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NATIONAL HOSPITALS ASSESSMENT PRELIMINARY RESULTS

TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH. NATIONAL HOSPITALS ASSESSMENT PRELIMINARY RESULTS. Dr. Denis Broun April 4, 2004 Kabul. TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH. Organization of the Assessment.

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NATIONAL HOSPITALS ASSESSMENT PRELIMINARY RESULTS

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  1. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH NATIONAL HOSPITALS ASSESSMENTPRELIMINARY RESULTS Dr. Denis Broun April 4, 2004 Kabul

  2. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Organization of the Assessment • A survey of 117 hospitals was conducted in October – November 2003 • The survey was undertaken by surveyors and supervisers of the Ministry of Health • The surveyed hospitals were identified from the national facilities database • Excellent cooperation was received from hospital managers and staff.

  3. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Acknowledgement This assessment has been made possible thanks to the financial support of: • The European Commission • The French Government and • USAID • UNFPA • JICA

  4. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH GENERAL FINDINGS

  5. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Location of Hospitals & Clinics included in survey (with main roads)

  6. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Some facilities are called « hospitals » but have no beds: • Khan Abad Hospital (Kunduz Province) • Imam Sahib Hospital (Kunduz Province) • Shahjoi Hospital (Zabul Province) • Others have less than 10 beds and can hardly operate as hospitals: • Said Karam Hospita (Paktya Province) – 1 bed • Tamir Hospital (Paktya Province) – 2 beds • Tafahosat Hospital (Balkh Province) - 3 beds • Hairatan Hospital (Balkh Province) – 4 beds • Qaisar Hospital (Faryab Province) – 6 beds • Bilchiragh Hospital (Faryab Province) - 6 beds • Panjwayi District Hospital (Kandahar Province) – 6 beds • Arghistan District Hospital (Kandahar Province) _ 8 beds • Rustaq Hospital (Takhar Province) – 9 beds • Dehrawood Hospital (Uruzgan Province) – 9 beds • 3 health clinics without beds were also surveyed

  7. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Type of facilities covered by the survey Facilities without beds, health centers and clinics with beds 10 (8.5%) Specialized hospitals 10 (8;5%) 7 in Kabul District hospitals 76 (65%) Provincial hospitals (or equivalent) 21 (18%)

  8. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Number of beds per hospital: Less than 10 beds 17 14.5% 10 to 20 beds 17 14.5% 29 to 30 beds 17 14.5% 30 to 40 beds 11 9.4% 40 to 50 beds 6 5.1% Total hospitals of less than 50 beds: 68 (58%) 50 to 100 beds 28 23.9% 100 to 200 beds 8 6.8% 200 to 300 beds 7 6.0% More than 300 beds 6 5.1%

  9. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Number of beds by hospital

  10. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Distribution of hospital beds per province • Hospitals are unevenly distributed among the various parts of the country. The figures of population per hospital bed show these discrepancies rather well, although they to not give a full picture of the situation. • Kabul province has the largest concentration of hospital beds (although they are unevenly distributed among districts within the province). • The provinces of Utuzgan, Nuristan, Ghor and Sari Pul have the lowest quantity of hospital beds per population in the country.

  11. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Bed ratio per province : population per hospital bed

  12. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Variations in the number of beds Some facilities have an important discrepancy between the official and the actual number of beds. Discrepancies have been found in both directions Hospital with less beds than anticipated Qal-i-Naw hospital (Badghis): 60 beds instead of 96 expected Karte 3 Surgical hospital (Kabul): 416 beds instead of 454 expected Qalat hospital (Zabul): 82 beds instead of 102 expected Hospital with more beds than anticipated Faryab Central hospital (Faryab): 100 beds instead of 43 expected Emergency Surgical Centre for War Victims (Kabul): 102 beds instead of 81 expected Panjshir Emergency Surgical hospital (Parwan): 85 beds instead of 49 expected.

  13. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Types of hospital beds available According to the Basic Package, district hospitals (and provincial hospitals) should be able to provide at least medicine, surgery and maternity services. However, the assessment showed that this was seldom the case, and many districts do not have access to a facility able to provide such services. Thre provinces do not have a single such facility in any district (Uruzgan, Zabul, Nuristan).

