Case Study

Journal of Financial Management and Analysis, 27(2):2014:(41 -50) © Om Sai Ram Centre for Financial Management Research

ANALYSIS OF COST CONTAINMENT, COST RECOVERY AND SUSTAINABILITY OF HOSPITAL WASTE MANAGEMENT SYSTEM CASE STUDY OF SANJAY GANDHI POST GRADUATE

INSTITUTE OF MEDICAL SCIENCES, LUCKNOW, INDIA Professor (Dr.) HEMCHANDRA M.B.B.S.,M.H.A.,M.B.A.,Ph.D. Head Department o f H ospital Administration E-mail : hchandra555@ gmail.com

Ms. LEELA MASIH B.Sc (Nursing), M.Sc (Hospital Administration) Nursing Superintendent E-mail: leelah9j@ yahoo.co.in

SUNIL SHISHOO,M.Sc., P.G.D., H.H.M. Deputy Superintendent E-mail : sshishoo@ yahoo.com

BHARAT SAH,M .B.A. Associate Superintendent E-mail : bharatsah3@ yahoo.com

Dr. ARVIND VASHISHTA RINKOO M.B.B.S., M.D., D.N.B.

Senior Resident E mail- [email protected]

Department of Hospital Administration Sanjay Gandhi Post Graduate Institute o f M edical Sciences

Lucknow, UP. India

Professor, (Dr.) T. N. DHOLE M.B.B.S., M.D. Head, Department o f Microbiology Sanjay Gandhi Post Graduate Institute o f Medical Sciences Lucknow, India E mail : tndhole@ sgpgi.ac.in

Abstract Sanjay Gandhi Post Graduate Institute of Medical Sciences , Lucknow, Uttar Pradesh State of India, - - a 886- bedded, tertiary care hospital, - - is implmenting the methods of waste utilization /recycling, for wealth generation from solid waste and also containing the cost of treatment for needy patients. The study is intended to analyze the outcome of measures adopted by the hospital for solid waste utilization/recycling, in terms of cost recovery and cost reduction in treatment of patients. During the period (January 2008 to March 2014). The hospital earned Rs. 7669621 (US$127827) by selling the hospital solid waste materials such as disinfected/sterile, plastic/latex materials, card board, glass bottles, etc and, for containing the cost of the patients treatment, the plastic/rubber made consumable valued at Rs. 137.20 million (US$ 2.85 million) were sterilized, recycled and released.

Key words : Hospital solid waste and disinfection recycling; cost containment-cum-cost recovery, sustainability JEL Classification - D61; I I 1; 131; 053

ANKITA PANDEY M. Tech Senior Research Fellow Indian Institute o f Toxicology Research Lucknow, India E-mail : [email protected]

Introduction scarce resources which are many and varied. This is especia lly so in a country like India. The

A Hospital Administrator is primarily a manager of success of a hospital administrator depends on

The authors own full responsibility for the contents of the paper.

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how well he or she organizes and utilizes the available resources. A hospital administrator may be compared to a conducto r of an orches tra; making optimum use of each resource. ' Equally imperative is the development of new innovative ideas on the part of hospital administrators to g en e ra t e w e a l th and r e v en u e as m on ey is invariably a scarce entity in most cases.

It is ironic that the health care facilities, which restore the health of the diseased, pose a huge health risk and environmental degradation due to improper hospital waste management. Safe and sustainable health care waste management is not possible wi thout a favourable at ti tude among health care providers.2 One of the most important matters in planning a hospital is to consider the disposal routes of all waste and infected material. In every part of the hospital where patients are treated, there will be infected mater ia l to be disposed of. Dirty materials should, in general, go into a bin, bag or other disposal container at its point of origin and remain in that container until it re aches a po in t at which it is s t e r i l i z ed or incinerated3. It is noteworthy that Government of India enacted an Act in July 1996, followed by laying down Biomedical Waste (Handling and Management) Rules in 1998 to ensure proper handling and disposal of hospital wastes4.

T h o u g h w ea l th migh t not be co n s id e r ed as significant as health, it is a universal truth that wealth and funds are salient inputs for any system. Thus it is a refreshingly confounding fact that wealth can actually be generated by utilizing the solid / medical wastes in hospitals after adequate treatment5.

