PESSI as per ranking of the staff.
Preference of Institutions’ Staff Regarding Public – Private Partnership
PSSHMC has been established under public – private partnership, registered under company
Ordinance, 1984, parallel to Punjab Employees Social Security Institution (PESSI). The principal
objective of both the institutions was the provision of medical care services to the secured
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persons and their dependents. This was a quite new experience specifically in Pakistan, so its
continuation might be made capturing the perceptions / views of the staff as well as considering
comparative performance of allocated work pattern to both the institutions and also the
experienced opinions of the beneficiaries. Ultimately, the views of the staff of both the
institutions (PESSI and PSSHMC) expressed have been presented in the table-10.
A significant proportion of staff (56.8 %) working in PSSHMC hospitals ( A Company setup)
and 97.6 percent of PESSI staff did not prefer the Public –Private Partnership, whereas 5.4
percent of PSSHMC staff preferred the partnership to some extent. When inquired about the
reasons for not preferring PPP setup, 76.2 percent and 65.9 percent staff of PSSHMC and
PESSI hospitals Respectively reported that there was no job security in PPP setup, whereas 33.3
percent and 22.0 percent of PSSHMC and PESSI hospitals’ staff reported no-pension benefits
after job the reason for not preferring the PPP setup. However personal respect factor in Govt.
setup was reported by 4.8 percent and 12.2 percent of the staff of PSSHMC and PESSI hospitals
respectively as the reason not preferring the PP partnership.
All the considered staff of PESSI reported favoring PPP set up due to the solution of the
problems and better atmosphere and working condition, while 57.1 percent and 21.4 percent
favored preference for PPP system because of immediate problem solution and better working
environmental conditions.
From the above indicated environmental situation almost the entire PESSI staff did not prefer the
PPP system, so the staff of PESSI strongly supported the Sole Government setup and they were
quite satisfied and comfortable with the existing Government system.
Views of Beneficiaries
The Sample beneficiaries were distributed on the basis of usage of the hospital facilities such
Outdoor Patients, Emergency Patients and Indoor Patients. The views expressed by all the three
types of beneficiaries are discussed below.
Out Door Patients (OPD)
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A comparative behavior of the staff of both the hospitals with the secured persons regarding their
check up behavior of the doctors and waiting time in OPD has been assessed. An equal number
of patients i.e., 99 percent of both types of hospitals reported that the doctors (specialist,
MO/WMO) were available in their respective room
In PESSI hospitals 98.5 percent and in PSSHMC hospitals 99.5 percent of the beneficiaries
reported that the concerned doctor checked them. About 89.0 percent and 93.0 percent OPD
patients of PESSI were satisfied about their check up and behavior of the doctors respectively,
while the corresponding figures in case of PSSHMC were 59.9 percent and60.8 percent. About
21.3 percent and 21.6 percent of the respondents were not satisfied with their medical checkup
and behavior of the doctor respectively.
The patients, who had to remain waiting for more than half an hour to get themselves checked
up, were 10.5 percent in case of PESSI hospitals and 40.8 percent in case of PSSHMC hospitals
(Table-11). A relative better situation was obvious in PESSI hospitals considering reported
satisfaction level by the beneficiaries regarding check up and doctor’s behavior as compared
with PSSHMC hospitals.
Experience about Availability and Quality of Medicines
Respondents Experience about availability and quality of medicines for outdoor Patients and
indoor patients were considered for making comparison of the dealing of both types of hospitals
to assess for the continuity of the PPP hospitals on the basis of the experience of the patients by
visiting themselves or with their dependents there.
Since the availability of free medicine is a part of services provided to the secured workers by
the hospitals, their views might get appropriate weight to make decision in the context of
continuity of PPP hospitals.
