Sub-district hospitals (SDHs) serve as crucial healthcare facilities at the intermediate level, bridging the gap between primary health centers and larger district hospitals.
These hospitals provide essential medical services, including emergency care, maternity services, outpatient consultations, diagnostic procedures, and minor surgeries. SDHs are designed to cater to semi-urban and rural populations, ensuring that specialized care is accessible without requiring long-distance travel to major cities.
Their role is vital in strengthening regional healthcare networks by offering prompt medical intervention, reducing the burden on higher-level facilities, and acting as referral centers for more complex cases.
Importance of Infrastructure in Improving Patient Care
Infrastructure plays a fundamental role in enhancing patient care by creating an environment that supports efficiency, safety, and comfort. Well-planned hospital layouts optimize patient flow, reduce waiting times, and improve staff productivity.
Adequate space allocation for departments, proper ventilation, natural lighting, and ergonomic design contribute to infection control, patient recovery, and overall well-being.
Moreover, integrating technology infrastructure, such as digital health records and telemedicine capabilities, enables timely diagnoses and better coordination of care. Sustainable design practices not only reduce operational costs but also create a healthier indoor environment for patients and healthcare providers alike.
The term Sub-district / Sub-divisional Hospital is used here to mean a hospital at the secondary referral level responsible for the Sub-district / Sub-division of a defined geographical area containing a defined population.
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1) Categorization of Sub-district Hospitals
The size of a Sub-district hospital is a function of the hospital bed requirement, which in turn is a function of the size of the population it serves. In India the population size of a Sub-district varies from 1,00,000 to 5,00,000.
Based on the assumptions of the annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5 days, the number of beds required for a Sub-district having a population of 5 lakhs will be around 100-150 beds.
However, as the population of the Sub-district varies a lot, it would be prudent to prescribe norms by categorizing the size of the hospitals as per the number of beds.
For the purpose of classification, we have arbitrarily labeled Sub-district Hospitals as Category-I (31-50) and Category II (51-100). We presume that above 100 beds strength, health care facility will constitute District Hospital Group.
Category I : Sub-district hospitals norms for 31-50 beds.
Category II : Sub-district hospitals norms for 51-100 beds.
The minimum functional requirement of both categories of Sub-district hospitals are given as under.
Physical Infrastructure for hospital below
1) Size of the hospital
The size of a Sub-district hospital is a function of the hospital bed requirement which in turn is a function of the size of the population serve. In India the usual population size of a Sub-district varies from 1,00,000 to 5,00,000.
For the purpose of convenience the average size of the Sub- district is taken in this document as 2,50,000 populations. Based on the assumptions of the annual rate of admission as 1 per 50 populations.
And average length of stay in a hospital as 5 days. The number of beds required for a Sub- district having a population of 2,50000 will be as follows
The total number of admissions per year = 2,50,000 x 1/50 = 5,000
Bed days per year = 5,000 x 5 = 25,000
Total number of beds required when occupancy is 100% = 25000/365 = 69 beds
Total number of beds required when occupancy is 80% = 25000/365 x 80/100 = 55 beds
i) Area of the hospital
An area of 65-85 m2 per bed has been considered to be reasonable. The area will include the service areas such as waiting space, entrance hall, registration counter etc.
In addition, Hospital Service buildings like Generators, Heat Ventilation and Air conditioning Plant (HVAC plant), Manifold Rooms, Boilers, Laundry, Kitchen and essential staff residences are required in the Hospital premises. In case of specific requirement of a hospital, flexibility in altering the area be kept.
ii) Site information
Physical description of the area which should include bearings, boundaries, topography, surface area, land used in adjoining areas, limitation of the site that would affect planning, maps of vicinity and landmarks or centers, existing utilities, nearest city, port, airport, railway station, major bus stand, rain fall and data on weather and climate.
Hospital Management Policy should emphasize on quake proof, fire proof, protected, flood proof buildings and should be away from high tension wires. Infrastructure should be eco-friendly and disabled (physically and visually handicapped) friendly.
Provision should be made for water harvesting, solar energy/power back-up, and horticulture services including herbal garden. Local agency Guidelines and By-laws should strictly be followed. A room for horticulture to store garden
implements, seeds etc. will be made available.
Factors to be considered in locating a district / Sub-district hospital
- The location may be near the residential area.
- Too old building may be demolished and new construction done in its place.
