County perspectives 2018 health workforce dr. nelson muriu. director, depar...
Bagram PRT Medics Conference Recap
1. Bagram PRT Medics
RC-East Joint Surgeon’s
Conference
Major Tim Gacioch
TSgt Deborah Taylor
SRA Joshua Tolaro
2. Overview
●PART I: What has been built to date (public & private)?
•PART II: What is planned / budgeted?
•PART III: Are health facilities being staffed?
•PART IV: Are Health Facilities supplied & equipped?
•PART V: What are the challenges for these provinces?
… Conclusions
3. Setting the Stage
RIPTOA complicated
Flooding
Hasty departure
Organizational Deficiencies
No BDE SG
No Maneuver BDE – SECFOR issue
No USAID or USDA representatives
CA understrength
4. PART I – Taking Stock
What has been built to
date, to include legacy
and private facilities?
15. PART II: Parwan Budget
What is planned / budgeted?
Parwan Province
FY '08 Budget Submission Project Cost
Mandikol BHC $105,000
Shengarian BHC $105,000
Total $210,000
16. List of Projects- Awaiting funding
Parwan Province
FY '08 Budget
(NON-SUBMITTED ITEMS)
Project Cost
20-Bed DH (#1 Priority MoH) Unknown
Lolanje Upgrade to DH Unknown
Repair Women’s Clinic of Sia Gerd Unknown
17. PART II: Kapisa Budget
What is planned / budgeted?
Kapisa Province
FY '08 Budget Submission Project Cost
Kohistan II DH at Kulala Kanda $370,000
Tag Ab DH at Tamir $370,000
Total $740,000
18. List of Projects - Awaiting funding
Kapisa Province
FY '08 (NON-SUBMITTED ITEMS) Project Cost
Sadq Abad Facility $500,000
Midwife Learning Center
Public Health Office
EPI Office
QC Lab & Pharmacy Stock
BHC (Sayiad, Shokhi, Zahikhel & Pashai, Dara
Kalan, Giaweh, Shpi, Koti, Skain, Budrab, Shenkay)
$900,000
(10 BHC @90,000 ea)
Dara Pachagan CHC $130,000
Total $1,700,000
20. Parwan Key Staff
There are 400 Health Care staff for all the following:
Provincial District CHC BHC Health
Hospital Hospital Post
1 1 8 31 148
NOTE-“Minimal Staffing” is defined in the following:
1) Essential Package of Healthcare Services, 2005
2) Basic Package of Healthcare Services, 2005
Minimal staffing required is 678
Parwan is staffed at 59% of minimal need
22. Parwan Excess Capacity
Provincial District CHC BHC Health
Hospital Hospital Posts TOTALS
1 1 8 31 148 189
MIN Capacity 100,000 240,000 465,000 148,000 953,000
MAX Capacity 300,000 480,000 930,000 222,000 1,932,000
Population 550,200
MIN Excess 402,800
MAX Excess 1,529,200
23. Kapisa Key Staff
There are 322 Health Care staff for all the following:
Provincial District CHC BHC Health
Hospital Hospital Post
1 1 8 15 100
NOTE-“Minimal Staffing” is defined in the following:
1) Essential Package of Healthcare Services, 2005
2) Basic Package of Healthcare Services, 2005
Minimal staffing required is 582
Parwan is staffed at 55% of minimal need
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Kapisa Staffing
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LEGEND
Provincial Hospital
District Hospital
● CHC
BHC
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Positive Note:
Staffing Adequate
Despite insurgency
Sultan of Brunei did not
Deliver funds … 3+ yrs.
If built who staff 100 beds?
Surgical Suite
Never staffed
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25. Kapisa Excess Capacity
Provincial District CHC BHC Health
Hospital Hospital Posts TOTALS
1 1 8 15 100 125
MIN Capacity 100,000 240,000 225,000 100,000 665,000
MAX Capacity 300,000 480,000 450,000 150,000 1,380,000
Population 367,400
MIN Excess 297,600
MAX Excess 1,082,400
26.
27. PART IV – Parwan Supplies & Equip
Are Healthcare facilities supplied & equipped?
31. PART V – Parwan Challenges
What are the health
challenges for this
Parwan province?
… OR What areas need
improvement?
