Cablegate: Prt/Kunduz: Hospital Reform Working in Northeast
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OO RUEHDBU RUEHIK RUEHYG
DE RUEHBUL #5926/01 3551339
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O 211339Z DEC 06
FM AMEMBASSY KABUL
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UNCLAS SECTION 01 OF 04 KABUL 005926
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SUBJECT: PRT/KUNDUZ: HOSPITAL REFORM WORKING IN NORTHEAST
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SUMMARY
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1. (SBU) The provincial hospitals in Kunduz and Takhar
Provinces are two of five pilot projects under the World-Bank
funded Hospital Reform Program. They receive extensive
support from the Ministry of Public Health and are relatively
well-equipped, have capable and well-paid staff, and appear
to be delivering good care to the population of the two
provinces. The recent decision to re-open the Spinzar
Hospital in Kunduz, rather than focusing expansion efforts on
the provincial hospital, may, however, have an overall
negative impact on health care for Kunduz Province and the
region. END SUMMARY.
2. (U) PRTOff and German Foreign Office colleagues visited
the Takhar Hospital in Taloqan, the capital of Takhar, on
December 9 where Hospital Director Dr. S. Ashrafuddin Aini
provided information about the hospital's current and future
programs and took PRT Reps on a tour of the facility. PRT
Reps had a similar briefing and tour of Kunduz Hospital on
September 10 hosted by Hospital Director Dr. Zaher Paknehad
(who left the hospital in early December) and met with the
hospital's acting director and other officials for an update
on December 16.
Kunduz and Takhar Showcase Hospital Reform Program
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3. (U) The hospitals in Kunduz and Takhar Provinces are two
of the five pilot projects in the Ministry of Public Health's
World Bank-funded Hospital Reform Program (the others are in
Baghlan, Zabul, and Ghor Provinces). This program provides
for a standard package of services in each province --
Emergency Provincial Health Services (EPHS) -- to cover all
life-threatening cases, at least to the extent of getting
patients stabilized and, if necessary, sending them to Kabul
or another location for the required specialized care.
4. (U) One major component of the program is a plan to
address Afghanistan's very high maternal and infant mortality
rates. In addition to the range of medical care provided by
general practitioners, the EPHS package includes specialists
in maternity and pediatric care, as well as internal medicine
and basic surgery. Specialties that are not included in this
package include ENT (Ear, Nose and Throat), Ophthalmology,
and Orthopedics. These are supposed to be covered in a
regional hospital, but this program is not yet functioning in
Kunduz, the designated location for the region, due primarily
to the lack of space.
5. (U) In the absence of the regional ENT and eye care
capability, the Takhar Hospital has managed to cover most of
these requirements with resources in Taloqan. The hospital
can call on a private eye care clinic when necessary, and
they are currently looking into working with Kinderberg, a
German NGO, to set up ENT and Ophthalmologic care in the
hospital. In Kunduz, these capabilities currently are
provided by private practioners or are covered with
assistance from the German PRT Hospital. Kunduz Hospital has
requested an additional building to house the planned
regional capability, but it appears that a Ministry of Public
Health plan to re-open Spinzar Hospital in Kunduz may derail
that plan.
6. (U) Other aspects of the Hospital Reform Project include
measures for infection control -- including banning re-use of
needles -- and careful waste management. For example, an
incinerator is available on site in Kunduz to burn medical
waste daily.
Program Provides Realistic Salaries and Substantial Support
--------------------------------------------- -------
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7. (U) Key aspects of the Hospital Reform Program include
realistic salaries for the medical staff and provision of
necessary equipment and medicines, as well as assistance in
building facilities needed for patient care, that is,
hospital rooms. The equipment includes EKG, X-ray, and
ultrasound equipment, as well as laboratory equipment and
supplies. The Takhar hospital had just received new
incubators and F-100 formula to combat child malnutrition, as
well as additional examination equipment; Kunduz has received
similar equipment.
8. (U) The capacity of the Kunduz Hospital is 110 beds, while
the Takhar Hospital currently has only 65. To reach the
target for a provincial hospital of 100 beds, the Ministry of
Public Health funded an expansion project in Taloqan for an
annex -- due to be completed within a few weeks -- that will
accommodate 35 beds. (Note: All rooms in both hospitals are
multi-bed rooms, usually four beds but sometimes more;
private rooms are unknown. End Note.) The Ministry did not,
however, fund the actual beds, and the only beds that are
locally available are plain wooden beds, some of which
already are in use in the hospital. The Hospital Director
welcomed a German Foreign Office offer to consider funding
35-40 additional hospital beds, and the PRT Civilian Leader
was surprised to receive the written proposal two days later
during another visit to Taloqan.
