Tertiary Hospital in Major Cities of Pakistan

8/17/2019 Tertiary Hospital in Major Cities of Pakistan

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DISCLAIMER

The purpose and scope of this Pre Feasibility Study is to introduce the Project and

provide a general idea and information on the said Project including its marketing,

technical, locational and financial aspects. All the information included in this Pre-

Feasibility is based on data/information gathered from various secondary and primary

sources and is based on certain assumptions. Although, due care and diligence has been

taken in compiling this document, the contained information may vary due to any change

in the environment.

The Planning & Development Division, Government of Pakistan, nor National

Management Consultants (Pvt.) Limited who have prepared this Pre-Feasibility assume

any liability for any financial or other loss resulting from this Study.

The prospective user of this document is encouraged to carry out his/her own due

diligence and gather any information he/she considers necessary for making an informed

decision


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TABLE OF CONTENTS

ACRONYMS.....................................................................................................................iii

EXECUTIVE SUMMARY..............................................................................................iv

CHAPTER 1 - INTRODUCTION...................................................................................1

CHAPTER 2 – NEED ASSESSMENT............................................................................2

2.1 INFLUENCING FACTORS.....................................................................................................................2

2.2 EXISTING HEALTH FACILITIES IN PAKISTAN...........................................................................3

2.3 NEED TO SET UP TERTIARY HOSPITAL IN PAKISTAN ..........................................................4

2.4 MAJOR FINDINGS.................................................................................................................................10

2.5 MARKETING IMPERATIVES/ ANALYSIS ....................................................................................11

2.6 CONCLUSION.........................................................................................................................................12

CHAPTER 3 – TECHNICAL EVALUATION............................................................13

3.1 LOCATION...............................................................................................................................................13

3.2 FACILITIES AND PHASING ...............................................................................................................14

3.3 FLOW PATTERN ....................................................................................................................................23

3.4 INFRA STRUCTURE.............................................................................................................................263.5 SUPPORT SERVICES............................................................................................................................27

3.6 CAPITAL ITEMS....................................................................................................................................28

3.7 IMPLEMENTATION PROGRAMME................................................................................................29

CHAPTER 4 – GOVERNANCE AND MANAGEMENT.........................................30

4.1 GOVERNANCE.......................................................................................................................................30

4.2 MANPOWER ............................................................................................................................................32

CHAPTER 5 – FINANCIAL EVALUATION..............................................................33

5.1 CAPITAL COST .....................................................................................................................................33

5.2 OPERATING RESULTS .......................................................................................................................33

5.3 CASH FLOW............................................................................................................................................34

5.4 PAYBACK PERIOD...............................................................................................................................

355.5 IRR ..............................................................................................................................................................35

5.6 ROE.............................................................................................................................................................35

LIST OF FIGURES

FIGURE 1 – OPERATIONAL FLOW IN OPD.......................................................................................................16

FIGURE 2 – PROJECT COMPLETION SCHEDULE ..........................................................................................29

FIGURE 3 – MANAGEMENT STRUCTURE........................................................................................................31

FIGURE 4 –DETAIL OF MANPOWER ..................................................................................................................32

LIST OF TABLES

TABLE 1 – SOCIAL INDICATORS...........................................................................................................................2

TABLE 2 – HEALTH FACILITIES ............................................................................................................................3

TABLE 3 – PROPOSED DISTRIBUTION & BEDS.............................................................................................14

TABLE 4 – PROPOSED PHASING AND FACILITIES ......................................................................................15


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TABLE 5 – PROJECTED CAPITAL COST ............................................................................................................33

TABLE 6 – PROJECTED PROFIT & LOSS ACCOUNT .....................................................................................34

TABLE 7 – PROJECTED CASH FLOWS ...............................................................................................................34

ANNEXURE- 1 PAKISTAN – A PROFILE

ANNEXURE- 2 PROFILES OF MAJOR CITIES


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ACRONYMS

BP Blood Pressure

CCH Creek City Hospitalat DHA, Karachi

CDG City District Government

DHA Defence Housing Authority

ECG Electrocardiogram

ENT Ear Nose and Throat

GoP Government of Pakistan

GP General Practitioner

ICU Intensive Care Unit

IPD In-Patient Dept.IV Intravenous

M.O. Medical Officer

MR Medical Record

NICU Neonatal Intensive Care Unit

NMC National Management Consultants (Pvt.) Ltd.

OPD Out Patient Dept.

OT Operation Theater

P&DD Planning and Development Division, GoP

PICU Pediatric Intensive Care Unit

SPC Special Purpose Company

TH Tertiary Hospital


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EXECUTIVE SUMMARY

Pakistan’s health indicators have shown little improvement over time. Although

the government has increased allocations for the health sector in the last few

years, a lot more needs to be done.

A number of private clinics and hospitals have been established to augment the

public sector. The government is now planning to invite the private sector in a big

way to set up all types of health related facilities including Tertiary Hospitals.

One such facility is presently coming up in DHA Karachi on a private-public

partnership basis. This model can be replicated elsewhere in the country as well.

In order to determine various parameters of such hospitals, the consultants

conducted a selected survey around DHA, Karachi with regard to Area profile,

General Perception, Hospital/ Clinics, Consultants’ views, Prevailing illnesses,

Pathological and Radiology Labs, Prevailing charges etc.. The details of the

survey results are given in Chapter 2 and it is assumed that similar conditions

prevail in other selected localities of Lahore, Faisalabad , Islamabad, Multan and

Quetta.

The major findings of the survey reveal that:

• Population is literate (65% literacy rate). People visit doctors, if needed

• Income levels are higher than other areas

• Environmental conditions are generally good

•

Major illnesses are viral, bacterial, hypertension and seasonal

• Most of the population belongs to middle class and affluent class generally go

abroad for major treatment/ surgeries spending huge amount of foreign

exchange.


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• Existing hospitals/ clinics have adequate facilitates with Labs. However

everywhere, there is long waiting time because of shortage of beds, OTs and

specialists.

It can fairly be assumed that the above findings may be similar to the conditions

in other large cities of the country. In view of these findings it is concluded that

such tertiary hospitals may be set up in all major cities of Pakistan.

Tertiary Hospitals (THs) are proposed to be set up on 20 acres of land in all major

cities of Pakistan e.g. Lahore, Faisalabad, Islamabad, Multan, Peshawar, and

Quetta under the aegis of DHA at Lahore, DHA Islamabad and City District

Governments in other cities.

Beside hospital facilities, TH Complex will have Doctors’ Accommodation,

Serviced Apartments, Health and Wellness centers and medical Super Market.

TH will be ground plus five storeyed building, having 300 plus beds in the first

phase. All the major hospital facilities will be located on the ground floor.

However, provision should be kept to even double the capacity in future

depending on requirement.

The facilities of TH include OPD, Wards, Neuro and Cardiac Surgery,

Rehabilitation Centre, Dentistry, ENT, Ophthalmology, Neurology, Cardiology,

etc. beside support facilities e.g. laundry, kitchen, clinics for specialists solid and

liquid waste management, Administration, stores, staff accommodation etc..

Most of the facilities will be set up in 1st Phase (2 years). The remaining facilities

will be set up in next 3 years. The details have been provided in Chapter 3.


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A detailed flow pattern of patient right from his reception, waiting area,

registration to consulting and examination room has been discussed in Chapter 3

as well.

The Infra-Structure facilities of TH e.g. water, power, telecommunication, gas air

conditioning, sewage disposal have been discussed in Chapter 3. The details of

capital items e.g. generator, medical equipment, office equipment, furniture,

ambulance and other transport etc. have been given in the same Chapter.

The hospital is estimated to be completed in three to five years as per schedule

given.

TH is proposed to be operated by a Special Purpose Company (SPC) jointly

owned by carefully selected private parry/ Group and concerned civic agencies

such as in case of Lahore, DHA; Islamabad, DHA; Faisalabad, FDA or CDGs and

so on. The details are given in Chapter 4.

The sharing of equity between the private party and civic body may be 75% to

25% approximately. The private party will manage the TH preferably in

collaboration with selected foreign specialists to ensure delivery of top quality

service.

TH will be run by the Board of Directors of the Special Purpose Company.

Including the Chairman, and a Chief Executive Officer. The total manpower of

the TH will be 194.

TH will be set up with total capital investment of US$ 40 million.