  14. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Presence of medicine, surgery and maternity together in an least one hospital Provinces without one facility with the 3 basic hospital services Hospitals with functional « maternity, surgery and medicine » departments. In yellow, provinces without such hospitals

  15. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH BED OCCUPANCY RATES

  16. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Questionnaires included questions about average length of stay and bed occupancy rate. • Most hospitals did not have this information available. Only 19 of the 117 facilities surveyed (16%) had both indicators available. • The average length of stay varied between 4 and 10 days, with a median at 7 days. • The bed occupancy rate varied between 10% and 85% with a median at 50% • The bed occupancy rates declared by the hospital directors corresponded to the observations made by the surveyors.

  17. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • On the day of the survey • Of the 8,237 beds in the surveyed facilities, 3,843 were occupied. The corresponding bed occupancy rate amounts to 46.4% • 46.7% of the beds were occupied by female patients • 21 of the hospitals with beds (19%) did not have a single in-patient hospitalized. These empty hospitals wards were seen in facilities with 10 to 30 beds

  18. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Only 7 hospitals had an occupancy rate above 80% on the day of the survey: • Bamyan Central Hospital (Bamyan province) • Hirat Regional Hospital (Hirat province) • Ali Abad Hospital (Kabul province) • IbnSina Emergency Hospital (Kabul province) • Indira Gandhi Child Health Hospital (Kabul province) • Mirwais Hospital (Kandahar province) • Parwan Provincial Hospital (Parwan province)

  19. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH STAFFING OF HOSPITALS

  20. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Levels of staffing in the surveyed hospitals The 117 surveyed facilities declared that they had a total of 13,247 employees, of which 7,635 support staff (57.6%). Th number of staff per facility varied from 5 in Panjwayi District hospital (Kandahar) to 584 in Indira Gandhi Child Health hospital (Kabul). Hospitals in Kabul district employed a total of 5,441 staff, representing 41% of the total hospital staff of the country.

  21. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Proportion of Staff categories by province (size=total nb staff in province)

  22. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Staff ratio per bed By all standards, Afghan hospitals have too much staff compared to the required level, especially in the light of the needs of primary care facilities. The average number of staff per bed for the country is 1.57, which corresponds to a level of specialization that Afghan hospitals do not have on the whole. This figure takes in consideration the actual number of beds. Another ratio to consider is that of the total number of personnel present at the time of the survey over the number of occupied beds. This ration is as high as 2.7. There are important variations in the ratio from one province to another.

  23. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Total staff per bed, by province (all categories)

  24. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH « Medical » staff per bed, by province (doctors, nurses/midwives, other health workers)

  25. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Staff density Some facilities operate well with a reasonable number of staff: Medical Hospital of Nangarhar (Nangarhar), General Hospital of Public Health (Nangarhar), Nasgee hospital (Baghlan), Ata Turk hospital (Kabul), Hirat Regional hospital (Hirat) operate with a density of 1 staff per bed or less. Others have a much larger staff density, still with a low bed occupancy rate: Kabul Mental hospital (Kabul), Police Hospital (Kabul), Indira Gandhi Child Health hospital (Kabul), Kunduz Regional hospital (Kunduz) have more than 2.5 staff per bed. In spite of high densities of staff, 25% of facilities declared that they had to cancel vacations in 2002 because of staff shortages.

  26. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Payment of staff In more than 64% of surveyed cases, full salaries had not been received in 4 months or more. Only 7% of facilities had received full civil servant salaries in the last 3 months.

  27. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Female staff Female staff represented 24.5% of the total staff of the surveyed hospitals

  28. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Male/female ratio among hospital staff

  29. Percentage Female Staff • 0-15% • 15 – 25% • 25 – 38% TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Percentage of female staff (all categories) by province

  30. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Preliminary conclusions on the first part of the survey analysis • Afghanistan has a relatively low number of hospitals and hospital beds compared with other developing countries. The ratio of 1 bed for 1,000 people is not reached in any province • The distribution of hospital facilities and services is uneven with large parts of the population unable to access referral facilities • Hospitals are generally over-staffed, particularly in the large urban areas. • Too few facilities have an adequate number of female staff to provide accesptable services to the whole population they are supposed to serve.

  31. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH PHYSICAL CONDITION OF HOSPITALS

  32. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Age and Rehabilitation Afghan hospitals are not very old. Dates of construction stated by interviewees during the survey ranged between 1312 (Maiwand Hospital) and 1382 (Sharan district hospital in Paktika). The physical condition of buildings is often acceptable. It was assessed in detail service by service. 43 hospitals (37%) are currently undergoing a rehabilitation project. This imposes heavy management and coordination constraints. 53 hospitals (45.3%) are currently undergoing an expansion project (which may be part of the rehabilitation project).