Medical Staff and Salaries
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9. (U) Both hospitals have specialists covering the same four
specialties: general surgery (3), internal medicine (2),
gynecology/obstetrics (3), and pediatrics (2). Kunduz has 14
and Takhar 13 general practitioners. Takhar also has one
trained mental health professional and one GP trained in
medical sonography. In addition to its 25 doctors, Takhar
has 30 nurses and 6 midwives (plus two vacant midwife
positions). Kunduz has 120 total staff, including 24
doctors, 30 nurses, and 8 midwives. Both hospitals have
several staff members, both doctors and administrators, who
have been trained overseas and speak excellent English.
10. (U) The reported monthly pay scales for hospital staff
varied somewhat between the two hospitals, and appear to
depend on training and experience, but are approximately as
follows: MD Specialists $400-500; GPs $300-400; Nurses
$150-240; Midwives about $180, and Orderlies about $100.
These wages are quite good in the Afghan context (where
judges, for example, still earn less the $100 a month), and
the working conditions are also quite good. At Kunduz, for
example, the staff normally work from 8 am to 2 pm, though
they can be called in other times. Because of this
attractive pay scale and good working conditions, both
hospitals have been able to attract and retain good staff.
The transparency of the financial arrangements -- both
hospital directors noted that their staff actually do get
paid what is due them -- also helps.
Storage and Space Problems Key
------------------------------
11. (U) Although overall conditions are relatively good, both
hospitals continue to experience problems, the most obvious
of which is lack of space. The Takhar Hospital was built 40
years ago as a 35-bed facility, but now has 65 beds. The new
annex, which is being built as a second story on the original
one-story building, will provide more space for patients, but
neither hospital has adequate storage areas for drugs or
other hospital stores and equipment. In Takhar, various old
buildings, including the old kitchen, are used as storage
areas. Staff were in the process of building and installing
wooden shelving to better organize the drug storage area, but
this is only a stop-gap, as the building itself clearly was
inadequate. The hospital in Kunduz, which is a recently
built three-story building outside of the city (funded by
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USAID and the original U.S. PRT in Kunduz, and initially
managed by the Swedish Committee), has no such extra
outbuildings and has been forced to use the balconies of
hospital rooms on the second floor as storage areas.
12. (U) In addition to storage issues, both hospitals lack a
place where relatives can wait while their family member is
in the hospital. As in many other places, it is normal in
Afghanistan for families to accompany, and neither hospital
has waiting rooms or other space for these non-patients to
stay. The problem is more acute in winter, of course, and
also more difficult in Kunduz, where the hospital is outside
of town and there are no other buildings around where family
members can wait.
13. (U) Electricity is another problem. Kunduz has a fairly
reliable grid that is part of a transmission system coming in
from Tajikistan, but Takhar continues to rely on a 100KW
generator, with no effective backup capability. However, the
Ministry reliably pays for fuel for the generator, so as long
it works, needed electricity is available.
Reform Program Includes Cost-Sharing Plan
-----------------------------------------
14. (U) Both hospitals have instituted a cost-sharing plan
that is part of the Reform Program arrangements, which also
include a hospital board with community participation.
Although public health care is supposed to be free in
Afghanistan, the hospitals have begun charging a flat fee of
10 (Takhar) or 20 (Kunduz) afghanis (about 20 or 40 cents)
per patient for hospital care or drugs, and 50 afghanis (one
dollar) for more elaborate procedures such as X-rays. Kunduz
also charges 100 afghanis (two dollars) for surgery. This
all goes into the Hospital Support Fund, which usually
amounts to about $800 to $1000 a month. Upon approval by the
hospital board, this fund can be used to purchase any missing
drugs, expendable supplies, or other needed items. The
Takhar Director told us this cost-sharing plan was difficult
to start up due to both official and community resistance,
but with the assistance of the board, it seemed to be working
well.