A great majority of beneficiaries i.e., 95.6 percent of PESSI and 92.1 percent of PSSHMC
hospitals shared their experience that they got full quantity of medicines as prescribed by the
doctor. However 3.4 percent and 7.9 percent patients of PESSI and PSSHMC hospitals
respectively indicated negating responses in the context of provision of full quantity of medicine
as prescribed by the doctor, From them75.0 percent of patients of PESSI patients reported that
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hospital staff arranged the medicine where as 25.0 percent from negating response reported
purchase of the medicine by themselves, while from the negating responding patients of
PSSHMC hospitals, 50.0 percent reported purchasing the medicine by themselves (Table-12).
Emergency Patients
Emergency unit is very crucial with respect to attending patients. Consequently this unit provides
chances for patients to attend the other units of the hospital considering the dealings, quality of
services, availability of doctors and medicines in the emergency unit of the hospitals. The
information regarding performance of the emergency unit of both types of the hospitals on the
basis of patients’ responses has been obtained and presented in Table-13.
Since the time is the most critical factor for the emergency patients, time taken to treat the
patients was given top priority. The staff of PESSI hospital emergency units found ahead for
giving treatment within five minutes as it was reported by 85.3 percent beneficiaries, whereas
only 50.0 percent beneficiaries of PSSHMC hospitals were provided treatment in emergency
within 5 minutes. An equal proportion i.e., 25.0 percent of patients of PSSHMC hospitals have to
wait for 6 to 10 minutes and above 10 minutes to have treatment in the emergency. The indicated
situation was better in PESSI hospital relative to PSSHMC hospitals in all the considered
aspects.
All the patients were checked by the doctors in the emergency of PESSI hospitals as compared to
92 percent in case of PSSHMC hospitals. The patients (7.7 percent) not checked by the doctors
in the PSSHMC hospitals’ emergency was due to non-availability of the relevant doctors at that
time. Underlying reason might be less staff deputed in the emergency unit, nature of emergency,
holiday or late night emergency etc.
In-Door Patients
Indoor patients are referred the patients, recently admitted in the hospital for more than one day
due top minor or major operation or for medical treatment/ complication. The responses of the
indoor patients regarding their satisfaction level regarding frequency of visits of the specialists,
MO/ WMO and their availability and behavior of the nurses according to views of the
beneficiaries were obtained.July 2-3, 2013Cambridge, UK
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About equal proportion of beneficiaries i.e. 38.1 and 40 percent stayed in the hospital up to 2
days in PESSI and PSSHMC hospital respectively. The stay of one third (33.7 percent) of the
PESSI hospital patients was more than 6 days as compared to one fourth (25 percent) in case of
PSSHMC hospital beneficiaries. (Table-14)
When the patients were inquired about their satisfaction regarding visits and behaviour of the
specialist, MOs / WMOs and nurses in the ward, the response was quite encouraging. It was
observed that more than 94 percent of PESSI hospital beneficiaries were satisfied with the visits
and behaviour of the Specialist, MOs / WMOs and Nurses during their stay in the hospital. For
PSSHMC hospital, 84 to 90 percent of beneficiaries showed their satisfaction regarding the same
indicators under review. It is thus evident that the PESSI hospitals beneficiaries were more
satisfied as compared to those of the PSSHMC hospitals.
Satisfaction of Indoor Patients regarding Availability and Quality of Medicines
As far as the availability and quality of medicines is concerned, about 99 percent of respondents
of PESSI hospitals got full quantity of medicines while their treatment in the hospitals, whereas
the corresponding figure in case of PSSHMC hospitals was 95 percent (Table - 15). The response
about the quality of medicines was also encouraging. About 98 percent and 95 percent
beneficiaries of PESSI and PSSHMC hospitals respectively were satisfied about the quality of
the medicines.