  33. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Damages 47 of the 117 surveyed hospitals (40%) suffered some degree of damage because of actions of war. War damages to hospitals started as early as 1358, and the most recent war damaged dated back to 1380. The peak of destructions happened in 1371. In addition, two hospitals of Wardak province were damaged by an earthquake in 1379.

  34. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Access to power • 19 hospitals had no access to power at all (16%). • 34 hospitals had a haphazard supply of electricity with power available less than 12 hours per day. • 85 hospitals (73%) had a functional generator to supply electricity • 4 hospitals used solar energy as a complement: Rukha hospital (Parwan), Mehtar Laam Baba Regional hospital (Laghman), Noor hospital (Kabul) and Dasht-i-Qala hospital (Takhar) and one used wind energy: Mehtar Laam Baba Regional hospital (Laghman)

  35. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Access to electrical power in surveyed hospitals

  36. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Access to water 20 hospitals had no access to water at all (18%) 12 additional facilities had access less than 12 hours per day. 14 of hospitals connected to a water distribution network also have a water tower in case of failure Number of hospitals with access to water.

  37. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Access to drinking water in surveyed hospitals

  38. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Water & Power Supply • Water & Power> 12h (53) • Water & Power< 12h (22) In green: good access to water and power In red: access to water and power less than 12 hours/day.

  39. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Sanitation 96 out of 117 hospitals indicated the sanitation system in use. Waste water was generally managed by a combination 2 or more systems: 7 of the 10 hospitals connected to a city sewage system had a septic tank or a pit before spreading 67 of the 69 hospitals with a septic tank but no connection to a city sewage system used in addition a pit before spreading and or had pits below latrines. 17 hospitals have neither a connection to a city sewage system nor a septic tank but have pits before spreading and or below latrines. On the whole, appropriate attention was paid to sanitation in surveyed hospitals

  40. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Solid waste management 47 hospitals, accounting for 35% of the beds in the country, had no functional waste management system: 74 hospitals had an incinerator, of which 53 in perfect condition; 24 hospitals have an additional system for medical waste or other solid waste to compensate for the relatively poor condition of their incinerators. Specific management of medical waste remained exceptional and deserves more attention.

  41. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Access to communication 16 facilities ( 13.5%) had no communication capability whatsoever, but more reported that their communication was not permanently functional.

  42. Provinces with worst access to communication TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Surveyed hospitals with access to communication (functional phone or radio)

  43. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Transportation A lot of cars and ambulances have been supplied to Afghan hospitals over the past 2 years. There are major discrepancies between regions and facilities regarding the availability of transportation. It is often facilities located in difficult to access areas which are less well equiped.

  44. Provinces with worst access to transportation TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Surveyed hospital with vehicle (ambulance, car or van)

  45. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH Diagrams to determe investment priorities

  46. Hirat Regional Hospital (Hirat) has a better than average infrastructure, but still access the power network irregularly. In Garziwal hospital (Faryab), the good infrastructure is not supported by any other element that would make the hospital functional

  47. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Preliminary conclusions on the second part of the survey analysis • Afghan hospitals are in a relatively good condition in spite of the 20 years of armed conflict. Strong international cooperation is rehabilitating and expanding facilities, but actual needs seem not to have always been thoroughly analyzed. • In spite of recent investment, access to power and water remains a problem for many hospitals, and could be addressed relatively easily. • Waste management, especially for medical waste, requires additional efforts. • The building cluster indicators approach may help target investment priorities.

  48. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Analysis of specific hospital functions • The survey gathered elements of a complete functional analysis of facilities. However, particular functions were analyzed in priority: • Emergencies • Blood banks • Maternities and emergency obstetric care • Operating theaters and sterilization

  49. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH EMERGENCIES Emergencies are the main point of entry of patients with the hospital system. The emergency department (ER) is often used for primary care consultations Many district hospitals that did not have in-patients received patients in the ER.

  50. TRANSITIONAL ISLAMIC STATE OF AFGHANISTANMINISTRY OF HEALTH • Performance of emergency rooms • 30% of all surveyed facilities had no emergency room at all. • Some entire provinces have access to only one single ER. • Most ER were poorly equipped and not able to handle some of their basic functions: • only 10 hospitals could perform an electrocardiogram in the ER. • only 26 hospitals had oxygen available in the ER. • Over 40,000 patients/month are seen in ER of 82 hospitals • Actual total is probably much larger, as several hospitals do not keep a registry of emergency cases. • 252 hospital beds are labeled “emergency room beds”.

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