Distribution of Assets
Insufficient staff
Insufficient supplies
Austrian Hospital
Western Parwan
clinics vs Kohi Safi
Emergency Transport
Training Pipeline
Professionals
Paraprofessionals
Support Personnel
32. PART V – Kapisa Challenges
What are the health
challenges for Kapisa
province?
… OR What areas need
improvement?
Access to care
Provider Distribution (Nijrab)
Tag Ab & Alasay
PH Funding (Sultan of Brunei)
Emergency Transport
Training Pipeline
Professionals
Paraprofessionals
Support Personnel
Active Insurgency
34. MoPH Policy Statement on Hospitals
1. Hospitals provide necessary curative and emergency services which complement BPHS,
including disability care
2. Must be rationally distributed so are accessible for entire population
3. MOH will plan #, location, # & type of beds to ensure maximum impact on population health
status
4. Care must be provided based on need and not ability to pay.
5. Must be managed in an efficient manner IAW basic clinical and managerial standards
6. The proportion of the government's annual operational budget for hospital will not exceed
40% of the total health budget
7. MOH will develop financial systems, such as BoD, for budgetary accountability &
transparency.
8. To enable sustainability, cost-sharing strategies appropriate to Afghanistan will be
developed.
9. Hospitals will provide training and supervision of lower health care facilities
10. Private hospitals are allowed, part of the system and must meet the same standards as other
facilities.
Feb 2004
35. Providing Care in Active Insurgency Areas
Continue supply push for BHC and HP in disputed areas
Use MEDCAPS in 24-hour period after kinetic ops
Work through elders to access children for vaccinations
Withhold large projects in disputed zones as cannot staff
or guarantee construction worker safety
Increase project spending at margins of disputed zones
to increase access for allies
Advocate women’s health careers
36. Sources of Data (where not otherwise stated)
Afghanistan National Development PollAfghanistan National Development Poll
3600 respondents in every province of the country
The Measure of Progress Study
1000 qualitative and in-depth interviews
Direct formal Medical Assessments of healthcare facilitiesDirect formal Medical Assessments of healthcare facilities
performed by PRT BN Surgeonperformed by PRT BN Surgeon
40. Health Post
HP- Outpatient community health center for 1,000 – 1,500 people
Community-Based and owned w/ essential technical and material support from
NGO & MoH. Often Community Health Committees oversee the functioning of
Health Posts, which operate out of a privately owned home. Employees must live
FT in the community they serve.
HP employees work under supervision, and in concert with, BHC staff. Training is
to be local, use sequential tasks & a standard curriculum.
Compensation. FT work is paid, PT workers receive only incentives.
A.K.A. Health Post = Community-level Outreach
Community Health Worker (CHW) Dx/Tx Malaria, diarrhea, & ARI, distribute condoms &
OCP, and micronutrient supplementation. Also Tx common illnesses.
Traditional Birth Attendants (TBA) oversee normal deliveries, ID danger signs, refer to
higher HC facilities
41. Basic Health Center (BHC)
BHC – 15,000 -30,000 people
Staffed Nurse, Midwife or Auxiliary (Community) Midwifes, CHW/Vaccinators, and
support personnel (janitors, guard)
Antenatal, delivery, post-delivery care, growth monitoring, mgmt of Child DS,
routine EPI, Tx malaria & Tb (DOTS), drug distribution.
A.K.A. Small Health Center, C2 Sub-Center, MCH Clinic - Outpatient Care only
42. Community Health Center (CHC)
Inpatient Care & Lab for a community of 30,000-60,000 people
First level of care with physicians (male & female) and nurses (male & female).
Open 24-hours per day for emergency access
Can handle some complicated deliveries, grave childhood DS, complicated malaria,
inpatient/outpatient physiotherapy for disability.
HIV, Hep B/C, Ziehl Nelson for Tb, Diphtheria, Hgb, RBC, WBC, ESR, UA (w/ glu,
protein, albumin), microscopy.