- It should be free from dangers of flooding; it must not, therefore, be sited at the lowest point of the district.
- It should be in an area free of pollution of any kind, including air, noise, water and land pollution.
- It must be serviced by public utilities: Water, sewage and storm-water disposal, electricity, gas and telephone. In areas where such utilities are not available, substitutes must be found, such as a deep well for water, generators for electricity and radio communication for telephone.
- Necessary environmental clearance will be taken.
- Disability Act will be followed. Barrier free access environment for easy access to non-ambulant (wheel-chair, stretcher), semi- ambulant, visually disabled and elderly persons as per “Guidelines and space standards for barrier-free built environment for Disabled and Elderly Persons” of Government of India. This will ensure safety and utilization of space by disabled and elderly people fully and full integration into the society.
2) Site selection criteria
A rational, step-by-step process of site selection occurs only in ideal circumstances. In some cases, the availability of a site outweighs other rational reasons for its selection, and planners arid architects are confronted with the job of assessing whether apiece of land is suitable for building a hospital.
In the case of either site selection or evaluation of adaptability, the following items must be, considered: size, topography, drainage, soil conditions, utilities available, natural features and limitations.
In the already existing structures of a district / Sub-district hospital
- It should be examined whether they fit into the design of the recommended structure and if the existing parts can be converted into functional spaces to fit in to the recommended standards.
- If the existing structures are too old to become part of the new hospital, could they be converted to a motor pool, laundry, store or workshop or for any other use of the Sub-district hospital.
- If they are too old and dilapidated then they must be demolished and new construction should be put in place.
3) Building and Space Requirements
i) Signage
The building should have a prominent board displaying the name of the Centre in the local language at the gate and on the building. Colour coded guidelines and signage indicating access to various facilities at strategic points in the Hospital for guidance of the public should be provided
ii) Disaster Prevention Measures
(For all new upcoming facilities in seismic zone 5 or other disaster prone areas)
Desirable – For prevention of disasters due to Earthquake, Flood and Fire
Building structure and the internal structure of Hospital should be made disaster proof especially earthquake proof, flood proof and equipped with fire protection measures.
iii) Earthquake proof measures
Structural and non- structural should be built in to withstand quake as per geographical / State Govt. Guidelines. Non-structural features like fastening the shelves, almirahs, equipment etc. are even more essential than structural changes in the buildings.
Since it is likely to increase the cost substantially, these measures may especially be taken on priority in known earthquake prone areas. Hospital should not be located in low lying area to prevent flooding.
iv) Fire fighting equipment
Fire extinguishers, sand buckets, etc. should be available and maintained to be readily available when there is a problem. There should be regular drill of the staff for use of these equipment. All health staff should be trained and well conversant with disaster prevention and management aspects.
v) Environmental friendly features
The Hospital should be, as far as possible, environment friendly and energy efficient. Rain-Water harvesting, solar energy use and use of energy-efficient bulbs/ equipment should be encouraged.
vi) Administrative Block
Administrative block attached to main hospital along with provision of MS Office and other staff will be provided.
vii) Circulation Areas
Circulation areas like corridors, toilets, lifts, ramps, staircase and other common spaces etc. in the hospital should not be more than 55% of the total floor area of the building.
viii) Floor Height
The room height should not be less than approximately 3.6 m measured at any point from floor to floor height.
ix) Entrance Area
Physical Facilities: Barrier free access environment for easy access to non-ambulant (wheelchair, stretcher), semi-ambulant, visually disabled and elderly persons as per GOI guidelines.
Ramp as per specification, Hand-railing, proper lightning etc. must be provided in the health facility and retrofitted in older one which lack the same.
4) Departmental Lay-Out for Sub- district hospital
i) Ambulatory Care Area (OPD) Waiting Spaces
Registration, assistance and enquiry counter facility be made available in all the clinics along with proper sitting arrangement, drinking water, ceiling fans and toilet facility separate for male and female.
Main entrance, general waiting and subsidiary waiting spaces are required adjacent to each consultation and treatment room in all the clinics.
Clinics
The clinics should include general, medical, surgical, ophthalmic, ENT, dental, obsetetric and gynaecology, Post Partum Unit, paediatrics, dermatology and venereology (Desirable), psychiatry (Desirable), neonatology, orthopaedic and social service department.
The clinics for infectious and communicable diseases should be located in isolation, preferably, in remote corner, provided with independent access. Doctor chamber should have ample space to sit for 4-5 people.
