Attachments
This public health care research study and report, based on a survey by Integrity Watch Afghanistan (IWA), provides support to the oversight activities of donors investing in the health sector in Afghanistan. IWA’s work assists donors and the Afghan government to assess the quality of health care services, provided by public health clinics and hospitals, the main channels of health care delivery in Afghanistan. This particular study assessed (a) conditions of hospitals and other public health facilities built and/or operated with donor funding; (b) the extent of their use for health care delivery; and (c) their capacity to deliver quality services to the people.
IWA’s inspection team undertook inspections of 184 health facilities in 8 provinces. The initial list was pre-selected- IWA received a list of facilities financed by USAID from the Special Inspector General for Afghanistan Reconstruction (SIGAR). IWA then conducted security assessments of the areas, where the initial SIGAR selected facilities are located and finally included in the sample survey only those that are located in the most accessible and secure areas of the provinces.
The survey instruments used were: (a) a tour of the facility by the surveyor and recording of their observations; and (b) interviews of personnel and community members (clientele) of the facility and recording their responses.
The survey findings assisted in making inferences on: (a) operational status and operational efficiency of the facilities, indicating their capacity to deliver the needed services; (b) identification of existing and potential issues that are likely to adversely affect service delivery; and (c) the extent of the utilization of the facilities.
A positive picture does not emerge out of an overall assessment of the surveyed health care facilities, with issues of concerns observed in the following areas:
▪ Physical condition- structural and maintenance and repairs problems;
▪ Operational needs- ranging from supply of electricity, medications and medical equipment to availability of vehicles and ambulances;
▪ The state of basic health, hygiene and sanitation;
▪ Accessibility of staff and patients to facility grounds;
▪ Adequacy of personnel, especially female medical personnel;
▪ Management oversight;
▪ Determination of facility locations as per GPS coordinates:
The study observes that more than two thirds of the facilities are not found within two kilometers of the MoPH-provided geospatial coordinates. Wrong locations noted in official documents can generate various problems. For instance, misdirection to the facility sites may cause monitoring difficulties.
A section in the main report is devoted to current discussions on the latter issue between donors and MoPH.
Overall, the site visit observations deliver clear lessons on the nature of the deficiencies in health facilities that limit their capacities to deliver quality care. Lessons are learned on serious structural, operational, maintenance and management deficiencies that health facilities are subjected to.
The buildings are in poor physical shape, with structural problems (such as defective foundations; failing and cracked walls; leaking roofs; lack of repair and building safety issues) showing up; and the supporting infrastructure needed for efficient health care delivery not in place. Fifty-three percent of the facilities experience structural and maintenance problems, with 33% needing urgent repair.
Poor hygiene and sanitation conditions are found in 45% of the facilities, with no toilets in a quarter of the facilities, along with no running water supply. Water pumping and plumbing weaknesses and absence of potable water supply (the latter in 40% of the facilities) are the major areas of deficiency on the infrastructure side that breed poor health, hygiene and sanitary conditions. Lack of stable supply of electricity, a daily need, is another serious infrastructure deficiency that incapacitates the health facilities from provision of quality care delivery. Twenty percent of the facilities have no electricity supply.
It has been learned that communities in certain areas are unable to access the facility in the vicinity due to unfavorable road conditions or uncertain security situation. Sixty-four percent of the facilities have no vehicles, contributing to difficulties in accessing care facility. With respect to ease of access to the facilities, security concerns are raised. But exact data on the number of facilities under security threats and on the nature of insecurity is not available, except that 34% of the facilities have no boundary walls and gates to provide minimum protection. Since twenty percent of the facilities have no electricity, no lighting arrangements are available to allow surveillance of night time activities around the facility sites.
Lessons on absence of essential supplies, resulting in inefficiencies in operations, are reported. Lack of refrigeration, medicines, standard medical equipment and machinery, absence of on-site pharmacies and transportation are common. Lessons are learnt on inadequate supply of personnel, especially female personnel, the latter so necessary to address needs of female clientele. Female staff is estimated to be less than 40% of the total number of personnel deployed in all facilities surveyed, a situation untenable in a society with the cultural tradition of female patients’ treatment by female professionals. In addition to deficient personnel supply, fifty-two percent of the facilities are squeezed for space. Space problem is identified as a major problem in seven out of eight provinces surveyed.
Lessons are also learned on management deficiencies that weaken delivery capacity of health facilities. It is learned that some personnel complain about salary scales and irregular receipt of salaries; and that MoPH ignores any advice provided by the service delivery personnel, who are necessarily familiar with the facility operations.
The very positive lesson that stands out is that regardless of the weaknesses, 99% of the facilities are active, with presence of patients and medical professionals, during operating hours; and the clientele or users of the facilities, confirm the usefulness of the health facilities, with all the imperfections.
A combination of the lessons from this survey (along with existing lessons already recorded by other studies) on the utility value of the heath care centers and the deficiencies that are hampering delivery of quality care, conveys the message that the need for strengthening operations of the very useful channels of health care delivery is urgent. The survey results and analysis should be of help in planning reforms of the public health care system in Afghanistan.
The deficiencies, enlisted in the lessons clearly identify poor planning and budgeting and lack of regular oversight as roots of the operation, maintenance and management problems. Urgent attention is, thus, needed to improve oversight of the operation of the current facilities, and forward planning and budget allocation for any future construction and their operation and maintenance, especially with an eye to avoid the deficiencies that this study report enlists.
To accrue returns from both past and future investments in public health care, it is urgent for MoPH to first focus on rectification of the problems (structural, operational and management) of the current facilities and then undertake forward planning for new expansion and construction.
Sharing the findings and lessons of this survey with the ministry will set a good beginning to the process.
For realistic planning, visits to the operational facilities for appreciation of the existing problems and to the new planning sites for understanding of the contexts are recommended. For best results, the site visit team should be composed of ministry officials, civil society organizations, community representatives, medical professionals, engineers and budget and audit specialists. The inclusion of expertise on budget is essential for estimating realistic budget needs for construction, operation and maintenance and monitoring. Community monitoring and oversight is an option that should be considered. Consultation with the facility staff and the community in the locality should be a part and parcel of the site visits for planning and ongoing monitoring.