Prelude In India, the average production of hospital waste is 1.5 kg./bed/day (range: 1-2.50 kg/bed/day)5, out of which 20 per cent is biomedical (hazardous) in nature . However , waste p ro duced has been quoted up to 5.24 k g /bed /day in developed countries.6 These higher figures in developed countries are due to greater use of disposables in those countries. On an average, 1.8 million wastes are generated per day from about 1.2 million beds of about 11000 hospitals in India. Cost benefit measures of hospital wastes, especial ly the biomedical wastes, are not practiced; therefore em p h a s i s is g iven in this s tudy on cost conta inm ent/ cost ef fec t iv en es s . Thus the d o m es t i c w as te such as c a rd b o a r d , paper , container, glass bottles and a part of biomedical waste such as plastic materials (IV bottle, tube syringes, gloves, canula, bags etc.) and other rubber materials can be utilized by recycling after disinfection/ sterilization to recover some revenue out of it or to bring down the cost of treatment like in the case of recycling of high cost disposables such as catheterization tube, dialyzers, etc. The benefit can be shared with low socio-economic patients by providing them quality state of the art health care at an affordable (low) cost. Law does not mention whether re use the waste or not, but All India Audit Report on Management of Waste emphasizes on 3 Rs. i.e., Reduce, Recycle and Reuse7. Developed countries have also adopted the practice of reuse after recycle.

Methodology Used The Sanjay Gandhi Post Graduate Institute of Medical Sciences (S.G.P.G.I.M.S.), Lucknow, Uttar Pradesh, State of India which is a tertiary care

*The Sanjay Gandhi Post Graduate Institute of Medical Sciences (S.G.P.G.I.M.S.) is dedicated to quality tertiary care at an affordable cost. Over the years, it has achieved success to become a robust centre of excellence for providing super specialty care, medical education and research facilities of highest order. The (S.G.P.G.I.M.S.), established under an Act of State Legislature of Uttar Pradesh in 1983, functions as a university. The Institute catered to 400768 OPD patients, 35188 discharges, 26281 12 investigations were done in 2013. On an average, in a year, about 8734 surgical procedures are performed including more than 134 renal transplants8. This is made possible by a team of highly qualified-cum-richly experienced doctors and paramedical personnel using state of the art technology and high-end sophist icated equipment. Table 1 the hospital statistics for last nine years. The hospital facilities are provided on payment basis but rates are highly subsidized.

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TABLE 1 S.G.P.G.I.M.S. HOSPITAL STATISTICS : 01st JANUARY 2005 TO 31st DECEM BER 2013

Y e a r ------- -> 2005 2006 2007 2008 2009 2010 2011 2012 2013 OPD New patients 43530 46566 52521 58894 65547 71335 76620 80650 82141 Follow up patients 132415 146355 168831 183687 204095 243027 284062 307712 318627 D isc h a r g e 35190 36732 38994 40596 29259 33705 34762 34926 3 5 1 8 8 BO R 69.5% 68% 74.4% 76.1% 78.6% 74.4% 76.1% 77.1% 76 .5% S u r g e r y 6213 6296 7331 7680 7353 7724 8202 8402 8734 R e n a l TX 97 113 115 115 92 100 114 116 134 L iv er T ra n sp la n ML 3 1 0 ML ML NIL ML 1 B M Tx Of 4 1 0 2 2 ML 2 3 L i t h o t r ip s y 21* 326 295 125 ML 130 329 199 303 O p en H ea r t Sur 433 519 474 478 465 382 402 389 425 M. R. I 4664 5496 5984 6392 6395 8709 8286 6943 6340 H .d ia ly s is 8342 10483 12555 16097 14966 17433 18495 19220 18723 P. D ia ly s i s 417 354 156 57 32 15 28 ML 2 I n v e s t ig a t io n s 1277982 1426779 1587304 1658143 2051488 2282945 2385210 2567901 2628112 E n d o s c o p y 8042 9452 10723 12588 13277 13642 13546 15382 13427 C oro . A ng i 2004 2333 2396 2520 2712 2433 2193 2188 2059 PTCA 922 1056 1081 1196 1407 1352 1250 1248 1221 P a th o lo g y 7208 7718 9044 9506 9878 10392 11473 11713 11841 CT Scan 3164 4253 4843 5889 7293 9138 10960 12550 12654 U ltr a S o u n d 14322 18037 21049 21358 16810 20315 20694 21141 19112 B lo o d D o n a t io n 16768 17577 18995 21404 21541 22025 22486 22535 22941 E R S P a t ie n ts 10853 11011 12476 12985 13417 122114 11505 10785 9172 B lo o d D o n a t io n 16768 17577 18995 21404 21541 22025 22486 22535 22941 E R S P a t ie n ts 10853 11011 12476 12985 13417 122114 11505 10785 9172 R ev en u e Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. C ollec t ion 207147959 226260238 262842359 278251815 315291091 397711615 458548028 465860018 4 7 3 4 8 9 7 4 0