Chamber size of 12.0 sq meters is adequate. For National Health Programme, adequate space be made available. Immunization Clinic with waiting Room having an Area of 3 m x 4 m in PP centre/Maternity centre/Pediatric Clinic should be provided.
One room for HIV/STI Counseling is to be provided.
Nursing services
Various clinics under Ambulatory Care Area require nursing facilities in common which include dressing room, side laboratory, injection room, social service and treatment rooms, etc.
Nursing Station: need based space required for nursing Station in OPD for dispensing nursing services. (Based on OPD load of patient)
Diagnostic Services
Provision for following space be made
- separate room for doctors/consultants
- rooms for reporting
- space for technicians
- storage/records areas
- sufficient waiting areas
ii) Imaging (Radiology) Department
Role of imaging department should be radio-diagnosis and ultrasound along with hire facilities depending on the bed strength. The department should be located at a place which is accessible to both OPD and wards and also to operation theatre department.
The size of the room should depend on the type of instrument installed. The room should have a sub-waiting area with toilet facility and a change room facility, if required.
Film developing and processing (dark room) shall be provided in the department for loading, unloading, developing and processing of X-ray films. Separate Reporting Room for doctors should be there.
iii) Clinical Laboratory
For quick diagnosis of blood, urine, etc., a small sample collection room facility shall be provided. Separate Reporting Room for doctors should be there.
iv) Blood Storage Unit
The area required for setting up the facility is only 10 square meters, well-lighted, clean and preferably air- conditioned.
v) Intermediate Care Area (Inpatient Nursing Units)
General
Nursing care should fall under following categories:
- General Wards: Male/Female
- Private Wards
- Wards for Specialities
Location
Location of the ward should be such to ensure quietness and to control number of visitors.
Ward Unit
It is desirable that upto 20 % of the total beds may be earmarked for the day care facilities, as many procedures can be done on day care basis in modern times.
The basic aim in planning a ward unit should be to minimize the work of the nursing staff and provide basic amenities to the patients within the unit.
The distances to be traveled by a nurse from bed areas to treatment room, pantry etc. should be kept to the minimum. Ward unit will include nursing station, doctors’ duty room, pantry, isolation room, treatment room, nursing store along with wards and toilets as per the norms.
On an average one nursing station per ward will be provided. It should be ensured that nursing station caters to around 40-45 beds, out of which half will be for acute patients and rest for chronic patients.
Private ward : Depending upon the requirement of the hospital and catchment area appropriate beds may be allocated for private facilities. However, 10 % of the total bed strength is recommended as private wards beds.
Patient Conveniences
It is to be as per local byelaws.
vi) Pharmacy (Dispensary)
The pharmacy should be located in an area conveniently accessible from all clinics. The size should be adequate to contain 5 % of the total clinical visits to the OPD in one session.
Pharmacy should have component of medical store facility for indoor patients and separate pharmacy with accessibility for OPD patients.
vii) Intensive Care Unit and High Dependency Wards
In this unit, critically ill patients requiring highly skilled life saving medical aid and nursing care are concentrated. These should include major surgical and medical cases, head injuries, severe haemorrhage, acute coronary occlusion, kidney and respiratory catastrophe, poisoning etc.
It should be the ultimate medicare the hospital can provide with highly specialized staff and equipment. The number of patients requiring intensive care may be about 5 to 10 % of total medical and surgical patients in a hospital. The unit shall not have less than 4 beds nor more than 12 beds.
Number of beds for both the units will be restricted to 10 % of the total bed strength. Out of these, they can be equally divided among ICU and High Dependency Wards.
For example, in a 100 bedded hospital, total of 10 beds will be for critical care. Out of these 4 may be ICU beds and 6 will be allocated for high dependency wards. Changing room should be provided for. There should be clear-cut admission, discharge and referral policy
Location
This unit should be located close to operation theatre department and other essential departments, such as, X-ray and pathology so that the staff and ancillaries could be shared.
Easy and convenient access from emergency and accident department is also essential. This unit will also need all the specialized services, such as, piped suction and medical gases, uninterrupted electric supply, heating, ventilation, central air conditioning and efficient life services.
A good natural light and pleasant environment would also be of great help to the patients and staff as well.
Facilities
Nurses Station Clean Utility Area equipment Room
viii) Accidents and emergency services
These services are to be made available on 24×7 basis. Emergency should preferably have a distinct entry independent of OPD main entry so that a very minimum time is lost in giving immediate treatment to injured arriving in the hospital.