Views / Satisfaction of Indoor Patients about Facilities regarding Operations Performed
Those beneficiaries who had gone through the services and facilities available in the operation
theater of both hospitals, their views have been obtained to assess performance of both the
hospitals of the system under study. About 31 percent of PESSI hospital beneficiaries reported
that they were operated in the hospitals, whereas the corresponding figure for PSSHMC
beneficiaries was 36 percent. A significant proportion (about 96 percent) of PSSHMC hospital
beneficiaries and about 86 percent of PESSI hospital patients operated in the hospital were
satisfied with the facilities provided in the operation theater. It was noted that not even a single
person was dissatisfied with the facilities available in operation theater of PSSHMC hospitals
but 14 percent patients operated in PESSI hospitals showed their dissatisfaction (Table 16).
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Complaint Cell in the Hospital
Complaint cell reflects indirectly the performance of the hospital or provide guidance for the
management authority to make the working of the hospitals with introduced circumstances,
available resources and utilization of the available resources more effectively and efficiently for
the benefits of the beneficiaries considering their demands. About 78.5 percent of the PESSI
hospitals’ beneficiaries and 23.2 percent of PSSHMC hospitals’ beneficiaries stated that there
was a complaint cell established in the respective hospital. (Table-17).
Only 5.8 percent and 14.1 percent respondents of PESSI and PSSHMC hospitals respectively
informed that they did not know about the Complaint Cell in the hospital. About 73.5 percent of
the beneficiaries of PESSI hospitals reported their Complaint Cell as efficient when compared
with 42.9 percent patients in case of PSSHMC hospitals. About one third of the beneficiaries
(33.9 percent) of PSSHMC hospital opined that their Complaint Cell was not efficient as against
17.9 percent beneficiaries of PESSI hospital. Thus the Complaint Cell to deal with the problems
of patients was present in both types of hospitals but its effectiveness varied a lot as reported by
the beneficiaries of these hospitals. (Table-17)
Ranking of PESSI & PSSHMC Hospitals by the Beneficiaries
The beneficiaries of both types of hospitals were asked to give their opinion for their satisfaction
about the behavior of administration and overall performance of the respective hospitals and then
rank them accordingly. The response of the respondents is given in Table-18.
According to Table 18, a great majority i.e. 90 percent beneficiaries of PESSI hospitals were
satisfied with the behavior of their hospital administration, while 58.7 percent beneficiaries of
PSSHMC hospitals showed their satisfaction in this regard indicating better performance of
PESSI hospitals.
An interesting response came out when the beneficiaries of the both hospitals were asked to
evaluate and rank their hospitals i.e. ‘Excellent’, ‘Good’, ‘Average’ or ‘Poor’. A little less than
half of the respondents (47 percent) of PESSI hospitals ranked their hospitals as “Excellent’ as
compared to only 20 percent respondents in case of PSSHMC hospitals. 43.4 percent
beneficiaries of PESSI hospitals ranked their hospitals as ‘Good’ as against 32.3 percent
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respondents in case of PSSHMC hospitals. It is important to note that 34.3 percent and 13.7
percent beneficiaries of PSSHMC hospitals ranked their hospital as ‘Average’ and ‘Poor’
respectively, while the corresponding figures for PESSI beneficiaries were 8.0 percent and 1.6
percent this reflected that about 50 percent of the beneficiaries of PSSHMC hospitals were not
satisfied with the overall performance of their hospitals.
Conclusion and Recommendations
The conclusions derived from the above described results were briefly discussed as follows;-
It was observed that PSSHMC hospitals have generally better infrastructure, properly
equipped with latest machinery/equipment and laboratory facilities but their performance
was not as good as it should have been, when compared to the PESSI hospitals . Overall
performance of PESSI hospitals was better as compared to PSSHMC hospitals.
The doctors/paramedics and other staff of PESSI hospitals generally were more
qualified, experienced, better paid, have job security, pension benefits and other facilities.
Therefore, they are more satisfied with their jobs and performance. The PSSHMC staff
performed their duties with less pay package, lack of job security and pension benefits,
which obviously affected their performance adversely.