Source : Sanjay Gandhi Institute o f Medical Sources, Hospital Statistics 2005-2013 (Lucknow)

super specialty (868-bedded) is a pioneer in using modern management (innovative) techniques vis- a-vis cost -containment, cost -ef fec tiveness and sav in g s m e th o d s in w as te u t i l i z a t i o n and recycling*. The present study was done with an intention to analyze the outcome of measures adopted for hospi ta l so lid waste u t i l iza t ion/ recycling, in terms of wealth/ revenue generation and medical ‘treatment cos t ’ reduction.

A retrospective study was carried out in the month of April 2014 at S.G.P.G.I.M.S. - - data pertaining

to selling of solid wastes including some of the biomedical wastes and recycling/reuse of wastes (after disinfection/ sterilization), for the last six years was collected and analyzed assiduously.

Like in any health care facility, solid wastes at S.G.P.G.I.M.S. may be divided into two broad categories, viz., general waste or domestic waste or municipal waste originating primarily from kitchen and medical stores, and the biomedical waste . Genera l waste or domest ic waste or municipal waste consists primarily of cardboard,

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TABLE 2 MAJOR BIOMEDICAL WASTES GENERATED AT SGPGIMS

ALONG WITH THEIR MODE OF DISPOSAL. CATEGORY 4, 6 AND 7 ARE THE MAJOR SOLID WASTES USED FOR SELLING AND RECYCLING*

Category Method of Disposal Colour Code of Collection Bag Human anatomical waste (organ, tissue, blood etc.)

Incineration/DB Yellow plastic bag

Animal tissue (organ, tissue, blood etc)

Incineration/DB Yellow plastic bag

Microbiology and Autoclave, microwave, Yellow-red plastic bag Biotechnology incinerator Sharp Disinfection at site-chemical Puncture proof white container (needle, syringes, blades etc.) disinfection Discarded and cyto-toxic Incineration/DB Black plastic bag Solid waste Autoclave, microwave, Yellow-red plastic bag (plastic, cotton, bandage etc.) chemical disinfection Solid waste (rubber, catheter, Autoclave, microwave, Red -b lue plastic bag plastic material) chemical disinfection. Liquid waste** (washing, cleaning fluid)

Chemical disinfection Discharged in drain

Incineration ash Land fill Black plastic bag Chemical waste** (disinfectant, pesticides)

Chemical treatment Discharged in drain

Notes : * Classification based on Biomedical Waste (Handling and Management) Rules : 19985 ** Amended rules 2011 - category No. 8 & 10 have been omitted.

paper and wrappers, containers , glass bottles, eatables and discarded food, kitchen waste etc. Biomedical waste, in turn, is any solid, fluid and liquid or liquid waste including its container and any in term ediate product, which is generated during the diagnosis, treatment or immunization of human being, animals in research pertaining there to or in the production of testing biological and the animal waste from slaughter houses or any other like establishments8. In a hospital setting, categories 4, 6 and 7 of the biomedical wastes (as delineated in Table 1) are the major solid wastes w hich can be recy c led , reused or sold after s te r i l iz a t io n . A reas that g en e ra te m axim um biomedical wastes at S.G.P.G.I.M.S. are Operation T hea tres , In ten s iv e Care U nit, B lood Bank,

Dialysis, Laboratory, Sample collection area and wards.

