Functional Area: Responsibilities of Management (ROM)
Standard 1 | Indicator 3 | Category: YELLOW 🟡 (80% required)
The Acknowledgement Slip She Could Not Find
Dr. Amna Riaz had applied for her PHC license eleven months ago. She remembered it clearly because it had fallen on a particularly hectic week: two staff members were absent, a flu wave was bringing double the usual number of patients, and a pharmaceutical company audit was scheduled for the same day she had driven to the PHC office in the city to submit her forms. She had filled out the application, attached the required documents, paid the fee at the designated bank, and submitted everything at the counter. The staff had given her an acknowledgement slip. She had put it in her bag.
That was eleven months ago. Somewhere between that day and today, the acknowledgement slip had found its way into a file, and the file had found its way into a drawer, and the drawer had acquired several other files on top of it, and life had continued without another thought about the matter.
No news, she had assumed, was good news. The clinic was running. Patients were coming. Nobody from PHC had called.
When the assessor arrived on a Tuesday and asked to see her PHC Registration Certificate or License, Dr. Amna opened the filing cabinet with complete confidence. PM&DC certificate there, framed on the wall. Degree in the file, as always. FCPS certificate beside it.
PHC Registration Certificate or License, she searched for three full minutes while the assessor waited.
It was not there.
She tried her desk drawer. Then the reception desk. Then she called her husband, who sometimes managed the administrative files at home.
He eventually found, on her phone, a photograph she had taken of the acknowledgement slip eleven months ago, never printed, never followed up on.
“I applied,” she said to the assessor, showing him the phone screen. “I have the proof here.”
He looked at the photograph. He explained the scoring. And he explained something else that Dr. Amna had not understood until that moment: applying for a PHC license and having a PHC license are two entirely different things. She had only done the first part.
The PHC License: What It Actually Is
The PHC license authorises the clinic premises to operate as a healthcare establishment. It is issued by the Punjab Healthcare Commission under Sections 13 and 14 of the PHC Act 2010. It belongs to the clinic, not the doctor. It is the legal permission for that specific location to provide healthcare services to the public.
Under the PHC Act 2010, all healthcare establishment clinics in Punjab, including those of general practitioners, family physicians, and specialists, are legally obligated to be registered and licensed with the PHC for lawful operation. Operating without this license is not a technicality. It is a legal exposure.
Indicator 3 assesses exactly this: Is your clinic registered and licensed with the PHC?
The indicator reads: The Clinic is registered/licensed with the PHC.
The survey process has two steps. First, the assessor verifies whether a Registration Certificate or License under the PHC Act exists, whether in the actual document or in clear evidence of an application. Second, they check whether the PHC Registration or License number is displayed at a prominent place on the main signboard or outer wall, and whether a copy is kept inside the clinic in the waiting or consultation area.
The display requirement is specific: the PHC Certificate or License number should be visible at the main entrance and inside the clinic. The internal display should be on a simple, small board of any suitable material; it does not need to be large or expensive. A printed copy in a frame on the waiting room wall is sufficient.
This is a YELLOW indicator, which means it has a graduated scoring structure and allows for partial credit.
How the Assessor Scores This Indicator
Score of 10 (Fully Met): The clinic has a valid PHC License. The license number is written on the board or the outer wall. It is also displayed as a copy at the clinic, as described above. Both the external and internal displays are in place, and the license itself is current.
Score of 5 to 7 (Partially Met): One of two situations:
The clinic has a PHC Registration Certificate (an earlier stage than the full license), and it is properly displayed; or
The clinic has clear evidence of having applied for a grant of license, an acknowledgement from PHC, a bank receipt for the fee, a submission confirmation, and this evidence is available.
Dr. Amna’s case sat at the lower end of partial. She had applied. She had the proof on a phone photograph, not printed. The assessor scored it below the midpoint of partial.
Score of 0 to 4 (Not Met): The clinic has no certification, no registration certificate, and no evidence of having applied. Nothing on file, nothing displayed, no follow-up initiated.
Two Things Must Be True for a Full Score
This is a detail that many clinic owners miss even after they receive their PHC license.
Getting the license is only the first part. Displaying it correctly is the second part. A clinic that has a valid PHC license sitting in a drawer scores lower than a clinic that has the license prominently displayed at the entrance and inside the premises.
The MSDS explicitly states that a copy of the original Registration Certificate or License must be displayed at a prominent place in the waiting area, reception, and/or within the clinic. The original must be available at the clinic and shown on demand. It is not enough to know you have it. Patients entering your clinic should be able to see, before they sit down, that the premises they are in are licensed to provide healthcare.
This connects directly to the broader purpose of Standard 1: the clinic must be identifiable as a legal entity. The PHC license is the document that establishes the clinic’s legal identity. Without it being visible, a patient has no way to verify they are in a licensed facility.
The Registration and Licensing Process
For clinic owners who have not yet applied or who applied and never followed up, the process is as follows.
The PHC registration and licensing forms, guidelines, and fee information can be obtained from the Directorate of Licensing and Accreditation, Punjab Healthcare Commission. You can search Address, Phone Number and Email IDs on their official facebook Page.
The process involves submitting the application with required documents, paying the prescribed fee, and awaiting the physical inspection and assessment of the clinic. Once the clinic meets the required MSDS standards, the license is issued. The acknowledgement of application is a temporary position; it is not a substitute for the license itself, and it does not carry the same legal standing.
What Dr. Amna Did Next
The assessor’s visit, uncomfortable as it was, gave Dr. Amna something she had been missing for eleven months: clarity.
That same afternoon, she called the PHC office. It turned out that her application had been received and processed, and that her clinic was scheduled for a physical inspection, something she had not been adequately informed about. Within six weeks of following up, the inspection was conducted, the deficiencies were minor and quickly addressed, and the license was issued.
She printed two copies. One went into a frame at the main entrance beside the door. One went onto the waiting room wall in a clear plastic holder she bought from a stationery shop for eighty rupees.
At her reassessment, Indicator 3 scored a 10.
“The strange thing,” she said to a colleague afterwards, “is that the license was almost ready. I just had not followed up. One phone call was the difference between a partial score and a full one.”
You can also connect with the writer of this blog post series to share or receive suggestions: Dr. Junaid Rashid (Founder of UPMED) at 03042397393 (WhatsApp).
List of all the posts in this journey.