PSSHMC Hospital Manga – Raiwind Road referred 7321 patients to Nawaz Sharif Social
Security Hospital, Lahore during 2007-08 to 2009-10. The number of patients referred by
PSSHMC hospitals, Muzaffargarh to Khawaja Fareed Hospital / Nishter Hospital, Multan
during this period was 3097. One of the reasons for referring the patients to PESSI
hospitals was better treatment in the hospitals of the PESSI. It was interesting to observe
that the PSSHMC hospitals referred a large number of patients to PESSI hospitals even
for those diseases whose departments were functioning in the Company’s hospitals. This
also reflected adverse effects on performance of PSSHMC hospitals.
The PESSI hospitals patients have a choice for their treatment. If they want to visit their
allocated / registered PSSHMC hospital they may go there, otherwise they can go to
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PESSI hospital for their free medical treatment and PESSI hospital does not charge any
amount from PSSHMC hospital. A large number of patients who were registered in the
Company’s hospital Manga-Raiwind Road for treatment have preferred / chosen Nawaz
Sharif Social Security Hospital, Multan Road, Lahore. This reflected the confidence of
the secured workers in PESSI hospitals due to better medical treatment/facilities. It was
reported by the doctors of Nawaz Sharif Hospital that the Manga-Raiwind Road hospital
referred the patients to their hospital at the stage when their condition was very critical
due to improper treatment and mishandling by the doctors of Manga – Raiwind Road
hospital.
The PSSHMC hospitals are 150 bedded hospitals with more infrastructural facilities
when compared with the PESSI 100 bedded hospitals. The number of doctors and other
staff is insufficient in the company hospitals. The result is that the daily workload of
checking / treating the patients is much more as compared to PESSI doctors / professional
staff. For instance, 29 percent PSSHMC doctors have to check more than 70 patients
daily as compared to 6 percent in case of PESSI doctors.
The PSSHMC hospitals at Manga-Riawind Road and Muzaffargarh have been
functioning for the last 3 years. Despite their good office buildings, better cleanliness and
working environments, equipped with latest machinery and above all financial autonomy
(in comparison with the PESSI hospitals), these hospitals could not perform their duties
as efficiently and effectively as they should have been. Rather, their performance was
much lower as compared to the PESSI hospitals.
The significant proportion of PSSHMC hospitals staff (57 percent) did not prefer Public
Private Partnership (PPP) because of job insecurity, lack of pension benefits and other
service conditions. The corresponding figure in case of PESSI hospitals was 98 percent.
About 94 percent, 98 percent, 89 percent and 95.5 percent of outdoor patients of PESSI
hospitals were satisfied with the behavior / guidance provided by the receptionist,
facilities available in waiting area of OPD, checkup by the doctors and quantity / quality
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of medicines provided, respectively. The corresponding figures in case of PSSHMC
hospital were 76, 97, 60 and 92 percent respectively.
Around 95.5, 96.8, 97 and 98 percent in-door patients of PESSI hospitals were satisfied
about the frequency of specialist visits, visits of the doctors, availability / behaviour of
nurses, and quantity / quality of medicines provided, respectively. The corresponding
figures for the PSSHMC hospitals were 84, 89, 89 and 95 percent respectively.
About 44 percent staff of PSSHMC hospitals on the basis of overall working /
performance of the hospitals ranked their hospitals as ‘Good’ as compared to 74 percent
staff of PESSI hospitals. Moreover, 8 percent staff of Company hospitals ranked their
hospitals as ‘Poor’ to Average’ but none of the PESSI staff ranked their hospitals in this
category.
From the findings of the study, it was concluded that the overall performance and service
delivery of PESSI hospitals was better as compared to the PSSHMC hospitals.
6.2 Recommendations
Considering the prevalent circumstances the following options are suggested to be followed for
the better performance to win the favor of the people to make this public –
private partnership venture successful.