Disposal of Solid Wastes The S.G.P.G.I.M.S. follows the Biomedical waste (Management and Handling) Rules : 1998 for disposal of hospital waste. But in addition to this, it had dev e lo p ed its own m ethods o f waste disposal for cost recovery, cost containment and self sustainability of system without violating the rules. S.G.P.G.I.M.S. being a government hospital, t r a n s p a r e n c y in the system is a prim e requirement, therefore, a tender was floated to invite the bidders to get maximum revenue for discarded/ sterilized waste. Table 3 reflects the h ig h es t se l l in g ra tes a t ta in ed for d iffe ren t

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categories of solid waste by tender process.. Some of the solid wastes like card board, bottles are sold as such and some of them like plastic, rubber etc. are shredded after sterilization and made ready for sale. (Figure 1). The Institute also developed the modality for solid waste to recycle some of

the wastes including biomedical waste, after disinfection/ sterilization to reuse it on subsidized rates and facilitating the economically poor class patients by cost containment / cost reduction. (Figure 2). Prior to 2008, the same hospital wastes were discarded after treatment.

FIGURE 1 IMAGES SHOWING THE STERILIZED SOLID SHREDDED WASTE READY FOR SALE

FIGURE 2 IMAGES SHOWING THE STERILIZED SOLID WASTE READY FOR USE FOR PATIENTS

TABLE 3 SELLING PRICE OF SOLID WASTES : SEPT. 2009

(Solid Waste) Selling Price per Kg. (Rs.)

Card Board 6.80 Glass 3.00 Gloves 17.25 Tubes/Catheters/Pipes 17.50 Syringe 27.25 L.D. Bottles 39.00

Cost Containment/reduction, Cost Recovery and Sustainability

The average production of 868-bedded hospital waste ranges from 1.50 to 1.75 kg. per bed per day. Out of this, approximately 20 per cent is biomedical (hazardous) in nature and rest is like general/ domestic waste. Bulk of hospital waste is solid in nature, but revenue cannot be generated from all solid wastes. The hospital selected certain w astes w h ich can ea s ily be sold w ithou t

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TABLE 4 REVENUE GENERATED BY SELLING DISINFECTED / STERILE PLASTIC / LATEX MATERIALS,

CARDBOARD, GLASS BOTTLES, ETC. : 2008-2014

Financial Year Items Weight (kg) Revenue (Rs.) Total (Rs.) 2013-2014 Plastic, gloves etc. 42137

Card board 39110 Glass bottles 16900 14,30,528 14,30,528

2012-2013 Plastic 33058 7,72,626 11,05,784 Card board 38710 2,79,967 Glass bottles 16460 53,191

2011-2012 Plastic, gloves etc 40670 9,85,147 12,82,867 Card board 38390 2,41,538 Glass bottles 17835 56,182

2010-2011 Plastics, Gloves, 55197 11,55,195 15,45,232 Rubber Materials etc. Card Board 48740 3,31,432 Glass Bottles etc. 19535 58,605

2009-2010 Plastic 32551 6,41,953 9,44,642 Card board 41030 2,68,612 Glass bottle 13360 34,077

2008-2009 Plastics, Gloves, 41233 8,24,673 10,98,101 Rubber Materials etc. Card Board 35200 2,39,625 Glass Bottles etc. 11490 33,803

January 2008 - Plastics, Gloves, 10300 1,98,000 2,62,467 March 2008 Rubber Materials etc. •

Card Board 8810 58,025 Glass Bottles etc. 2873 6,442

GrandTotal — — — 7669621 (US$ 127827)

compromising the environmental factors. It was observed that the hospital earned Rs. 7669621 (US$. 127827) during 75 months (January 2008 to March 2014) by selling the hospital solid waste materials such as disinfected/ sterilized plastic/ latex materials, card board, glass bottles etc. The selling price per unit for these wastes is tabulated in Table 2 and the revenue earned year wise is being tabu la ted in Table 4. F igure 3 clearly indicates the unabated increase in revenue over the years. The hospital started the practice in late 2008, therefore proportionate revenue of 2,62,467 rupees was generated by selling the solid wastes

in that year as shown in Table 4. Thereafter, c o n t in u o u s ly the h o sp i ta l has g en e ra ted reasonable amount of money every year to the extent of earning of maximum revenue Rs. 15,45,232 in 2010-201 1. F ig u re 4 show s the in d iv id u a l contribution in revenue generation by different types of solid waste during 2008-2013. The revenue so generated is used in system maintenance and up-gradation as and when required - - thus, the hospital recovers some of the cost incurred.

