1. Five hospitals were selected for RHA and visits were carried out from 7 to 12 of February 2008.

They were Dushanbe City Medical Centre (Dushanbe), Rudaki Central District Hospital (Rudaki region, RRS), Shahrinav Central District Hospital (Shahrinav, RRS), Khujand Regional Clinical Hospital (Khujiand, Soghd), Khujand City Clinical Hospital (Khujand, Soghd), Soghd Regional Maternity Hospital (Khujiand) and Kulyab Regional Hospital.

Also the Central District Hospital in Chkalovsk, Soghd Region was visited but there were no patients admitted, although the hospital was considered still open and operative as well as staff (doctors and nurses) were present inside.

Hospital size ranged from 680 Regional referring hospital to 226 beds (Central District Hospital) and 210 (Regional tertiary Hospital for maternity).

Main findings arising from data collected, direct observation and interview to chief doctors can be summarized as follows:

- Primary health care is almost completely paralyzed; no services are delivered to population.

- Shortage of energy, water and food supply has produced sharp increase of inflation rate; higher prices are due also for food, drugs, fuel and portable heaters.

- All hospitals are suffering energy cuts for several hours/day; water supply is also affected and proper heating of hospital wards is impossible.

- Central heating systems of hospitals are almost always not functioning due to lack of maintenance; few medical instruments still operative (diagnostic and curative) are outdated and unreliable, and cannot work without electricity.

- All hospital are therefore unable to deliver assistance and appropriate care, moreover, shortage of resources strongly hamper food and essential drugs supply to patients (on average only 5-10% of their needs is purchased by the hospitals).

- Temperature inside hospitals is extremely low (no more than 5 C) and living conditions are unacceptable for patients but also for healthy subjects and staff.

Access to hospitals is also hampered by other factors (road conditions, lack of money for hospital fees and 'unofficial' payment for staff) and obviously poor and unacceptable quality of hospital services. Nevertheless, primary care has completely vanished and hospitals still represent the only one option for severely sick patients.

In fact we are now observing that:

- Some hospitals have increased up to 50% admissions, although they have cancelled all 'non urgent' elective medical and surgical care.

- Hospital activities and beds are 'spontaneously' gathered in selected areas of hospital buildings in order to spare energy and optimize use of equipment.

- Hospitals have plans for emergency but these plans are inappropriate to face energy shortage: most of hospitals are continuing to operate trying to maintain all services previously scheduled.

Moreover:

- Some district hospitals are still open and operating (theoretically) although they are not admitting patients anymore, since those who are desperately seeking for hospital care prefer to refer to city hospitals.

PROPOSALS for immediate actions to be taken to improve hospital management:

- Select number of hospitals on geographical, demographical and epidemiological criteria to maintain service provision to the population.

- Close rural and district hospitals unless in remote and isolated areas.

- Save energy, fuel, drugs and resources from closed hospitals and address resources to open hospitals.

- Re-direct hospital staff for assistance to families at territorial level. Utilize ambulances for selected cases.

- Assess carefully appropriate distribution of resources on the basis of population's needs.

- Establish daily report system from hospitals operating with MoH (WHO support) for strict follow up of clinical and epidemiological findings.