j i c a (jica)cwek central workshop for equipment in kabul dfid department for international...

JAPAN INTERNATIONAL COOPERATION AGENCY (JICA)

URGENT REHABILITATION SUPPORT PROGRAMME IN AFGHANISTAN - EDUCATION, HEALTH AND

BROADCASTING SECTOR (URSP-EHB)

PART 3: HEALTH SECTOR SHORT-TERM REHABILITATION PLAN

IN KABUL CITY

AUGUST 2002

PACIFIC CONSULTANTS INTERNATIONAL, TOKYO JAPAN NHK INTEGRATED TECHNOLOGY INC., TOKYO JAPAN

ABBREVIATIONS AACA Afghanistan Assistance Coordination Authority ACBAR Agency Coordinating Body for Afghan Relief ACF Afghan Community Foundation ADB Asian Development Bank AIA Afghanistan Interim Administration (Authority) AIMS Afghan Information Management System ANCB Afghan NGOs’ Coordination Bureau ARF Annual Risk for Infection ARI Acute Respiratory Infection ATA Afghanistan Transitional Administration (Authority) BCG Bacille de Calmette et Guérin BPS Basic Package of Services CHW Community Health Workers CIMIC Civil Military Cooperation CJMOTF-USA Coalition Joint Military Operations Task Force - USA CNA Comprehensive Needs Assessment CWEK Central Workshop for Equipment in Kabul DFID Department for International Development, U.K. DOTS Directly Observed Treatment Short-Course EC European Commission ECHO European Commission’s Humanitarian Aid Office EHB Education, Health and Broadcasting ENT Ear, Nose and Throat EPI Expanded Program on Immunization EU European Union GMS German Medical Service GOJ Government of Japan GTZ Deutsche Gesellschaft für Technische Zusammenarbeit HIS Health Information System HNP Health, Nutrition, and population IACC Inter-Agency Coordination Committees ICC International Chamber of Commerce ICRC International Committee of the Red Cross ICU Intensive Care Unit IDA International Development Association IDPs Internally Displaced Persons IMR Infant Mortality Rate IPD In-Patient Department ISAF International Security Assistance Force ITNs Insecticides Treated Nets JICA Japan International Cooperation Agency KfW Kreditanstalt fuer Wiederauf KTC Kabul Tuberculosis Center MCH Maternal-Child Health MICS Multiple Indicator Cluster Surveys MOPH Ministry of Public Health MOWA Ministry of Women’s Affairs

MSF Medicine Sans Frontieres MSH Management Sciences for Health NGO Non-governmental Organization NTBI National Tuberculosis Information NTI National Tuberculosis Institute NTP National Tuberculosis Program OPD Out-Patient Department ORS Oral Rehydration Solution PARSA Physiotherapy and Rehabilitation Support for Afghanistan PHC Primary Health Care PIH Pregnancy Induced Hypertension PPAs Performance-based Partnership Agreements SWAPAC Source Water Assessment Program Advisory Council TB Tuberculosis TBA Traditional Birth Attendants TDH French NGO UN United Nations UNAMA Union Nations Assistance Mission in Afghanistan UNDP United Nations Development Programme UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund URSP Urgent Rehabilitation Support Programme URSP-EHB Urgent Rehabilitation Support Programme covering the Education, Health,

and Broadcasting sectors USAID United States Aid for International Development UXO Unexploded Ordinance WFP World Food Programme WHO World Health Organization WRA Women of Reproductive Age

- i -

TABLE OF CONTENTS PREFACE ABBREVIATIONS MAP OF HEALTH INSTITUTIONS

Page

PART 3 HEALTH SECTOR SHORT-TERM REHABILITATION SUPPORT PLAN

CHAPTER 1: INTRODUCTION ........................................................................... 1 - 1

1.1 Background of the Plan Formulation ............................................................... 1 - 1 1.2 Objective of the Plan Formulation................................................................... 1 - 1 1.3 Definition of the Planning Period .................................................................... 1 - 2 1.4 Long-Term Goals and Short-Term Objectives ................................................ 1 - 3 1.5 Overall View of the Health Sector Situation in Afghanistan ............................. 1 - 4

CHAPTER 2: UNDERSTANDING OF THE PRESENT HEALTH-SECTOR CONDITIONS IN KABUL CITY ....................................................... 2 - 1

2.1 Maternal-Child Health (MCH) Care.................................................................. 2 - 1 2.2 Hospitals for Women’s Health Care................................................................. 2 – 2 2.3 Tuberculosis and Communicable Diseases...................................................... 2 – 5 2.4 Public Health Care and Referral System........................................................... 2 – 7

2.4.1 Referral System ................................................................................. 2 - 7 2.4.2 Health Information System................................................................ 2 - 7 2.4.3 Financial Issues ................................................................................. 2 - 8

2.5 MOPH Organization and Functions ................................................................. 2 - 8

CHAPTER 3: DONOR COORDINATION AND ACTIVITIES .................................. 3 - 1

3.1 The World Health Organization (WHO) ............................................................ 3 - 1 3.2 Activities of International Agencies and NGOs ................................................ 3 - 1 3.3 Present Situation of Donor’s Support for Hospitals and Clinics ....................... 3 - 4

CHAPTER 4: SHORT-TO-MID-TERM REHABILITATION STRATEGY FOR THE SECTOR ................................................................................ 4 - 1

4.1 Basic Strategy for the Short-to-Mid-Term Rehabilitation Plan ........................ 4 - 1 4.2 Maternal and Child Health Care....................................................................... 4 - 1 4.3 Tuberculosis and Communicable Diseases...................................................... 4 - 3

- ii -

4.4 Preventive Medicine ........................................................................................ 4 - 4 4.5 Public Health Care and Referral System........................................................... 4 - 5 4.6 Health Care Planning and Management........................................................... 4 - 5 4.7 Priority Areas for the Short-Term Health Sector Rehabilitation in Kabul City ......... 4 - 6

CHAPTER 5: CONCEIVABLE SHORT-TERM REHABILITATION PROJECTS AND PROGRAMS .......................................................................... 5 - 1

5.1 Basic Strategies for the Formulation of Projects and Programs ....................... 5 - 1 5.2 Recommended Short-Term Rehabilitation Projects and Programs .................. 5 - 1

5.2.1 Integrated Improvement Program for Maternal-Child Health (MCH) Clinics in Kabul City.......................................................................................... 5 - 1

5.2.2 The National TB Center Strengthening Program for Training, Research & Information, Reference Laboratory Functions.................. 5 - 2

5.2.3 Gynecological Clinical Capacity Strengthening Program of Malalai Hospital and Rabia Balki Hospital in Kabul to Assume Central Functions to Expand Reproductive Health Care over Afghanistan ...................................... 5 - 3

5.2.4 Comprehensive Communicable Disease Measures Support Program in Kabul City ................................................................................................... 5 - 4

5.2.5 The Disability Care Center in Kabul City ............................................ 5 – 5 5.2.6 Establishment of Maintenance and Management System for Medical Facility

in Kabul City...................................................................................... 5 – 5

APPENDIX: A) LISTS OF EXISTING EQUIPMENT AT RABIA BALKHI HOSPITAL AND MALALAI HOSPITAL B) DRAWINGS OF RABIA BALKHI HOSPITAL AND MALALAI HOSPITAL C) RESULTS OF QUICK INTERVIEW SURVEY OF PATIENTS AT RABIA BALKHI HOSPITAL D) RESULTS OF QUESTIONNAIRE SURVEY AT RABIA BALKHI HOSPITAL AND MALALAI

HOSPITAL

Part 3

Health Sector Short-term Rehabilitation Plan (1-1)

CHAPTER 1: INTRODUCTION 1.1 Background of the Plan Formulation Since 1979, Afghanistan has been in total disorder from the political instability. The years of conflict have had massive effects on the physical and mental health conditions of Afghan people. Post conflict reconstruction supported by international agencies has been initiated since September 2001 and the Interim Government of Afghanistan has been set up to reorganize the whole country. In response to the commitments of international communities for Reconstruction Assistance to Afghanistan made at the Tokyo Conference in January 2002, the Government of Japan (GOJ) has pledged financial assistance of 500 million dollars for urgent humanitarian assistance in the sectors of education, health and medical care, resettlement of repatriated refugees, landmine clearance, and empowerment of women. In line with the urgent humanitarian assistance, Japan International Cooperation Agency (JICA) has initiated the Urgent Rehabilitation Support Programme covering the Education, Health, and Broadcasting sectors (URSP-EHB) in Afghanistan in April 2002, in collaboration with the Afghan Interim Administration (AIA)1. In a humanitarian crisis, food, shelter, and water are the essential components needed to save lives of Afghans. Without medical facilities to treat common disease, fatality rates cannot be improved rather could even become worse. Especially in winter months, cold weather brings life threatening diseases that are difficult treat without shelters or medical supply. In hot summer months, epidemic diseases are easily rampant chiefly due to lack of safe water availability and poor hygiene environments. The URSP-EHB intends to rehabilitate or reconstruct the war-damaged and destroyed buildings and their associated equipment for selected schools in Kabul City, the National TB Institute and its Kabul TB Center (hereinafter collectively called “the TB Center”). The URSP-EHB also attempts to formulate a short-term rehabilitation plan so that the above-stated urgent rehabilitation projects should be rightly positioned and seamlessly sustained from urgent rehabilitation towards future reconstruction and development. And this is a part of the plan covering the health sector in Kabul City. Helping Afghans survive and improve their lives is one of key concerns for the GOJ. Lifeline supplies such as safe water or shelters or medical facilities to Afghanistan is critical as many Afghans are unable to afford to get them nor to complete medical treatment when they get sick for many reasons. 1.2 Objective of the Plan Formulation While international donor agencies and the Government of Afghanistan are developing health sector development strategies for all regions in the country, the Short-Term Health Sector Rehabilitation Plan, proposed by JICA, focuses on comprehensive health sector rehabilitation and reconstruction in Kabul City only2. Kabul is the most important city center in the country and is situated on cross roads to economic, social and industrial development – all aspects that in turn affect the overall development in other parts of Afghanistan. It is believed that a strong health care system in Kabul City, in terms of both capacity and quality, would have positive ripple effects in other regions of the country. 1 After the Emergency Loya Jirga, it is called “Transitional Government of Afghanistan”. 2 Security is of the principal constraint for GOJ to conduct projects outside Kabul City.

Part 3


During April 8-27 and June 25 – July 27, the URSP-EHB Team members held a series of dialogues with the government officials of the Ministry of Public Health (MOPH), WHO, other international donor agencies and NGOs, as well as administrative staff and doctors of various hospitals and clinics in Kabul. The purpose was to assess the current situation in the health sector and to develop a tentative short-term rehabilitation plan for Kabul City. Based on the rehabilitation needs identified from these discussions and the Aide-Memoire prepared by the Joint Donor Mission to Afghanistan participated by a JICA expert, this Health Sector Rehabilitation Plan is proposed. The Health Sector Rehabilitation Plan is recommended to be a “rolling plan” where program implementation strategies should be flexible enough to accommodate the fluid situation arising from the political and social dynamics of the Afghan society. The objectives of formulating the plan are threefold. (1) To analyze the current situation of the health sector and study for its possible

restoration in Kabul City, (2) To conceive reconstruction strategies and inspire the planning direction and

activities for the national tuberculosis control program in the future, and (3) To formulate short-term projects and programs for priority areas in the health

care sector. In formulating the plan, the Aide-Memoire discussed and agreed upon in March 2002 between MOPH and the Joint Donor Mission to Afghanistan on the Health, Nutrition, and Population Sector3 , was quoted elsewhere as a basic policy guideline. The Aide-Memoire covers the framework for assistance to the sector over the next 2.5 years, beginning discussions on an investment program that could be operational in the next 3-4 months, and attempting to identify a practical, efficient, and the government-led mechanism for partner coordination. 1.3 Definition of the Planning Period As agreed upon at the International Conference on Reconstruction Assistance to Afghanistan held in January 2002 in Tokyo, the international community pledged the financial assistance amounting to 45 billion dollars over the coming two and a half years, or by the middle of the year 2004. At present, most of the international donor agencies are working for the urgent rehabilitation of Afghanistan along this time frame, and therefore, it is reasonably presumed that the short-term rehabilitation plan should adopt the same target period consistent with the internationally coordinated efforts for the rehabilitation.

3 Joint Donor Mission to Afghanistan on the Health, Nutrition, and Population Sector: The First Donor Mission led by the World Bank, the World Health Organization (WHO), the Asian Development Bank (ADB), the Department for International Development (DFID) of the United Kingdom, the European Union (EU), the United Nations Children’s Fund (UNICEF), the United Nations Fund for Population Activities (UNFPA), and the United States Agency for International Development (USAID), visited Afghanistan from March 19 to April 2, 2002. The Second Joint Donor Mission led by ADB, EC, French Cooperation, GTZ, JICA, KfW, UNFPA, UNICEF, USAID, WHO, and the World Bank, in addition, visited Afghanistan from July 13 to 27, 2002.

Part 3


1.4 Long-Term Goals and Short-Term Objectives Long-term goals are naturally to reduce to a reasonable level the morbidity, mortality and disability through an appropriate and equitable balance of preventive, curative, rehabilitative and emergency health services based on the concept of Primary Health Care (PHC). More specifically, it includes the following requirements. (1) Increase of accessibility to basic health services from current levels and promote

equitable access across geographic, ethnic, religious, and gender boundaries, (2) Improvement of the quality of existing health services and integrate the PHC

components, including reproductive health, child health and immunization, nutrition, safe water, sanitation, health education, treatment for common diseases and injuries including essential drugs, care and rehabilitation of disabled people, and mental health, as well as promotion of gender equity and respect for human rights in all health services,

(3) Strengthening the capacity and competency of health workers at all levels

including operation and management, and (4) Improvement of the rehabilitative services for people with disabilities, including

their integration in the community as a mainstream of development processes. In order to fulfill the requirements, MOPH is required to play a national leading role, assuming the previous responsibilities for politically and administratively mandated areas. This is an important share of responsibility distinctive from a system where NGOs and UN agencies were perceived as being responsible for the provision of health services. The departments of MOPH are not yet fully functional at present. Work has still been undertaken to identify the main health policy lines. Health information systems, and budgeting and planning processes in MOPH are not well developed and they consequently limit the capacity of MOPH to plan strategically. Communication systems between hospitals and public / private clinics are hampered by lack of its capability, coupled with the limited information transmitted via NGOs and UN agencies. While the short-term goals are to reduce the rate of infant and child mortality, maternal mortality, child malnutrition, and fertility, there are no sensible indicators to use for reasonably accurate planning over the next 2.5 years. These impact indicators should be tracked over the fairly long period in the health sector with the initial tracking progress over the next 2.5 years. Instead, the Government should focus on improving output indicators directly related to its essential services. It would be of importance to rapidly obtain baseline data on these from a national-level survey (refer to Table 2.1). Given the paucity of baseline data, targets should be seen as approximate only. What is needed is to clear reasonable progress along these parameters. Given the current situation where NGOs are heavily involved in the health sector, it would be responsible for MOPH to explicitly work with them through performance-based partnership agreements (PPAs). PPAs are not new and have been successfully implemented in other post-conflict situations such as in Cambodia. They allow the Government to harness existing NGO capacity and allow the Government to set the strategic direction for the health sector and ease the burden on the government of providing services and allow it to focus on its key strategic roles. The Inter-agency Coordination Committees (IACC) has already been working effectively in coordinating with partner activities.

Part 3


The URSP-EHB will rehabilitate the TB Center that was built 23 years ago by the grant-aid assistance of the GOJ but thereafter damaged considerably due to the war affairs, thus resulting in the long-abandoned situation. During the chaotic period in Afghanistan, curative methods for TB have been much advanced in the world as represented by Directly Observed Treatment Short-Course (DOTS), and Afghanistan was left behind the modern technology with the result that TB still remains as the most serious infectious disease in the country. MOPH has expected that the GOJ will contribute in the field of TB program, such as rehabilitation of the TB Center, supply of medial equipment, training of human resources, and/or refreshment of knowledge of medical faculties. Along the line of these expectations, expanding DOTS treatment supported by the TB Center having primary functions for training and reference laboratory will be focused in this plan. As a basic strategy, although an urban bias issue should be properly addressed, the national functions for health services in Kabul should be reinstated first, and then the effects should be rippled over the country. Along the line of this concept, the priority field that WHO and MOPH have agreed upon is to rehabilitate the TB Center in Kabul and expand its effects to regions and provinces as transportation and communication systems are rehabilitated and improved. Improving the nation-wide health referral system and enhancing the people’s accessibility to basic health services, essential drugs and immunizations could cut the mortality rates in half. 1.5 Overall View of the Health Sector Situation in Afghanistan Afghanistan has been in total disorder from the political instability. Post conflict reconstruction supported by international agencies has been initiated after the wholesale socio-political changes in the country since September 2001 and the Interim Government of Afghanistan has been set up to reorganize the whole country. According to studies of international organizations and NGOs, there is a vicious circle that prevails linking war-torn situations and poor health societies in conflict areas. In those periods, what made the situation worse in Afghanistan was that there were many non-health system factors that influenced the health of Afghans including gender, security, education, transportation, and environmental issues and they still remain even at present. A long history of gender discriminatory policies and some of the worst elements of patriarchy value system have resulted in misery and depravation for Afghan women. Gender inequality and discrimination have dis-empowered women and have had a significant effect on women’s life expectancy and health situation. The low status afforded women is having a significant impact on their own health and that of their families. Intense ethnic rivalries and local conflict have undermined trust in public and government institutions and will remain a challenge for years to come. The pre-war human resource capacity has been eroded and there is scarcity of technical skills. The health care system could potentially do a lot of improve health status, but its coverage is limited at the moment. Little reliable information is known about the numbers and conditions of district hospitals, basic health centers nor sub-centers in Kabul City. However, according to the assessments made recently by ISAF, 13 of 28 health facilities are recorded as being in poor condition. Generally, a common need to health facilities is for reliable water

Part 3


supply and quality electricity installations and a power source. Rehabilitation is currently proceeding through international organizations and NGOs. However, data on exactly which facilities have been rehabilitated are not being collated systematically, but many NGOs have been engaged in renovating or new construction of health centers and district hospitals in Kabul City. As a matter of fact, due to lack of administrative capacity coupled with fast-changing circumstances in Kabul, MOPH is not in a position to grasp such baseline information and data4. One of the basic policies agreed upon between MOPH and the Joint Donor Mission to Afghanistan on the Health, Nutrition, and Population Sector is that the MOPH can work with NGOs on the basis of performance-based partnership agreements (PPAs) with NGOs. Given the current situation where NGOs are heavily involved in the health sector, it would be reasonable for the MOPH to explicitly work with them through PPAs. However, many issues need to be reasonably solved for the application of PPAs such as how to secure equity services in rural areas and how to introduce a “fee-for-service” concept vis-à-vis the concept of “public service obligation”. There are about 90 NGO partners active in the health sector in Afghanistan including international and local NGOs. They constitute the largest health care providers in the country, particularly in rural areas. Most NGOs focus on Primary Health Care. Several NGOs specialize in surgery and rehabilitation of victims of war (e.g. ICRS, ARCS, MDC), tuberculosis (MEDAIR), nutrition (e.g. Action Contre le Faim), Malaria and leishmaniasis (HealthNet), drug management (Pharmacy Sans Frontiere). NGOs have established a number of coordinating bodies such as ACBAR, ANCB, ICC and SWAPAC to synchronize action and share information. Not all NGOs, however, are members of these coordination bodies. The coverage of essential health services that could make a big difference to the health of the population is very poor at the moment. It is obvious that it needs to be expanded rapidly for the proper health status of the population. Therefore, JICA accepted the rehabilitation of the TB Center to include in the URSP-EHB. Also, in relation to the rehabilitation, JICA arranged to provide the URSP-EHB Team with some budget allocation to conduct a supplementary survey that can produce useful information for the implementation of the URSP in the health care sector. Accordingly, the URSP-EHB Team has arranged to conduct on a sub-contract basis the fact-finding surveys for the tuberculosis patients and the existing MCH clinics in Kabul City5.