There should be an easy ambulance approach with adequate space for free passage of vehicles and covered area
for alighting patients.
Emergency should have separate X-ray and basic laboratory facilities. Mobile Xray, Plaster room and minor OT facilities are also to be provided. Separate emergency beds may be provided. Duty rooms for Doctors/nurses/paramedical staff and medico legal cases.
Sufficient waiting area for relatives and located in such a way which does not disturb functioning of emergency services.
ix) Operation Theatre
Operation theatre usually has a team of surgeons’ anesthetists, nurses and sometime pathologist and radiologist operate upon or care for the patients.
The location of Operation theatre should be in a quite environment, free from noise and other disturbances, free from contamination and possible cross infection, maximum protection from solar radiation and convenient relationship with surgical ward, intensive care unit, radiology, pathology, blood bank and CSSD.
This unit also needs constant specialized services, such as, piped suction and medical gases, electric supply, heating, air-conditioning, ventilation and efficient life service, if the theatres are located on upper floors. Zoning should be done to keep the theatres free from micro organisms.
There may be four well defined zones of varying degree of cleanliness namely, Protective Zone, Clean Zone, Aseptic or Sterile Zone and Disposal or Dirty Zone.
Normally there are three types of traffic flow, namely, patients, staff and supplies. All these should be properly channelized. An Operation Theatre should also have Preparation Room, Pre-operative Room and Post Operative Resting Room. Operating room should be made dust-proof and moisture proof.
There should also be a Scrub-up room where operating team washes and scrub-up their hands and arms, put on their sterile gown, gloves and other covers before entering the operation theatre. The theatre should have sink/photo sensors for
water facility. Laminar flow of air is to be maintained in operation theatre.
Central air conditioning facility in the OT is desirable. It should have a single leaf door with self closing device and viewing window to communicate with the operation theatre. A pair of surgeon’s sinks and elbow or knee operated taps are essential.
Operation Theatre should also have a Sub-Sterilizing unit attached to the operation theatre limiting its role to operating instruments on an emergency basis only.
Theatre refuse, such as, dirty linen, used instruments and other disposable/non disposable items should be removed to a room after each operation. Non- disposable instruments after initial wash are given back to instrument sterilization and rest of the disposable items are disposed off and destroyed.
Dirty linen is sent to laundry through a separate exit. The room should be provided with sink, slop sink, work bench and draining boards.
x) Delivery Suite Unit
The delivery suit unit be located near to operation theatre. The delivery Suit Unit should include the facilities of accommodation for various facilities as given below:
- Reception and admission
- Examination and Preparation Room
- Labour Room (clean and a septic room)
- Neo-natal Room
- Sterilizing Rooms
- Sterile Store Room
- Scrubbing Room
- Dirty Utility
- Newborn care corner in Labour room. (Annexure V A)
- Newborn care Stabilization Unit: Details at (Annexure V B)
xi) Post Partum Unit
It is desirable that every Sub-district Hospital should have a Post Partum Unit with dedicated staff and infrastructure to provide Post natal services, all Family Planning Services, Safe Abortion services and immunization in an integrated manner. The focus will be to promote Post Partum Sterilization and will be provided if the case load of the deliveries is more than 75 per month.
xii) Physical Medicine and Rehabilitation (PMR)
The PMR department provides treatment facilities to patients suffering from crippling diseases and disabilities. The department is more frequently visited by out-patients but should be located at a place which may be at convenient access to both outdoor and indoor patients with privacy.
It should also have a physical and electro-therapy rooms, gymnasium, office, store and toilets separate for male and female. Normative standards will be followed.
5) Hospital Services
i) Management Information System (MIS)
Computer with Internet connection is to be provided for MIS purpose. Provision of flow of Information from PHC/CHC to Sub-district hospital and from there to district and state health organization should be established.
Relevant information with regards to emergency, outdoor and indoor patients be recorded and maintained for a sufficient duration of time as per state health policy
ii) Hospital Kitchen (Dietary Service)
The dietary service of a hospital is an important therapeutic tool. It should easily be accessible from outside along with vehicular accessibility and separate room for dietician and special diet.