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The major financial indicators are as under:

S. No. Items 1-yr. 2-yr. 5-yr.

1. Capacity Utilization (%) 45 55 85

2. Projected Revenue US$ million 11.6 14.0 23.03. Operating Expenses

US$ million8.4 9.6 13.0

4. Net Profit US$ million 2.24 5.43 22.00

5. R.o.E after tax% 11 16 31

6. I.R.R % - - 19.3

The project will pay back all its investment in 3.2 years.


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CHAPTER 1

INTRODUCTION

Pakistan’s health indicators have shown little improvement over time. Although

the government has been increasing budgetary allocation for the health sector yet

it is having little effect due to increasing population on one hand and falling

health standards on the other.

The increasing middle income and upper income classes can afford to pay for

health services at market rates. The success of many private sector hospitals all

across the Country are a testimony to this. However, most of the private hospitalsonly provide health care facilities in a few areas, leaving a number of areas either

partially covered or not covered at all. In view of above, Planning Division

Government of Pakistan is endeavoring to bring in private investment for setting

up Tertiary Hospitals in Major Cities of Pakistan.

In the recent past the DHA Karachi has embarked on setting up Creek City Hospital

in partnership with local and foreign investors. The foreign investors from UK

besides investment will also manage the proposed hospital. DHA has contributed its

share of capital for this project in the form of 16 acres of prime land. The

establishment of this hospital will greatly help the residents of DHA, Clifton and

other areas of the City.

Similar type of private-public partnerships may be established and the above model

replicated to establish world class Tertiary Hospitals in Lahore, Faisalabad,

Islamabad, Multan, Peshawar and Quetta.

It is proposed that the Tertiary hospitals proposed for all the cities mentioned above

may initially have 300 beds with provision for doubling them in future depending on

market requirements.


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CHAPTER 2

NEED ASSESSMENT

2.1

INFLUENCING FACTORSSeveral factors influence the establishment of a hospital in a locality. Although it

is true that in a developing country like Pakistan, where the health care

infrastructure is far below the international standard the decision to set up a new

hospital or any number of hospitals in a city, becomes easy and automatic. Still in

order to ensure continued financial support for building, maintenance and

operation of a hospital, certain important parameters are to be determined first.

At the macro level, worsening health condition in Pakistan is reflected in the very

high rate of mortality, child death and low life expectancy in comparison to

regional developing and neighboring countries as given in the table below:

TABLE - 1

SOCIAL INDICATORS

Country LifeExpectancyYear 2002

Infant

MortalityRate per 1000

Year 2002

Mortality

Rate under 5per 1000

Year 2002

Population

Avg. Annual(%) GrowthYear 2002

Pakistan 64 82 105 2.2

India 63 67 93 1.7

Sri Lanka 74 16 19 1.4

Bangladesh 62 52 77 1.7

Nepal 60 60 91 2.2

China 71 30 39 0.8

Bhutan 63 54 92 2.9

Thailand 69 24 28 0.7Philippines 70 29 38 2.2

Malaysia 73 8 8 2.3

Indonesia 67 34 45 1.3Source: World Development Report 2003

The human development indicators for Pakistan particularly health are still low

despite the fact that some progress has been made in recent years. The inter-


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country comparison of health indicators given in Table-1 shows that the national

health status is characterized by high population growth (2.2%), low life

expectancy (64.0/years), high infant mortality rate (82/1000) and child mortality

under 5 years (105/1000). This is due to the shortage of health care personnel,

uneven distribution of health facilities in the country, lack of medicines, regional

disparities in the health care services and scarcity of administration of healthcare

facilities. This calls for further expansion in health facilities all over the country.

2.2 EXISTING HEALTH FACILITIES IN PAKISTAN

Medical facilities in the country have improved significantly over the years.

However, there still remains a very large gap between the availability and

requirements. At present, there are 108,062 registered doctors, 5,530 dentists and

46,331 nurses in the country which comes to a population doctor ratio of 1,404

persons per doctor 27,414 persons per dentist and the availability of one nurse for

3,296 persons. There are about 906 hospitals, 4,554 Dispensaries, 5,290 Basic

Health Units and 552 Rural Health Centres. The availability of hospital beds in all

medical facilities has been estimated at 98,684 which comes to population bed

ratio of 1,536 persons per bed. USA Public Health Services regards a general

average of 200 person per bed as adequate. Thus Pakistan is far behind this ratio.

TABLE - 2

HEALTH FACILITIES

Health Manpower Upto 2001-02 Upto 2002-03 Upto 2003-04Registered doctors 96,248 101,635 108,062

Registered dentists 4,622 5,068 5,530

Registered nurses 40,114 44,520 46,331Population per Doctor 1,516 1,466 1,404

Population per Dentist 31,579 29,405 27,414

Population per Nurse 3639 3,347 3,296 Source: Economic Survey 2003-04


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2.3 NEED TO SET UP TERTIARY HOSPITALS IN PAKISTAN

In view of the appalling conditions of health care in Pakistan, GoP has launched

various health schemes to better the lot of the people. Yet public allocation in

health sector is not even 01% of the GNP. It would, therefore, be desirable tofacilitate private sector to invest in setting up large tertiary Hospitals in almost all

the major cities of Pakistan e.g. Karachi, Lahore, Faisalabad, Islamabad, Multan,

Peshawar, Quetta etc. Profiles of these cities are given in Annexure 2.

In order to determine various parameters of such Hospitals, a selected survey was

conducted around DHA in Karachi, with regard to the following:

• Area Profile

• General perceptions

• Hospitals and Clinics

• Consultants’ view

• Prevailing Illnesses

• Pathalogical and Radiology Labs

•

Prevailing Charges.

It is presumed that the conditions with regard to the above areas would be similar

in all major cities of Pakistan e.g. Lahore, Islamabad, Faisalabad, Multan,

Peshawer and Quetta etc. and findings of this survey will, more o less, be the

same for each of these cities.

2.3.1 AREA PROFILE

EDUCATIONAL LEVEL

According to the recent census, the literacy ratio of the area is 67.5% (male 72%

and female 63%)


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Out of the total educated persons in the area, 23% are at primary level, 23% at

middle level, 30% at matric and intermediate level and 11% at graduates and post

graduate level.

The education profile of the affluent areas of the cities mentioned above will be

similar.

OCCUPATION

The economically active population in the area is 28% of its total population 36%

of the population is aged 10 and above. The children below 10 are 24% while

11% are students and 6% all others.

Among the employed population about 44% are privately employed, followed by

27% self-employed and 17% Government employees.

The mix of occupations may be different in each city.

INCOME LEVELS

Of all the earning groups, about 15% earn upto Rs. 7,000 per month. About 30%

of the residents earn between Rs. 7,000 – Rs. 15,000 per month, 40% between Rs.

15,000 – Rs. 50,000 and 15% more than Rs. 50,000.

There maybe similarities to this in the larger industrialized and effluent cities such

as Lahore, Faisalabad, Islamabad, Multan etc. However, the income maybe lower

in other cities.

GENERAL ENVIRONMENTAL CONDITIONS

People are generally conscious of hygiene and cleanliness in the residential areas.

However, in many commercial areas the conditions are below environmental

standards in terms of land, air and water. Availability of potable water is often

problematic in the area with regard to its source, quality and costs.


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This may be true in all other cities mentioned above.

2.3.2 GENERAL PRACTITIONERS/ CLINICS

From the survey of clinics, it was found that the following diseases are commonly

prevalent in the areas, fees charged, medicines prescribed, investigation advised

etc., were identified as under:

• PREVALENT DISEASES

• SERVICES AVAILABLE AT CLINICS

The services generally available at clinics are following:

–

Stitches, Enema, Dressing, RBS by Glucometer, Stomach Wash, Stomach,BP examination, Cold Sponging, Injection – IV, etc.

• FEES CHARGED

The fees charged ranges from Rs. 100 to 300 for consultation and medication by

GPs.

The cost of other services varies from Rs. 50 to 100

NAME OF DISEASETOTAL NO. OF PATIENTS

SEEN IN A DAYViral Fever

Malaria FeverCommon PainHepatitis (A+B+C)JaundiceVaginal InfectionWormsDiarrheaHypertensionCommon Skin diseasesIndigestionPneumonia

UlcersTuberculosesTyphoidDiabetes

100 – 150

50 - 10050 - 100

Below 50Below 5050 - 100100- 150100 - 15050 -10050 -100

100 - 150Below 50

Below 50Below 50Below 50Below 50


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• MEDICINES PRESCRIBED

GPs generally prescribe common antibiotics, antipyretics, antidiarrhoeals,

bronchodialators, tranquilisers, Skin Ointments, IV fluids, and pain killers for

various diseases. Lab investigations are also advised where required.