4 The URSP-EHB Team investigated the MCH clinics according to the list provided by MOPH. However, many of them did not exist in the given locations, some were closed already and some were removed to other places due to termination of rent contracts with private owners. Eventually, the Team investigated 12 MCH clinics and found that most of them have 20 staffs including 2-3 doctors and provide services for EPI, care for pregnant women, pediatric consultation, and health education for nursing mothers. 5 The surveys will be completed by the end of October 2002, the results of which will be reported sometime in December 2002.

Part 3

Health Sector Short-Term Rehabilitation Plan (2-1)

CHAPTER 2: UNDERSTANDING OF THE PRESENT HEALTH-SECTOR CONDITIONS IN KABUL CITY

The health situation of the Afghans is one of the worst in the world. The public health services in Kabul cover only 8% of the population in 1990 and 55% in 1998 (35% in whole country). It is reported that 700 doctors were exiled from Afghanistan during 1990 and 2000. The nutritional status of children and women is obviously very poor and the low status afforded them is having a significant impact on their own health. Their lack of mobility interferes with their ability to obtain health service and women’s poor ventilated daily life inside houses may result in a higher risk of TB. 2.1 Maternal-Child Health (MCH) Care Gender inequality and discrimination have deprived empowerment of women and have had a significant effect on women’s life expectancy and health. There are risky traditional practices such as home delivery, which recent evidence shows less than 10% of deliveries being attended by health professionals (WHO 2001). Moreover, most of the Afghan population does not have access to those services such as MCH clinics or hospitals. There are massive unmet health needs although all too often data are lacking. High fertility rate and very low contraceptive rate contrast with the data showing that 80% of the women have knowledge of birth spacing and more than 90% express desire to use contraception. Such data indicate that a huge amount of work is required to overturn the situation long-neglected women’s reproductive rights. The Government policies on gender issues are standing at an early stage of development. There are more than 40 primary health care clinics including MCH clinics in Kabul City. Most of them are supported by various NGOs and they are managing in different ways without positive and effective linkage of each other’s program. A series of studies conducted by those NGOs during the last six months have found that 40% of children suffer from chronic malnutrition and 6% are acutely malnourished. The poor health status of women and children is exacerbated by a very high fertility rate and low contraceptive prevalence. The high rate of anemia in women is reported and the total fertility rate is about 6 children per women.

Table1 2.1 Health Situation in Afghanistan

Health Category Situation

Life expectancy Male 45 years, and female 47years Infant mortality (<1 year) 165 per 1,000 live birth Child Mortality (<5 years) 257 per 1,000 live birth Maternal mortality 1,700 per 100,000 live birth Chronically undernourished (<5 years) 50 % Note: Health in Afghanistan Situation Analysis, January 2002, WHO.

Part 3


Table 2.2 Mortality Rates by Cause of WRA, Kabul Region

Cause of Deaths Percentage Hemorrhage 50%PIH 15%Unknown 15%Cardiomyopathy 10%Others (sepsis, malaria) 10%Note: 74% of maternal deaths were considered to be preventable.

32% of non-maternal deaths were considered to be preventable. Maternal mortality was the leading cause of deaths accounting for 42% of WRA.

Source: UNICEF, June 2002

Nearly one thousand children died during the measles epidemic during the spring of 2000 in Afghanistan. Every one of these deaths could have been prevented if the children had been immunized or had access to basic health services. In addition to measles, Afghanistan was hit by outbreaks of hemorrhagic fever and cholera. The absence of surveillance system causes delay of the detection and confirmation of diseases, and resultant delay in taking preventive measures to control spread in the country. Focusing on the Primary Health Care (PHC) and making it available to all the population is the key to effective and efficient health services that can save and improve lives of the nation. Community-based initiative associated with poverty reduction policies need to be strengthened and expanded in parallel to the institutional capacity in order to rehabilitate the health sector in Afghanistan. 2.2 Hospitals for Women’s Health Care There are two large hospitals for women in Kabul City; the one is Rabia Balkhi Hospital that provides services in gynecology, obstetrics, surgery, internal medicine, dermatology and ENT, and the other is Malalai Hospital that provides services in gynecology and obstetrics. The existing conditions of the two Hospitals are outlined in Box 2.1.

Box 2.1 MCH and Female Hospitals in Kabul City

Rabia Balkhi Hospital The Organization Structure of Rabia Balkhi Hospital is as follows.

Director

Admini.dept Assistant Dir.

G.Service.dep

Financial dep.

Medical Records

Dermato-logy

G.Surgery Gyne &Obs.

ENT

Part 3


1. Administration (with 35 workers, consisting of 3depts. General Service dept.,

Financial Service dept., and Personnel dept.)

(1) General Service dept.(13staff) • Request drugs from the pharmacy for MOPH Curative dept. • Fuel supply from the MOPH Financial dept in terms of payment in kind. • Daily meals for patients & workers supplied by MOPH Financial dept. in

terms of payment in kind. (2) Financial Service dept.

• Salaries( for 390 workers) from MOPH. • Aid (500million Afghani/ month) for meals. • No other actual budget from MOPH

(3) Personnel dept. • Personnel management

2. Central Clinical Facilities

(1) OPD: 1 room for gynecology &obstetrics,1 room for internal medicine, ENT and Dermatology

(2) Pharmacy for IPD: OPD patients get prescriptions from the hospitals but have to buy in private clinics.

(3) IPD (total 185 beds):general surgery ward (40 beds) with 2 operation theaters, internal medicine word (40 beds), gynecology & obstetrics word (81 beds) with 2 operation theater, 1 delivery room, 1 curettage room, and 2 incubator for newborn.

(4) ENT (Otolaryngology) ward (6 beds) with 1 minor surgery room (5) Dermatology ward (24 beds)

3. Clinical laboratory 4. Radiological center 5. Blood transfusion room 6. Supply unit (source: Radia Balkhi Hospitsl.) Organization of Malalai Hospital Both the national hospitals have almost the same organizational structure except for specialties and size. (In addition, Appendix A shows lists of existing equipment, and Appendix B shows drawings of the hospitals.)

Director

Administration Assistant Dir.

G.Aff. Section

Finance Section

Medical Record

Personnel Section

Gyn. & OBST

Neonatal Ward

Pharmacy

Laboratories

Anesthetic Section

Nurse Section

Part 3


Besides these two, there are no other hospitals for women in Kabul and surrounding areas. Therefore, they are always crowded with patients and family members, who come from the city areas and surrounding regions as well. As a matter of fact, there is little opportunity for ordinary women to come these hospitals, although women, especially for reproductive age women, need to take health care services. The URSP-EHB Team conducted a quick interview survey at Rabia Balkhi Hospital in July 2002, and collected the female patients’ voices concerning their health problems and opinions in relation with the services received from the hospital. The survey identified most of the female patients have many children, suffer from various kinds of diseases, and have heavy burdens due to transportation and drug costs. Many patients have been enduring poor services and unsanitary environment in the hospital. Some of them have a mental problem caused by the prolonged civil war. Box 2.2 shows the case of a female patient who comes from outside Kabul City. Her case, however, may be a better than other women who suffer in rural areas without any relatives in Kabul City.

Box 2.2 Lailama’s Case

Her name is Lailama. She is a Pashtoon lady of 30 years old, lives in Palwan province with her husband and 5 children. She married when she was 18 years old with 5 years elder fiancée. She delivered 2 children in Peshawar and 3 in Palwan. Her sister-in-law and sometimes, her neighbour helped all the deliveries at her house. Lailama has been in Rabia Balkhi Hospital for 5 days to have operation for throat problem. Firstly, she went to an indigenous doctor in her village, and the doctor prescribed indigenous medicine, but not effected. Her relative in Kabul knows a doctor who is working at Rabia Balkhi Hospital. Then her family decided to send her to Kabul. Her hometown, Palwan is adjacent province of Kabul Province. It takes 7 hours from Palwan to Kabul and then more than 30 minutes to Rabia Balkhi hospital. She paid 200,000 afghani for taxi from Palwan to Kabul and 50,000 afghani from relative’s house to the hospital. She suffered from her absence in her house. Her husband works in the firm and no one take care their children and livestock. She wants to finish operation and go back to home as early as possible. She suffered from delay of operation. She came to the hospital to have the doctor’s consultation. The doctor, unfortunately, was in her 3 months maternity leave. Staff told her to wait for her coming back to the hospital at first, but the situation had changed to have another doctor’s consultation and operation last Saturday. Lailama asked to a doctor if she could go back to the relative's house in Kabul because the doctor said to wait a few more days for the operation. Since he said OK to go back home, she left the hospital and came back to the hospital a couple of days later. But the fact was no one had changed the actual operation schedule, and the doctor in charge of her case scolded her strongly for her absence for the scheduled operation time. Her demand for hospital is nothing but having early operation and back to home as soon as possible. (Appendix C shows other cases)

Part 3


UNICEF plans to provide a training programme for 4 female doctors in the field of “Emergency Obstetrics” in Bangladesh after the next year. In July, Rabia Balkhi Hospital requested WHO to establish a “neonatal ward”. They have some rooms for the purpose but need to have training programs for the staff to obtain the latest specialized knowledge in that field. Moreover, they need to raise funds for purchasing equipment and then for the operation and maintenance of the equipment. In reality however, the hospital facilities have common constraints for medical works in the hospitals. The following are major constraints common to the two hospitals in terms of their buildings and medical equipment. (1) Lack of safe water and poor sanitary conditions in the hospital buildings due to

obsolete facilities. (2) There are no essential equipment such as vacuum set, anesthesia machine and

monitoring machine in Operation Theater (OT) and Intensive Care Unit (ICU). These rooms also do not have Air conditioning (AC) equipment.

(3) During power failure a small generator can light only a few lights. There is no

standby power or backup system for equipment and lighting fixtures for the rooms in OT and ICU.

(4) Supply of oxygen and consumable goods is very irregular and inadequate. (5) Many problems are faced in operation of equipment in the hospitals. It seems that

it is very difficult for the maintenance section of hospital to maintain the building and equipment due to lack of knowledge, funds, spare parts, skills, and tools. Also there is no monitoring by MOPH.

(6) There is no systematic management of the hospital waste. Different types of solid

waste including medical waste are found in the hospital compound. There is no incinerator in the hospital compound to burn the hazardous hospital waste.

(7) The waiting space / place for patients or family members does not have any roof

or walls and it is very cold in winter season. Many donors and NGO are going to provide support for hospitals, but still the conditions of most hospitals and other medical facilities stand at a seriously inadequate situation. Most of them are not being operated effectively and efficiently. Other than physical constraining factors, they need human resource development by training medical staff as well as staff for operation and maintenance. 2.3 Tuberculosis and Communicable Diseases Afghanistan is said to have the highest incidence of TB of all the countries in the WHO Eastern Mediterranean Region.

Table 2.2 High TB Infection Rates

New cases of Pulmonary Sputum Smear-positive in 815 patients Male: 172 cases Female: 266 cases Total 438 cases (54%)

Note: GMS clinic in Kabul, 2001 Among adults, tuberculosis (TB) accounts for an estimated 15,000 deaths per year with approximately 70% of detected cases being among women in Afghanistan (WHO 2001).

Part 3


Curing a patient requires the Directly Observed Treatment Short-Course (DOTS) treatment over months, and hence, systems must be put in place to ensure that drugs are made available, cases are supervised, and patients are cared for during the course of their recovery. There are 9 sub-centers and a couple of clinics for DOTS treatment supported by NGOs in Kabul, but most of private clinics do not follow strictly the DOTS treatment so that patients often get incomplete treatment. Since 1996, the DOTS strategy has been started in selected areas, with varying levels of success in implementation. In Kabul City, the National TB Institute supported by MEDAIR and the clinic run by GMS have provided daily observed outpatient treatment. There has neither seen any statistics nor been able to trace patient records prior to 1996. Patient records from 1996 and a large part of 1997 are very unreliable, as many cases were not diagnosed according to the international standards. There is no case that notification is being received from private clinics, although they continue to share a significant part of the population of Kabul. Malaria, cholera, and measles occur as deadly outbreaks in Afghanistan. Malaria is an important contributor to the burden of disease and leishmaniasis is a common infectious disease. Health management information systems are in their infancy and need considerable strengthening with information technology and training, as well as streamlining and stabling support systems. Antani hospital in Kabul was a main hospital for communicable diseases in Kabul City but now the level of facilities cannot be accepted as a leading one.

Table 2.3 Mortality Rate in Afghanistan

Infectious Disease Mortality Rate TB 15,000 per year (female 13,000 per year)

Women account for 70% of cases and 64% of deaths

Measles 35,000 per year (estimated) Note: Health in Afghanistan Situation Analysis, January 2002, WHO, MICS 2001 The morbidity rate of TB is 3% in Afghanistan (data in Kabul not available). 65% of them are of female working age population (Tuberculosis in Afghanistan, WHO). 23 years of war and recent droughts have eroded household effects and assets. The coverage of essential health services that could make a big difference to the health of the population is very poor. It is an obvious need to expand rapidly the proper health care system over the country. According to MOPH, the principal objectives of the Tuberculosis Control Program are to achieve the following issues. (1) Reduce the burden of TB in the community; successful treating at least 85% and

diagnosing at least 70% of patients, (2) Initiate, strength and maintain TB control activities integrated in the PHC

activities, (3) Implement the Program and create the needed organizational structure at all

levels, (4) Enhance coordination, and (5) Develop program infrastructure and human resources

Part 3


2.4 Public Health Care and Referral System The health sector is in a critical state during and after the war period. WHO is trying to strengthen and expand the coverage of integrated Primary Health Care (PHC) for the population, focusing on disease prevention and control through immunization and outbreak response, and on essential obstetric care and trauma care, as they are regarded as key issues to turn around the worsening trends of morbidity and mortality. 2.4.1 Referral System The referral system has been slightly functioning between MCH clinics and 3 higher-level facilities that include Malalai Hospital, Rabia Balkhi Hospital, and one policlinic with 52 beds. But there is no standard referral papers or records. When doctors see serious patients in MCH clinics, they are simply told to go to those 3 hospitals by themselves. In the circumstances, one of the most serious problems for the patients is a means of transportation because they do not have any emergency public transportation. Those hospitals have ambulance cars but they are often used as staff cars not for use of patients. 2.4.2 Health Information System A Medical Records System in hospitals and clinics is not functioning virtually. Most hospitals and clinics have no standard patients cards, registration records, and prescription sheets. They usually substitute used papers for the purpose. Also, there is no systematic monitoring and supervision by MOPH. Therefore, it is difficult to trace and check the quality control of hospitals or clinics. Since June 2002, MOPH and WHO have just started “Matenal Dead Reporting System” which comprises 3 hospitals, i.e. Malalai Hospital, Rabia Balkhi Hospital and 52-Bed Policlinic. Moreover, to improve the capacity, MOPH needs a kind of “top-down & bottom-up approach”. Concerning the health situation of the rural area of Kabul, MOPH and WHO have just opened 3 Basic Health Centers under MOPH’s PHC Dept. The Planning Dept. of MOPH will establish the Health Information System (HIS) to promote the health situation of the nation all over this country. The target period of accomplishment is scheduled to be the next three years. At the moment, they have (or used to have) 4 ways of collecting medical data about approx 50 diseases which are: (1) OPD monthly report from hospitals and MCH clinics, (2) EPI regarding Measles or Tetanus and so on, monthly report mainly from MCH

clinics, (3) Refugee camp monthly report, and (4) Weekly report about main diseases They are trying to rehabilitate the system in Kabul first, and then expand to the provinces. So far, the URSP-EHB Team confirmed the actual performance of the above (1) and (2) in most hospitals and MCH clinics of Kabul City, and those medical facilities are faithfully attempting to follow the system. But the problem is that there is no feedback reaction on the reports from MOPH, although they are very much expectant to receive the MOPH’s reaction (e.g. requirement for more medicine for epidemic diseases or vaccines).