So far as cost containment in medical care is concerned, the hospital sterilized the used plastic/

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rubber disposables such as catheters, canula, tubes/pipes etc. of worth o f Rs. 137.20 million (US$.2.85 million) during the last six years, which predominantly belonged to departm ent of CVTS, Radiology, Nephrology, N uclear M edicine and Operation Theatres (Table 5A and 5B). By using these sterilized disposables/appliances based on discretion of the treating doctor, treatment cost was brought down in comparison to a newer one bought by patients. It is pertinent to m ention that as cost - benefit analysis cannot be done in such

situ a tio n s , the need for co st-e ffec tiv en ess / containment analysis becomes imperative.

In addition to above, other types of non infected/ disinfected hospital solid wastes was utilized for land filling, which is not mentioned here in monetary terms. The recycling of solid waste was thus found to be cost contained for waste management at S.G.P.G.I.M.S. and also sufficient amount of money was recovered. The environm ental pollu tion threats were also mitigated, this was an additional plus point.

FIGURE 3 REVENUE BY SELLING THE HOSPITAL SOLID WASTE MATERIALS OVER THE YEARS

1600000 -i

1400000 - /

1200000- /

1000000- / Total Revenue 800000 - (Rs.) ' 600000 - /

400000 -

200000 -

0 - /

< /

iT '

TABLE 5 TOTAL APPLIANCES / ITEMS STERILIZED AND THEIR COST

A. TOTAL COST Departments Total items Total Cost (Rs.) Radiology 218323 13,41,84,409 CVTS 635 22,40,096 Uro OT 71 8,491 Nuclear medicine

350 72,8417

Cath lab 143 37,857 Total 219529 13,71,99,270

(US$ 2.85 million)

Table 5 contd. on next page

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TABLE 5

B. DEPARTMENT-WISE COST • RADIOLOGY

Item Average Unit Cost (Rs.) Dilator 50 Sheath 900 Rining bilary 1500 Guide wire 1051 Catheter 950 Stiff wire 1250 Blue sheath 20 Sheath 750-1050(900) Micro catheter 10,000-25000(17500) Small wire 350 Connecting tube 999 Super stiff wire 3500 Green stiff wire 4000 LMP cath 1500 Long diltor 50 Micro puncture set 1150 LES wire 2500 Swan gang 3500 Zebra wire 6000 Mandrill wire 5000 Micro couth 20000 Ans stiff700 Connecting tube 900 Vigan needle 20 Dilate tern 45 Micro balloon 100-16000(8500) Infiltration device 4500 skinny needle chiba tip 501

• CATH LAB

Item Size Average Unit Cost (Rs.)

T.K.D. 500,197,150 282.00 Reduce cap - 150.00 Antisuture pdmc bulb 200,143,94 145.00 Aortic punch 500,47,144 230.00 Troca dilator tip - 100.00 Auto suture 200,302,150 217.00 Vushe seal _ 200.00

• CVTS

Item Size Average

Unit Cost

(Rs.l

Aortic arch cannula 8 FR= 827,2952,2652 2159 10 FR= 872,2952,2652 2159

12 FR= 872,2952,2652 2159

14 FTL= 872,2952,2652 2159

20FR= 1548,1881 1714

22FR=1453,1881 1278

24 FR= 1881,872,987,

1201,1453 1278

Vinous cannula 12FR= 1956,1651,1525 1710

14FR= 1651,1525 1528

16FR= 1711,1651,1525 1629

18FR= 1440,1651,1525 1538

20FR= 1956,1651,1525 1583

22FR=1453,1651,1525 1543

24FR=1651,1525 1588

28FR=1100,1651,1525,855,

1666,1307 1350

30FR=855,1666,1307 1276

32FR=869,1666,1307 1280

36FR=910,1666,1307 1294

36'46FR=828,1666,1307 1267

Femoral arterial cannula 10659,7001,3518,10659 7959

Chest drainage tube 68249 985

Venoussheath - 470

Suction tube - 4.90

Linear calh - 177

Dilator - 7300

Jejunal cath - 177

Folleycath 63,40 51

Drainage sheet - 9.00

Guide wire 4180,154m 1442 1925

Big tube - ' 500

CVCathTLR - 200

Dropping sheet - 100

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• D IALYSIS

Item Size Average Unit Cost (Rs.)