The PSSHMC was a company by its present set-up and status. In a company structure,
the salaries of the employees’ of hospitals were assumed generally higher than the
Government hospitals. But the salaries of the doctors / other staff of PSSHMC hospitals
were much lower as compared to the staff of PESSI hospitals. Moreover, there was no
job security, pension benefits and other benefits as in case of Government service. The
result is that the doctors / paramedical staff and other staff of PSSHMC hospitals were
not satisfied with their jobs which affect their efficiency adversely.
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1. The company structure of organizations in our country had not proved effective as also
experienced in case of other companies such as PAMCO, Punjab Transport Company,
Punjab Entertainment Company and Rice / Cotton Companies etc. It would be more
appropriate that the Government should restructure / strengthen the existing government
organizations instead of converting them into company mode and increasing their budget
manifold.
2. The working of our society was generally not company setup-oriented psychologically.
Public sector job was relatively secured having more short-time financial benefits as well
as long time pension benefits. The pay was less in the case of the doctors / other staff of
PSSHMC hospitals, which was merely past service phenomenon. With the result that the
staff was not satisfied with their jobs which is affecting their efficiency and consequently
the patients were dissatisfied with the service delivery of PSSHMC hospitals.
3. The PSSHMC hospitals lacked the trained and experienced doctors / other staff, since the
hospitals were newly established and fresh qualified staff was recruited and appointed
there, they lacked the proper capacity and competency to deal with the complicated cases.
In – brief it was finally concluded, that the structure of the company with the salary of the public
sector institutions without job security, pension benefits and other benefits could not be
justifiable. Thus, the explored option of Public- private partnership would remain beyond
acceptance under the prevalent environment. The following alternatives are, therefore,
proposed:-
a. The Punjab Social Security Health Management Company
(PSSHMC) may be wound up and their staff may be adjusted in the hospitals of
Punjab Employees’ Social Security Institution. The PESSI may, however, be
reformed/ strengthened for the purpose.
b. PSSHMC hospitals at Manga – Raiwind Road and
Muzaffargarh may be
c. converted to the status of autonomous bodies.
d. Salary package of the staff of PSSHMC hospitals may be
increased significantly and their service structure improved so as to attract and
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retain the experienced and qualified staff in the organization and minimize the
turnover of the doctors/professional staff.
Table-1:- Basic Information of Both of PESSI and PSSHMC Hospitals (Nos.)
Items PESSI PSSHMC
Number of Wards 36 50Number of Rooms for:Doctors in OPD 36 23Operation Theaters 6 10Admin Staff 16 21Laboratory 6 14Waiting Areas 21 16 Pharmacy Stores 8 6 Other Stores 7 9Total Hospital Beds 200 300
Table-2:- Staff Strength in Both PESSI and PSSHMC Hospitals(Nos.)
ItemsPESSI PSSHMC
Sanctioned Filled-in Vacant Sanctioned Filled-in VacantChief Executive Officer - - - 1 1 -Medical Superintendent/ Administrator 2 2 - 2 2 -
Deputy Medical Superintendent 2 2 - - - -
Specialist Doctors 43 35 8 29 26 3Medical Officer 85 75 10 39 37 2Paramedical Staff 248 239 9 153 147 6Lab- Technician 3 3 - 13 11 2Supporting Staff 260 259 1 175 171 4Daily Wages Staff - - - 20 20 -Total 643 615 28 412* 395* 17Exclusive to Daily wages Staff
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Table-3:- Availability of Laboratory Facilities Average Number of Tests Performed in both PESSI and PSSHMC Hospitals During 2007-08 to 2009-10.