Part 3


2.4.3 Financial Issues The biggest problem faced by the hospitals is simply a financial issue coupled with the political situation, and they need financial support from any organizations especially for budgeting the recurrent costs. Malalai and Rabia Balkhi Hospitals, for instance, do not obtain any other incomes except for personnel cost. MOPH per se obviously does not have the budgetary capacity for the operation and maintenance of health facilities and equipment, as well as to enhance their services in the future. Therefore, those hospitals under MOPH are directly affected by the financial situation of MOPH and they cannot cope with the financial problems by themselves. Concerning the budget, the World Bank, WHO, MOPH and other organizations have already started discussing about the possibility of adoption of “the Basic Package of Services (BPS) in the Joint Donor Meeting in July 2002. As to the matter to management, the Administration Department of MOPH does not have the capacity for the management and leadership, which is, in fact, one of the most crucial issues for the hospitals and clinics under MOPH. There seems to be an urgent need to establish a steering committee for the administration and management of hospitals under MOPH. Simultaneously, activities aiming at the recovery of the sector should also be initiated, including needs assessment, improving communications between central and peripheral levels, policy development and overall strategic planning for reconstruction. Improving the delivery of essential services will eventually require an increased network of facilities in rural areas. It would make sense for MOPH to undertake the reconstruction systematically. In the context of Kabul City, it was agreed upon in principle that MOPH puts a “freeze” on new builds and consider renovation and remodeling existing facilities to meet new identified needs such as intermediate medical training and nurse training schools. Health facilities are relatively easy to reconstruct but in the long term expensive to operate and maintain. A pragmatic approach is to rehabilitate existing facilities that are economic to repair, followed by supporting the development of rural health workers. The MOPH intention to repair health facilities in Kabul should be reviewed carefully based on a rationalization exercise, but the proposed rehabilitation of the TB Center is in fact along the line of this concept and thus can be justified. 2.5 MOPH Organization and Functions Long-lasting political and economic instability in Afghanistan has understandably weakened the capacity of MOPH and other medical institutions. Given the lack of financial and human resources, MOPH faces a serious challenge to re-establish its capacity to take leadership in the health care and medical sector. Figure 2.1 shows the existing organization of the MOPH. Taking the National TB Institute (NTI) for instance, it must be a central agency responsible for the formulation and implementation of the National TB Program (NTP). However, the existing NTI is only functioning for diagnostic and curative operations with the support of MEDAIR. The NTI should assume the mandates of planning, monitoring, coordination, surveillance, logistics, training, etc. with fairly strengthened capacity. The proposed rehabilitation of the TB Center is expected to contribute to this requirement, providing the NTI with the facilities necessary for planning, training, management, and

Part 3


coordination, and so on. The Central Workshop for Equipment in Kabul (CWEK) was established in 1975 with the objectives for maintaining the medical facility and vehicles belonging to MOPH. The service area of CWEK includes the maintenance of the medical facility of Kabul City and other regions. During the years of civil war and the Taliban regime, the Central Workshop has been damaged and many equipment/tools have been lost. Now the area/space of major buildings of the CWEK is still useable after rehabilitation, but the Equipment Maintenance System in Kabul city has been totally destroyed. There are still about 200 staffs assigned to the Central Workshop for Equipment, but the real volume of work and performance of the workshop is very limited. There are 2 major buildings in the compound and both of them require repair and maintenance works. Now the Public Health Team of Coalition Joint Military Operations Task Force (CJMOTF-USA) is providing assistance for rehabilitation of building for Equipment repair section and Administration. According to the Director of CWEK, the following assistance is required for rehabilitation and maintenance of the CWEK workshop. Different tools and equipment for maintenance works have to be added and installed. Vehicles for transportation of medical supplies and equipment are necessary. Training and orientation programs for new installations/equipment are also required. On the other hand training for medical staff and staff of maintenance section of the hospital is required for the correct use and regular inspection of machinery/equipment. Regular monitoring as well as financial support from MOPH is also essential. Especially, in the field of personnel management, there is a vicious circle between “the excess of staff” and “the budget shortfall”. WHO is thinking about the proper number of workers in hospitals or clinics (e.g. 23 workers in a MCH clinics should be reduced to 13, about half less). Because of the government policy for employment of job-seekers, especially of women, the number of workers under MOPH is actually increasing without any additional budget. MOPH will promote the Essential Package of Health Services. (1) Priority of basic health promoting information and services including hygiene,

sanitation, safe birth practices, (2) Provision of basic supplies and essential drugs, (3) EPI/child health (immunization, vitamin A, ORS, iron, iodine, food

supplements, basic treatments), (4) Communicable disease control, and (5) Support in training incentives, logistics, monitoring and evaluation. As a promotion system of health personnel, there is a “Report Card” system for workers in hospitals. These reports are prepared by the directors of hospitals every three years to inform MOPH about their activities. For workers who have any kind of national degree from MOPH, there is a grading system, ten grades (lowest 10-highest 1) to evaluate them. MOPH check these reports and if they are accepted, these workers can be upgraded (from Grade 10 to 9). To be a trainer or chief or director, they need to get upper grades. If the activity cannot be accepted by MOPH, they remain the same grade. As the National Training Program for doctors, new graduates practice medicine as general curative doctors for the first three years in training hospitals. After passing the examination, there is another four-year training program it become specialists. The

Part 3


quality of the program is not adequate because of lack of books, equipment or up-to-date knowledge. Diagnostic and therapeutic capability is inadequate because most diseases are diagnosed only by symptoms without any examination.

Part

3

Hea

lth S

ecto

r Sh

ort-

Term

Reh

abili

tatio

n Pl

an (2

-11)

Figu

re 2

.1 O

rgan

izat

ion

of M

OPH

Min

iste

r

Cen

tral S

tock

Dep

.

Tech

nica

l Dep

uty

Adm

inis

trat

ive

Dep

uty

Med

ical

law

& In

quiry

Dep

.

Con

stru

ctio

n D

ep.

Adm

inis

tratio

n D

ep.

Plan

ning

Dep

.

Prev

entiv

e D

ep.

Fore

ign

Rel

atio

n D

ep.

Cur

ativ

e D

ep.

7. C

omm

unic

able

Dis

ease

Dep

.

6. E

PI D

ep. (

Vacc

inat

ion)

5. P

ublic

atio

n D

ept.

1. P

rimar

y H

ealth

Car

e (P

HC

)

2. M

alar

ia &

Lei

shm

ania

sis I

nstit

ute

3. N

atio

nal T

B In

stitu

te

4. M

CH

Dep

.

Hos

pita

ls &

Clin

ics i

n Pr

ovin

ces

Hos

pita

ls &

Clin

ics i

n K

abul

C

ity

Part 3


CHAPTER 3: DONOR COORDINATION AND ACTIVITIES 3.1 The World Health Organization (WHO) The World Health Organization (WHO), which is a leading International Agency in the health sector in Afghanistan, stated that the guiding principle for health sector reconstruction in Afghanistan is to save and improve the lives of Afghan people. WHO has indicated that health sector reconstruction must tackle the following five areas to save and improve the lives of Afghan people. (1) Reproductive health (2) Child health (3) Communicable disease control (4) Mental health (5) Injuries WHO, UNICEF and ICRC have provided both technical and financial support to MOPH for the health sector-planning workshop where 35 international and local NGOs join and undertake collective planning exercise. WHO focus on the Primary Health Care that is essential public health service accessible to all Afghans - male, female, children, elderly, disabled, minority including geographic accessibility, financial accessibility, cultural accessibility. The Kabul regional priorities of WHO are as follows: (1) High incidence of waterborne disease (2) High incidence of sanitation-base disease; Malaria, TB, Leishmaniasis, & ARI (3) Inadequate curative infrastructure; poor diagnostic technology 3.2 Activities of International Agencies and NGOs There is an organization called the Agency Coordinating Body For Afghan Relief (ACBAR) made up with many different agencies involved in the health sector. The international agencies such as WHO, UNICEF, the World Bank, and UNDP, as well as NGOs coordinate joint meetings to work rationally and share the information of their health activities. WHO and UNICEF are leading the Vaccination Campaign and EPI in communities. Several donors individually and collectively have conducted needs assessment of the health sector rehabilitation and reconstruction in Afghanistan. The Joint Donor Mission to Afghanistan on the Health, Nutrition, and Population Sector led by WHO, ADB, DFID, EC, UNICEF, UNFPA, USAID, and the Government of Afghanistan, in addition, have prepared a framework for assistance to the health, nutrition, and population (HNP) sector over the next two and half years on April 2002. The objectives of the Mission is to follow up on the HNP sector preliminary needs assessment and to reach broad agreement with the Government on: (1) A framework for assistance to the HNP sector over the next 2.5 years, (2) An investment program aimed directly at improving and expanding health

service delivery that would begin in the next 3-4 months, (3) A practical, collaborative, open, efficient, and Government-led mechanism for

partner coordination, and (4) An action plan for carrying out studies to fill the knowledge gaps in the sector.

Part 3


The Second Joint Donor Mission led by ADB, EC, French Cooperation, GTZ, JICA, KfW, UNFPA, UNICEF, USAID, WHO, and the World Bank, furthermore, visited Afghanistan from July 13 to 27, 2002 to discuss about. The objectives of the Second Mission is to assist the Government in identifying the major impediments to and opportunities to improving the delivery of health services, and to reach broad agreement with the Government on: (1) Review the current health situation and assessing information that has become

available since the last donor mission; (2) Assess the progress on issues raised and agreements reached during the first

joint donor mission and continue the policy dialogue with the Government and MOPH;

(3) Help the Government and its partners get a more accurate picture of the resources available from the various donors and assess what is known about the likely cost of delivering health services;

(4) Discuss in detail the mechanisms for the MOPH to work systematically with NGOs agencies in improving the delivery of health services (PPAs); and

(5) Develop a set of concrete actions that would assist the MOPH to move forward (Programme Secretariat).

(Source: Aide-Memoire of the second joint donor mission, August 2002) Next joint donor mission will be carried out in 4 to 6 months. On the other hand, there are a number of organizations which are engaged in support activities in health sector in Kabul city. Current assistance activities by donors and NGOs can be summarized as Table 3.1.

Table 3.1 Donor and NGO Assistance in Kabul City Donor/NGO Activities 1. WHO Donor/programme Coordination, Participation to the Joint Donor

Mission to Afghanistan on the health, nutrition, and population sector, Technical and financial support to MOPH for the health sector-planning, Immunization Campaign

2. UNICEF Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector, Technical and financial support to MOPH for the health sector-planning, Immunization Campaign, Over 180 water points and sanitation facilities around Kabul city, Financial support for MCH and emergency obstetric care and training for obstetricians, Household maternal mortality survey, Supporting foundation of the Afghan Society of obstetricians and Gynecologists, Donor coordination for refurbishing Malalai Hospital. Obstetric and gynecologic care training at Malalai Hospital is under planning.

3. ICRC Emergency medical equipment and drug supply, Technical and financial support to MOPH for the health sector-planning

4. World Bank Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector, IDA is preparing grant for health sector.

5. ADB Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector

Part 3


Donor/NGO Activities 6. EU Participation to the Joint Donor Mission to Afghanistan on the

health, nutrition, and population sector, Financial support for health sector

7. UNDP Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector

8. UNFPA Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector, Institutional capacity building for MOPH and Central Statistics Department, Medical equipment supply for Malalai Hospital and Rabia Balkhi Hospital, and MCH clinics, Financial support for reproductive health kits. Rehabilitation and renovation of maternity hospitals in Kabul city is under planning.

9. France Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector

10. Germany Consultant rep health / EHA, Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector (GTZ, KfW), Reconstruction 7 hospitals in Kabul city (GTZ), Rehabilitation hospitals and supply equipment and drug (KfW),

11. India Support for hospitals (Indira Gandhi Hospital) 12. Italy Training and equipment, Operational cost, Rehab post-

earthquake 13. Japan (JICA) Participation to the Joint Donor Mission to Afghanistan on the

health, nutrition, and population sector, Equipment supply for several hospitals. Rehabilitation and equipment supply for the National TB Institute (NTI), its Kabul TB Centre, and Daluraman Polyclinic, Dispatch of Experts, Construction wells at hospitals and clinic, Survey on TB patients and MCH clinics, and Preparing health sector short-term rehabilitation plan

14. Korea Staff, training, rehab, warehouse 15. Kuwait Charekar Water Supply, BDN support in 4 regions 16. Netherland NIDS 17. Norway Drugs and training, IDPs, International staff for rehabilitation

sector, Consultation for surveys and trainings, Consultation for workshop, radio program

18. Turkey Equipment Supply 19. United Arab Emirates Training, equipment RBM 20. UK (DFID) Participation to the Joint Donor Mission to Afghanistan on the

health, nutrition, and population sector, Development of human resources, Health planning and policy, health system development, Supply equipment, cars and computers, Equipments sub- offices, Training, supply, equipment, Training 120 Doctors and 500 nurses, Training routine EPI, 1 round NIDs, Leishmaniasis, drugs and training, Kits and trainings Training server malnutrition and micronutrients

21. US (USAID) Participation to the Joint Donor Mission to Afghanistan on the health, nutrition, and population sector, Technical and financial support to MOPH, Consultant, training, equipment RBM

22. ACF Support for hospitals and clinics, Construction of toilet and wells at District 6 (UNHCR) and District 9 (UNAMA)

23. AMI Support for hospitals and clinics 24. CHA Support for hospitals and clinics

Part 3


Donor/NGO Activities 25. GAVI EPI routine 26. HOPE Support for hospitals and clinics 27. IAM Support for hospitals and clinics 28. MDM Support for MCH clinics 29. MEDAIR Support for TB treatment, and MCH clinics 30. MERLIN Support for clinics 31. MRCA Support for hospitals and clinics 32. MSF Support for hospitals and clinics 33. MSH Health Resource Survey, Support MCH clinics (MSH/HANDS),

Development of the capacity and systems of MOPH (USAID) 34. PARSA Support for hospitals and clinics 35. TDH Support for hospitals and clinics 36. Todai Clinic for Malaria and Leishmainaisis 37. USPMR IPDs, rehabilitation health structure 3.3 Present Situation of Donor’s Support for Hospitals and Clinics As it is shown in Table 3.1 and Table 3.2, some TB hospitals and MCH clinics are not functioning properly and some are in operation leasing private properties. The MOPH has not yet reorganized the exact situation involved in each hospital and MCH clinic, and hence, it is necessary to inventory the present conditions immediately.

Table 3.1 TB Facilities in Kabul City

Name Operational Category 1. NTI OPD, Diagnosis, Treatment 2. Khair Khana Treatment (NTI & MEDAIR) 3. Maywand IPD for children, Treatment (NTI &MRDAIR) 4. Karte Parwan Women’s hospital, IPD, Treatment (NTI & MEDAIR) 5. Dashte Barch Treatment (NTI & MEDAIR) 6. Karte Nau Treatment (GMS) 7. Qalahe Daman Khan Treatment (GMS) 8. Darwaze Lahari OPD, Diagnosis, Treatment (GMS) 9. Wazir Akbar OPD, Diagnosis, Treatment (GMS) 10. Hotale Zarafzhan Treatment (GMS) 11. Chahr Qalah Wazirabad Treatment (GMS) 12. Kulahe Pusta Treatment (GMS)

Part 3


Table 3.2 Current MCH Clinics in Kabul City

Table 3.2 Current MCH Clinics in Kabul City No.

Name Location Supp. NGO Building Popu- lation

PatientsA day

1 Khwaja Bughra Khauja Bighra MDM-MSF Rental 30,000 1202 Meerwais Maidan Kutisangi MDM Rental 3 Wasel Abad Bagh-e-Raees MDM Rental 4 Dogh Abad Dogh Abad Rental 5 Karti Se Karte Se IAM Rental 6 Khushal Khan Khushal Khan MDM Rental 7 Rahman Mena Rahman Meena Rental 8 Char Asyab Char Asyab CHA Rental 9 Arzan Qeemat Arzan Qeemat MSF Rental

10 Qasaba Qasaba MERLIN Rental 11 Panjsad Family Panjsad Family ACF Rental 40,000 9012 Makrorayan-e-Se Makrorayan-e-Se TDH Rental 13 Char Qalai Wazeerabad Char Qalai Wazeerabad ACF Rental 14 Qalai Zaman Khan Qalai Zaman Khan MDM Rental 15 Parwan-e-Se Parwan-e-Se HOPE Rental 16 Gul Khana Gul Khana Rental 17 Qalai Wazeer Qalai Wazeer ACF Rental 18 Aqa Ali Shams Aqa Ali Shams ACF Rental 19 Shah Shaheed 1st St. of Shah Shaheed Rental 20 Hese Se Khair Khana Ibraheem Maseque Rental 30,000 21 Taimani Haj Moh. Dad Charrahee Rental 50,000 9022 Allaudin Allaudin Rental 23 Shahrara Karti Mamorin Public 24 Do Rahi Paghman Char Rahi Qamber Rental 25 Qalai Bakhtyari Rental

Source: Preventive Department of MOPH Note: ACF is not supporting MCH clinics just for malnutrition but they have support section in

MCH clinics. Table 3.3 shows the existing conditions of central hospitals and polyclinics in Kabul City prepared by the Curative Department of MOPH in May 2002. Most of the hospitals and polyclinics are considerably short of doctors and intermediate practitioners. Enhancement of health referral system in Kabul City is one of the most important challenge of the MOPH.

URSP-EHB Interim Report (3-6)

Part 3

Tabl

e 3.

3 C

entr

al H

ospi

tals

and

Poly

clin

ics i

n K

abul

City

N

o N

ame

Loca

tion

Bed

Bui

ldin

gSu

pp.

Patie

nt

Doc

tors

In

term

edia

te

Adm

inis

trate

Su

pp. S

taff

1 W

azir

Akb

ar K

han

Waz

ir A

kbar

Kha

n 25

0M

OPH

IC

RC

24

0 11

812

013

513

534

3414

516

1 2

Jam

hory

at

Cha

r Rah

ee S

edar

at

180

MO

PH

MSF

13

0 91

9510

710

728

2912

212

6 3

Rab

ia B

alkh

i Fo

rosh

gah

250

MO

PH

UN

FPA

35

0 87

9111

413

933

3612

212

6 4

Ibn

Sena

Che

st

Pul-e

-Arta

n 70

MO

PH

70

25

4859

6931

3160

71

5 Ib

n Se

na E

nerg

ency

Pu

l-e-A

rtan

100

MO

PH

90

48

8576

124

2829

7510

2 6

Ant

ani

Cha

r Rah

ee S

edar

at

70M

OPH

M

SF

100

1974

5187

2731

7712

2 7

Noo

r Eye

C

enim

a Pa

mee

r 50

MO

PH

IAM

40

0 31

6462

8417

1771

90

8 M

aiw

and

Jada

-e-M

aiw

and

150

MO

PH

AC

F-M

RC

A

200

7098

9110

230

3012

715

4 9

Mal

alai

Sh

ahr A

ra

150

MO

PH

UN

ICEF

12

0 73

103

7416

932

3512

717

4 10

A

tatu

rk

Kar

t-e-S

akhi

10

0M

OPH

Tu

rkis

h G

ov.

30

4039

4118

1957

63

11

Men

tal H

ealth

C

enim

a Pa

mee

r 50

MO

PH

80

13

8033

7985

178

8018

2 12

K

hair

Kha

na

Lise

Mar

yam

52

MO

PH

AC

F-U

NFP

A70

0 47

8282

9121

2159

59

13

Stom

atol

ogy

Foro

shga

h 20

MO

PH

40

0 17

717

710

1025

2863

70

14

Chi

ld H

ealth

W

azir

Akb

ar K

han

300

MO

PH

Indi

a G

ov.

400

125

129

154

154

3535

163

187

15

Para

pleg

ic

Cen

ima

Pam

eer

10M

OPH

PA

RSA

80

5

814

1513

1729

34

16

Cha

har A

syab

C

haha

r Asy

ab

10M

OPH

C

HA

311

1823

46

1114

17

A

li A

bad

Sh

ahr A

ra

150

MO

PH

MSF

11

0 76

129

174

229

5960

249

303

18

Rad

iolo

gy In

stitu

te

Pul-e

-Arta

n 0

MO

PH

40

2

3448

5616

1924

31

19

Cen

tral L

abor

ator

y Pu

l-e-A

rtan

0M

OPH

A

MI

110

012

6978

2326

3133

20

C

entra

l Blo

od B

ank

Cen

ima

Pam

eer

0M

OPH

100

22

5757

3737

4848

21

O

rthop

edic

Tec

hnic

al

Waz

ir A

kbar

Kha

n 0

MO

PH

30

0

05

517

1722

28

22

Fore

ign

Sic

Labo

rato

ry

Kar

t-e-S

akhi

0

MO

PH

33

77

44

1111

23

C

entra

l Pol

yclin

ic

Cen

ima

Pam

eer

0M

OPH

14

130

1188

2123

6512

3 24

R

ahm

an M

eena

Pol

. C.