A.K.A. CHC, Large Health Center, C1 Basic Health Center
43. District Hospital
Inpatient Care - 25-75 beds, population of 100,000 - 300,000, Serves 1-4 districts
Provides all BPHS and can care for the most complicated cases: Includes major
surgery under general anesthesia, X-ray, comprehensive emergency obstetric care
(including C-sections), family planning, blood transfusions w/o blood banking, bladder
stones, physiotherapy, dental, nutrition, and physical therapy
Usually staffed by junior GMO, "mainly an emergency hospital where pt are assessed,
dx, stabilized & either Tx or referred up/down the HC system, 24-hour Comprehensive
Emergency Obstetric Care is a crucial aspect. Two entrances 1) ER, 2) OPD."
AFB for Tb, Blood type, Bleed Time, Hct, Widel's, Brucellosis, Glu, BUN/Creat, Pro, LFT,
X-ray, US, O2 concentrator, proctoscope
Roles include: Collecting information, community outreach, education and as an entry
point for care (in absence of BHC or CHC) and so has admin/finance/HRO, kitchen,
laundry, sterile supply, waste mgmt, med records & stats, transportation for
emergencies and transfers
44. The Provincial Hospital
100-300 Beds
More sophisticated Dx & Tx, support some specialists. Referral center for access
to Regional Hospitals and specialty care.
"Because it is primarily an emergency hospital, it does not perform complicated
elective surgery"
Has ENT, Mental health, blood banking, possibly mortuary, PT & rehabilitation,
Infectious DS plus District Hospital complement of services.
Can Tx electrolyte and fluid imbalances, alveolitis, diabetes mellitis, uterine
fibroids, pelvic mass, PID, osteomyelitis, RA, pre-term delivery, respiratory
distress, infants of DM mothers or other complicated births, open Fx, urologic
conditions
46. Population:
28,513,677 (July 2004 est.)
Age structure:
0-14 years: 44.7% (male 6,525,929; female 6,222,497)
15-64 years: 52.9% (male 7,733,707; female 7,346,226)
65 years and over: 2.4% (male 334,427; female 350,891) (2004 est.)
Median age:
total: 17.5 years (2004 est.)
Birth rate:
47.27 births/1,000 population (2004 est.)
Death rate:
21.12 deaths/1,000 population (2004 est.)
Infant mortality rate:
total: 165.96 deaths/1,000 live births
male: 170.85 deaths/1,000 live births
female: 160.82 deaths/1,000 live births (2004 est.)
Life expectancy at birth:
total population: 42.46 years
male: 42.27 years
female: 42.66 years (2004 est.)
Total fertility rate:
6.78 children born/woman (2004 est.)
The People
Dangerous stat because this group is easily
influenced by the rhetoric of radicals
Nutrition Problem
Lack of health knowledge
Lack of education in avoidance of diseases and landmines
Post-war society
47. Barriers to Care
Invisibility of women
Shortage of female
physicians
The Charikar PH
Community Midwife
program is a model
48. MDG Millennium Development Goals
In 2004 Afghanistan’s transitional government declared its intention
to achieve the Millennium Development Goals (MDGs) established
at the 2000 UN Millennium Summit. MDGs are intended to act as a
framework to guide the development of national policies and
reconstruction priorities around the world, with benchmarks set for
2015 and 2020. The government has incorporated the MDGs into
the Interim Afghanistan National Development Strategy (I-ANDS).
The eight MDGs are:
• Eradicate extreme poverty and hunger;
• Achieve universal primary education;
• Promote gender equality and empower women;
• Reduce child mortality;
• Improve maternal health;
• Combat HIV/AIDS, malaria and other diseases;
• Ensure environmental sustainability; and
• Develop a global partnership for development.
49. “By end 2010, in line with Afghanistan’s
MDGs, the Basic Package of Health
Services will be extended to cover at least
90% of the population; maternal mortality
will be reduced by 15%; and full
immunization coverage for infants under 5
for vaccine preventable diseases will be
achieved and their mortality rates reduced
by 20%”
Dr. Wali, Office of MoPH - 12 Sep 07
ANDS Benchmark
50. Aims of all Afghan Health Care Centers
& Hospitals
MMR
(Maternal Mort Rate) 1.9 / K
1 every
30
Min
IMR (Infant Mort Rate) 160.2 / K births 1 : 5
U5M
(Under 5 Mort)
239.9 / K
51. Challenges
Even with these impressive gains, it is only a start—
much remains to be done:
Infant, child and maternal mortality remain high
Health is an essential element for improving the
country’s security
Many communities continue to have inadequate
access to health services
Quality of health services must be improved
Further health gains require sustained support
from our partners for the long-term
52. Effect of Distance from Health Facility on
Prenatal Care Coverage (%)PercentageofPrenatalCareCoverage
Distances in Kilometers
53. Financing Afghan Medical Coverage
Experience thus far shows that delivering the
BPHS costs $5-$6 per person per year
Just for BPHS delivery, Afghanistan needs
$125 to $150 million per year.