Lab/ Diagnostic Test
PESSI PSSHMC
2007-08 2008-09 2209-10 2007-08 2008-09 2009-10
Radiology
Plain-X-Rays 7173 8241 10187(25601)* 4261 3550 4751
(12562)*
Dye- Induced X-rays ( IVP BariumMeals) 357 468 608
(1433)* 42 51 53(146)*
Ultrasonograph 6424 7243 8154(21821)* - - -
Memography - - - 838 558 1628(3024)*
Pathology
Clinical Pathology 10436 17262 17836(45534)* 2551 12130 12738
(27419)*
Chemical Pathology 20144 48016 31654(99814)* 7011 26919 35621
(69551)*Histo-pathologyElisa Test:(H. HIV. –etc.) 506 842 905
(2253)* 50 36 68(154)*
P.C.R Tests 118 145 175(438)* - - -
Bone Marrow 20 29 46(95) - - -
Other TestsECG 2107 2195 2292
(6594)* 907 1690 2391(4988)*
Hematology 1665 5618 4276(11559)* - - -
Total 48950 90059 76133(215142)* 15660 44934 57259
(117853)**3 years total of respective rows
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Table-4: Total Patients Referred by the Sample Hospitals to other Hospitals
DepartmentsPESSI PSSHMC
Shahdara Multan Manga Muzaffargarh2007-8 2008-9 2009-10 2007-8 2008-9 2009-10 2007-8 2008-9 2009-10 2007-8 2008-9 2009-10
Medical 15 35 25 - - - 60 111 59 49 115 204Renal Dialysis
10 12 18 - - - - - - - - -
Psychiatry 31 60 50 - - - - 7 16 - - -Oncology 6 7 13 - - - - 5 23 - - -Urology 160 226 269 108 88 62 - 39 113 - - -Orthopedic 35 45 25 - - - 85 223 165 50 108 180Gynae & Obs 20 25 60 - - - 15 129 141 10 50 98ENT 4 10 7 78 58 43 65 23 - - -Dental Surgery
2 7 5 - - - - 12 7 - - -
Eye 25 35 28 - - - 51 154 164 37 116 170Cardiology 446 543 600 1059 958 636 45 209 226 40 115 199Cardiac Surgery
8 10 15 192 164 108 - 11 15 - - -
Neurology 29 55 70 231 208 136 - 16 77 - - -Neurosurgery 60 90 105 113 98 63 - 63 50Child 20 30 40 - - - 23 66 101 18 40 80Surgical 10 15 30 - - - 15 145 122 15 30 35T. B. & Chest 25 15 25 - - - - - - - - -Radiology - - - - - - 182 163 - - -Total 906 1220 1385 1781 1574 1048 294 1437 1465 219 574 966
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Table -5: Total Patients Treated in PESSI Hospitals Referred by PSSHMC
Department
Referred by PSSHMC, Manga to Nawaz Sharif SSH, Lahore (2009-10)
Referred by PSSHMC, Muzaffargarh to KFSSH, Multan
Admission On ChoiceNo
BindingBinding 2007-8 2008-9 2009-10
Eye 38 254 152 55 19 12ENT 32 152 18 - - -Skin 4 165 16 23 12 9Urology 78 291 148 - 165 27 17Surgical 83 293 148 - 189 108 55Medical 164 1166 486 - 547 247 126Dental - 46 8 - 1 2 1Child 47 134 62 - 183 70 47Cardiac 77 493 235 - - - -Gynae 103 231 83 - 218 124 56Orthopedic 98 546 207 - 224 135 84NNN 33 - - - -Oncology 46 45 44 - - - -Nephrology 9 - - - - - -Psychiatry 14 - - - - - -C. Surgery 19 - - 73 - - -Dialysis 312 68 177 - - -ICU 9 - - - - - -TB 19 - 146 37 12 11Psychiatry - 183 66 187 69 25Total 1185 4067 1737 332(7321) 1829 825 443 (3097)*
Indicate Total Nos. of Patients
Table-6:- Budget of the Concerned Hospitals in 2009-10
HospitalTotal Expenditure
(Rs.)