Rah

man

Mee

na

0M

OPH

2

4728

8413

1426

36

25

Khu

shha

l Kha

n Po

l. C

. K

hush

hal M

eena

0

Priv

ate

345

1065

1216

1331

26

M

aida

n-e-

Haw

al P

ol. C

. M

aida

n-e-

Haw

al

0M

OPH

1

143

122

23

7 27

C

asab

a Po

l. C

.

Qas

be K

hana

Saz

i 0

Qas

aba

00

00

00

00

28

Arz

an Q

eem

at P

ol. C

. A

rzan

Qee

mat

0

MO

PH

220

524

36

914

29

D

arul

Arm

an P

ol. C

.

Dar

ul A

man

0

MO

PH

33

1214

22

915

30

G

ov. S

taff

Pol.

C.

Waz

ir A

kbar

Kha

n 0

MO

PH

40

7

6923

8517

1742

69

31

Kar

te S

e Su

rgic

al

Kar

t-e-S

e 25

0M

OPH

IC

RC

2865

208

280

3232

225

225

Not

e: (1

) No.

27 a

nd 3

0 ow

ner o

f clin

ic a

re G

over

nmen

t but

not

MO

PH, (

2) N

o.25

has

a p

lace

but

ther

e is

not

bui

ldin

g, s

o th

ey re

nt a

priv

ate

hous

e, (3

) No.

7-Th

e or

igin

al b

uild

ing

is

in D

arul

Am

an, b

ut is

des

troye

d., a

nd (4

) Non

-sha

dow

ed a

nd sh

adow

ed n

umbe

rs im

ply

thos

e pr

esen

t and

targ

eted

, res

pect

ivel

y.

Part 3


CHAPTER 4: SHORT-TERM REHABILITATION STRATEGY FOR

THE SECTOR 4.1 Basic Strategy for the Short-Term Rehabilitation Plan There is an obvious desire to return to the high standard health care situation in the past, which is enticing but not necessarily practical. As a matter of fact, the health service delivery system is seriously urban biased and curative focused. The health workforce is seriously unbalanced with an oversupply of doctors who are mainly concentrated in Kabul and large cities. There is a serious shortage of nursing and allied health workers. The MOPH planners need to be exposed to alternative models of health service delivery with accompanying approaches to training health workers to deliver services on an equitable basis over the country. The definition of the different types of heath facilities is not clear at this moment, which should be defined by the MOPH. However, the type of services, number of beds and population served need to be defined for the following: Regional Hospital (H1), Provincial Hospital (H2), District Hospital (H3), Basic Health Center (C1), Sub Center (C2), and Poly Clinic. Apparently, structuring a nation-wide hierarchical referral system requires time-consuming and capital intensive process, thus it should be regarded as a long-term objective. For the time being, particularly in Kabul City, priority policy option is to proceed with inexpensive rehabilitation and re-equipping of existing facilities. Building new facilities in provinces and districts should be based on population density and weighted for rurality, and deprivation and terrain, and based on the health-zoning system. There is an urgent need to rapidly increase training for female health care providers which is based on recommended WHO technical guidelines and which ensures that the appropriate skills are available for reproductive health at the periphery to address the major causes of morbidity and mortality. At the same time there is a need to reorient the training of medical doctors from Primary Health Care hospitals based on curative approach to community based family medicine which is more responsive to the prevailing health problems of the community. 4.2 Maternal and Child Health Care WHO and MOPH state that the key objectives are to reduce the rates of infant and child mortality, maternal mortality, child malnutrition, and fertility. These impact indicators should be tracked over the long-term, and tracking progress over the next 2.5 may not be so useful as they are unlikely to change much during that period, and most of them are difficult to measure. For technical reasons, they could not easily yield data for the relevant time period. They could be even affected by events outside the control of the health care system. Instead of focusing on these outcome measures, it makes sense to concentrate on achieving measurable improvements in indicators directly related to the delivery of its essential package of services. These are described in Table 4.1, along with best guesses about current values. Given the paucity of baseline data, targets should be seen as approximate. It should be noted also that these targets are the national average, and that the targets for Kabul should be much higher as the public health care situation in Kabul is much better than other parts of the country.

Part 3


Table 4.1 Proposed Core Output Indicators for Afghanistan Health Program

Area Indicator Latest

Available Data

Expected Levels for

2005 Maternal Health 1. Coverage of antenatal care - proportion of all

pregnant women receiving complete antenatal care

2. Proportion of pregnant women receiving two doses of tetanus toxoid

3. Proportion of births attended by skilled attendants

4. Rates of operative delivery

8%*

19%*

8%*

na

50%

50%

15%

5-15% Birth Spacing 1. Proportion of health centers offering at least

two birth spacing methods 2. Proportion of women in reproductive age group

(15-49 years) having knowledge of at least three methods of birth spacing

3. Contraceptive Prevalence Rate - % of women in the age group 15-49 years currently using a family planning method (modern or traditional)

Na

Na

2-10%*

20%

20%

10-20%

Tuberculosis 1. To be determined Malaria 1. Proportion of families using insecticides treated

nets (ITNs) 10%** 40%

Micronutrient deficiencies

1. Proportion of children 6-59 months that have received vitamin A supplement within last 6 months

2. Proportion of targeted females receiving iron folate supplements

70%***

na

95%

30%

Breastfeeding Promotion & Weaning

1. Proportion of having appropriate knowledge about introducing complimentary food

2. Proportion of women exclusively greast feeding for 6 months

Na

na

50%

50& Acute Respiratory Infection (ARI)

1. Proportion of parents able to name the danger signs of ARI and the appropriate response when they are observed

na 40%

Diarrhea diseases 1. Proportion of under 5 children who had diarrhea in last two weeks who were treatment with oral re-hydration salt or appropriate household solution

39.6%**** 60%

Immunization 1. DPT3 coverage among children 12-23 months 2. Measles coverage among children 12-23months

32%**

37%**

50%

65% National level indicators (outside province’s control)

1. Proportion of households with iodized salt 2. Interruption of wild polio transmission by

mid-2003

na 50%

Note: *Data source – UNFPA Reproductive Health fact sheet on Afghanistan; **Data Source WHO 2001; ***Data Source NID 2001; and **** MICS 2000 Afghanistan.

Part 3


Hospitals and clinics seems to be able to get enough human resources but the quality of them is various. The MOPH need to begin the process of clarifying and finalizing categories of workers and determining the approximate total size of the workforce for the sector and sources of pay. In addition, the MOPH should establish mechanisms for certifying, recruiting and deploying workers relevant to the health needs. They should be to incorporate the most recent WHO technical standard maternal and newborn care. It is also necessary to revise refresher’s training programs for midwives and doctors with a view to updating their knowledge and skills relevant to maternal and new-born care including Emergency Obstetric Care.

Table 4.2 Target Number of Staff in a MCH Clinic

Category Number Pediatrician doctors 2Gynecologist 2Dentist 2Pharmacist 2Lab. technician 1Nurse 5Administrative staff 2Supporting staff 6

Total 22Source: Preventive Department of MOPH

Table 4.3 List of Un-operated MCH Clinics 1. Tanee Coat 10. Proje Taimany 2. Bebi Mahro 11. Qalai Nusa 3. Shash Darak 12. Beneee Hesar 4. Behazad 13. Dasht-e-Barchi 5. Asmaee 14. Afshar 6. Meerza Qader 15. Jamal Mina 7. Nese Awal-e-Khair Khana 8. Hese Dowom-e-Khair Khana 9. Tahee Maskan Source: Preventive Department of MOPH There are MCH clinics that are not working and need to restart as listed in Table 4.3. The MOPH are supposed to renovate existing MCH clinics to make them run properly in a short-term rehabilitation plan such as: (1) Improve the case management skill of health staff and provide adopted

guidelines on MCH clinic activities; (2) Improve the health system requirements for adequate MCHs; and (3) Maintain basic (standards) services. 4.3 Tuberculosis and Communicable Diseases The Inter-Agency Coordination Committee has set up with the MOPH and WHO and will make a multi-year strategy this year. It is necessary to have surveys of health facilities including sub-centers for TB treatment.

Part 3


Table 4.4 Health Facilities

Malaria & Leishmaniasis Institute

TB Institute

Location Allaudin Cinema Pameer (temporarily

Functioning or not Yes Yes Ownership MOPH MOPH Outpatients in a day na 20-30 Doctors: present 6 14 Doctors: targeted 6 20 Nurse & lab. technician na Nurse 30, lab. technician 11Staff: present 148 130 Staff: targeted 218 250 Administrator: present 43 na Administrator: targeted 56 na Support staff: present 84 na Support staff: targeted 127 na Note: Target number by the Institutes means the former ones. A health zoning study about sub-centers need to be undertaken so that the MOPH can assess where health facilities are best positioned. The BCG vaccination of EPI (Expanded Program of Immunization) in Kabul has been working for more than 10 years. BCG vaccination is given at birth up to 2 years old. About BCG coverage, the survey was done by MEDAIR in 2000 for the age of 6-7 years (the average age 7.05). It appears that BCG coverage as assessed by scar prevalence was 46% (7,599 children, male: 45% female: 47%). It did not vary much among the three main ethnic groups (Tadjik, Pashtun, and Hazar) nor between the sexes. The average annual risk of infection was estimated to be 0.6%. The previous survey was conducted in 1963 among children aged 10 years old. The average annual decline in the risk of infection is extrapolated to be 3.9% in this 40-year period. This study demonstrates that the transmission of Mycobacterium tuberculosis in the community has been reduced. To continue this trend, it will be crucial to maintain and expand existing diagnostic and treatment facilities. 4.4 Preventive Medicine Training programs for doctors, nurses, community health workers (CHW) and Traditional Birth Attendants (TBA) need to be standardized. MOPH also needs to reorient medical education from a curative to a community medicine approach and review basic medical curriculum to prepare doctors to practice community-based family medicine. Promote auxiliary staff training to fill the gap of skilled attendant in the communities will also be required. This field of medicine does not have updated system so that it is important to improve the following components. (1) Training centers, including rural training centers, (2) Trainers preceptors, and (3) Standardized training package

Part 3


4.5 Public Health Care and Referral System MOPH is primarily responsible for planning, monitoring and evaluating the health workforce in order to meet the health services needs. They need to set minimum acceptable educational standards and performance level required to be attained by health professionals and ensure appropriate training courses. During the upcoming year, expansion of coverage of integrated primary health care for the population with focus on disease prevention and control will be a key to turning around the worsening trends of morbidity and mortality. Simultaneously, activities aiming at the recovery of the sector must also be initiated, including needs assessment, streamlining supply and logistics, policy development and planning for reconstruction. Support will be provided to building the material and technical capacity of MOPH to plan and implement a strategy for quick impact rehabilitation and to start an accelerated training program across the health system. Surveys should be carried out with the involvement of provincial health staff since they are familiar with health facilities in their areas and they can be introduced and trained on the job in survey techniques. Results will be presented to the MOPH and the authorities. 4.6 Health Care Planning and Management Private practitioners are already providing a large proportion of outpatient consultation and the number of pharmacies is large, growing and becoming more reliable for patients than the public. Given the size of the profit sector the Government needs to find a way to harness its presence, such as through social marketing. Besides regulating it, the Government needs to find, in the longer term, a way of using social insurance and private providers to cover health care needs in the future. MOPH needs to ensure availability of essential drugs in the country, mainly assisted by donors’ financial support. Simultaneously, it is important to produce guidelines on production, quality, procurement, storage, rational use and distribution of drugs. Because of the rise of private medical facilities, MOPH will be supposed to develop national standards treatments guidelines such as DOTS for TB, and ensure proper dissemination of drugs. Also the development of the pharmaceutical industry from public funds and through donors and private sector needs to be ensured. MOPH clearly states that they would like to maintain a strong partnership with the NGO community. The Government is also clear on its desire to expand essential health services and recognizes that its own involvement in service delivery at community level is limited. However, it has not yet devised a way of systematically working with NGOs to substantially increase the coverage of essential services. In this regard, it is important that the MOPH take a strong leadership position coordinating assistance coming from donors. It would make sense for donors to have a joint program based on a few principles and share the information of their activities. There are a couple of health education programs on radio in Kabul and many MCH clinics supported by NGOs provide health education to women about communicable diseases or hygiene and nutrition. However, MOPH have no systematic program of those quick impact projects so that those levels of health education are various and incoherent. Especially in the field of communicable disease, it is necessary to expand the coverage of those programs to reduce the morbidity as a jointed plan of donors.

Part 3


The lack of reliable data causes the difficulty to get sensible indicators for planning in the health sector. In this regard, research priorities of the short-to-mid-term objective include baseline household data on the output indicators, a health facility survey, a study on human resources, studies on mental health and HIV sero-prevalence. 4.7 Priority Areas for the Short-Term Health Sector Rehabilitation in Kabul

City The URSP Team recommends the following as “priority areas” for rehabilitation and reconstruction of the health sector in Kabul City. These priority areas were identified as per the requests for assistance in specific areas from MOPH partners in April and July 2002, the Aide-Memoire of the Joint Donor Mission, and discussion with international donor agencies and NGOs, as well as various staff of the hospitals and clinics the Team visited. A. Institutional Capacity Building of MOPH As stated above, many donors and agencies are assisting MOPH chiefly in capacity building through provision of health facilities, equipment, drugs, some expatriate experts, and overseas training programs. However, as pointed out in the aid-memoire of the Joint Donor Mission, MOPH should establish a Strategy Policy and Evaluation Unit to: (1) Coordinate donor resources with AACA, (2) Prepare and lobby for the annual health budget, (3) Review coverage of the essential package, (4) Establish guidelines and procedures for PPA preparation, (5) Develop a unified health information system, and (6) Monitor the PPA process. In order to achieve these immediate mandates, the MOPH organization needs to be augmented with appropriate human resources and reasonable fiscal capacity. Also, in the long run, MOPH should take the initiative of formulating and regulating ways of using social insurance and private health providers to cover health care needs. A-1 Immediate institutional strengthening and capacity building in selected critical

operations of MOPH A-2 Enforcement of health manpower A-3 Promotion of public-private partnership A-4 Establishment of Procurement and Maintenance Department to maintain

MOPH health facilities and equipment A-5 Development of effective and efficient referral system A-6 Development of health information system (HIS) A-7 Development of drug supply and management system B. Reducing Preventable Communicable Disease Elimination of preventable communicable disease is a significant issue to reduce mortality rate of children. MOPH and donors emphasis to increase EPI immunization coverage for reducing preventable communicable diseases. In Kabul City, on the other hand, TB control is a serious issue. As a matter of fact, the existing TB facilities in Kabul City are mostly attended by NGOs, particularly by GMS and MEDAIR, and therefore, they are in a fairly reasonable quality levels as far as the curative treatment of

Part 3


TB patients is concerned. However, there is no effective and efficient coordination or referral system at present, since neither central TB institute nor hospital has not been available up to now to control such an integrated system. After the rehabilitation of the TB Center in Darulaman by the URSP-EHB, the first floor of the NTI will be used for the office of the National Tuberculosis Program (NTP) that assumes the central functions for undertaking the nation-wide TB measures in the country. In the light of this, it is deemed essential to substantiate the functions to be assumed by NTP including supervision and evaluation of TB measures, surveillance of performance, logistic system to supply materials and equipment, training of laboratory technicians particularly for sputum smear tests, quality control systems of regional laboratories, expansion of reference system to other regions, and so on. B-1 Immunization campaign B-2 Rehabilitation of the National TB Institute (NTI) B-3 Training of laboratory technicians, and administration and management staff B-4 Establishment of information and database systems for NTP C. Integrated Improvement Program of Maternal-Child Health (MCH) Clinics According to the information from MOPH, there are 22 MCH clinics currently in operation in Kabul, but most of which are renting buildings from private owners and others. Also, according to the Preventive Dept. of MOPH, there are another 18 MCH clinics currently not in operation but desired by MOPH to resume their previous functions. In fact, MCH clinics are providing primary health care services on a community basis, and hence, importantly positioned to enhance public health care functions to reduce risks not only for maternal-child diseases but other communicable diseases. Currently, many NGOs are working for the rehabilitation of MCH clinics rather in haphazard manner without proper coordination with MOPH or among them, thus creating potential risks to produce different quality levels of service, arbitrary registration and data compilation of patients, not standardized diagnostic and curative methods, inefficient operation and management, and so on. In the light of these, there are urgent necessity to establish a unified system for the operation and management of MCH clinics in Kabul City to enhance their service levels by system integration and standardizing. C-1 Rehabilitation and reconstruction of MCH facilities and equipment C-2 Standardization of MCH functions and service quality C-3 Standardization of MCH administration and management C-4 Establishment of leading MCH clinics as PHC centre D. Clinical Capacity Strengthening for Reproductive Health The Maternal-Child (MCH) care requires basically the safe delivery of births and the Expanded Program on Immunization (EPI), and the basic strategy for the safe delivery of births requires to (1) fabricate the urgent obstetrical diagnosis system particularly urgent transport system of patients and blood transfusion system, (2) expand antenatal care including anti-malaria and anti-anemia measures, and (3) promotion and education of reproductive health knowledge on a community basis. Many donors and NGOs are supporting the above items (2) and (3) but not the item (1) substantially despite the fact that virtually no hospital or clinic that can provide a reasonable level of obstetrical diagnosis is available in Afghanistan at present.

Part 3


D-1 Promotion of reproductive health education D-2 Promotion of Family Planning D-3 Strengthening of urgent obstetrical diagnosis ability E. Development of Care System for Disabled and Psychological Traumatized

People Disabled people together with traumatized people due to war affairs, landmines, and unexploded ordinance (UXO) should be taken care of in the immediate future, and the disabled persons should be rehabilitated over the long-term course in order for them to be integrated into society and able to lead productive lives. This is one of the WHO’s Priority Health Program but so far there has been no substantial support committed by international donors and NGOs by April 2002. E-1 Establishment of care system for disabled people E-2 Establishment of care system for traumatized people F. Rehabilitation/Establishment of Central Service System for Management

and Maintenance of Facilities The Previous management and support system for maintenance of health facility and equipment has been destroyed by the civil war and difficult circumstances in the country. Now the donors and NGOs are supporting management and maintenance works by providing the running cost and repairing the necessary facilities by themselves. It has been found that many old and broken machinery and equipment still exists in hospital and they require a sustainable method of management and maintenance in the hospitals. In future for cost effectiveness and sustainable management as well as maintenance of the hospital and medical facilities in Kabul City, the following activities are needed. F-1 Rehabilitation of central service system for maintenance of equipments F-2 Establishment of a central administration and service system for the

management of swage, hospital waste, medical gas, and other supplies for hospitals and medical facilities

G. Securing Safe Water and Sanitation Unsanitary environment and contaminated water are a cause of outbreak of communicable disease. Securing safe water and sanitary environment is a significant to eliminate the causes. Especially in Kabul City, increasing population due to the repatriation refugees and aid workers has affected environmental capacity of the city. It is necessary for the city to secure safe water and sanitary environment through rehabilitation of infrastructure and community based hygiene education. G-1 Securing safe water and sanitation G-2 Promotion of hygiene education Table 4.5 shows the Health Sector Rehabilitation Matrix.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-9)

Ta

ble

4.5

Kab

ul C

ity H

ealth

Sec

tor

Shor

t-Te

rm R

ehab

ilita

tion

Plan

(Jun

e 20

02 –

Dec

embe

r 20

04)

Imm

edia

te S

uppo

rt/I

nput

s Ju

ne 2

002-

Mar

ch 2

003

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0 Pr

iori

ty A

rea

Inpu

ts

Ong

oing

/Att

entio

nN

eede

d

Shor

t-Te

rm In

puts

Mar

. 03-

Dec

. 04

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Inpu

ts

Out

puts

Goa

l A. I

nstit

utio

nal C

apac

ity B

uild

ing

of M

OPH

A

-1 Im

med

iate

in

stitu

tiona

l st

reng

then

ing

and

capa

city

bui

ldin

g in

se

lect

ed c

ritic

al

oper

atio

ns o

f M

OPH

.