It should be located such that the noise and cooking odours emanating from the department do not cause any inconvenience to the other departments. At the same time location should involve the shortest possible time in delivering food to the wards.
iii) Central Sterile Supply Department (CSSD)
As the operation theatre department is the major consumer of this service, it is recommended to locate the department at a position of easy access to operation theatre department.
It should have a provision of hot water supply and steam. Efficiency of sterilization process would be tested periodically.
iv) Hospital Laundry
It should be provided with necessary facilities for segregated collection, drying, pressing and storage of soiled and cleaned linens.
v) Medical and General stores
The medical and general store should have vehicular accessibility and ventilation, security and fire fighting arrangements. Inventory analysis (ABC/VED) should be undertaken periodically.
vi) For Storage of Vaccines and other logistics
Cold Chain Room: 3.5 m x 3 m in size. Every efforts will be undertaken to ensure that proper cold chain is maintained till point of delivery.
Vaccine & Logistics Room: 3.5 m x 3 m in size. Minimum and maximum Stock (0.5 and 1.25 month respectively). Indent order and receipt of vaccines and logistics should be monthly. Cold Chain & Vaccine Logistic (CC & VL) Assistant will be responsible for timely receipt of required vaccines and Logistics from the District Stores.
vii) Mortuary
It provides facilities for keeping of dead bodies and conducting autopsy (desirable). Facilities for proper illumination and hand washing should be available.
At least cold chamber for preservation of two dead bodies should be installed. It should be so located that the dead bodies can be transported unnoticed by the general public and patients.
viii) Engineering services
Sub Station and Generation
Electric sub station and standby generator to cater for the full load of the hospital should be provided.
Illumination
The illumination and lightning in the hospital should be done as per the prescribed standards.
Emergency Lighting
Shadow less light in operation theatre and delivery rooms should be provided. Emergency portable light units should be provided in the wards and departments.
Call Bells (Desirable)
Call bells with switches for all beds should be provided in all types of wards with indicator lights and location indicator situated in the nurses duty room of the wards.
Ventilation
The ventilation in the hospital may be achieved by either natural supply or by mechanical exhaust of air.
Mechanical Engineering
All OTs, ICUs and NICUs, (heat stroke room, if required) will be air conditioned. Room Heating in operation theatre and neo-natal units may also be provided depending upon weather condition. Air coolers or hot air convectors may be provided for the comfort of patients, relatives and staff depending on the local needs.
Hospital should be provided with water coolers and refrigerator in wards and departments depending upon the local needs.
Desirable – telephone booth, cable TV, cafeteria/tea shop.
Water Supply
Arrangement should be made for round the clock piped water supply along with an overhead water storage tank with a provision to store at least 3 days water requirement.
It should have pumping and boosting arrangements. Approximately 450 to 500 litres of water per bed per day is required for a 100 bedded hospital. Separate provision for fire fighting and water softening plants be made available.
Drainage and Sanitation
The construction and maintenance of drainage and sanitation system for waste water, surface water, sub-soil water and sewerage shall be in accordance with the prescribed standards. Prescribed standards and local guidelines shall be followed.
Other Amenities
Disabled friendly, WC with basins wash basins as specified by Guidelines for disabled friendly environment should be provided.
Waste Disposal System
As per National guidelines on Bio-medical Waste Management. and
Guidelines for management of Mercury waste.
Trauma Centre
Guidelines to be followed.
Fire Protection
- Regular training, demonstration, awareness and drill.
- Placement of fire appliances and their periodical servicing.
- Escape plan – signage.
Telephone and Intercom
Medical Gas
Cooking Gas: Liquefied petroleum gas (LPG).
Laboratory Gas: Liquefied petroleum gas (LPG) and other specified gases.
ix) Building Maintenance
Provision for building maintenance staff and an office- cum store will be provided to handle day to day maintenance work.
Annual Maintenance Contract (AMC)
AMC should be taken for all equipment which need special care and preventive maintenance done to avoid break down and reduce down time of all essential and other equipment.
Parking
Sufficient parking place as per the norms will be provided.
Administrative Services: Two sections (i) General section to deal with overall upkeep of the hospital and welfare of its staff and patients (ii) Medical Records section.
Committee Room: A meeting or a committee room for conferences, trainings with associated furniture.
x) Residential Quarters
All the essential medical and para-medical staff will be provided with residential accommodation.
If the accommodation can not be provided due to any reason, then the staff may be paid house rent allowance, but in that case they should be staying in near vicinity, so that essential staff is available 24 x 7 in case of need.