• SERVICES NOT AVAILABLE

Services which were not available at the clinics run by the GPs include:

– Oxygen inhalation, Steam inhalation, Nebulization, Circumcision, Blood

Transfusion etc.

The findings of the above survey of GPs/ Clinic will be quite applicable to other

large cities mentioned above.

2.3.3 HOSPITALS

There are few hospitals in the area with good facilities and some top class

consultants/specialists on their panels. Almost all these hospitals have private

wards and general wards The charges range from Rs. 500 – Rs. 1000 for general,

Rs. 1500 – Rs. 2500 for semi private and Rs. 2500- 4000 for private rooms.

The hospitals possess almost all the facilities to treat various diseases and

undertake surgery, if needed. Some of the hospitals possess facilities like ICU,

Casualty, NICU, PICU, Ventilator, Cardiac monitors etc. Angiography and

Angioplasty are also done in some of the hospitals.

The services of specialists consultants are also available in most of the hospitals

whose charges range from Rs.500 – 1000 per patient.

The number of patients visiting the hospitals range 200 (small) – 300 (large) per

hospital.


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Some hospitals provide high quality patient care in broad range of secondary and

tertiary care services, supported by personnel staff and facilities. Care is available

to all patients in need. Consulting clinics in hospitals have following specialties:

MEDICINE

SURGERY

The hospitals have their own diagnostic services both in radiology and pathology.

They also have 24 hours-run pharmacies.

The situation of hospitals may be different in each city depending on the planned

location of the hospital.

2.3.4 DIAGNOSTIC FACILITIES

RADIOLOGY

The major Radiological labs visited

possess adequate radiology facilities e.g. X-

rays, ultrasound, MRI, CT Scanning etc. Some of the tests include:

- Allergy

- Cardiology

- Dermatology

- Diabeties

- Gastroenterology

- Infectious diseases

- Neurology

- Pulmonary

- Obstetrics and Gynecology

- Cardiology

- Dentistry

- ENT

- General Surgery

- Lithotripsy

- Neurosurgery

- Orthopedics

- Pediatric

- Vascular


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- Chest (routine)

- Abdomen

- Cervical spine

- Skull

- Barium meal

- Cerebral angiogram

- Biopsy

- Endoscopies

- Etc

Ultrasound tests include:

- Pregnancy

- Abdomen

- Biopsy (ultrasound guided)

- Etc

Availability of MRI and CT Scan facilities may not be available in some of the

cities mentioned above, which brings out an urgent need to establish them.

CLINICAL LABORATORY

The hospitals have either their own facilities or collection points for various

clinical tests e.g:

- Blood Transfusion (including cross matching)

- Chemistry (all types of blood tests, liquids/fragile, cholesterol, closures at

fasting, triglycerides, pregnancy serum etc.

- Hematology (Hemoglobin, platelets, HIV, malaria, Bone marrow, Rh factor

etc)

- Histopathology (small bios, large bios etc)

- Microbiology (blood culture, urine D/R, stool D/R, fungus culture etc)

- Cardio pulmonary tests (Ambulatory B.P. momentary, ECG, ECO, ETT etc)

2.3.5 PHARMACIES

The more frequently sold medicines are:


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Antipyretics, Analgesics, Antibiotics, Antimalarials, Antihypertensive, Medicines

for ulcers, Psychogenic Drugs, Antidiarrhoeal drugs, Antiheminths,

Antihyperglycemics, Skin Ointments etc.

This is also confirmed by Pakistan Pharmaceutical Manufacturer Association,

Pharma Guide and the IMS for Pakistan.

2.4 MAJOR FINDINGS

Following are the major findings of the survey carried out in respect of existing

general conditions, clinics, hospitals, consultants, pharmacies, diagnostic

facilities, etc. in Karachi’s DHA and Clifton area which would be quite similar to

DHA Lahore, Islamabad, Canal Colony Faisalabad, Multan Cant, Hayatabad and

Cantt Peshawar, etc.

• Generally the population in the areas is literate (65% literacy rate) and aware

of their health care needs. They visit the doctors, if needed.

• The income levels in the area are much higher as compared to other areas of

Karachi.

• The environmental conditions of the area are better than most other localities.

• The major prevailing illnesses are viral and bacterial diseases/fevers,

hypertension, stomach ailments, skin diseases etc.

• The cross-section of the society comprises middle income group, Government

or privately employed (44%), self-employed (27%). The privately employed

population includes labor force (27%). Out of these categories the labor force

for their health care is covered by group insurance and social security, the

others by their employers under various agreed terms and condition of their

employment. The affluent class generally go abroad for major

treatment/surgeries and spend huge amount of foreign exchange.

• Existing hospitals have good facilities both in medicine and surgery. They

possess specialist clinics supported by operation theatres and diagnostics’


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facilities both in radiology and pathology. The consultancy charges vary from

Rs.500 to Rs.1000 per patient.

• The GPs and small clinics, however, charge much less. They do not have

elaborate operation and testing facilities.

• All hospitals are crowded with long queues

• There is long waiting time for admission in the hospitals on account of acute

shortage of:

- Beds

- Operation room facilities

- Specialists doctors / surgeons

2.5 MARKETING IMPERATIVES/ ANALYSIS

• From the above findings of the survey, it can be seen that the existing health

care facilities in the area, although adequate, are not affordable to the

population in general.

• The residents of the area have to go out of their localities for routine medical

and surgical facilities.

• Workers in private sector, who are covered by social security (ss), get their

treatment by the SS hospitals, whose services are below average.

• Self employed, like shopkeepers, traders etc., earning a middle level income

have to pay for their family’s medical treatment from their savings, ending up

spending all their savings.

•

Government employees have to avail whatever meager services are offered bygovernment run hospitals.

• There is long wait for treatment both in medicine, surgery and hospitalization.


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2.6 CONCLUSION

In view of the above findings and marketing analysis, it is imperative to set up

Tertiary Hospitals in each of the above cities to provide the following

conveniences to the patients.

• Reasonable cost for treatment (detailed competitive costs and charges for all

hospital facilities have been discussed in Chapter 4 ahead)

• Reduction in waiting time.

• Nearness to residences, thus eliminating unnecessary travelling.

• Assistance in providing specialist services, to be made available in the

Hospital Complex.

• It is also concluded that such Tertiary Hospitals should be set up in all major

Cities of Pakistan.


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CHAPTER 3

TECHNICAL EVALUATION

3.1 LOCATION

Tertiary Hospital (TH) should be located in all major cities of Pakistan e.g.

Karachi, Lahore, Faisalabad, Islamabad, Multan, Peshawar, and Quetta. The TH

should be built under the aegis of DHA at Lahore and Islamabad City district

Governments in other cities. One such hospital is already under implementation at

DHA (Phase VIII) Karachi under the name of Creek City Hospital (CCH).

THs alongwith its support facilities will form a Complex as under:

• TH

• Doctors Accommodation

• Service Apartments

• Health and Wellness Centre

• Medical Super Market.

The TH Complex may be spread over an area of 20 acres with built up area of the

TH as 30,000 sq. meter consisting of ground floor initially with provision to go

upto 5th floor. All the hospital facilities will be located on ground floor along

with private wards.


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3.2 FACILITIES AND PHASING

TH’s will be a 300 beds hospital with phasing as per the following table:

TABLE - 3PROPOSED DISTRIBUTION & BEDS

Phase – 1 Phase – 2 Phase – 3 Phase – 4Timing

Yr-1 & Yr-2 Yr-3 Yr-4 Yr-5Total

Built up Area ofHospital 18,000 m2 5,000 m2 5,000 m2 2,000 m2 30,000 m2

• BEDS- Adult- Maternity- Pedriatics

- Others

402020

20

70-

20

-

90--

-

---

-

2002040

40Total 100 90 90 20 300

Detailed breakdown of all the TH facilities and their phases is given below in

Table 4.


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TABLE - 4

PROPOSED PHASING AND FACILITIES

FACILITIES

PHASE-1 PHASE-2 PHASE-3 PHASE-4

YR-1 & YR-2 YR-3 YR-4 YR-5

?

OPD- Diagnostic Center- MRI, CT Scan.

- Nuclear MedicineRadiography.

- Pathology Lab.- Endescopy Suite

- Dialysis Suite- Physio Therapy

- Lithotropsy? Opedriatics

? Blood Bank? OT suites & ICUs? Wards (106 Beds)

? High dependency Unit? Admin. Block

?