Tech

nica

l ass

ista

nce

to b

e pr

ovid

ed to

re

leva

nt d

epar

tmen

ts

of M

OPH

to

esta

blis

h m

inim

um

capa

city

. D

ispa

tch

of e

xper

ts fo

r ove

rall

polic

y fo

rmul

atio

n an

d st

rate

gic

heal

th

sect

or d

evel

opm

ent

plan

s.

On-

Goi

ng: J

oint

D

onor

Mis

sion

to

Afg

hani

stan

on th

e H

ealth

, Nut

ritio

n an

d Po

pula

tion

Sect

or

(WH

O,W

B, A

DB,

D

FID

, EU

, UN

ICEF

, U

NFP

A, U

SAID

). D

ispa

tch

of

shor

t-ter

m e

xper

ts

(JIC

A).

Att

entio

n N

eede

d:

Coo

rdin

atio

n am

ong

dono

r age

ncie

s.

Dis

patc

h of

lo

ng-te

rm e

xper

ts.

Ove

rsea

s tra

inin

g of

M

OPH

staf

f.

All

MO

PH o

ffici

als

train

ed in

bas

ic

adm

inis

tratio

n an

d m

anag

emen

t ski

lls.

Trai

ning

in st

affin

g an

d pa

yrol

l man

agem

ent i

s co

mpl

eted

. Fu

nctio

nal j

ob

desc

riptio

n in

pla

ce

with

cle

ar li

ne o

f au

thor

ity.

Nat

iona

l Hea

lth P

lan

for A

fgha

nista

n re

ady

for i

mpl

emen

tatio

n.

To p

rovi

de

cont

inuo

us te

chni

cal

assi

stan

ce a

nd c

reat

e an

env

ironm

ent

whe

re M

OPH

of

ficia

ls d

o no

t de

pend

on

fore

ign

tech

nica

l ass

ista

nce

in h

ealth

pol

icy

mat

ters

. En

hanc

emen

t of

fisca

l cap

abili

ty o

f M

OPH

whi

lst

redu

cing

fixe

d ex

pend

iture

thro

ugh

PPA

s.

MO

PH fu

lly

equi

pped

and

abl

e to

m

ake

polic

y de

cisi

on

and

prov

ide

reas

onab

le p

ublic

he

alth

car

e se

rvic

es.

Ensu

re fi

nanc

ial

sust

aina

bilit

y of

M

OPH

.

A-2

Enf

orce

men

t of

heal

th m

anpo

wer

. Es

tabl

ishm

ent o

f re

fres

hers

’ tra

inin

g co

urse

. Re

patri

atio

n of

m

edic

al p

ract

ition

ers

who

are

in fo

reig

n co

untri

es.

On-

Goi

ng:

Tr

aini

ng o

f ob

stet

ricia

ns

(UN

ICEF

)

Expa

nsio

n of

re

fres

hers

’ tra

inin

g co

urse

. Es

tabl

ishm

ent o

f tra

inin

g pr

ogra

m fo

r in

-ser

vice

med

ical

pr

actit

ione

rs.

Impr

ovem

ent o

f qua

lity

and

quan

tity

of m

edic

al

prac

titio

ners

.

Con

tinuo

us

impr

ovem

ent o

f tra

inin

g fo

r in-

serv

ice

med

ical

pra

ctiti

oner

s. O

vers

eas t

rain

ing

of

in-s

ervi

ce m

edic

al

prac

titio

ners

.

Incr

ease

of q

ualif

ied

med

ical

pra

ctiti

oner

s.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-10

)

Imm

edia

te S

uppo

rt/I

nput

s Ju

ne 2

002-

Mar

ch 2

003

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0

Prio

rity

Are

a

Inpu

ts

Ong

oing

/Att

entio

nN

eede

d

Shor

t-Te

rm In

puts

Mar

. 03-

Dec

. 04

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Inpu

ts

Out

puts

A-3

Pro

mot

ion

of

publ

ic-p

rivat

e pa

rtner

ship

.

Intro

duct

ion

of

perf

orm

ance

-bas

ed

partn

ersh

ip

agre

emen

ts (P

PAs)

. Se

lect

ion

of p

ilot

proj

ects

to a

pply

op

erat

ion

syst

ems

base

d on

PPA

s.

On-

Goi

ng:

Jo

int D

onor

Mis

sion

to

Afg

hani

stan

on

the

Hea

lth, N

utrit

ion

and

Popu

latio

n Se

ctor

.

To a

pply

PPA

sy

stem

s for

MO

PH

hosp

itals

and

clin

ics

over

the

coun

try.

Subs

tant

iatio

n of

op

erat

ion

syst

ems

base

d on

PPA

s.

Esta

blish

of

self-

sust

aina

ble

publ

ic-p

rivat

e pa

rtner

ship

syst

em

base

d on

PPA

s

Impr

ovem

ent o

f qu

ality

and

equ

ity o

f he

alth

serv

ices

by

MO

PH h

ospi

tals

and

clin

ics.

A-4

Esta

blish

men

t of

a P

rocu

rem

ent

and

Mai

nten

ance

D

epar

tmen

t to

mai

ntai

n M

OPH

he

alth

faci

litie

s.

Inve

ntor

y of

exi

stin

g co

nditi

ons o

f hea

lth

faci

litie

s and

eq

uipm

ent.

Tech

nica

l ass

ista

nce

to tr

ain

mai

nten

ance

st

aff.

On-

goin

g:

Ass

ess

Hea

lth

Syst

em N

eeds

and

Re

sour

ces (

MSH

/ W

HO

, USA

ID, E

U,

and

UN

ICEF

)

Acq

uisi

tion

and

distr

ibut

ion

of

equi

pmen

t to

MO

PH

heal

th fa

cilit

ies.

Esta

blish

men

t of a

ce

ntra

l mai

nten

ance

de

pot t

o pr

ovid

e sp

ecifi

c m

aint

enan

ce

serv

ices

.

Bala

nced

and

st

anda

rdiz

ed

distr

ibut

ion

of

equi

pmen

t to

MO

PH

heal

th fa

cilit

ies.

Recu

rren

t cos

t effi

cien

t m

aint

enan

ce o

f MO

PH

heal

th fa

cilit

ies.

Con

tinuo

us e

fforts

to

ensu

re q

ualit

y le

vels

of

hea

lth se

rvic

es

supp

orte

d by

ad

equa

te

mai

nten

ance

with

re

ason

able

cos

t.

Self-

finan

cing

abi

lity

for o

pera

tion

and

mai

nten

ance

of

MO

PH h

ospi

tals

and

clin

ics.

A-5

Dev

elop

men

t of

refe

rral

syst

em.

Inve

ntor

y of

exi

stin

g ca

paci

ty o

f MO

PH

heal

th fa

cilit

ies.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

NG

Os a

nd p

rivat

e se

ctor

.

Func

tiona

l re

-cat

egor

izat

ion

and

dem

arca

tion

of

resp

onsi

bilit

ies

amon

g he

alth

fa

cilit

ies.

Esta

blish

men

t of t

otal

re

ferr

al sy

stem

in

Kab

ul C

ity.

Esta

blish

men

t and

en

hanc

emen

t of

refe

rral

info

rmat

ion

and

data

base

syst

em.

Esta

blish

men

t of t

he

natio

n-w

ide

refe

rral

sy

stem

thus

en

hanc

ing

equi

tabl

e ac

cess

ibili

ty to

hea

lth

care

. A

-6 D

evel

opm

ent o

f H

ealth

Info

rmat

ion

Syst

em (H

IS)

Inve

ntor

y of

exi

stin

g ca

paci

ty o

f MO

PH

conc

erni

ng H

IS.

Des

igni

ng H

IS a

nd

data

col

lect

ion.

Att

entio

n N

eede

d:

Sub-

sect

or ta

skfo

rce

for H

IS

(WH

O/M

OPH

)

Trai

ning

of s

tatis

tical

sk

ill a

nd c

ompu

ter

skill

. Su

pply

of c

ompu

ters

an

d so

ftwar

e

Esta

blish

men

t of H

IS.

Up-

grad

ing

HIS

by

MO

PH sp

ecia

lists

Es

tabl

ishm

ent o

f a

natio

nal H

IS to

be

used

hea

lth p

lann

ing

and

M&

E.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-11

)

Prio

rity

Are

a Im

med

iate

Sup

port

/Inp

uts

June

200

2-M

arch

200

3 Sh

ort-

Term

Inpu

tsM

ar. 0

3-D

ec. 0

4

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0

In

puts

O

ngoi

ng/A

tten

tion

Nee

ded

Inpu

ts

Out

puts

A-7

Dev

elop

men

t of

Dru

g M

anag

emen

t Sy

stem

Inve

ntor

y of

exi

stin

g co

nditi

ons o

f dru

g su

pply

and

m

anag

emen

t sys

tem

of

the

MO

PH.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

priv

ate

sect

or

Dev

elop

ing

drug

m

anag

emen

t sys

tem

. D

ispa

tch

of E

xper

ts.

Esta

blish

men

t of D

rug

man

agem

ent s

yste

m.

Ex

pand

ing

the

drug

m

anag

emen

t sys

tem

ov

er th

e co

untry

.

Esta

blish

men

t of a

na

tiona

l dru

g m

anag

emen

t sys

tem

.

Goa

l B. R

educ

ing

Prev

enta

ble

Com

mun

icab

le D

isea

se

B-1

Imm

uniz

atio

n C

ampa

ign

Vacc

inat

ion

of p

olio

, m

easl

es, a

nd o

ther

ro

utin

e EP

I.

On-

goin

g:

EPI p

rogr

amm

e (W

HO

/UN

ICEF

)

Esta

blish

men

t of

imm

uniz

atio

n pr

ogra

mm

e in

Kab

ul

city

EPI c

over

age

of 5

0% o

f th

e po

pula

tion

in K

abul

ci

ty

Con

tinuo

us e

ffort

of

imm

uniz

atio

n ca

mpa

ign

EPI c

over

age

of

100%

of t

he

popu

latio

n in

Kab

ul

city

B-

2 Re

habi

litat

ion

of

the

Nat

iona

l TB

Insti

tute

(NTI

).

Ass

ista

nce

for

reha

bilit

atio

n an

d su

pply

of e

quip

men

t.

On-

goin

g:

Reha

bilit

atio

n of

N

TI b

y th

e U

RSP

(JIC

A).

La

ying

foun

datio

n of

op

erat

ing

NTP

. C

ontin

uous

en

hanc

emen

t of t

he

NTP

cen

tral f

unct

ions

in

clud

ing

supe

rvis

ion,

M&

E of

N

TP p

erfo

rman

ce.

Esta

blish

men

t of t

he

natio

n-w

ide

regi

me

for T

B m

easu

res.

B-3

Trai

ning

of

labo

rato

ry

tech

nici

ans,

and

adm

inis

tratio

n an

d m

anag

emen

t sta

ff.

Tech

nica

l ass

ista

nce

to p

rovi

de tr

aini

ng

syst

em a

nd p

rogr

am.

Att

entio

n N

eede

d:

Dis

patc

h of

exp

erts

and

spec

ialis

ts to

fo

rmul

ate

train

ing

syst

em a

nd

prog

ram

me

(JIC

A).

Con

tinuo

us tr

aini

ng

of tr

aine

rs a

nd

train

ees.

Esta

blish

men

t of

refe

renc

e la

bora

tory

fu

nctio

ns.

Con

tinuo

us

prom

otio

n of

NTP

an

d ot

her

com

mun

icab

le

dise

ase

cont

rol o

ver

the

coun

try.

Qua

lity

enha

ncem

ent

of la

bora

tory

ex

amin

atio

n pa

rticu

larly

in sp

utum

sm

ear t

ests

.

B-4

Esta

blish

men

t of

info

rmat

ion

and

data

base

sys

tem

s for

N

TP.

Esta

blish

men

t of

stan

dard

crit

eria

for

data

repo

rting

and

co

mpi

latio

n.

Col

lect

ion

of

perti

nent

dat

a an

d in

form

atio

n.

C

ontin

uous

co

llect

ion

of

perti

nent

dat

a an

d es

tabl

ishm

ent o

f da

taba

se s

yste

m b

y us

ing

info

rmat

ion

tech

nolo

gy.

Stat

istic

al id

entif

icat

ion

of e

pide

mio

logi

cal

impl

icat

ions

of

drug

-res

ista

nce

and

optim

um u

se o

f dru

gs.

Con

tinuo

us

soph

istic

atio

n of

bu

ildin

g ap

prop

riate

da

taba

se s

yste

m

base

d on

info

rmat

ion

tech

nolo

gy.

Esta

blish

men

t of

effe

ctiv

e ph

arm

aceu

tical

su

ppor

t for

DO

TS

treat

men

t ove

r the

co

untry

.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-12

)

Imm

edia

te S

uppo

rt/I

nput

s Ju

ne 2

002-

Mar

ch 2

003

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0 Pr

iori

ty A

rea

Inpu

ts

Ong

oing

/Att

entio

nN

eede

d

Shor

t-Te

rm In

puts

Mar

. 03-

Dec

. 04

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Inpu

ts

Out

puts

Goa

l C. I

nteg

rate

d Im

prov

emen

t Pro

gram

for

Mat

erna

l-Chi

ld H

ealth

(MC

H) C

linic

s C

-1 R

ehab

ilita

tion

and

reco

nstru

ctio

n of

M

CH

faci

litie

s and

eq

uipm

ent.

Reha

bilit

atio

n an

d su

pply

of e

quip

men

t.A

tten

tion

Nee

ded:

C

oord

inat

ion

with

N

GO

s inv

olve

d in

re

habi

litat

ion

activ

ities

.

Con

tinuo

us te

chni

cal

and

finan

cial

as

sist

ance

.

Impr

ovem

ent o

f MC

H

faci

litie

s and

eq

uipm

ent.

Con

tract

ual

re-a

rran

gem

ents

for

land

and

bui

ldin

g ow

ners

hip.

Esta

blish

men

t of

mor

e sta

biliz

ed

com

mun

ity b

ased

M

CH

clin

ics.

C-2

Sta

ndar

diza

tion

of M

CH

func

tions

an

d se

rvic

e qu

ality

.

Inve

ntor

y of

exi

stin

g co

nditi

ons o

f ser

vice

qu

ality

. C

oord

inat

ion

of

NG

Os a

ctiv

ities

. Pr

omot

ion

of h

ealth

ed

ucat

ion

incl

udin

g re

prod

uctiv

e he

alth

, va

ccin

atio

n, a

nd

othe

r PH

C is

sues

.

Att

entio

n N

eede

d:

Stre

ngth

enin

g of

su

ppor

ts fr

om

NG

Os.

On-

goin

g:

Ass

ess

Hea

lth

Syst

em N

eeds

and

Re

sour

ces (

MSH

/ W

HO

, USA

ID, E

U,

and

UN

ICEF

)

Esta

blish

men

t of

regi

strat

ion,

dat

a co

llect

ion,

and

re

porti

ng sy

stem

s. Te

chni

cal a

ssis

tanc

e fo

r pre

parin

g st

anda

rd o

pera

tion

man

uals.

Tr

aini

ng o

f in

-ser

vice

med

ical

pr

actit

ione

rs

incl

udin

g nu

rses

, m

idw

ives

, and

hea

lth

wor

kers

.

Stan

dard

ized

serv

ice

qual

ity o

f MC

H c

linic

s in

Kab

ul C

ity.

Con

tinuo

us e

fforts

fo

r enh

ance

men

t of

serv

ice

qual

ity.

Con

tinuo

us e

fforts

fo

r hea

lth e

duca

tion.

Esta

blish

men

t of

com

mun

ity-b

ased

PH

C s

yste

m.

C-3

Sta

ndar

diza

tion

of M

CH

ad

min

istra

tion

and

man

agem

ent

Inve

ntor

y of

exi

stin

g co

nditi

ons o

f op

erat

ion

and

man

agem

ent o

f M

CH

clin

ics.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

NG

Os i

nvol

ved

in

oper

atio

n an

d m

anag

emen

t of

MC

H c

linic

s.

Trai

ning

of

adm

inis

trativ

e st

aff

by e

xpat

riate

exp

erts

and

over

seas

tra

inin

g.

Stre

ngth

enin

g of

ad

min

istra

tive

and

man

ager

ial c

apac

ity

incl

udin

g ac

coun

ting

and

finan

cial

cap

acity

.

Intro

duci

ng o

f par

tial

fee-

for-

serv

ice

syst

em.

Enha

ncem

ent o

f se

lf-su

stai

ning

fin

anci

al c

apac

ity.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-13

)

Imm

edia

te S

uppo

rt/I

nput

s Ju

ne 2

002-

Mar

ch 2

003

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0 Pr

iori

ty A

rea

Inpu

ts

Ong

oing

/Att

entio

nN

eede

d

Shor

t-Te

rm In

puts

Mar

. 03-

Dec

. 04

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Inpu

ts

Out

puts

C-4

Est

ablis

hmen

t of

Lead

ing

MC

H

clin

ics a

s PH

C

cent

res

Sele

ctin

g M

CH

cl

inic

s as P

HC

ce

nter

Im

prov

ing

man

agem

ent

capa

city

On-

goin

g:

Surv

ey fo

r MC

H

clin

ics i

n K

abul

city

(J

ICA

/URS

P)

Reha

bilit

atio

n an

d su

pply

of e

quip

men

t. D

ispa

tch

of e

xper

ts.

Trai

ning

of h

ealth

w

orke

rs

Esta

blish

men

t of P

HC

ce

ntre

s St

reng

then

ing

othe

r M

CH

clin

ics t

hrou

gh

the

activ

ities

of t

he

PHC

cen

ter.

Stan

dard

izat

ion

and

self-

sust

aina

ble

impr

ovem

ent

of

MC

H c

linic

s

Goa

l D. I

mpr

ovem

ent o

f Rep

rodu

ctiv

e H

ealth

Car

e

D-1

Pro

mot

ion

of

repr

oduc

tive

heal

th

care

edu

catio

n.

