Standardization of Obstetrics and Gynecology in Afghanistan

1. Standardization of Obstetrics and Gynecologyin Afghanistan Q. Mojadidi, M.D. FACOG

2. Main Causes of Maternal Mortality • Not recognizing the seriousness of the problem • Reluctance to take the patient to the doctor (not trusting the doctors and the hospitals and cultural influence) • Absence/lack of transportation • Lack/absence of roads • Lack/absence of family planning (the least expensive, fastest, easiest and most effective way to reduce MM by 30-50%) • Lack/absence of proper medical facility • Lack/absence of expert physician • Lack of financial resources • Lank/absence of education

3. عللوفیاتمادرهادرافغانستان ۱- مراجعه نکردن مریض و مریضدار به داکتر و شفا خانه  قرار احصا یه ۸۵ فیصد مردم افغانستان  اعتمادخود را بالای داکترها و شفاخانه ها از دست داده اند ۲- ندانستن وخامت مریضی که باید به شفاخانه مراجعه کنند ۳- فقدان یا نبودن وسایلنقلیه ۴- فقدانسرکمخصوصادرزمستان ۵- فقدان یا نبودن کلنیکهاو یا شفاخانهایشایستهوقابلاعتبار ۶- فقدان یا نبودن داکترهایشایستهوقابلاعتبار ۷- فقدان یا نبودن کلنیکهایرهنمایخانوادهبرایکنترولازولادتهایپیهمکهارزانترینسریعترینوموثرترینمیباشدووفیاتراتاحدود۵۰درصدتنقیصمیدهد۷- فقدان یا نبودن تنویرافکارعامه ۸- فقدان یا نبودن وسایلضروری ۹- فقدان یا نبودن پشتیبانیپول

4. Main Causes of Maternal Mortalityin USA The seven causes of death—hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions—each contributed 10% to 13% of maternal deaths. Mortality is increased in the USA from 12 per 100,000 to 14 per 100,000.

5. The reasons for the reported increase in pregnancy-related mortality are unclear; possible factors include: an increase in the risk of women dying, changed coding with the International Classification of Diseases, 10th Revision, and the addition of states of pregnancy checkboxes to the death certificate. State-based maternal death reviews and maternal quality care collaboratively have the potential to identify deaths, review the factors associated with them and take action on the findings.

6. Definition • To provide standard care (evidence based) in Obstetrics and Gynecology to a population • How do we define standard of care?

7. Management Administration Finance Cost Recovery Infrastructure and Supplies Authority Responsibility Accountability Standard Quality Health Care and Training Qualified Trainers Qualified Trainees Monitoring Certification Rewards

8. Introduction • Teaching medical personnel and health system employees about Standard care (evidence based medicine) • Recognition of the magnitude of the project • Program should be designed for the Afghan context, in terms of available resources • Teaching and assessing medical facility employees about professionalism and medical ethics

9. Necessary Elements • Knowledgeable and skilled faculty (Trainers) • Standard infrastructure within all supporting departments • Understanding evidence based medicine (standards) • Adequate funding • Absolute transparency and accountability • Over site and data collection • Authority and control for the programs directors

10. Program Design • Practical approach • Sites with limited infrastructure should be upgraded and rehabilitated according to health care standards into teaching hospitals for human resource development in the major specialties • Provide adequate funding for the first 3-5 years to pay for qualified faculty to train future trainers • Selection of limited provincial sites based on priority of needs, availability of human resources, funds, and security • Need for specific curriculum for every stage of the projects (available in OB/GYN) to meet the needs of Afghans • Long term and short term planning and sustainability for each term • Availability of protocols and policies to implement curriculum

11. Program Design continued • Fee for service on a sliding scale basis is essential for sustainability (because there is no free medical care in Afghanistan now, patients are paying for their expenses) • Approval of fee for service by the Afghan cabinet and parliament • Drastic policy changes for the Afghan physician’s private practices in terms of patient management, professionalism, and medical ethics • Protocols in Obstetrics and Gynecology and other specialties should be provided and taught to respective staff as a rapid infusion to the system. Physicians must be accountable for implementation • Planning and commitment by MoPH to utilize the trained physician properly. • MoPH must implement the same training program model in all perspective MoPH medical facilities.

12. Cost of Health care for Patients in Government Hospitals(Survey from the family) • D & C Afs 1,500.00 • Hysterectomy Afs 5.000.00 • Normal delivery Afs 1,500.00 • C/Section Afs 5,000.00 • Doctors fee (illegal) Afs 5,000.00 to 20,000.00 • Appendectomy Afs 5,000.00 • Bribes to supporting personnel not known • Medicine and equipment (cath etc.) not included

13. CURE International Costs • Normal delivery 6000 Af • D&C 3000 Af • C/Section 15000 Af • TAH 12000 AF

14. Main Approach to Standardization • Rapid infusion to the system (short term planning) • Development of EOC and OB/GYN protocols (standards) for all Afghanistan clinics and hospitals • Development of protocols for all specialties • Establishment of teaching institutions according to health care and health education standards to produce and develop human resources • Development of policies for accountability and responsibility to implement protocols • Development of a fellowship program in OB/GYN and other specialties to train the trainers • CURE International Hospital OB/GYN 2006-2007 fellowship program as a pilot project has proven to be very successful and applicable for Afghan needs • Implementation of JPIGO PQI standards in selective sites and hospitals by an independent task force, including accountability, observation, over site and data collection

15. Professionalism and Medical Ethics • Afghan OB/GYN medical practice is an absolute disaster • Unless we teach professionalism and medical ethics, emphasizing zero tolerance for violators, we won’t be able to standardize medical practice • The majority of Afghan OB/GYN private practices are unethical, unprofessional, and dangerous, costing the health and lives of hundreds of people every day • The most effective way to remedy this problem is to employ OB/GYN protocols in all private offices (essential protocols are available). Over site and accountability is essential for this issue

16. Long Term Planning • Development of 3-4 year structured residency program based on availability of resources • Development of curriculum for all specialties and training programs (The Cure Pilot Project in OB/GYN can be extrapulated to all specialties) • Development of house officer manual • Each project needs to have departmental policies and procedures based on the departmental standardization • Administrative and technical support and an allocated budget is needed for each department

17. Long Term Planning Continued • The selected institutions/hospitals/clinics should be rehabilitated to basic standards, in terms of infrastructure, administrative and logistic support, equipment, procurement, educational materials, library, information technology, supportive departments, security, sustainability, etc. • After development of resources, gradually, all hospitals and clinics should be standardized • After implementation of this project and the development of more resources and experience, the same project model can be applied to all other specialties • Within 5-10 years of proper implementation of this program, a large portion of Afghan women should be receiving standard medical care in OB/GYN

18. Initial Model Institution Training • Functions as a factory for producing human resources in all related health care and health management. • Health management and administration • Hospital management • Nursing administration and supervision • Laboratory training and management • Facility management and maintenance • House keeping and laundry • Risk management • Dietary management • Security • Infection prevention • Finance cost recovery, and collection • Hazardous material disposal • And many more

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