Expenditure on (%)
Medicine Pay & Allowances
Shahdara 116,186,447 24.2 55.8
KFSSH 104,268,392 15.8 62.0
Manga (PSSHMC) 113,705,796 36.7 40.8
Muzaffargarh (PSSHMC)
85,361811 39.2 38.1
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Table-7:- On the Job Experience, Monthly Remuneration and Satisfaction Status of theProfessional staff in the Concerned Hospitals
DesignationJob Experience Average Monthly Salary
(RS/month) Dissatisfaction
PESSI PSSHMC PESSI PSSHMC PESSI PSSHMCConsultants/ Specialists 16.9 14.5 46244 43929 - 42.9
DMS 16.4 16.0 52600 35000 - -MOs /WMOs 10.9 4.2 38175 24978 12.5 55.6Lab Tech. 3.0 15.3 27900 20133 - 66.7Nurses 8.3 2.9 20543 14462 - 50.0
Table-8:- Assessment of Work Performance of the Concerned Hospital
Items PESSI PSSHMC
Complete
Satisfied
Some Extent
SatisfiedNot Satisfied
Complete
Satisfied
Some Extent
SatisfiedNot Satisfied
Work Load of Doctors
84.8 9.1 6.1 44.1 20.6 35.3
Nurses’ Performance Competency
88.6 11.4 - 48.5 39.4 12.1
Hospital Administration Performance
97.4 2.6 - 75.7 8.1 16.2
Table -9: Overall Ranking of the Hospitals by Staff(Percent)
Rank PESSI PSSHMCVery Good 73.8 44.4Good 26.2 47.2Average - 5.6
Poor - 2.8
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Table-10-: Preference of Staff of PSSHMC and PESSI Regarding Public – Private Partnership
(Percent)Description PSSHMC PESSIPreference about Public- Private Partnership
Preferred Public-Private Partnership 37.8 2.4Not Preferred the Partnership 56.8 97.6Preferred the Partnership to Some Extent 5.4 -
If Preferred public – Private Partnership, ReasonsBetter Infrastructure 21.4Problems Can be Solved 57.1 100.0Better atmosphere and Working Condition in PPP Set up 21.4 100.0
If not preferred Public – Private Partnership, Then ReasonsNo Job Security 76.2 65.9 Lack of Pension benefit 33.3 22.0Better Atmosphere and Working Condition in Govt. Set up 23.8 26.8Personal Respect in Govt. setup 4.8 12.2Better Medical Facilities for Patients in Govt. Setup 19.0 36.6
Table -11: Satisfaction Level of Outdoor Patients regarding their Check Up, Behavior of Doctor and Waiting Time in OPD.
(Percent)
Item PESSI PSSHMC
Availability of Specialist / MO/WMO 99.0 99.0Checked by Specialist / MO/WMO 98.5 99.5Satisfaction About Check Up
Satisfied 88.7 59.9Satisfied to some extent 3.4 18.8Dissatisfied 7.9 21.3
Satisfaction Level about Doctor’s Behaviour Satisfied 92.6 60.8Satisfied to some extent 4.5 17.6Dissatisfied 3.0 21.6
Waiting Time (Minutes) Above Half an Hour 10.5 40.8
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Table 12: Respondents Views about Availability of Medicines for Outdoor Patients
(Percent)
Item PESSI PSSHMC
Respondents received full quantity of medicinesYes 95.6 92.1No 3.4 7.9Do not know 1.0 -
If no, who purchased / arranged the medicines for you? Hospital Staff purchased the medicines 75.0 25.0Patient Purchased the medicines 25.0 50.0Others - 25.0
Was the Quality of Medicines according to the Prescription? Yes 95.5 92.5No 3.0 4.5Do not know 1.5 3.0
Table -13: Respondents Response about Medical Treatment and Availability of Medicines in the Emergency Unit
(Percent)Item PESSI PSSHMCTime Taken by Staff for giving treatment to the patients (Minutes)
1 – 5 85.3 50.06 – 10 5.9 25.0Above 10 8.8 25.0
Whether the patient was checked by the Doctor? Yes 100.0 92.3No - 7.7
Did the respondents receive full quantity of medicines?