Coo

rdin

atio

n w

ith

MC

H c

linic

s re

gard

ing

educ

atio

n fo

r rep

rodu

ctiv

e he

alth

car

e.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

WH

O a

nd U

NFP

A.

Invo

lvem

ent o

f N

GO

s.

Dis

patc

h of

exp

erts

(MC

H, n

utrit

ion)

. Pr

oduc

tion

and

prom

otio

n of

m

ater

nity

hea

lth

reco

rds.

Expa

nsio

n of

ant

enat

al

care

incl

udin

g an

ti-m

alar

ia a

nd

anti-

anem

ia m

easu

res.

Prom

otio

n of

co

ntra

cept

ive

prev

alen

ce a

nd b

irth

spac

ing.

Redu

ctio

n of

ferti

lity

rate

. Es

tabl

ishm

ent o

f pr

enat

al a

nd a

nten

atal

ca

re sy

stem

ove

r the

co

untry

. D

-2 P

rom

otio

n of

Fa

mily

Pla

nnin

g

Coo

rdin

atio

n w

ith

MC

H c

linic

s re

gard

ing

educ

atio

n fo

r fam

ily p

lann

ing.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

WH

O a

nd U

NFP

A.

Invo

lvem

ent o

f N

GO

s.

Dis

patc

h of

fam

ily

plan

ning

exp

erts

. A

dvoc

acy

of fa

mily

pl

anni

ng a

t hos

pita

ls an

d co

mm

uniti

es

Expa

nsio

n of

kn

owle

dge

of fa

mily

pl

anni

ng (b

oth

wom

en

and

men

)

Con

tinuo

us e

fforts

fo

r pro

mot

ion

of

fam

ily p

lann

ing.

Redu

ctio

n of

birt

h ra

te.

D-3

Stre

ngth

enin

g of

ur

gent

obs

tetri

cal

diag

nosi

s abi

lity.

Stre

ngth

enin

g of

cl

inic

al c

apac

ity o

f M

alar

ai H

ospi

tal a

nd

Rabi

a Ba

lki H

ospi

tal

in K

abul

City

.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

NG

Os

invo

lved

in

M

alar

ai H

ospi

tal a

nd

Rabi

a Ba

lki

Hos

pita

l.

Enha

ncem

ent o

f tra

inin

g co

urse

for

mid

-wiv

es a

nd

obst

etric

ians

. Es

tabl

ishm

ent o

f ur

gent

tran

spor

t sy

stem

of p

atie

nts

and

bloo

d tra

nsfu

sion

syst

em.

Stre

ngth

enin

g of

urg

ent

obst

etric

al d

iagn

osis

ab

ility

.

Con

tinuo

us e

fforts

fo

r stre

ngth

enin

g of

ur

gent

obs

tetri

cal

diag

nosi

s abi

lity

over

th

e co

untry

.

Redu

ctio

n of

m

ater

nal m

orta

lity

rate

.

Redu

ctio

n of

infa

nt

mor

talit

y ra

te.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-14

)

Imm

edia

te S

uppo

rt/I

nput

s Ju

ne 2

002-

Mar

ch 2

003

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0 Pr

iori

ty A

rea

Inpu

ts

Ong

oing

/Att

entio

nN

eede

d

Shor

t-Te

rm In

puts

Mar

. 03-

Dec

. 04

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Inpu

ts

Out

puts

Goa

l E. D

isab

ility

and

Psy

chol

ogic

al T

raum

a C

are

E-1

Esta

blish

men

t of

care

syst

em fo

r di

sabl

ed p

eopl

e.

Tech

nica

l ass

ista

nce

to fa

bric

ate

artif

icia

l lim

bs.

Tr

aini

ng o

f te

chni

cian

s for

fa

bric

atin

g ar

tific

ial

limbs

. Es

tabl

ishm

ent o

f w

orks

hop

for

fabr

icat

ing

artif

icia

l lim

bs.

Layi

ng fo

unda

tion

for

disa

bled

peo

ple

to b

e in

tegr

ated

in so

ciet

y.

Esta

blish

men

t of

voca

tiona

l sch

ool f

or

disa

bled

peo

ple.

Ed

ucat

ion

of p

ublic

re

cept

ive

awar

enes

s of

dis

able

d pe

ople

.

Inte

grat

ion

of

disa

bled

peo

ple

into

so

ciet

y an

d ab

le to

le

ad p

rodu

ctiv

e liv

es.

E-2

Esta

blish

men

t of

care

syst

em fo

r tra

umat

ized

peo

ple.

Dis

patc

h of

exp

erts

for t

hera

peut

ic

reha

bilit

atio

n.

Att

entio

n N

eede

d:

Expe

rts p

ract

ice

ther

apeu

tic

reha

bilit

atio

n, a

nd a

t th

e sa

me

time,

nu

rture

ther

apeu

tic

prac

titio

ners

on

an

on-th

e-jo

b tra

inin

g ba

sis.

Educ

atio

n of

sp

ecia

lists

for

ther

apeu

tic

reha

bilit

atio

n.

Layi

ng fo

unda

tion

for

traum

atiz

ed p

eopl

e to

be

inte

grat

ed in

soci

ety.

Educ

atio

n of

pub

lic

rece

ptiv

e aw

aren

ess o

f tra

umat

ized

peo

ple.

.

Esta

blish

men

t of

cont

inuo

us su

ppor

t sy

stem

from

th

erap

eutic

exp

erts

and

com

mun

ity.

Inte

grat

ion

of

disa

bled

peo

ple

into

so

ciet

y an

d ab

le to

le

ad p

rodu

ctiv

e liv

es.

Goa

l F. R

ehab

ilita

tion/

Est

ablis

hmen

t of C

entr

al S

ervi

ce S

yste

m fo

r M

anag

emen

t and

Mai

nten

ance

of F

acili

ties

F-1

Reha

bilit

atio

n of

C

entra

l Ser

vice

Sy

stem

for

Mai

nten

ance

of

Equi

pmen

ts.

Inve

ntor

y of

exi

stin

g bu

ildin

g an

d eq

uipm

ent i

n th

e ho

spita

ls.

On-

Goi

ng:

Coo

rdin

atio

n w

ith

MSH

(NG

O) a

nd

Coa

litio

n Jo

int

Mili

tary

Ope

ratio

ns

Task

For

ce.

Trai

ning

of

tech

nici

ans b

y ex

patri

ate

expe

rts in

th

e co

untry

and

ov

erse

as tr

aini

ng.

Reha

bilit

atio

n of

the

Cen

tral w

orks

hop

for e

quip

men

t in

Kab

ul c

ity.

Reha

bilit

atio

n of

ce

ntra

l ser

vice

sys

tem

fo

r mai

nten

ance

of

equi

pmen

ts in

Kab

ul

city

.

Dev

elop

emnt

and

en

hanc

emen

t of d

ata

base

sys

tem

for

equi

pmen

t, fa

cilit

ies

and

regu

lar

Mon

itorin

g sy

stem

.

Trai

ning

of r

egio

nal

staf

fs fo

r ope

ratio

n an

d m

aint

enan

ce o

f eq

uipm

ent/f

acili

ties.

Esta

blish

men

t of a

m

onito

ring

and

mai

nten

ance

syst

em

for a

ll of

the

regi

ons

in c

ount

ry.

Part

3

Hea

lth S

ecto

r Sh

ort-

term

Reh

abili

tatio

n Pl

an (

4-15

)

Prio

rity

Are

a Im

med

iate

Sup

port

/Inp

uts

June

200

2-M

arch

200

3 Sh

ort-

Term

Inpu

tsM

ar. 0

3-D

ec. 0

4

Tota

l Out

put b

y 20

04(U

rgen

t &

Shor

t-Te

rm)

Lon

g-Te

rm In

puts

& E

xpec

ted

Res

ults

Ja

n. 2

005-

Jan.

201

0

F-2

Esta

blish

men

t of

a C

entra

l A

dmin

istra

tive

&

Serv

ice

Syst

em fo

r th

e m

anag

emen

t of

Sew

age,

Hos

pita

l W

aste

, Med

ical

Gas

&

oth

er su

pplie

s for

ho

spita

ls a

nd

med

ical

faci

litie

s.

Inve

ntor

y of

exi

stin

g bu

ildin

g an

d eq

uipm

ent i

n th

e ho

spita

ls

Coo

rdin

atio

n w

ith

Min

istry

of

Hou

sing

an

d To

wn

Plan

ning

an

d K

abul

M

unic

ipal

ity.

Trai

ning

of

tech

nici

ans b

y ex

patri

ates

.

Esta

blish

men

t of a

C

entra

l Adm

inis

trativ

e &

Ser

vice

Sys

tem

for

the

man

agem

ent o

f Se

wag

e, H

ospi

tal

Was

te, M

edic

al G

as &

ot

her s

uppl

ies f

or

hosp

itals

and

m

edic

al

faci

litie

s.

Dev

elop

men

t and

en

hanc

emen

t of d

ata

base

sys

tem

for

equi

pmen

t, fa

cilit

ies

and

regu

lar

mon

itorin

g s

yste

m.

Con

struc

tion

of a

C

entra

l Ser

vice

C

ente

r for

the

man

agem

ent o

f m

edic

al fa

cilit

ies.

Esta

blish

men

t of

mon

itorin

g an

d da

taba

se s

yste

m fo

r m

anag

emen

t of

faci

litie

s.

Goa

l G. S

ecur

ing

Safe

Wat

er a

nd S

anita

tion

G-1

Sec

urin

g sa

fe

wat

er a

nd sa

nita

tion

Reco

nstru

ctio

n an

d di

ggin

g w

ells

C

lean

-up

cam

paig

n in

Kab

ul C

ity

On-

goin

g:

Con

struc

tion

wel

ls a

t M

CH

cl

inic

s an

d ho

spita

ls

(JIC

A/U

RSP)

C

onstr

uctio

n of

to

ilet

and

wel

ls

(AC

F)

REA

P (U

ND

P)

Esta

blish

men

t wat

er

supp

ly s

yste

m

Esta

blish

men

t was

te

disp

osal

syst

em

Secu

ring

safe

wat

er a

nd

sani

tatio

n Es

tabl

ishm

ent o

f se

wag

e tre

atm

ent

syst

em

Secu

ring

hygi

enic

en

viro

nmen

t

G-2

Pro

mot

ion

of

hygi

ene

educ

atio

n

Coo

rdin

atio

n w

ith

MC

H c

linic

s re

gard

ing

hygi

ene

educ

atio

n.

Att

entio

n N

eede

d:

Coo

rdin

atio

n w

ith

NG

Os

Adv

ocac

y of

hy

gien

e ed

ucat

ion

at

hosp

itals

and

co

mm

uniti

es

Expa

nsio

n of

kn

owle

dge

of sa

fe

wat

er a

nd sa

nita

tion

Con

tinuo

us e

fforts

fo

r pro

mot

ion

of

hygi

ene

educ

atio

n.

Redu

cing

IMR

and

com

mun

icab

le

dise

ase.

Part 3


CHAPTER 5: CONCEIVABLE SHORT-TERM REHABILITATION PROJECTS AND PROGRAMS

5.1 Basic Strategies for the Formulation of Projects and Programs A balance must be maintained between immediate impact and long-term planning. Emergency assistance that delivers services but detracts from long-term development is inefficient, whereas an emphasis on long-term planning that fails to meet immediate critical needs is ultimately ineffective because it undermines the short-term stability needed to achieve long-term goals. An appropriate balance is needed between the parallel tracks of immediate service delivery and planning and development.1 In effect, short-to-mid-term rehabilitation projects and programs should be rightly positioned within the future reconstruction process. In order to avoid any adverse effects on the future reconstruction, they should take an “integrated program approach” as much as practical, rather than a fragmentary approach on a piecemeal basis. This is to secure flexibility under the fast-changing environments and balance that should be maintained between immediate impact and long-term planning. In this context, besides physical components, they are preferred to cover so-called “soft-area assistance” including technical assistance, human resource development, institutional capacity building, and so on, in order to support endogenous efforts of the Afghan people. Naturally, the Afghan Government should take the driver’s seat in both terms of ownership and responsibility in implementing the projects and programs. Also, in order to ensure flexibility and speeds for implementation, the experts dispatched under projects and programs should be given the authorization to formulate and implement the components included in such projects and programs. 5.2 Recommended Short-Term Rehabilitation Projects and Programs While Table 4.1 provides a synopsis of the overall health sector rehabilitation plan for Kabul City, the following provides specific strategies that need to be implemented to achieve the broader goals of the Plan. It is believed that donors’ contribution in implementing these strategies would be instrumental in creating a viable health policy and programme development and implementation in Afghanistan. Each project and program needs to have intensive consultation and discussions with the Afghan side during the next visit of the URSP Team to Kabul. Perhaps some more additional ones may come up with the results of the consultation and discussion with the Afghan side. 5.2.1 Integrated Improvement Program for Maternal-Child Health (MCH)

Clinics in Kabul City According to the information from MOPH, there are 22 MCH clinics currently in operation in Kabul, but most of which are renting buildings from private owners and others. Also, according to the Preventive Department of MOPH, there are another 18 MCH clinics currently not in operation but desired by MOPH to resume their previous functions. In fact, MCH clinics are PHC services on a community basis, and hence, 1 The Comprehensive Needs Assessment (CNA) Report on the education sector prepared by the multi-donor CNA Mission

Part 3


importantly positioned to enhance PHC functions to reduce risks not only for maternal-child diseases but other communicable diseases. Currently, many NGOs are working for the rehabilitation of MCH clinics rather in haphazard manner without proper coordination with MOPH or among them, thus creating potential risks to produce different quality levels of service, arbitrary registration and data compilation of patients, non-standardized diagnostic and curative methods, inefficient operation and management, and so on. In the light of these, there are urgent necessity to establish a unified system for the operation and management of MCH clinics in Kabul City to enhance their service levels by system integration and standardizing. The proposed Program will include the following components. (1) Minimum rehabilitation of defective and destructed building facilities, (2) Supply of minimum required medical equipment, (3) Establishment of standard operation manuals, (4) Establishment of registration, data collection and reporting systems, (5) Training of in-service doctors as well as other medical practitioners including

midwives and other health workers, (6) Training administrative and managerial staff, (7) Strengthening of information dissemination functions for health care including

antenatal care of pregnant women, contraceptive prevalence, Acute Respiratory Infection (ARI), micronutrient deficiencies, and so on,

(8) Strengthening of financial capacity by introducing reasonable income generation systems,

(9) Formulation of a medium-term MCH development plan including a reconstruction plan of currently non-functional MCH clinics, and

(10) Positioning explicitly the above components in the medium-term MCH development plan.

The implementation of the Program requires dispatch of a few program management experts together with other professional specialists of different category who will support the MCH Department of MOPH over the period of the Program. In order to facilitate quick decision, flexible response, and integrated program approach, it is preferred that the program management experts will be authorized to decide the implementation of the part or whole of the components as mentioned above along with the budget allocation for the implementation thereof. 5.2.2 The National TB Center Strengthening Program for Training, Research &

Information, Reference Laboratory Functions The National TB Institute (NTI) and its annexed Kabul TB Center in Darulaman will be rehabilitated by the Urgent Rehabilitation Support Program of the Japanese Government and will be completed for use sometime in March 2003. According to the agreement made recently between MOPH and Japanese experts, the NTI will be used for the office of the National Tuberculosis Program (NTP) as well as the Training Center for Communicable Diseases with training and reference laboratory functions, and the Kabul TB Center will be used as the Darulaman Polyclinic for diagnosis of diverse outpatients. The NTP function will have the data and information center functions that shall compile all TB-related statistical data collected from TB hospitals and clinics in regions and provinces over the country, and shall disseminate the necessary information on TB to them. The reference laboratory function will include the sputum smear testing referred

Part 3


to the NTI from TB hospitals and clinics in regions and provinces, and will compile and feedback the results. However, regional and provincial TB hospitals and clinics stand at a devastated situation currently, thus taking considerable time to resume their functions reasonably. Taking into consideration the situation, the proposed Program will aim at establishing a model system for training, research and reference laboratory functions taking Kabul City as a pilot study area. Therefore, the Program will focus on the training of the staff presently working at TB facilities in Kabul including the sub-centers in Cinema Pamier and Khair Khana (designated as DOTS centers), and other hospitals and clinics. As a matter of fact, the existing TB facilities in Kabul are mostly attended by NGOs particularly GMS and MEDAIR, and therefore, they are in a fairly reasonable level for the treatment of TB patients. However, the fact is there is no effective and efficient coordination or referral system at present, since central TB institute or hospital has not been available up to now. The Program will aim at establishing an effective and efficient coordination system in Kabul first, and then expand the system to other parts of the country in the future to substantiate the NTP. The Program will include, but not necessarily limited to, the following components. (1) Design training course for diverse TB-related personnel together with

preparing curricula, (2) Strengthen the data and information center function by means of information

technology, (3) Establishment of reference laboratory functions including data compilation

and feedback systems, (4) Establish an effective and efficient coordination system with sub-centers as

well as other TB hospitals and clinics in Kabul City The implementation of the Program requires dispatch of a few experts of different category who will support the NTP of MOPH for certain period. The Program will be combined with different training programs including overseas training. 5.2.3 Gynecological Clinical Capacity Strengthening Program of Malarai

Hospital and Rabia Balki Hospital in Kabul to Assume Central Functions to Expand Reproductive Health Care over Afghanistan

The Maternal-Child Health (MCH) care requires basically the safe delivery of births and the Expanded Program on Immunization (EPI), and the basic strategy for the safe delivery of births requires to (1) fabricate the urgent obstetrical diagnosis system particularly urgent transport system of patients and blood transfusion system, (2) expand antenatal care including anti-malaria and anti-anemia measures, and (3) promotion and education of reproductive health knowledge on a community basis. Many donors and NGOs are supporting the above items (2) and (3) but not the item (1) substantially despite the fact that virtually no hospital or clinic that can provide a reasonable level of obstetrical diagnosis is available in Afghanistan at present. The proposed Program is to have the following objectives. (1) To strengthen the clinical capacity of the female Malarai Hospital and Rabia

Balki Hospital in Kabul City as pilot hospitals, and then expand the high clinical levels to other parts of the country,

(2) To establish training functions for in-service medical doctors and practitioners based on a refresher course, aiming at enhancing the clinical service level, and

Part 3


at the same time, human resource development, and (3) To nurture training experts and dispatch them to regional hospitals, thus

standardizing the quality of clinical services over the country. Under the Program, a few experts of different category, preferably female experts taking into consideration the social specificities of gender issues in Afghanistan, shall be dispatched to the Hospitals of MOPH. The Program includes the following components. (1) Rehabilitation and renovation of building facilities, (2) Supply of medical equipment, (3) Technical assistance for enhancement of clinical capacity, (4) Formulation of a strategic expansion program to ripple over other parts of the

country The implementation of the Program requires dispatch of a few program management experts together with other professional specialists of different category who will support the Malarai and Rabia Balki Hospitals over the period of the Program. In order to facilitate quick decision, flexible response, and integrated program approach, it is preferred that the program management experts will be authorized to decide the implementation of the part or whole of the components as mentioned above along with the budget allocation for the implementation thereof. 5.2.4 Comprehensive Communicable Disease Measures Support Program in

Kabul City In order to significantly reduce the rates of infection for communicable diseases, efforts should be exerted focusing on the preventive part. In the circumstances where a large number of repatriated refugees and IDPs would settle in Kabul under inadequate living environments, it is of prime importance to apply appropriate preventive measures to avoid the rampancy of epidemic disease. In this context, appropriate information on the preventive medicine should be disseminated to as much citizens as possible. One of the constraining factors for this is the high rate of illiteracy, especially in female who are key persons for families’ health care situation. For the information dissemination, it is deemed practical to develop public hygiene education in MCH clinics at community levels. Each MCH clinic has some health education programs for hygiene but the levels vary considerably among them, normally just applying to the patients in a waiting room having a time to listen the lecture of about 15 minutes by nurses. This implies that there is no regular, standardized, and systematic programs. The Preventive Department of MOPH can formulate a consensus or share unified view with MCH clinics for the commission to implement public hygiene education. Such education needs to cover appropriate knowledge of sewage and waste disposal as it dominantly affects adversely on the hygiene situation in Kabul City. One of the important points for education is to use visual presentation for teaching and provide a pamphlet that they can bring their houses to inform to other family members. Nurses of MCH clinics are quoted as saying that female feel easier to access to MCH clinics than to any other places due to established social environments. Apart from the preventive medicine to control MCH clinics, it also needs to supply basic medicine such as antibiotics in each clinic. The system of storage and use of such medicine should be established so that written records should be kept properly not only by doctor but also by pharmacist.