Mortuary? Laundry? Kitchen/Dining Facility

? Stores? House Keeping Office

? Maintenance Workshop? Power Generation? Waste Management

Facility? Hospital Pharmacy

? Health & WellnessFacilities, Exec. Screening

? Staff Accommodation

? Doctors Accommodation? Serviced Apartments

? Medical Super Market

?

Wards (92 beds)? Out-Patient

Consultancy Rooms &

Facilities? Augmentation of

Support Services? Other Specializations- Cardiology

- Angiography- Angioplasty

- Heart bypass surgery- Dermatology

- Plastic Surgery- Neurology

- Ophthalmology- ENT

-Dentistry

?

Additional Wards (96 beds)? Addition of further

specializations and labs.

?

Wards (30 beds)? Neuro Surgery? Cardiac Surgery

? ICUs (Add.)? Catheterization Lab.

? RehabilitationCentre


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3.2.1

OUT – PATIENT DEPARTMENT

Some major facilities have been described below. The operational flow in OPD is

illustrated as under:

FIGURE - 1OPERATIONAL FLOW IN OPD

The OPD is an integral part of the hospital organization, collaborating with the in-

patient department (IPD) in the diagnosis and treatment of diseases. Therefore, all

the diagnostic and therapeutic facilities of TH will be used in common and similar

will be the situation in case of medical staff. OPD will have separate entrance and

direct communication with I.PD. It needs to be situated on ground floor.

There will be General O.P.D as well as casualty / emergency. Both types of

medical cases can be dealt with in General O.P.D but in TH, the provision for a

separate casualty / emergency department would be considered where severe &

acute emergency cases along with supportive emergency cases would be dealt by

senior R.M.O / Doctor on duty. But initially for a short period of time, the doctor

on duty in O.P.D should be able to deal with all medical cases. The doctor on duty

would be senior and competent enough to diagnose and treat the patients.

Registration OPDMED Records

Reception &Enquiry Waiting

Waitin

C L I N I C S

XRay

Lab

Hospitalin atient

Dispensary

Inj RoomDressin

OtherInvesti ations

AdmissionOffice


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Before coming to the General duty doctor, the patient will be registered. His

particulars, complaint & past history will be briefly noted down at the Reception /

Enquiry / Registration Counter / Front Office. The patient will be given a small

card / ticket mentioning on it the Medical Record (M.R) Number and his /her

necessary particulars as well as a large file or card in a protective cover on which

the doctor on duty would prescribe the treatment and at the same time would feed

the information in computer.

It order to facilitate the work in OPD, the component units will be carefully

planned and logically arranged as under:

• Waiting Room

• Admitting Office

• Appointment Office

• Head of OPD office

• Medical Staff Room

• Supervisor’s Office

• Record Office

• Dressing Rooms

TH will follow the minimum standard organization which has been found

practical by the American College of Surgeons. Briefly it is given under:

• ADMINISTRATION: Medical Services for OPD shall be organized under

supervision and direction of qualified administrative officials of the TH.

• FACILITIES: Adequate and properly arranged facilities and accommodation

shall be provided for patients, medical staff etc., in addition to necessary

equipment.

• PERSONNEL: OPD shall be provided with sufficient para-medicinal staff

and other personnel.

• CONFERENCES: Regular review and conferences will be held to analyze

the clinical work of OPD.


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• RECORDS: Complete records of OPD patients shall be maintained both in

hard and in soft form.

• SERVICES: Clinical laboratories, x-ray and other diagnostic and therapeutic

services of the TH shall be available to OPD patients.

• CLINICS: Adequate number of clinics will be provided in OPD with

sufficient space, equipment and facilities as well as the required personnel

which includes medical, nursing, technical and clinical staff.

Following clinics are recommended to be housed in OPD:

• Medicine (Internal and Family)

• Gynecology

• Surgery

• Ophthalmology

• ENT

• Dermatology

• Cardiology

• Pediatrics

• Dental

• Orthopedics

• Neurology

• Vascular

3.2.2 PATHOLOGICAL LABORATORY

The Pathology laboratory will be located at such a place that it will be easily

accessible to all clinical departments. Preferably also on the ground floor

Laboratory service is extensively used by outpatients and, therefore should also be

easily accessible to the outpatients. Separate entrance for the outpatient and

inpatient areas will be desirable.

The TH laboratory will consist of clinical pathology, microbiology, biochemistry,

hematology, and histopathology etc. sections. To serve these sections, associated

service areas will be required.


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For patients sent to the laboratory, provision for waiting rooms and toilet facilities

have to be catered for. Staff requirements such as common room, changing room

and toilet facilities will also be part of laboratory. Administrative areas will

consist of specimen receiving counters separately for outpatients and inpatients,

result-distribution counters and office space for pathologists.

3.2.3 RADIOLOGY LABORATORY

State-of-the-art radiology lab will be set-up as an important component of the

Diagnostic Center.

Radiology Lab is used by outpatients, inpatients and emergency cases. Therefore,its location has to be taken into consideration ready for accessibility from all

wards, OPD and casualty department.

All radiology Labs have potential radiation hazards. The design of the

radiography room and directional placement of x-ray machines in them have to be

done to reduce scattered radiation to the minimum and should be according to

existing regulations against radiation.

Both MRI and CT scan facilities will be available for the outpatients as well as for

the in patients of the TH

In Radiology Department the facility of ultrasonography will also be provided to

patients for which a separate room along with machine and other necessary

accessories will be established.

3.2.4 NEONATAL INTENSIVE CARE UNIT (N.I.C.U) AND PEDIATRIC

INTENSIVE CARE UNIT (P.I.C.U.)

This department will have incubators for critically ill / premature babies and as

well as phototherapy arrangement and other facilities for new born babies. This

unit will be equipped with oxygen, baby carts, crash carts, infant warmer and


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baby resuscitation trolley for all emergencies. This area can be used as Nursery

for a short period of time just after the delivery of baby or otherwise baby may be

kept with mother.

There will be a P.I.C.U for critically ill children. For this purpose glass partition

can be arranged in the N.I.C.U room as the R.M.O / consultant would see through

the glass and would be able to control both the units.

The facility of air-conditioning will be provided as it is mandatory.

3.2.5 OPERATING THEATRE (OT) & BLOOD BANK

A properly functioning Blood Bank is a pre-requisite for both the operation

theatres as well as Emergency section of OPD. The TH will have a world class

Blood Bank having requisite facilities for blood transfusion, screening, extraction

of different elements from the blood, storage, etc.

OT is the heart of the hospital. It is capital and skill intensive. In order to achieve

maximum utilization, OT will operate on shift basis and under efficient

organization.

OT requires its own sub-organization, consulting and supervisory services,

workrooms, sterilizing room, dressing rooms for surgeons and nurses, scrub

rooms, operating rooms for specialties and general use.

The organization of OT includes the following:

• Administration

• Supervisor

• Coordination

• Nursing

• Preoperative study

• Consultation

• Records

• Tests

• Conferences

• Post – Operative care


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3.2.6 LABOUR ROOM (DELIVERY SUITE)

The most important facility of Labour Rooms (Delivery Suite) provided with all

sort of Labour room facilities i.e. supply of oxygen, good lighting arrangement,

air-conditioning, baby resuscitation trolley, baby corts, instruments, gynae couch

etc.. This important unit will work for 24 hours equipped with senior and

experienced female staff and female doctors.

There would be recovery rooms for mothers after delivery. This area can also be

used as baby nursery for a short period of time.

3.2.7

IN-PATIENTS DEPARTMENT (I.P.D)

The nursing unit, also called the “ward” is a grouping of accommodation for the

patients with services’ facilities which enable a team of nurses to care for

inpatients under the best possible conditions. Also included under one roof are

patient beds, the nursing station, the service area, storage area, work area and

sanitary area.

Total Number of Beds. 100 will be located at first floor and ground floor. The

remaining 200 beds will be setup on the 2nd and 3rd floors, if needed.

The ward will have the following support facilities:

• NURSING STATIONS

The nurses’ station is the nerve centre of the ward unit. Its position will be such

that the nurse can keep watch on as many patients as possible so it could be

achieved by the provision of transparent glass to see through it. Paging system

and intercommunication system panel will also be installed at a convenient spot in

the nurse’s station.


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• DOCTOR’S DUTY ROOMS

Separate rooms for use of resident doctors i.e.. Male and Female are required in a

ward unit. It can also serve as a clinical conference room. It will have an

examination couch, desk, chairs and a wash basin.

• SANITARY FACILITIES

Toilet and bathrooms need to be provided in single bed (Private Room) and two-

bed rooms (Semi Private) as well as in wards.