Yes 100.0 84.6No - 12.8Do not know - 2.6
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Table-14: Respondents Response of Indoor Patients(Percent)
Item PESSI PSSHMCStay in the Hospital (Days)
Up to 2 38.1 40.03 – 4 20.7 15.05 – 6 7.6 20.0More than 6 33.7 25.0
Satisfaction Level about Frequency of Specialist Visits Satisfied 95.6 84.2Satisfied to some extent 1.1 8.8Dissatisfied 3.3 7.0
Satisfaction Level about Behavior of Specialist Satisfied 94.5 87.5Satisfied to some extent 2.2 8.9Dissatisfied 3.3 3.6
Satisfaction Level about Frequency of MOs / WMOs Visits Satisfied 96.8 89.1Satisfied to some extent 1.1 7.3Dissatisfied 2.2 3.6
Satisfaction Level about Behavior of MOs / WMOs. Satisfied 95.7 89.3Satisfied to some extent 2.2 8.9Dissatisfied 2.2 1.8
Satisfaction Level about Availability of Nurses Satisfied 96.8 87.7Satisfied to some extent 2.2 8.8Dissatisfied 1.1 3.5
Satisfaction Level about Behaviour of NursesSatisfied 96.8 90.0Satisfied to some extent 3.2 8.3Dissatisfied - 1.7
Table -15: Respondents Response of Indoor Patients for Quantity and Quality of Medicines July 2-3, 2013Cambridge, UK
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(Percent)Did the Respondents Received Full Quantity of Medicines
Yes 98.9 94.9No 1.1 -Do not know - 5.1
Was the Quality of Medicines according to the PrescriptionYes 97.8 94.9No 2.2 -Do not know - 5.1
Table-16: Respondents Views / Satisfaction about Operations Performed in the Hospitals(Percent)
Item PESSI PSSHMC
Were you /your Family Member Operated in the Hospital?
Yes 31.4 36.2No 68.6 63.8
Satisfaction Level about the Services in the Operation Theater
Satisfied 86.4 95.5Satisfied to some extent - 4.5Dissatisfied 13.6 -
Was the Blood required for Operation?
Yes 48.0 37.5No 52.0 62.5
Were Post- Operation Facilities Provided?
Yes 88.0 66.7No - 9.5Not Applicable 12.0 23.8
Table -17: Respondents Response about Complaint Cell in the Hospital
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Item PESSI PSSHMC
Was there any Complaint Cell? Yes 78.5 23.2No 15.7 62.7
Not Applicable / Don't know 5.8 14.1Was the Complaint Cell Efficient?
Efficient 73.5 42.9To Some Extent Efficient 8.2 23.2Not Efficient 17.9 33.9Don't know 0.5 -
Table-18: Satisfaction about Hospital Administration and Overall Ranking of the Hospital According the Respondents
(Percent)Item PESSI PSSHMCSatisfaction Level about Behavior of Administration
Satisfied 90.0 58.7Satisfied to some extent 7.2 31.2Dissatisfied 2.8 10.1
Overall Ranking of the Hospital Excellent 47.0 19.8Good 43.4 32.3Average 8.0 34.3Poor 1.6 13.7
Annexure-1: Medical Wards / Departments Functioning
(Nos.)Departments PESSI PSSHMCJuly 2-3, 2013Cambridge, UK
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Shahdara Multan Manga MuzaffargarhENT * Eye Gynae & Obs. T. B. & Chest Urology * * *Oncology * * * *Medical Skin *Radiology
Pathology / Blood Bank
Gastroenterologist * * * *Surgical
Orthopedic
Pediatrics/Child
Cardiology * *
Dental Care
Psychiatry * *
Physiotherapy
Anesthesia
ICU
CCU * *
Burn Unit X x
Hypertension/Diabetes x x xHepatitis-C Clinic x x xGastroscopy x x xAsthma Clinic x x xSatellite Clinic (Milk Pak) x x xPsychology x x x
Functional =, Exist but Non-Functional = *, Not Existed = x
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