Part 3


The Program should include, but not necessarily limited to, the following components. (1) Supply of basic medicine (2) Training of administrative staff (3) Training of nurses (4) Supply of presentation equipment The implementation of the Program requires dispatch of a few experts of different category who will support the Preventive Department of MOPH for certain period. 5.2.5 The Disability Care Center in Kabul City Disabled people and traumatized people due to war affairs, landmines, and unexploded ordinance (UXO) should be taken care of in the immediate future, and should be rehabilitated over the long-term course in order for them to be integrated into society and able to lead productive lives. This is one of the WHO’s Priority Health Program but so far there has been no substantial support committed by international donors and NGOs by April 2002. Japan has the reputation of technological support of this field such as fabricating artificial limbs or physical therapeutic rehabilitation in the Wazir Akbar Khan Hospital in Kabul provided in the past. Therefore, it might be helpful to provide necessary support again of this field under the initiative of Japan. The Project for the development of a new disability care center will utilize one of the existing appropriate hospitals (such as Wazir Akbar Khan Hospital) that can meet the requirements for the purpose. The Project for the disability care center development shall include the components of the renovation of an existing hospital together with supply of necessary equipment, and the technical assistance program to support post-development operation and management shall require, but not necessarily limited to, the following components. (1) Training of fabrication and fitting of artificial limbs and so on (2) Training of medical practitioners for rehabilitation of disabled patients (3) Training and programming of physical therapeutic rehabilitation course The implementation of the technical assistance program requires dispatch of a few experts of different category who will support the Disability Care Center of MOPH for a certain period. The experts should include a specialist for therapeutic rehabilitation for traumatized people, who shall provide therapeutic rehabilitation services, and at the same time, training of potential therapeutic rehabilitation specialists by means of on-the-job training. 5.2.6 Establishment of Maintenance and Management System for Medical Facility in Kabul City At present, donors and Non-Governmental Organisations (NGOs) are implementing or considering assistance projects/programs for rehabilitation in Kabul City hospitals individually. Mostly of the programs/projects are directed towards rehabilitation, repair works of the infrastructure and buildings. Some are involved in the installation of minor machinery/equipments, etc. There is no systemic management and maintenance of the hospitals due to lack of financial support from the Afghanistan side. The Previous management and support system has been destroyed by the civil war and

Part 3


difficult circumstances in the country. Now the donors and NGOs are supporting management and maintenance works by providing the running cost and repairing the necessary facilities by themselves. It has been found that many old and broken machinery and equipment still exists in hospital and they require a sustainable method of management and maintenance in the hospitals. In future for cost effectiveness and sustainable management as well as maintenance of the hospital and medical facilities in Kabul City, the following activities are recommended from the Central Workshop for Equipment and Central Service Center. (1) Central Workshop for Equipment in Kabul has to be restored and rehabilitated

for proper repair and maintenance works. For this purpose the available equipment and facilities have to be repaired and the existing staff have to be properly trained.

(2) Minor repair works as well as regular inspection of building, equipment,

facilities, etc and monitoring of activities should be done by hospital it self. Financial support and training of personnel for the hospitals should be provided by the Ministry of Public Health.

(3) A Central Service Center is to be established and it will manage the sewage

and solid waste including medical waste, and medical gas supply for hospital. The Central Service Center will have sufficient number of vehicles such as vacuum car and trucks to manage and dispose the sewage and solid waste, incinerator for hazardous hospital waste and dumping site/land far away from City.

(4) According to the analysis of Inventory survey for medical facilities in

Afghanistan, strategy of rehabilitation and development for facility/equipment will be measured. Standard of facility/equipment in each level of facility to be set up in strategy plan.

APPENDIX A

LISTS OF EXISTING EQUIPMENT AT

RABIA BALKHI HOSPITAL AND MALALAI HOSPITAL

APPENDIX B

DRAWINGS OF

RABIA BALKHI HOSPITAL AND MALALAI HOSPITAL

APPENDIX C

RESULTS OF QUICK INTERVIEW SURVEY OF

PATIENTS AT RABIA BALKHI HOSPITAL

APPENDIX D

RESULTS OF QUESTIONNAIRE SURVEY

AT RABIA BALKHI HOSPITAL AND MALALAI HOSPITAL

MOPH - JICA Study Team The Urgent Rehabilitation Support Programme (URSP-EHB) in Afghanistan

1

QUESTIONNAIRE

Hospitals in Kabul July 2002

Name of Hospital Rabia Balkhi Hospital

Director Name Dr. Nasree ORYAKHIl

Speciality Gynaecology

Respondents Name Dr. Maryam BAHRAMI Position (Title) Assistant Director Gynaecology

Name Position (Title)

1. General Information 1-1 Where does the Hospital locate? Address: Foroshga-Kabul, Afghanistan 1-2 When did the Hospital open? 1-3 Consultation days of the week: Please fill in the following blanks with time.

Mon Tue Wed Thu Fri Sat Sun a) Open time 8:00 8:00 8:00 8:00 off 8:00 8:00 b) Close time 16:00 16:00 16:00 13:00 16:00 16:00

1-4 Donor Support: Please describe the projects, which you have been having, supported by donors or international organizations which have been.

Project or programmes supported by Donor:

c) Project Duration a) Name of the Projects b) Donor Year to start Year to

finish

d) Main Components

,ICRC Occasional - Pharmacy(drugs etc)

WHO “ - X-ray machine etc

UNFPA “ - Autoclave machine etc

Month:xxxxxx Year: 1990


2

1-5 Does your hospital have in- patients wards? If yes, what speciality do you have, and how many rooms and beds in a room? (e.g. 2 s ;6 beds in each room ,etc )

Category of ward No. of room No. of bed

Internal medicine 5 37

General Surgery 6 40

ENT 2 12

Gynecology and Obstetrics 9 86

Dermatology 4 20


3

2. Human Resource

2-1 How many full-time doctors does the hospital have?

Specialities Male

(Cadre)

Male

(Actual No.)

Female

(Cadre)

Female

(Actual No.)

e.g. Anaesthesiology 2 1 1 0

Gyne& Obs. 1 49

Internal medicine 5 6

ENT 4 1

General surgery 4 8

Dermatology 1 2

Total

2-2 How many nurses does the hospital have?

Male

(Cadre)

Male

(Actual No.)

Female

(Cadre)

Female

(Actual No.)

Qualified/Senior nurses 1 79

Assistant nurses

2-3 How many paramedical staff does the hospital have?

Category Male

(Cadre)

Male

(Actual No.)

Female

(Cadre)

Female

(Actual No.)

Midwife (qualified) 1 25

Midwife (unqualified)

Pharmacist 2 7

Medical Laboratory Technologist 2 5

Radiographer 3 2

Physiotherapist 1

Other ( )

Other ( )


4

2-4 How many Non-technical staff does the hospital have?

Category Male Female

Administrative staff 10 99

Accountant 1 7

Maintenance Engineer

Driver 1

Cook 4

Others 5

2-5: In-service Training: Which kind of in-service training programme does the hospital have?

Name of Programme Target personnel Duration

e.g. Middle level manager training course Managers 1 week

National training programs doctors 4 years

2-6 Salary and Incentives: Please describe salary and incentives for staff of the hospital.

Salary: Male Female

Director 1200000Af./month 1200000Af /month

Manager “ /month “ /month

Doctor “ /month “ /month

Nurse “ /month “ /month

Midwife “ /month “ /month

Pharmacist “ /month “ /month

Administrative staff “ /month “ /month

Others “ /month

“ /month

Incentives: e.g. food incentives 40,000 Afg.


5

2-6 Management of health personnel: Does the hospital have autonomy for personnel matter? If yes, please describe recruitment and promotion system of health personnel.

All recruitment of promotion system on according to the rule of Ministry of Public Health.It means after each 3 years period working records are checked by MOPH and relating Department. After approval MOPH issues his/her promotion from one degree to another.

2-7. how do you think of service quality of your hospital staff? Please fill in the following blanks with [ A. Good, B.Fair, C.Bad/Not good]

(1) Knowledge & Skill

(2) Attitude

(3) Availability of

necessary equipment / device

(4) Quality of service to the patients (Overall

evaluation of (1)-(3) )a. Medical Doctor B A B B b. Medical Assistant B A B B c. Pharmacist (Include all level)

B A B B

d. Laboratory Assistant (include all level)

B A B B

e. Registered Nurse (Middle level)

B A B B

f. Primary Nurse (Low level)

B A B B


6

3. Health Services 3-1. Health service provided in the hospital

(1) Services

No. Category Check 1.Yes 2.No

Inpatients service 1. Yes 2. No

Out-patient Service 1 Internal Medicine 1

2 Surgery 1

3 Paediatrics 2

4 Obstetrics/Gynaecology 1

5 Dermatology 1

6 Ophthalmology 2

7 Dental Service 2

8 Oto-Ringo-Laryngology 1

9 Emergency Care 1

10 Pharmacy 1

11 Orthopaedic Surgery and rehabilitation

2

12 Neurology and Neuropsychiatry 2

13 Health Education 2 1..for patients 2.for medical students 3. others ( )

14 Training for the staff 1.Regularl 2.occasionally

1.for doctors 2.nurses. 3.health workers

Medical Service 15 Laboratory Test 1 How many working microscopes ?

1.bloodtest: 12.urinalysis:

16 Radiology 1 How many x-ray available 1.for males 2.for females 2

17 Operation (Major) 1 Average number a month( 15 )

18 Operation (Medium) 1 ( 50 )

19 Operation (Minor) 1 ( 80 )


7

20 Delivery ( 950 )

21 Occupational Therapy Describe details about the therapy

22 Rehabilitation 1 Describe details about treatments

23 Blood Bank 1

(2)Out-patient Services : a) Number of Out-patients by disease in the last 5 months

Number of Cases,2002 Disease Feb March April May Jun

1 Obstetrical 2620 2590 2600 2630 2633

2 Gynaecological 2700 2706 2820 2812 2850

3 Dermatology 650 700 500 510 600

4 Internal Medicine 850 880 800 810 800

5 G. Surgery 120 98 96 95 98

6 ENT 170 179 185 190 208

7

8

9

10

11 Others

Total Number 7110 7153 7071 7047 7189*1

(3) In-patients services:

a) Number of admission cases by disease in past 5 months Number of Cases 2002 Disease

Feb March April May Jun Internal Medicine

1 Obstetrical 705 780 800 1200 1500

2 Gynaecological 800 885 700 1500 1550

3 Dermatology 96 98 110 150 180

4 Internal Medicine 120 200 210 280 350

5 G. Surgery 50 80 85 88 98

6 ENT 260 65 60 80 81

7

8


8

9

10

11 Others

Sub-total No

Surgical Cases

1 80 85 90 90 85

2

3

4

5

6 Others

Ob/Gyn. Cases

1 60 65 70 68 72

2

3

4

5

6 Others

Sub-total No

Total No. of Cases

Total No. of day-stay 5 - 10

(4) Surgery

a) Please list the surgery conducted in this hospital.

Name of the Case No. of the case / year Remarks

Goiter 24

Cholecystectomy 36

Nephrolithiasis 12

Obstetric 720

a-1) Major Surgery

Umblical Harnia 60

Appendicitis 80

Hernia / Rapture 6

a-2) Medium / Intermediate Surgery Caesarean Operation 240


9

89

70 a-3) Minor Surgery

3-2 Vertical Program: If your hospital has any programs, please answer the following questions regarding the vertical programs which has been conducted in this hospital.

Questions and choice: Please select from the following choices.

Questions Choices

Q1. Does this hospital do any activities of the program? 1 Yes , 2 .No 1

Q2. Is the hospital still implementing the program now? 1 Yes , 2 .No 1

Q3. How many staff trained for the program does the hospital have? Numerical answer 30

Q4. Does the hospital receive any budget for the program? 1 Yes , 2 .No 2

Q5. If “Yes”, from which organization does the hospital get budget? 1. MOH 2. Donor( )

Q1). Does this

hospital do any activities of the program?

Q2). Is the hospital still implementing the program now?

Q3). How many staff trained for the program does the hospital have?

Q4). Does the hospital receive any budget for the program from MOH/donor?

Q5). If “Yes”, from which organization?

a) Malaria Control No b) Acute Respiratory Infectious Control No

c) Diarrhea Diseases Control No

d) Tuberculosis and Leprosy No

e) Trauma No f) Reproductive Health and Maternal Care Programmes

No

g) Nutritional Status No h) Water and Environmental Sanitation

No

i) EPI Yes


10

4. Examinations (1)Laboratory Examination Performed

a) Please look at the following table to check if these laboratory examinations are conducted in this hospital.

Total: cases/year in 2002

No. Examination Yes/NoYes 1No 2

No. of test cases /year (2002)

1 WBC 1

2 RBC 1

3 Haemoglobin test 1

4 Haermatocrit test 1

5 Blood differential count 1

6 Pregnancy test 1

7 Stool test 1

8 Malaria test 1 Number of positive case

9 Sputum test 1 Number of positive case

10 Skin test for leprosy 2 Number of positive case

11 Water portability test 2 12 Others (Please specify)

b) Do you have any staff trained in using microscopes? 1. Yes, 2.No 2

c) If “Yes”, how many? 1.male 2.female

(2) Radiology Service

N

o.

Examination Yes/No Yes 1 No 2

If “Yes”, please fill describe the number of cases/year

Do you have a staff trained in using the equipment?

How many? 5 Number of cases/year

3600 1. Yes 2. No

1

Who?

1 X – ray

1

Which kind of images are taken in the hospital?

1.Head 2. Chest

1,2, 3.Abdomen 3,4 4.Born 5. Others 5

(Multiple choice)

How many? 1 2 ECG

1 Number of cases/year

7200 1. Yes 2. No

Who?

3 Echo 2 Number of cases/year 1. Yes How many?


11

2. No Who? Which kind of images are taken in the hospital?

5. Drug Supply 5-(1) Is your pharmacy able to provide enough drugs for patients? No 5-(2) Is your hospital able to provide drugs for outpatients, or only in-patients? Only in-patients

5-2 Store Condition

(1) Does this hospital have a space to keep drug? 1.Yes 2. No (If “Yes”, please go to (3))

1

(2) If “No” How do you keep your drug?

(3) How many stores do you have? (Please put the number.) 1 (4) Safety for door 1.Key locked 2. Unlocked 1 (5) Safety for window 1. Window only

2. Window with security grill 3. No window

1 0 0

(6) Box for Expired Drug 1.Box 2. Nothing 2 (7) How do you manage the disposal of expired drugs?

1. Burn 2. Burry 3. Others( ) 1

(8) How often do you dispose the expired drugs per year? 1 /year

(9)Cleanliness 1. good 2. fair 3.bad 2

(10)Drugs in shelf 1. in order 2.out of order 1

(11)Labelling at shelf 1. labelled 2.nothing 2

(12) Pallet use 1. Pallet use 2.direct on floor 2

6. Quality of Service

6-1 . How do you think of the quality of this hospital?

<Physical Inputs> 1. How do you think of pharmaceuticals and medical supplies to this hospital? 1. Enough 2. So-so 3. Not enough 3

2. Ho do you think of the equipment and clinical furniture in this hospital? 1. Enough 2. So-so 3. Not enough 3

3. How do you think of the procurement and distribution of drugs?

1. Systematic 2. So-so 3. Un systematic

3

4. How do you think of the necessity of repair / deterioration of the building? 1. Necessary 2. Not necessary 2


12

5. How do you think of the physical condition of the hospital building?

1. Good 2. So-so 3. Sub-standard/unsuitable

3

<Personnel Inputs> 1. How do you think of the number of qualified staff in this hospital? 1. Enough 2.So-so 2. Not enough 2

2. How do you think of the staffing to the hospital? 1. Adequate 2.So-so 3. Inadequate 2 3. How do you think of the credibility of your staff? 1. High 2. Middle 3. Low 2 4. How do you think of staff attitude to the patients? 1. Good 2. Fair 3. Bad 1 5. How do you think of staff training? 1. Enough 2. So-so 3. Not enough 2 <Financial inputs> 1. How do you think of operating budget? 1. Enough 2. So-so 3. Not enough 3 2. How do you think of the financial capacity of the hospital? 1. Enough 2. So-so 3. Not enough 3

<Organizational Structure and Management> 1. How do you think of the managerial capability of this hospital?

1. Good 2. So-so 3. Poor 1

2. How do you think of the staff allocation within this hospital?

1. Balanced 2.Fair 3.Unbalanced

1

3. How do you think of the diagnostic and therapeutic capabilities in this hospital?


4. How do you think of the quality control & monitoring of communicable diseases?

1. Good 2.Fair 3. Week 1

6-2. How do you think of the service of the quality of your hospital? (1) Reception 1.Good 2.Fair 3.Not good 1

(2) Treatment for out-patients 1.Good 2.Fair 3.Not good 1

(3) Treatment for in-patients 1.Good 2.Fair 3.Not good 1

(4) Prevention and promotion 1.Good 2.Fair 3.Not good 1

(5) Pharmacy 1.Good 2.Fair 3.Not good 2

(6) Laboratory test 1.Good 2.Fair 3.Not good 2

(7) X-ray 1.Good 2.Fair 3.Not good 2

(8) Operation 1.Good 2.Fair 3.Not good 1

6-3. Have you had a program / project for service

quality improvement? 1. Yes 2. No 2

6-4. If “Yes”, please describe the project.