• WASH BASINS

The nature of work in hospitals demands a high standard of hand cleanliness.

Therefore, easily accessible wash basins have to be provided at appropriate

places.

• DIRTY UTILITY ROOM AND SAFAI WORKER’S CLOSET

The room required for emptying and cleaning of bedpans, urinals, and sputum

mugs and for temporary storage of stool and urine specimens is termed the dirty

utility room. It will be fitted with a slop – sink or bedpan washer for emptying and

cleaning of bedpans and fly proof cupboards for storage of stool / urine

specimens.

• TREATMENT AND DRESSING ROOMS

These are the rooms where dressings, minor treatment including special

examinations, lumber puncture, intravenous injections administrations or other

treatment and procedures which cannot be carried out in the patients’ beds are

performed.

• WARD PANTRY

Although the main meals will come from the central kitchen, it is desirable to

have facilities for reception, warming and distribution of meals on a ward basis.


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• CLEAN UTILITY ROOMS

A room is required for storage and preparation of materials, equipment and

supplies such as infusion fluids and sets, sterile packs from CSSD, dressing drums

and for setting up of treatment trolleys and trays.

3.2.8 ADMINISTRATION AND FINANCE AND ACCOUNTS

DEPARTMENTS

In addition to the above medical facilities, organization will also have

Administration and Finance and Accounts Departments to look after the activities

related to these departments.

3.3 FLOW PATTERN

On outpatient visits, patient flow usually progresses from enquiry and registration

to waiting, then to examination rooms, and thereafter to investigation facilities,

and lastly the pharmacy.

The area required for the outpatient department should be adequate to

accommodate the reception and waiting hall, waiting rooms, registration and

outpatient medical records, clinics, toilet facilities, and the injection and dressing

room, pharmacy, minor OT and circulation routes, scales of space for outpatient

department can hardly be standasized in view of the varied requirements and

range of services provided. For planning premises, half, square foot for each

expected annual outpatient visits is considered to provide adequate space in case

of most general hospitals.

3.3.1

RECEPTION AND ENQUIRY (FRONT OFFICE)

The Front Office will be used as reception and enquiries which is necessary at the

entrance lobby from where patients seek information, procedures and so on. This

has to be located at a prominent place at the entrance of the department and also

in close proximity to the emergency and casualty department. The entrance lobby

should connect with public facilities and with a tea and snack bar.


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The reception and enquiry will be prominently signposted and will have good

communication through telephone and intercom sets with all clinics and other

departments.

A well illustrated, easily understandable guide map showing locations of all

clinics and adjunct services units will be prominently displayed in this location.

Moreover, all payments will be made on reception counter (Front Office) of

endorsing printed receipts for patients particulars. The receptionist will receive

the fees.

The patient now would be directed the contact to Registration counter / Medical

Record room to show the receipt and to get the ticket bearing M.R No. and a

prescription card / file to show these two things to the doctor on duty sitting in

general O.P.D / casualty.

3.3.2 WAITING AREA

There will be a main entrance hall where people first arrive and get registered. On

entering, the patient should find himself or herself in the entrance hall faced by

the reception and enquiry counter.

Adequate number of toilet facilities will be provided separately for males and

females.

3.3.3 WHEELCHAIR AND TROLLEY BAY

For patients who cannot walk, stretcher – trolleys or wheelchairs will be required

to carry them through the department. A place to park them should be provided at

the very entrance to the Out Patient Department. Adjoining to the reception and

enquiry room (Front Office) would be good location. The issue and replenishment

of trolleys and wheelchairs should be catered for.


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3.3.4

REGISTRATION COUNTERS AND MEDICAL RECORD ROOM

The registration counter and outpatient medical record room should be

conveniently located, preferably close to the reception enquiry.

All patients have to be register themselves at the outpatient registration counter.

Each new patient will have to be given a registration number in the form of a

ticket, and an outpatient card will be made for him / her which will be sent to

doctor on duty sitting in the General O.P.D / Casualty / Emergency. The doctor

will examine the patient and prescribe the treatment on the treatment card feeding

the same in the computer simultaneously. If the patient could not be diagnosed by

the doctor on duty than he would seek the expert advice from the pertinent

consultant through internet / help desk even showing the condition / vitals /

history of patient.

On subsequent visits, the patient will show his M.R No & pay the fee / charges at

front office / reception, will get printed receipt by receptionist bearing the M.R.

No and when the patient presents his / her ticket at registration counter, his or her

folder will be taken out from the record room and it would be handed over to the

patient and the patient will be sent to the doctor on duty / or to the concerned

consultant to whom the patient would have been visiting. The doctor / consultant

will retain patient’s card / folder and will feed in the computer about patient’s

condition / history and treatment to be given. He will write down on card / folder

as well as give the printed paper / prescription by dot matrix printer. The folder

will be deposited back in the medical records room by the clinic staff at the end of

the day and are restored to their appropriate place by the medical records clerk. It

will be the prime duty of medical record room staff to check all daylong cases

whether these are already fed in the computer or otherwise.

A centralized registration and record system, wherein all outpatient visits are

registered and record kept at one place has advantages of conserving manpower

and space, as opposed to the decentralized registration and record system.


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3.3.5

CONSULTING AND EXAMINATION ROOMS

The essential point for consulting and examination rooms is that privacy of

consultation should be assured and the flow of patients should be smooth. This

aspect has been discussed in OPD Sector.

3.4 INFRA STRUCTURE

To establish and to operate in a smooth and proper manner following public

utilities of will be required which are mentioned here:

3.4.1 WATER

For planning purpose, the overall requirement of water in TH is estimated at about

300 to 400 liters per bed per day. Storage capacity for five days requirement must

be built at the site.

3.4.2 SEWAGE DISPOSAL

Liquid and semisolid effluent in the hospital originate from all departments and

service areas. Solid waste from hospitals is approximately 1 kg per bed per day.

Liquid effluents will be about the same as the hospitals requirement of water i.e.

between 300 to 400 liters per bed per day.

Adequate arrangements will have to be made to handle and dispose-off hazardous

solid waste and effluents.

3.4.3 POWER

Requirement of electric power is approximately 1.5 kw on a per bed per day basis

(total 150 kw). This includes the needs of all departments and services including

power requirement of X-Ray department, operation theatres, laboratories, central

sterile supply department, laundry, and kitchen. The stand by generator would

however, be of higher specification to cater to the increased requirement and

future expansion of the facility.


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3.4.4

GAS

The facility of gas is essential for various purposes i.e., hospital kitchen, cafeteria,

pantry, labs, for sterilizations, laundry etc. and preferably for generation of

electricity as well.

3.4.5 TELEPHONE / INTERCOM

TH will need to have adequate phone and Intercom system.

3.4.6 AIR – CONDITIONING

There are some areas in TH where facility of air-conditioning is a must e.g. OT,

labour room, recovery rooms, Neo-Natal Intensive Care Units, P.I.C.U. Private

Rooms, Semi Private Rooms, General Wards, Reception Area, Emergency, OPD,

Offices etc. may also need to be air-conditioned.

3.4.7

PA SYSTEM & BELL SYSTEM

The TH will need to be equipped with a PA and bell systems for the rapid

communications in settled and emergency states. All rooms, floors and

departments will be connected for this purpose.

3.5 SUPPORT SERVICES

In TH, following will be needed as support services:

• Hospital Stores

• Hospital Pharmacy

• Hospital Kitchen

• Security Systems

• Gift Shop

• Hospital Works / Maintenance Department

• Laundry

• Cafeteria

• Ambulance Service


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• Seminar Room / CONFERENCE Room

• Landscaping / Parking

3.6

CAPITAL ITEMSThe capital items of TH include medical equipment for OT, Sterilisation, Ward,

Labour rooms, L.C.U, Radiology Lab, Emergency, Hospital Linen, Nursery

(ICU+PICU), Pathological Lab, Oxygen Supply etc. besides office equipment,

Computers, Vehicles, Ambulances, Electrical and Mechanical equipment,

Furniture and Fixtures, etc.


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3.7 IMPLEMENTATION PROGRAMME

The implementation of the Project will commence with the selection of private party by the 2nd quarter of 1st year. Simultaneously, design and

preparation of contracts and their processing will also be undertaken. This activity will be followed by construction and procurement.

Before the hospital is operational, some key personnel e.g. Administrator, nursing supervisor, accountant, housekeepers, engineers, etc. will

already have been employed to assist the hospital in running order. Gradually, under the guidance and direction of the Administrator and

supported by Board of Directors , the organization of medical and other staff will be completed and soon the Hospital is prepared to function.