Tencuff traight cath - 3632.00 P.D. techkof cath 3135,2978,

3550,4796 3614.00 Dialator - 7300.00 Jemoral connector 88,600 344.00 CAPD connector - 999.00 Crude wire - 1250.00 Jugular kit - 3020.00 Guide wire 4130,154,1442 1925.00 Needle 5,26 15.00

• UROLOGY, NUCLEAR MEDICINE AND ANAESTHESIA '

Item Size Average Unit Cost (Rs.)

Bvf/ssf (merinic sigma)

141,94,90 282.00

Different type 3020,177,63,40, of cath (ep, abl, 150,2978,3550, duadph, regi.) 3632,3135,4796 2154.00 Ventilator device 3708,5000,1651, (plastic): regular basis

1525,82,555 2086.00

T-connector - 110.00 Endotracheal Tube Oxygen mask

- 67.50

(with tubing) - 23.00

FIGURE 4 REVENUE EARNED BY SELLING THE HOSPITAL SOLID WASTE CATEGORY WISE : 2008 TO 2013

y . “ “ ~ ” ... .... .... ... .... ....

L400000 ^ 1079503 1210517

1200000

L000000

800000

600000

400000

200000

0 Saline Cardboard Glass Gloves IV set Syringe Water Bottle Bottle bottle

Conclusions and Im plications for Policy: The p resen t study was ca rried out w ith an in ten tion to analyze the outcom e o f m easures adop ted for h o sp ita l so lid w aste u tiliz a tio n / recycling, in terms of w ealth/ revenue generation

and w a s te t r e a tm e n t c o s t re d u c t io n . A re trospective study was carried out in the month o f A p ril 2014 at S .G .P .G .I .M .S 5 w ith da ta co llec tion and analysis p erta in ing to selling of so lid w astes including some o f the biom edical

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wastes (after d isinfect ion/ s teri lizat ion) for 75 months and thei r recycl ing for six years.

The S.G.P.G.I.M.S. hospi ta l has been ut il izing/ recycl ing the hospi ta l sol id wastes including b i o m e d i c a l w a s t e s ( a f t e r d i s i n f e c t i o n / s te r i l i za t ion ) for the las t six years , and the

j ru tcome of which is highly satisfactory in terms of conta inment in t rea tment cost o f pat ients. Rs. 137.20 million (US$.2.85 million) surgical items were recycled and used at subsidized rate for needy and econom ically poor patients and g e n e r a t e d c o p i o u s w e a l t h r e v e n u e o f Rs. 7669621 (US$ 127827) dur ing the last 75 m o n t h s , w h i c h in t u r n , is b e i n g u sed for m a i n t e n a n c e an d u p - g r a d a t i o n o f w a s t e m a n a g e m e n t f a c i l i t i e s and o t h e r h o s p i t a l

services - - commendally, the system has turned out to be a s e l f - s u s t a in a b le com bined with cos t - recovery techn iqued system.

Solid waste recycling/reuse /selling of solid wastes practices, after proper treatment, are viable tools for cost containment and waste management/ wealth generation resulting in mobilization of funds towards reduction in cost of patient treatment/ cost recovery. Thus the same practice and where the bulk o f so l id wa ste s is gene ra ted with environmental pollution threats almost mitigated, which is an additional plus point should be adopted by other hospitals (especially tertiary care) in almost all countries where the treatment cost is very high and non-affordable by the majority of the needy patients.

REFERENCES

1. Francis, C.M., De Souza, M.C.; Hospital Administration (New Delhi, 2004)

2. Chattopadhyay, D, et. a i , Study of attitude regarding health care waste management among health care providers of a tertiary care hospital in Kolkata , Indian Journal of Public Health (April-June 2010)

3. Davies, R L, Macaulay, H.M.C.; Hospital Planning and Administration (New Delhi, 1995)

4. Government of India, Ministry of Forest and Environment, Biomedical Waste (Handling and Management) Rules : 1998.

5. Chandra, H, Jamaluddin, K; Hospital Administration at a Glance (Lucknow, 2010).

6. i) Sakharkar, BM; Principles of Hospital Administration and Planning (New Delhi, 2006)

ii) Shah, H.K., Ganguli, S.K.; Hospital waste management-A review: Journal of Academy of Hospital Administralion (3 : 2000).

7. All India Audit Report on Management of Waste : 2008, Chapter 3 (PA 14 of 2008)

8. Hospital Statistics of Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow for the Year 2005-2013.

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