In brief, the key issues facing hospitals in the Afghan health system are:
- Maldistribution of hospitals and hospital beds throughout the country, which means a lack of equitable access to hospital care. People in urban areas have access but semi-urban and rural populations have limited access. For example, Kabul has 1.28 beds per 1,000 people while the provinces have only .22 per 1,000;
- Lack of standards for clinical patient care, resulting in poor quality of care; and
- Lack of hospital management skills, which results in inefficiently run hospitals, poorly managed staff, lack of supplies, and inoperable equipment due to lack of maintenance.10
Response: The Hospital Management Improvement Initiative
REACH began helping to rebuild the health sector in 2003. Initial efforts focused on expanding basic services, and in two years we have moved from 5% to 77% coverage of the population of Afghanistan. In 2004, the contract was amended to include the hospital sector, with a focus on provincial hospitals. REACH developed the Hospital Management Improvement Initiative to build the clinical and management capacity of hospitals so that:
- Health services are delivered more efficiently;
- The quality of services are improved;
- The population has increased access to hospital services; and
- There is a positive impact on health status—especially on the morbidity and mortality of women and children.
Introducing clinical and management improvements, combined with appropriate resources, will improve quality of care, increase access to hospital services, and streamline hospital operations. These improvements will ultimately result in achievement of the goals of improved health status, improved patient and community satisfaction with hospitals, and an improved referral system for Afghanistan.
Although the need was great, it was not possible to train the management team at each hospital in Afghanistan. Instead, clinical and management capacities at the provincial and central hospitals were strengthened through training, mentoring, networking and modeling, and provision of resources.
The Standards Based Management/Performance Quality Improvement approach that JHPIEGO has successfully developed and used to improve the quality of reproductive health services in many resource-poor settings has been expanded and adapted by REACH into a comprehensive approach to improve hospital management in Afghanistan. This process includes all clinical services (surgery, anesthesia, emergency care, pediatrics, infection prevention, and blood transfusion and blood banks) and management systems (governance, facilities and equipment management, pharmacy management, human resource systems) for general hospitals.