This does not include improving hospital
services or further expanding primary care
Until government revenues increase, MoPH
will be dependent on external financing
Editor's Notes
Tagab- Tamir DH is MoH Kaapisa Project (07-08) list for $300K
Khangah is via NGO (USAID, WB or EC) 15 Apr 07 List
Budrab SubBHC per MoPH plan for Kuchi care on MoH Kapisa Project (07-08) list $90K
Shenkey os on MoH Kapisa Project (07-08) list $90K
AlisaySkain and Koti BHC upgrades are per MoH Kapisa Project list (07-08)
Markaz CHC is via NGO (USAID, WB or EC) 15 Apr 07 List
NijrabShaherwani DH opened 2007. NGO funded
Dara Pachagan is PRT project
Zabakhil-Pashai & Dara Farouksha sub-BHC’s are per MoH Kapisa plan for Kuchi care on MoH Kapisa Project (07-08) list $90K
Dara Kalan given purpose built building per MoH Kapisa Project List (07-08) - $90K
Giaweh BHC is on MoH Kapisa Project (07-08) list $90K
KohbandMalikar Sub-BHC built from funds designated for Sphi (Ashei) BHC for Alasay. Village did not want. Will provide Kuchi care - $90K
M. RaqiSayiad & Shoki BHC per MoH Kapisa Project List (07-08) - $90K
EPI / QA/QC lab / PH offices per MoH Kapisa Project List (07-08) - $500K
Kohistan IOnly wall for CHC
Kohistan IIDH at Kulala Kanda per MoH Kapisa Project List (07-08) - $300K
Staff existing centers – Sia Gerd staffing and supplies inadequate (only CHC in area)
Often the numbers are counted. Number of schools built, the amount of money spent, polce trained.
The ANDP was funded by CFC-A and carried out by Altai Consulting, a local research organization. This is a nation-wide survey that included 3600 respondents in all 34 provinces. The study has been carried out in four separate surveys through 2005 -2006. The goal was to get a sense of Afghan perceptions of the reconstruction efforts, the new government and the international community.
There are a number of other polls out there, this in my view is the most comprehensive and with fairly reliable methods.
A standard questionnaire, was designed and Afghans were trained, select people at random and ask each of the them the pre designed close-ended questions. It has yielded a number of useful findings, but it is also a process in which the person being surveyed, in this case the Afghans, have very little options but to give a standard yes/no or pick from a list designed by someone else.
To get a more holistic view, therefore useful to couple this kind of survey with qualitative interviews, where the respondent has the freedom to ask questions, elaborate on their answers and focus on the issues that are most critical to them
I have been working on a study at CSIS that gathered qualitative interviews with 1000 Afghans in various provinces across the country in 2005 and in 2006. Men, women, different ethnic groups, and a variety of ages and occupations, such as farmers, construction workers, teachers, police, government workers, and housewives, were included.
We trained Afghans to undertake the open ended interviews. They were able to elicit response often not shared with internationals and go to places that have become too insecure for internationals. These conversations produced 700 pages of text which have been analyzed for trends and common themes
Provincial Reconstruction Teams (PRT) are small bases with both military and civilian staff that provide security and facilitate reconstruction at the provincial level. The concept was first proposed by the Coalition Forces (CF) and the US embassy in mid-2002 during discussions about shifting from Operation Enduring Freedom’s Phase III (combat phase) to Phase IV (reconstruction phase). The establishment of PRTs was officially announced and endorsed by President Karzai in November 2002. Many NGOs are concerned that PRT involvement in humanitarian assistance blurs the distinction between the military and aid sectors. The first PRTs, established in early 2003, were led by Coalition Forces. The International Security Assistance Force (ISAF) began taking over and establishing new PRTs in the north and west in 2004, after an October 2003 UN Security Council resolution adjusted its mandate to allow for expansion beyond Kabul. Command of PRTs in the south and east was transferred from Coalition to ISAF in 2006. As of late October 2006, there are 25 PRTs operating under ISAF’s five regional commands (North, South, East, West and Central).