After the selection of personnel and also during their time of employment, comprehensive training programme for them will be organized

which may include: general orientation; on-the-job-training; follow-up training; re-training etc. In the meantime, various hospital

standardization Manuals for patients satisfaction, Accounts, Marketing, Operations etc. will also be prepared.

TH is expected to be completed and inaugurated in 2 year as per schedule illustrated below:

FIGURE - 2

PROJECT COMPLETION SCHEDULE

YEARS

1 2S.

NO.ACTIVITIES

Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4

1. Selection of Private Party

2. Design / Arrangement ofContract

3. Construction (civil, elect,furnish)

4. Procurement / furnishing

5. Manpower Deployment

6. Training and Preparation ofManuals


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CHAPTER 4

GOVERNANCE AND MANAGEMENT STRUCTURE

4.1

GOVERNANCE

The THs are proposed to be owned and operated by special purpose companies

jointly owned by a carefully selected private party/ group and the concerned civic

agencies such as in the case of Lahore, DHA; Islamabad, DHA; Faisalabad FDA,

Islamabad CDA; Multan, MDA; Peshawar PDA; Quetta, QDA, etc.

Each civic agency will provide land for the specific purpose of building TH in the

city which will form its equity share in the special purpose company.

The sharing of equity between the private party and the civic body maybe 75% to

25% or thereabouts. Both the parties will be represented on the Board of Directors

of the special purpose company in the ratio of their shareholding.

The private sector party will manage the TH preferably in collaboration with

selected foreign specialists to ensure delivery of top quality service.

TH will be governed and run by the Board of Directors of the SPC and 3

Directors as shown below:

• Chairman, Board of Directors

• Chief Executive Offices

•

Administrator• Director Finance and I.T.

• Director Support Services.

The organization is illustrated in fig. 3


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• Chairman

• Board Members

Chief ExecutiveOfficer

Public

Relations

Internal Audit

Legal

Medical Director(Administrator)

Director ofNursing & Quality

Assurance

Director ofFinance & IT

Director Of supportServices

MAC

Medical Staff

All SpecialtiesRadiology/

RadiotherapyPathology

Physiotherapy

Dietetics

Pharmacy

Education

OPD & Staff

ClinicOperatingTheatres

A&E / ICU

O&G

Pediatrics

Finance

MedicalRecords

Information

Technology

Marketing

Procurement

Human

Recourses

General

Services

Maintenance

& Facilities

Quality

Assurance

TH Board

Library

FIGURE - 3

MANAGEMENT STRUCTURE


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The total manpower strength under the TH’s Administrator will be 194 as shown in fig. 4

3 Shifts 3 Shifts 3 Shifts 3 Shifts 1 Shift 2 Shifts 2 Shifts 2 Shifts 2 Shifts 3 Shifts 3 Shifts 3 Shifts 1 Shift 1 Shift 3 Shifts

SR.# DESIGNATIONPRIVATE

ROOM(40 BEDS)

SEMI PRIVATEROOM (20 x

2 BEDS)

GENERALWARD

(5 x 4 BEDS)

CASUALTY /EMERGENCY

OPDCLINIC

ULTRASOUND

R AD IO LO GY P AT HO LO GYOPERATION

THEATORICU NICU

LABOURROOM

PHYSIO-THARAPY

ADMINHOSP.

MEDICALSTORE

PHARMACYHOUSE

KEEPING &SECURITY

KITCHENCAFÉ-TERIA

LAUNDRY

1 R. M. O. 3 3 3 3 2 14

2 Junior Doctor 3 3 3 3 3 3 18

3 Nurses 12 9 6 6 2 6 6 3 50

4 Unit Clerks 3 3 3 1 10

5 Ward Boys 3 3 3 3 3 3 18

6 Specialist 2 2 2 1 3 10

7 Asstt. 2 2 2 2 1 3 12

8 Dr. Anesthesia (Part Time) 0

9 Sr. Administrator 1 1

10 Asstt. Administrator 1 1

11 Chief Accountant 1 1

12 Accounts Officer 1 1

13 Accounts Asstt. 2 2

14 Cashier 3 3

15 Billing Staff 3 3

16 Recetionist 6 6

17 Drivers 8 8

18 HR Executive 1 1

19 HR Asstt. 3 3

20 Record Maintenance Staff 6 6

21 House Keeping Staff 12 12

22 Peons 4 4

23 Gardener 1 1

24 Repair & Maintenance Staff 6 6

25 Telephone Operator 3 3

24 21 18 15 1 4 4 4 6 12 12 3 2 62 6 194 TOTAL

---------- CONTRACT BASIS ----------

C ONT RA C T

BA S I S

TOTALSTAFF

FIGURE - 4

DETAIL OF MANPOWER

4.2 MANPOWER


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CHAPTER 5

FINANCIAL EVALUATION

5.1

CAPITAL COST

Total capital required for each TH would be US$ 40 Million in debt-equity ratio

of 50 : 50

TABLE – 5

PROJECT CAPITAL COST

US $Description Amount

Land & Land Development 5,000,000Hospital Building & Construction 12,313,154

Staff Accommodation, Medical Super Market 1,500,000

Health & Wellness Center 1,000,000

Equipment (Including Furnishings) 15,205,948

Professional Fees 1,552,282

Contingency 3,428,616

Total Capital Cost 40,000,000Financing Arrangements % Amount

Equity 50% 20,000,000

Debt 50% 20,000,000

5.2 OPERATING RESULTS

The operating results of the Project can be seen from the summarized Profit and

Loss Account for the next 5 years as given in the table below:


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TABLE – 6

PROJECTED PROFIT & LOSS ACCOUNT US $

Description YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5

Turnover 11,579,270 14,364,728 18,552,564 21,511,711 23,184,272

Less: Direct Costs 5,816,020 6,709,629 8,036,216 8,983,451 9,533,460

Less: Overhead Cost 2,609,935 2,853,259 3,206,214 3,463,117 3,619,440

Operating Profit 3,153,315 4,801,840 7,310,134 9,065,143 10,031,372

Less Depreciation 1,625,000 1,625,000 1,625,000 1,625,000 1,625,000

Profit before Interest 1,528,315 3,176,840 5,685,134 7,440,143 8,406,372

Less: Financial Charges 1,925,000 1,725,000 1,525,000 1,325,000 1,125,000

Net Profit Before Tax 3,453,315 4,901,840 7,210,134 8,765,143 9,531,372

Tax @ 35% 1,208,660 1,715,644 2,523,547 3,067,800 3,335,980

Net Profit After Tax 2,244,655 3,186,196 4,686,587 5,697,343 6,195,392

Accumulated Profit 2,244,655 5,430,851 10,117,438 15,814,781 22,010,173

5.3 CASH FLOW

The Projected Cash Flow for 5 years is given in the table below:

TABLE – 7

PROJECTED CASH FLOWSUS $

Description YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5

Operating Profit 3,153,315 4,801,840 7,310,134 9,065,143 10,031,372

Less Cash outflows

Interest Payment 1,925,000 1,725,000 1,525,000 1,325,000 1,125,000

Repayment of Loan 2,000,000 2,000,000 2,000,000 2,000,000 2,000,000

Income Tax 0 1,208,660 1,715,644 2,523,547 3,067,800

Total Cash Outflow 3,925,000 4,933,660 5,240,644 5,848,547 6,192,800

Net cash (771,685) (131,820) 2,069,490 3,216,596 3,838,572

Cumulative Cash Flow (771,685) (903,505) 1,165,985 4,382,581 8,221,153


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5.4 PAYBACK PERIOD

The payback period of the Project is 3 years and 2 months

5.5 IRR

The IRR of the Project is 19.3% which shows good health of the Project.

5.6 RoE

The average RoE of the Project is 22%


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i

ANNEXURE 1

PAKISTAN - A PROFILE

INTRODUCTION

Pakistan is located in South Asia. It borders Iran to the southwest, Afghanistan to the

northwest, China to the northeast and India to the east. The Arabian Sea marks Pakistan’s

southern boundary.


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The total area of Pakistan is 796,095 square kilometers and the country is divided

administratively into four provinces – Balochistan, North-West Frontier Province, Punjab

and Sindh – and numerous federally administrated areas. The disputed territory of Azad

Jammu & Kashmir lies to the north of Punjab.