Re-opening Spinzar May Obstruct Kunduz Hospital Development
--------------------------------------------- ---
14. (U) The PRT has recently learned about plans by the
Ministry of Public Health and Kunduz Province officials to
re-open the Spinzar Hospital, which was built in the 1940s by
the Spinzar Cotton Company and, prior to the construction of
the Kunduz Provincial Hospital in 2003, was the only hospital
in Kunduz. The Spinzar Hospital is a lovely old building
with high ceilings, verandas, and skylights, but the
electrical wiring and plumbing have not been updated, there
are virtually no furnishings, and the entire building --
although well built -- is in serious need of repair and
renovation. The operating room, for example, is completely
empty except for an ancient light fixture that hangs
crookedly from the ceiling -- and clearly would not work,
even if the electricity were to be turned on.
15. (SBU) The Spinzar Hospital is allegedly to be officially
re-opened by the Minister of Public Health when he comes to
Kunduz on January 9 to open the District Hospital in Imam
Sahib. When PRT Reps visited Spinzar on December 16, some 25
or 30 people -- including the Kunduz Deputy Director of
Public Health, who reportedly will be the new Spinzar
Hospital Director -- were busily moving in beds (not hospital
beds), chairs, and cabinets -- apparently the only
furnishings so far acquired. The Ministry reportedly is
paying the owner of the hospital, the Ministry of Mines and
Industry, $2000/month in rent, but no one seemed concerned
about where the necessary equipment, staff, and funding to
run the "new" hospital would come from. We were first told
that Spinzar would take on only the regional functions (ENT,
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Ophthalmology, and Orthopedics), then that it would also do
surgery and include an emergency room, and finally that it
would offer the "same services" as the existing hospital and
"be better equipped than the other one." Rows of chairs were
lined up in a hallway in preparation for the opening
ceremony, but as far as PRT Reps could see, there was very
little to open, and would not likely be a great deal more
before January 9.
Comment
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16. (SBU) Both the Kunduz and Takhar Hospitals appear to
function considerably better than many other public
facilities in the region, and the standards at both are
higher than one might expect. Kunduz has received
substantial assistance from the German PRT in Kunduz, which
has a Role 2 hospital on site capable of fulfilling most
requirements for the ISAF soldiers and others in the PRT,
including dental care and basic surgery. In addition to
permitting access by local Afghans in need of substantial
care, the German Hospital staff visit Kunduz Hospital
regularly and provide on-site medical care and consultation.
17. (SBU) Although the Takhar Hospital has not benefited from
such direct PRT assistance, the hospital staff (including a
medical director who trained for several years in Holland),
taking advantage of the Reform Program benefits from the
Ministry and the assistance of several other donors, have
developed a facility and a capability that appear to be even
better than that so far attained in Kunduz.
18. (SBU) PRT Reps are concerned that the decision to re-open
the Spinzar Hospital will shift the focus away from the
Kunduz Provincial Hospital and the expansion necessary before
it can fulfill its provincial and regional functions. The
Spinzar Hospital is located in Kunduz City, so it will be
easier to reach than Kunduz Hospital and may also take away
patients, doctors, and other staff. The only identified
funding stream, however, is from the Ministry of Public
Health, which is unlikely to have either the resources or the
focus to make the Spinzar project succeed. During
discussions at Kunduz Hospital, it was intimated that some
equipment would end up shifting to the "new" hospital, which
could leave donors reluctant to provide any additional
assistance to Kunduz. Yet once the Spinzar Hospital is
officially open, it almost certainly will start canvassing
donors for support. All of this is bound to set back the
pilot project in Kunduz, and may already have done so. The
Hospital Director resigned two weeks ago, and PRT Reps agree
that the Takhar Hospital seems to be running much better than
Kunduz; the specter of Spinzar may be part of the reason why.
Biographic Notes
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19. (U) Takhar Hospital Director Dr. S. Ashrafuddin Aini is a
trained internal medicine specialist originally from Chah Ab
District of Takhar, though he attended school in Taloqan.
Although he has never lived for any length of time outside of
Afghanistan, he speaks English very well, and he also appears
to have excellent management skills. He worked for UNICEF
for two years in Kunduz, and has also worked for the Ministry
of Public Health in Kabul. He ran as a candidate for the
Wolesi Jirga (lower house of parliament) in Takhar in 2005
and narrowly missed gaining a seat. He appears to be in his
early to mid-forties.
NORLAND