6-5. What is your assessment of the quality of services provided in this hospital?

1.Good 2.Fair 3.Not good

1


13

7. Communication and Information system 7-1. Medical Record System

(1) Type of records Source of each type a) Out-patient Department

1.Notebook of Patients 2.Card of Individual Patients 3.Others

1 1. Procured in the market 2. Provided by MOPH 3. Provided by Donor ( )

2

b) MCH 1. Patients Notebook 2. Mother & child notebook 3. Growth Chart


2

c) In-patient Department



2 3

(2) Does the hospital keep the card of individual patients? 1. Yes 2.No 1 (3) Do patients have record or registration numbers? In the number written in the individual card? 1. Yes 2.No 1

(4) Who is in-charge of medical record? Administrator (5) What are the problems about the existing System? Please describe them.

Lack of stationary(papers,pens etc)

(6) Is the record written clearly in order? 1. Clear 2.So-so 3. Not clear

3

7-2. Reporting System

7-(1) Does your hospital have any reporting system? Yes

7-(2) If yes, please fill in the following table

b) How often do

you write?

c) To whom do you submit

them?

d) Do you keep the duplicate of the

report?

f) Do you get feed back? a)

Name / type of report 1. Weekly

2. Monthly 3. Semester 4. Yearly

1. DHO 2. PHO 3. PH 4. Donor

1. Yes 2. No

e) How many hours

in a month do you spend to make report?

(hours) 1. Yes 2. No

Professional Report

2 MOPH 1 1 Hour 1

Administrative Report

2 MOPH 1 1 Hour 1


14

g) Do you analyse the records or reports? 1. Yes 2. No

1

8. Operation and Management 8-1 Organization Organization Structure：Please draw the organization chart of this hospital.

8-2 Autonomy Does the hospital have autonomy of hospital management? If yes, what kind of autonomy?

Director

Administrative

Assistant Dir.

Service.Dep Financial Dep. Medical Records

Dermatology G.Surgery Gyne &Obs. ENT


15

9. Budget 9-1. Annual Financial Records

(1) Do you have the actual(not planned) annual financial records? 1. Yes, 2.No => 2

(2) Does your hospital get a proper budget from MoPH? 1. Yes 2.No 2 (3) What percentage of the total running costs of your hospital does the budget cover?

% (4) If “Yes” to (1), please fill in the following table.

1999/2000 2001/2002 2002/2003 a) Revenue 1. Government budget 2. Revolving Drug Fund 3. Cost Recovery 4. Donor Agency 5. Community Fund 6. Private donation etc.

Total *3 *3 *1

b) Expenditure

1. Staff Salary

2. Administration Cost

3. Subsidy

4. Investment

Total *3 *3 *1

(3) Who (position) is in charge of finance, accounting and disbursement?

9-2. Do you have the monthly financial records for year 2001/02broken down by item? 1. Yes, 2.No =>

9-3. Which kind of income do you get? (1) Government Budget 1. Yes 2. No

(If”Yes”, please answer the question “3-4”.) 1

(2) Cost Recovery: Do you charge the patients? 1. Yes 2. No (If”Yes”, please answer the question “3-5”.)

2

(3) Revolving Drug Fund 1. Yes 2. No (If”Yes”, please answer the question “3-6”.)

2

(4) Donor support 1. Yes 2. No 2


16

(5) Private Donation 1. Yes 2. No (If”Yes”, please specify: )

(6) Community Contribution 1. Yes 2. No

(7) Others(Please specify ) 1. Yes 2. No

9-4. Government Budget

(1) Which kind of budget do you get?

(Multiple answer)

1. Staff Salary 2.Administration cost X- Subsidy 4.Investment

5.Others( )

(2) Is there a gap between government budget and actual remittance? 1.Yes 2.No


1

QUESTIONNAIRE

Hospitals in Kabul July 2002

Name of Hospital Malalai Maternity Hospital

Director Name Dr. Fahima

SEKANDARI

Speciality Gynaecology

Respondents Name Dr. Hafiza UMARKHIL Position (Title) Gynaecology, Assistant Director

Name Position (Title)

1. General Information 1-1 Where does the Hospital locate? Address: Charahi-Quwai, Markaz, Kabul, Afghanistan 1-2 When did the Hospital open? 1-3 Consultation days of the week: Please fill in the following blanks with time.

Mon Tue Wed Thu Fri Sat Sun a) Open time 8:00 8:00 8:00 8:00 off 8:00 8:00 b) Close time 16:00 16:00 16:00 13:00 off 16:00 16:00

1-4 Donor Support: Please describe the projects, which you have been having, supported by donors or international organizations which have been.

Project or programmes supported by Donor:

c) Project Duration a) Name of the Projects b) Donor Year to

start Year to finish

d) Main Components

Water Supply UNICEF Mar.2002 -

Sanitation UNICEF Mar.2002 -

-

Month: xxxxxx Year: 1972


2

1-5 Does your hospital have in- patients wards? If yes, what speciality do you have, and how many rooms and beds in a room? (e.g. 2 s ;6 beds in each room ,etc )

Category of ward No. of room No. of bed

e.g. neurological male room 2 12 (6 beds in each room)

Obstetric ward 10 130

Gynecology ward 4 50

Neonatal ward 2 60

Septic ward 1 10


3

2. Human Resource

2-1 How many full-time doctors does the hospital have?

Specialities Male

(Cadre)

Male

(Actual No.)

Female

(Cadre)

Female

(Actual No.)

e.g. Anaesthesiology 2 1 1 0

Gynaecologist 20

Obstetrician 72

Anaesthesiologist 7

Paediatrician 7

Total

2-2 How many nurses does the hospital have?

Male

(Cadre)

Male

(Actual No.)

Female

(Cadre)

Female

(Actual No.)

Qualified/Senior nurses na na

Assistant nurses na na

2-3 How many paramedical staff does the hospital have?

Category Male

(Cadre)

Male

(Actual No.)

Female

(Cadre)

Female

(Actual No.)

Midwife (qualified + unqualified) 146

Pharmacist 5

Medical Laboratory Technologist 8

Radiographer 4

Physiotherapist 0

Other ( )

Other ( )


4

2-4 How many Non-technical staff does the hospital have?

Category Male Female

Administrative staff 2 10

Accountant 2 10

Electrician 4 2

Driver 7 0

Cook 8 0

Others 44 130

2-5: In-service Training: Which kind of in-service training programme does the hospital have?

Name of Programme Target personnel Duration

e.g. Middle level manager training course Managers 1 week

Doctors’ training course Junior doctors 3 years

2-6 Salary and Incentives: Please describe salary and incentives for staff of the hospital.

Salary: Male Female

Director /month 1690000Af./month

Manager /month 1575000Af./month

Doctor /month 1690000Af./month

Nurse /month 1630000Af./month

Midwife /month 1638000Af./month

Pharmacist /month 1593000Af./month

Administrative staff /month 1678000Af./month

Others /month /month

Incentives: e.g. food incentives No incentive


5

2-6 Management of health personnel: Does the hospital have autonomy for personnel matter? If yes, please describe recruitment and promotion system of health personnel.

All technical and administrative workers are recruited and employed by MOPH.

2-7. How do you think of service quality of your hospital staff? Please fill in the following blanks with [ A.Good, B.Fair, C.Bad/Not good]

(1) Knowledge &

Skill

(2) Attitude

(3) Availability of

necessary equipment / device

(4) Quality of service to the patients (Overall

evaluation of (1)-(3) )

a. Medical Doctor B B B b. Medical Assistant B B B c. Pharmacist (Include all level)

B B B

d. Laboratory Assistant (include all level)

B B C

e. Registered Nurse (Middle level)

B B C

f. Primary Nurse (Low level)

C C C


6

3. Health Services 3-1. Health service provided in the hospital

(1) Services

No. Category Check 1.Yes 2.No

Inpatients service 1. Yes 2. No

Out-patient Service 1 Internal Medicine 2

2 Surgery 2

3 Paediatrics 2

4 Obstetrics/Gynaecology 1 1

5 Dermatology 2

6 Ophthalmology 2

7 Dental Service 2

8 Oto-Ringo-Laryngology 2

9 Emergency Care 2

10 Pharmacy 1

11 Orthopaedic Surgery and rehabilitation

2

12 Neurology and Neuropsychiatry 2

13 Health Education 1 1..for patients

14 Training for the staff 1.Regularly

1.for doctors

Medical Service 15 Laboratory Test 1 How many working microscopes?

1microscope for both bloodtest and urinalysis

16 Radiology 1 How many x-ray available; 1 for females

17 Operation (Major) 1 Average number a month( 145 )

18 Operation (Medium) ( )

19 Operation (Minor) 1 ( 86 )

20 Delivery 1 ( 1547 )

21 Occupational Therapy 2


7

22 Rehabilitation 2

23 Blood Bank 1 About 500 bags(500ml) are used a month

(2)Out-patient Services : a) Number of Out-patients by disease in the last 5 months

Number of Cases,2002 Disease Feb March April May Jun

1 Gynaecology and Obstetrics

800 780 800 700 870

Others

Total Number 870

(3) In-patients services:

a) Number of admission cases by disease in past 5 months Number of Cases 2002 Disease

Feb March April May Jun Gyn/Obstetrics 1600 1283 1550 1903 1430

1 (not available)

2

(4) Surgery

a) Please list the surgery conducted in this hospital.

Name of the Case No. of the case / year Remarks

(na)

a-1) Major Surgery

Caesarean Operation(c.s)

490 a year

c.s + Hysterectomy 36 a year

a-2) Medium / Intermediate Surgery

Tubal ligation 59 a year


8

others 391 a year

529 a year

a-3) Minor Surgery

3-2 Vertical Program: If your hospital has any programs, please answer the following questions regarding the vertical programs which has been conducted in this hospital.

Questions and choice: Please select from the following choices.

Questions Choices

Q1. Does this hospital do any activities of the program? No

Q2. Is the hospital still implementing the program now? No

Q3. How many staff trained for the program does the hospital have?

Q4. Does the hospital receive any budget for the program?

Q5. If “Yes”, from which organization does the hospital get budget?

Q1). Does

this hospital do any activities of the program?

Q2). Is the hospital still implementing the program now?

Q3). How many staff trained for the program does the hospital have?

Q4). Does the hospital receive any budget for the program from MOH/donor?

Q5). If “Yes”, from which organization?

a) Malaria Control b) Acute Respiratory Infectious Control

c) Diarrhea Diseases Control

d) Tuberculosis and Leprosy

e) Trauma f) Reproductive Health and Maternal Care Programmes

g) Nutritional Status h) EPI


9

4. Examinations (1)Laboratory Examination Performed

a) Please look at the following table to check if these laboratory examinations are conducted in this hospital.

Total: cases/year in 2002

No. Examination Yes/NoYes 1No 2

No. of test cases /year (2002)

1 WBC 1

2 RBC 1

3 Haemoglobin test 1

4 Haermatocrit test 1

5 Blood differential count 1 1-5+7; total 2900 a year

6 Pregnancy test 2

7 Stool test 1

8 Malaria test 2

9 Sputum test 2

10 Skin test for leprosy 2

11 Water portability test 2 12 Others (Please specify) 2

b) Do you have any staff trained in using microscopes? .No

c) If “Yes”, how many? No

(2) Radiology Service

N

o.

Examination Yes/No Yes 1 No 2

If “Yes”, please fill describe the number of cases/year

Do you have a staff trained in using the equipment?

How many? 4 Number of cases/year

66 1. Yes 2. No

1

Who? 1 X – ray

1


Chest

(Multiple choice)

How many?

2 ECG 2

Number of cases/year

No

Who?

How many? Number of cases/year

No

Who? 3 Echo

2



10

5. Drug Supply 5-(1) Is your pharmacy able to provide enough drugs for patients? No(Only 60%) 5-(2) Is your hospital able to provide drugs for outpatients, or only in-patients? Basically only for in-patients.

5-2 Store Condition

(1) Does this hospital have a space to keep drug? Yes (not large enough) (If “Yes”, please go to (3))

(2) If “No” How do you keep your drug?

(3) How many stores do you have? (Please put the number.) 1 (4) Safety for door Key locked (5) Safety for window Window only

(6) Box for Expired Drug Nothing (7) How do you manage the disposal of expired drugs?

Burn

(8) How often do you dispose the expired drugs per year? once /year

(9)Cleanliness 1. good 2. fair 3.bad 2

(10)Drugs in shelf 1. in order 2.out of order 1

(11)Labelling at shelf 1. labelled 2.nothing 2

(12) Pallet use 1. Pallet use 2.direct on floor 2

6. Quality of Service

6-1 . How do you think of the quality of this hospital?

<Physical Inputs> 1. How do you think of pharmaceuticals and medical supplies to this hospital? 1. Enough 2. So-so 3. Not enough 2

2. Ho do you think of the equipment and clinical furniture in this hospital? 1. Enough 2. So-so 3. Not enough 2

3. How do you think of the procurement and distribution of drugs?

1. Systematic 2. So-so 3. Un systematic

1

4. How do you think of the necessity of repair / deterioration of the building? 1. Necessary 2. Not necessary 1

5. How do you think of the physical condition of the hospital building?

1. Good 2. So-so 3. Sub-standard/unsuitable

2

<Personnel Inputs> 1. How do you think of the number of qualified staff in this hospital? 1. Enough 2.So-so 2. Not enough 2


11

2. How do you think of the staffing to the hospital? 1. Adequate 2.So-so 3. Inadequate 1 3. How do you think of the credibility of your staff? 1. High 2. Middle 3. Low 2 4. How do you think of staff attitude to the patients? 1. Good 2. Fair 3. Bad 2 5. How do you think of staff training? 1. Enough 2. So-so 3. Not enough 2 <Financial inputs> 1. How do you think of operating budget? 1. Enough 2. So-so 3. Not enough 2 2. How do you think of the financial capacity of the hospital? 1. Enough 2. So-so 3. Not enough 2

<Organizational Structure and Management> 1. How do you think of the managerial capability of this hospital?


2. How do you think of the staff allocation within this hospital?

1. Balanced 2.Fair 3.Unbalanced

1

3. How do you think of the diagnostic and therapeutic capabilities in this hospital?


4. How do you think of the quality control & monitoring of communicable diseases?

1. Good 2.Fair 3. Weak 3

6-2. How do you think of the service of the quality of your hospital? (1) Reception 1.Good 2.Fair 3.Not good 2

(2) Treatment for out-patients 1.Good 2.Fair 3.Not good 2

(3) Treatment for in-patients 1.Good 2.Fair 3.Not good 2

(4) Prevention and promotion 1.Good 2.Fair 3.Not good 2

(5) Pharmacy 1.Good 2.Fair 3.Not good 2

(6) Laboratory test 1.Good 2.Fair 3.Not good 2

(7) X-ray 1.Good 2.Fair 3.Not good 2

(8) Operation 1.Good 2.Fair 3.Not good 2

6-3. Have you had a program / project for service

quality improvement? 1. Yes 2. No 2

6-4. If “Yes”, please describe the project.

6-5. What is your assessment of the quality of services provided in this hospital?

1.Good 2.Fair 3.Not good

2


12

7. Communication and Information system 7-1. Medical Record System

(1) Type of records Source of each type a) Out-patient Department


２ 1. Procured in the market 2. Provided by MOPH 3. Provided by Donor ( )

２

b) MCH 1. Patients Notebook 2. Mother & child notebook 3. Growth Chart

1. Procured in the market 2. Provided by MOPH 3. Provided by Donor ( )

c) In-patient Department



2

(2) Does the hospital keep the card of individual patients? 1. Yes 2.No 1 (3) Do patients have record or registration numbers? In the number written in the individual card? 1. Yes 2.No 1

(4) Who is in-charge of medical record? Doctors (5) What are the problems about the existing System? Please describe them.

Need stationary

(6) Is the record written clearly in order? 1. Clear 2.So-so 3. Not clear

1

7-2. Reporting System

7-(1) Does your hospital have any reporting system? Yes

7-(2) If yes, please fill in the following table

b) How often do

you write?

c) To whom do you submit

them?

d) Do you keep the duplicate of the report?

f) Do you get feed back? a)

Name / type of report 1. Weekly

2. Monthly 3. Semester 4. Yearly

1. Yes 2. No

e) How many hours in a

month do you spend to make

report? (hours)

1. Yes 2. No

Technical report 2 MOPH 1 6 hours 1 Administrative report

2 MOPH 1 6 hours 1


13

g) Do you analyse the records or reports? 1. Yes 2. No

1

8. Operation and Management 8-1 Organization Organization Structure: Please draw the organization chart of this hospital.

8-2 Autonomy Does the hospital have autonomy of hospital management? If yes, what kind of autonomy?

Director

Administrative Technical Deputy

Dept. of Commodity

Financial Dep.

Dep. Of Medical

Personal Dep.

Dep. Of Registration

Dep. Of General

X – Rays Room

Pharmacy

Laboratory

Nurse Dep.

Anesthetic Ward

Neonatal Ward

Gynocology Ward

Obstetrics Ward


14

9. Budget 9-1. Annual Financial Records

(1) Do you have the actual(not planned) annual financial records? 1. Yes, 2.No => 2

(2) Does your hospital get a proper budget from MoPH? No (3) What percentage of the total running costs of your hospital does the budget cover?

Only get for

salaries (4) If “Yes” to (1), please fill in the following table.

1999/2000 2001/2002 2002/2003 a) Revenue 1. Government budget 2. Revolving Drug Fund 3. Cost Recovery 4. Donor Agency 5. Community Fund 6. Private donation etc.

Total *3 *3 *1

b) Expenditure

1. Staff Salary

2. Administration Cost

3. Subsidy

4. Investment

Total *3 *3 *1

(3) Who (position) is in charge of finance, accounting and disbursement?

9-2. Do you have the monthly financial records for year 2000/01 broken down by item? 1. Yes, 2.No => 2 If “Yes”, please fill in the table in the next page.

9-3. Which kind of income do you get? (1) Government Budget 1. Yes 2. No salaries and payment

in kind (kerosene or foods) (If”Yes”, please answer the question “3-4”.)

(2) Cost Recovery: Do you charge the patients? 1. Yes 2. No (If”Yes”, please answer the question “3-5”.)

2


15

(3) Revolving Drug Fund 1. Yes 2. No (If”Yes”, please answer the question “3-6”.)

(4) Donor support 1. Yes 2. No 1

(5) Private Donation 1. Yes 2. No (If”Yes”, please specify: )

2

(6) Community Contribution 1. Yes 2. No 2

(7) Others(Please specify ) 1. Yes 2. No

9-4. Government Budget

(1) Which kind of budget do you get?

(Multiple answer)

1. Staff Salary 2.Administration cost X- Subsidy 4.Investment

5.Others( )

1

(2) Is there a gap between government budget and actual remittance? 1.Yes 2.No 1

j i c a (jica)cwek central workshop for equipment in kabul dfid department for international...

Documents