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Pakistan has a diverse array of landscapes spread among nine major ecological zones

from north to south. It is home to some of the world’s highest peaks including K-2 which

at 8,611 meters above sea level is the world’s second highest peak. Intermountain valleys

make up much of the North-West Frontier Province, while the province of Balochistan in

the west is covered mostly by rugged plateaus. In the east, irrigated plains along the Indus

River cover much of Punjab and Sindh. In addition, both Punjab and Sindh have deserts,

Thal, Cholistan and Thar deserts respectively.

Most of Pakistan has a generally dry climate and receives less than 250 mm of rain per

year. The average annual temperature is around 27oC, but temperatures vary with

elevation from -30oC to -10oC during cold months in the mountainous and northern areas

of Pakistan to 50oC in the warmest months in parts of Punjab, Sindh and the Balochistan

Plateau. Mid-November to February is dry and cool; March and April bring sunny spring,

May to July is hot, with 25 to 50% relative humidity; Monsoons start in July and continue

till September; October- November is the dry and colourful autumn season.

Pakistan had an estimated population in 2005 of 160 million, 40% of this population was

less than 15 years of age. The major cities of Pakistan and their estimated populations

are; Karachi (16.0 million), Lahore (8.0 million), Faisalabad (6.0 million), Rawalpindi

(5.0 million), Multan (4.5 million), Hyderabad (3.0 million), Gujranwalla (1.8 million)

Peshawar (1.6) and Quetta (0.85). Islamabad, the Capital of the country, has a population

of around 750,000.

According to the 1973 Constitution, Pakistan is governed under a federal parliamentary

system with the President as head of state and a Prime Minister as head of government.

The legislature, or parliament, consists of the Lower House (National Assembly) and the

Upper House or Senate. Members of the National Assembly are directly elected for five-

year terms.

Executive power lies with the President and the Prime Minister. The Prime Minister is an

elected member of the National Assembly and is the leader of the majority party in the


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National Assembly. An electoral college consisting of members of the national and

provincial legislatures elects the president for a five-year term.

After the events of 9/11, Pakistan has become a key US ally in the war against terror.

This alignment is totally in-line with the views of the majority of Pakistanis who practice

and preach a moderate version of Islam. The Government of Pakistan fully realizes the

need for promoting Islam as a modern progressive religion. The Government has chosen

the difficult option of fighting the war against terror by clamping down on Taliban and

Al-Qaeda remnants along the border with Afghanistan. The people of Pakistan fully

support the Government in its efforts to promote the true face of Islam.

The US Government fully backs and supports Pakistan in this war against terror. US Aid

which was stopped after the 1998 Nuclear Test has been restored and Pakistan will

receive US$ 3.0 billion over the next 5 years, divided equally between economic and

military aid.

Pakistan follows a very active policy of regional alliances for trade and economic

development. It is an active member of the South Asian Association for Regional

Cooperation (SAARC) which groups Pakistan, India, Bangladesh, Sri Lanka, Nepal,

Bhutan and the Maldives. It is also an active member of the Economic Cooperation

Organization (ECO) comprising of Turkey, Iran, Pakistan, Afghanistan, and the six

Central Asian Republics. Pakistan has an observer status at the Gulf Cooperation Council

(GCC) as well as ASEAN and Shanghai Cooperation Organization. Being a member of

WTO it conforms to most of the international trade regimes.

ECONOMY

Pakistan’s economy has made significant progress in the last six years. This has been

possible because of the Government’s policy of initiating growth through domestic and

foreign direct investment. The GDP growth rate has increased from 1.8% per annum in

2001 to 8.4% per annum in 2005. Despite the devastating earthquake in October 2005,

the economy is expected to grow at over 6.6% in 2006. Pakistan’s GDP in 2005 was


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estimated at US$ 385.2 billion and its per capita GDP was US$ 2,400. The Country’s

credit rating has been upgraded by Moody’s from Caa1 in 2002 to Ba3 i.e. “stable” in

2006.

Pakistan has over 3.5 million laborers working in various countries of the Middle East. In

addition, Pakistani technical and professional manpower is engaged in lucrative pursuits

in USA, UK, Canada, Malaysia, etc. These non-resident Pakistanis annually send over

US$ 4.0 billion in foreign remittances.

The Government of Pakistan’s policy of encouraging Foreign Direct Investment (FDI)

has seen it grow from a mere US$ 376.0 million in 1999 to more than US$ 1.5 billion in

2005 which is expected to grow to over US$ 3.0 billion in 2006.

In addition to Foreign Direct Investment, low domestic interest rates have meant that

there has been an upsurge in domestic investment; the weighted average rate of lending

has fallen from 16% in 1999 to approximately 8% in 2005.

The Government’s economic policy has seen foreign currency deposits rise from US$ 1.7

Billion in 1999 to now US$ 13.0 billion in 2006; this has led to both low rates of inflation

and to a stable exchange rate.

With the Government of Pakistan targeting annual growth in the economy at 7.5% per

annum in the next 5 years, Pakistan is the country of choice for foreign and domestic

investors.

INFRASTRUCTURE

The National Highway Authority (NHA) has the responsibility for 17 of Pakistan’s major

inter provincial links called the National Highway including the Motorways, which are

access controlled and tolled highways. Total length of roads, under NHA, currently

stands at 8845 Kms.


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These roads account for only 3.5% of Pakistan’s entire road network but cater for 80% of

the commercial road traffic in the country. Improvement and extension of the existing

network is, therefore, essential to develop remote areas and provide better connection

between the economic centers of Pakistan. In addition a first class road network is

essential if Pakistan is going to connect its all-weather Arabian Seaports with the

landlocked Central Asian Republics and Western China. The Government has initiated

work on the North-South Trade Corridor with planned investment of over US$ 60 billion.

In order to further speed up the development of the road network, the Government is

actively seeking the participation of the private sector to implement road projects on a

Build-Operate-Transfer (BOT) basis. A number of projects are currently being

implemented under the BOT concept and others are in the identification stage. These

BOT projects cover the construction of new roads as well as the upgrading of existing

roads.

Pakistan has about 1062 km of coastline on the Arabian Sea running from the Indian

border to the Persian Gulf. The Karachi Port is the premier port of Pakistan and is

managed by the Karachi Port Trust (KPT). Karachi port handles about 75% of the entire

national cargo. It is a deep natural port with a 11 km long approach channel to provide

safe navigation up to 75,000 DWT tankers, modern container vessels, bulk carriers and

general cargo ships. The Karachi Port has 30 dry cargo berths including two Container

Terminals and 3 liquid cargo-handling berths. KPT intends to cater for 12-meter draught

ships, which are the most widely used container vessels. In order to facilitate

accommodate and fast turnaround time of mother vessels, the KPT is offering to the

private sector the opportunity to develop a terminal on BOT basis. In addition KPT has

plans to develop a Cargo Village on 100 acres. This Cargo Village shall serve as a

satellite to the port, integrating container, bulk and general cargo handling as well as

providing processing plants for perishable exports. With direct connection to the National

Highway Network, as well as National Railways Network the cargo village shall also

alleviate the problem of upcountry trade with cost effective storage/handling services in

the vicinity of the port. A master plan is under preparation and all the units within the


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village shall be allocated to the private sector on BOT and Build-Operate-Own (BOO)

basis within the next year.

Pakistan’s second Sea Port, Port Qasim is located 50 kilometers to the South East of

Karachi. It is the Country’s first industrial and multi-purpose deep-sea-port. Currently it

is handling 23% of Pakistan’s sea trade. Port Qasim has attractions and advantages for

investment both in port facilities and port-based industrial development. Port Qasim

Authority from the very beginning has actively sought the help of the private sector in the

development of its port structure. Some of the projects which have been completed with

private sector involvement include; dedicated oil terminal developed in private sector on

BOO basis at a cost of US$ 87 million to cater for oil imports with a handling capacity of

9 million tons per annum, a container terminal developed by P&G Group, Australia, at a

cost of US$ 35 million on BOO basis, for chemicals imports a facility in collaboration

with Vopak of Netherlands on BOT basis at a cost of US$ 67 million. Some of the

projects which the Port plans to develop with the private sector on the basis of BOT

include; establishment of a second oil jetty, establishment of a dedicated coal and

clinker/cement terminal and the establishment of a marine workshop and dry dock

facilities.

To encourage industrial development the Port Qasim Authority has reserved 300 acres of

land on a prime location in the Eastern Industrial Zone (EIZ) for allotment of plots to

Overseas Pakistanis to induce and encourage foreign investment and provide them an

opportunity to establish small size industries in Pakistan. Each plot is measuring 100

square yards at a very low cost on attractive terms and conditions. This is in addition to

existing 1,200 acres of industrial zone which houses a number of auto assemblers such as

Toyota, Suzuki, Chevrolet and the Textile City spread over 1,250 acres.