The PRTs comprise an average of 100–200 staff depending on location. The military personnel provide protection for the civilian component, which includes foreign affairs representatives, development officers and donors. Some PRTs also have agricultural and veterinary advisers as well as civilian police trainers. The coordination of reconstruction and development activities is the responsibility of civilian staff, as civil-military cooperation (CIMIC) officers are primarily concerned with force protection.
PRT activities are monitored and guided by a PRT Executive Steering Committee chaired by the Minister of Interior and the Commander of ISAF. The Committee includes representatives from the Ministry of Finance, Ministry of Rural Rehabilitation and Development, Coalition Forces, ISAF, UNAMA and troop contributing nations (TCNs). A PRT working group meets fortnightly to support the work of the Steering Committee.
The mission of PRTs, as endorsed by the PRT Executive Steering Committee, is to:
“assist the Islamic Republic of Afghanistan to extend its authority, in order to facilitate the development of a stable and secure environment in the identified areas of operations, and enable SSR and reconstruction efforts.”
This broadly stated mission statement is not backed by a detailed mandate, and there is no single PRT model. Instead, the structure and operation of PRTs are influenced by the situation in particular provinces as well as by TCN-specific caveats and instructions.
Provincial Reconstruction Teams (PRT) are small bases with both military and civilian staff that provide security and facilitate reconstruction at the provincial level. The concept was first proposed by the Coalition Forces (CF) and the US embassy in mid-2002 during discussions about shifting from Operation Enduring Freedom’s Phase III (combat phase) to Phase IV (reconstruction phase). The establishment of PRTs was officially announced and endorsed by President Karzai in November 2002. Many NGOs are concerned that PRT involvement in humanitarian assistance blurs the distinction between the military and aid sectors. The first PRTs, established in early 2003, were led by Coalition Forces. The International Security Assistance Force (ISAF) began taking over and establishing new PRTs in the north and west in 2004, after an October 2003 UN Security Council resolution adjusted its mandate to allow for expansion beyond Kabul. Command of PRTs in the south and east was transferred from Coalition to ISAF in 2006. As of late October 2006, there are 25 PRTs operating under ISAF’s five regional commands (North, South, East, West and Central).
The PRTs comprise an average of 100–200 staff depending on location. The military personnel provide protection for the civilian component, which includes foreign affairs representatives, development officers and donors. Some PRTs also have agricultural and veterinary advisers as well as civilian police trainers. The coordination of reconstruction and development activities is the responsibility of civilian staff, as civil-military cooperation (CIMIC) officers are primarily concerned with force protection.
PRT activities are monitored and guided by a PRT Executive Steering Committee chaired by the Minister of Interior and the Commander of ISAF. The Committee includes representatives from the Ministry of Finance, Ministry of Rural Rehabilitation and Development, Coalition Forces, ISAF, UNAMA and troop contributing nations (TCNs). A PRT working group meets fortnightly to support the work of the Steering Committee.
The mission of PRTs, as endorsed by the PRT Executive Steering Committee, is to:
“assist the Islamic Republic of Afghanistan to extend its authority, in order to facilitate the development of a stable and secure environment in the identified areas of operations, and enable SSR and reconstruction efforts.”
This broadly stated mission statement is not backed by a detailed mandate, and there is no single PRT model. Instead, the structure and operation of PRTs are influenced by the situation in particular provinces as well as by TCN-specific caveats and instructions.
The tough geography of Afghanistan is a challenge. The population is spread out over mountainous and difficult terrain and providing services to such a dispersed population is a hard. Preliminary data suggests that distance from a health center is one of the most important predictors of whether a woman receives antenatal care or not.
In response to this challenge, the Ministry is trying to secure the resources to expand coverage of the basic package of health services (BPHS) from 82% of the population to 100%. We are also financing the establishment of many health sub-centers, health facilities with just two health workers. This will reduce the distance people have to travel to reach health facilities in rural areas. We are also deploying mobile teams to conduct clinics in hard to reach areas.