The Pakistan Merchant Marine Policy 2001, has deregulated the shipping sector and aims

to attract investment; both local and foreign, public and private, by offering a range of

incentives. The new policy in addition to offering duty-free import of ships, offers many

new incentives to local and foreign investors including Income Tax exemption till 2020.


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Pakistan's annual seaborne trade is about 45 million tons, just 5 per cent of which is

carried by the national carrier Pakistan National Shipping Corporation (PNSC), the

country's annual freight bill surpasses staggering $ 1.5 billion which is causing a colossal

drain on foreign exchange resources, the marine policy aims to reverse this situation to

some extent.

The Shipping Policy aims to revive and augment national ship-building/capacity to meet

20 per cent ship construction requirements of the country merchant marine and entire

requirements of support and ancillary crafts. The policy also aims to rejuvenate and

expand the ship repair potential to undertake the entire range of repairs and maintenance

of 50 per cent of Pakistani Flag ocean-going vessels and all ancillary sectors. The new

Shipping Policy offers many financial incentives for potential investors. It offers tax

exemptions and concessional tax measures backed by assurances. It also aims at

simplifying the rules by deregulating the sector.

To begin with, ships and floating crafts — tugs, dredgers, survey vessels, and specialized

crafts — purchased or bareboat chartered by a Pakistani entity flying the Pakistani flag

will be exempt from all import duties and surcharges till 2020. The policy accords shop-

building and ship-repair the status of an industry under the investment policy which is

entitled to all incentives contained therein.

To attract foreign investment, all port and harbor authorities in Pakistan will allow all

ships and floating crafts 10 per cent reduced berthing rates when the same are berthed for

purposes of repair and maintenance. Under the Policy, ships and all floating crafts are

considered bonafide collateral against which financing can be obtained from Banks and

Financial Institutions subject to policy of the financial institution.

There are 42 airports in the country managed by the Civil Aviation Authority (CAA). Out

of these, five airports; Lahore, Karachi, Islamabad, Peshawar and Quetta are international

airports. The CAA is planning to develop a new international airport at Islamabad for


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which land has been acquired and it is planed to fund the US$ 250-300 million on BOT

basis.

The Pakistan International Airlines (PIA) is the national flag carrier flying to 46

international and 36 local destinations. Other Pakistani airlines in the private sector

include, Aero Asia, Air Blue, Shaheen Air International and Pearl Air. In addition to

direct flights from most parts of the world, Pakistan can also be accessed through the

regional hubs of most international airlines, which operate through airports in the Gulf

countries.

The Pakistan Railways provides an important nation-wide mode of transportation in the

public sector. It contributes to the country’s economic development by catering to the

needs of large-scale movement of freight as well as passenger traffic. Pakistan railway

provides transport facility to over 70 million people and handles freight above 6 million

tons annually.

The Pakistan Railways Network was based on a total of 11,515 track kilometers

(including track on double line, yard & sidings) at the end of 2001-2002. This network

consists of 10,960 kilometers of broad-gauge and 555 kilometers of meter gauge.

Pakistan Railways has launched modernization activity with rehabilitation and

improvement plan both for its infrastructure and rolling stock including prime mover.

The ongoing schemes worth over US$ 500 million are progressing satisfactorily and have

brought a radical improvement in service. The railways is gearing up to the challenge of

providing improved connectivity to Iran, India, and link the upcoming Gwadar Port to

Afghanistan and onward to Turkmenistan.

Pakistan Telecommunication Limited (PTCL) dominated Pakistan’s telecommunications

market for the fixed-line services. Today the Pakistan Telecommunication Authority

(PTA) has the role of a regulatory body and is responsible for implementing the telecom

deregulation policy. For a long time, Pakistan lagged behind in the region as far as


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telecom access is concerned. With cellular mobile revolution taking place, Pakistan's

tele-density currently stands at 10.37%, with gross subscribers base of fixed (5.05

million) as well as mobile subscribers (10.54 million) touching 15.59 million for a

population of 160.0 million.

The Telecomm Sector has attracted the largest FDI in Pakistan with approximately

US$ 1.5 billion having been invested in 2005.

At the moment there are six companies providing mobile phone services in Pakistan, with

the largest of them, Mobilink (owned by Orascom Telecom) with nearly 50% of the

market share, other foreign players include MCE, Telenor and Warid.

In addition Wateen Telecom, a subsidiary of UAE-based Al Warid Telecom, has

launched a US$ 75.0 million project to lay an optic fiber optic backbone across the

Country. The first segment of the project of 800 kms would stretch from Karachi to

Rahimyar Khan and would be further linked with the rest of the country up to Peshawar

through 63 cities. When completed the backbone would be 5,000 kilometers, long

spanning the length and the breadth of Pakistan and would facilitate both the corporate

and residential segments, providing voice and high-speed data services on a converged

wireless network.

Pakistan in 2005 had 70 operational providers of internet services across 1,900 cities and

towns of the Country catering to about 2 million subscribers. In addition the Government

has reduced bandwidth rates for high speed board band internet connections and the

number of subscribers in this category is expected to grow to 200,000 by end of 2006.

AGRICULTURE

Agriculture accounts for nearly 23 percent of Pakistan’s national income and employs 42

percent of its workforce. Nearly 68 percent of the population lives in rural areas and is

directly or indirectly dependent on agriculture for their livelihood. Livestock is the single

largest contributor 47 percent share in the national income. The major crops; cotton,


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wheat, sugarcane and rice contribute 37 percent to agriculture while the minor crops like

oilseed, spices, onion and pulses contribute another 12 percent.

Pakistan is the fifth largest producer of milk in the world. The per capita availability of

milk at present is 185 liters, which is the highest among the South Asian countries. Milk

production in Pakistan has seen a constant increase during the last two decades. The

production has increased from 8.92 million metric tons in 1981 to 28 million metric tons

in 2005. There is a large and untapped potential in the dairy industry. With a population

of 160 million, a significant demand for dairy products exists in Pakistan. There is a need

for establishing modern milk processing and packaging facilities based on advanced

technology to convert abundantly available raw milk into high value added dairy

products. In addition, with improved conditions for milk pasteurization, availability of

chilled distribution facilities and consumer preference for the low cost pasteurized milk,

the sector provides unique opportunity for investment in establishing pasteurized milk

production plants.

There is also great scope for establishing related industries in the form of an efficient

milk collection system and refrigeration & transportation facilities. The sector offers

opportunity to foreign investors for establishing a joint venture for the production of

dairy products, particularly dried milk and infant formula milk for which great demand

exists in the neighboring countries like Afghanistan, Iran, UAE and Saudi Arabia.

Out of the 28 million tons of milk produced per annum in Pakistan, only 2.5 to 3 per cent

reaches the dairy plants for processing into variety of dairy products. Pakistan’s dairy

industry produces Ultra Heat Treated (UHT) Milk, Pasteurized Milk, Dry Milk Powder,

and Condensed milk. Other major milk products produced by the dairy industry include

butter, yogurt, ice cream, cheese, cream and some butter oil. Approximately half of the

0.3 million tons of milk available to the industry is processed into UHT milk, 40 percent

into powdered milk, and the remaining 10 percent into pasteurized milk, yogurt, cheese

and butter etc. Major players in the sector include Nestle, Haleeb and Engro Foods.


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Pakistan produced 1.1 million tons of beef, 740,000 kgs of mutton and 410,000 kgs of

chicken meat in 2005; in addition it also produced approximately 5 billion eggs in 2005.

Processed meat is exported to Saudi Arabia, UAE, Oman, Bahrain, Qatar and Kuwait in

the Middle East and Malaysia in the Far East. Pakistan exports around 40,000 live

animals and 2.83 million kg of meat to the Gulf.

Cotton is an important non-food crop and a significant source of foreign exchange

earning. It accounted for 10.5 percent of the value added in agriculture and about 2.4

percent of the GDP in 2005. Pakistan in 2005 produced about 14.5 million bales of

cotton.

Rice is a high value added cash crop and is also a major export item, it accounts for 5.7

percent of the total value added in agriculture and 1.3 percent of the GDP. Production of

rice in 2005 was about 5 million tones. In 2005 rice became the second largest export

from Pakistan when the country exported rice worth US$ 934 million. In addition to high

v

Tertiary Hospital in Major Cities of Pakistan

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