P&P General Directorate MoPH, WHO HPRO

Results of Health facility Functionality and Rationality assessment in 14 priority provinces

of Afghanistan (HFRA)

10/7/2015 1

P&P General Directorate MoPH, WHO HPRO

MOPH/Policy and Planning Directorate

Outline of presentation

• Introduction • Rational and objectives for the assessment • Coordination and Management of project • Methods • Field implementation • Quality assurance • Result BPHS • Discussion • Recommendations

10/7/2015 2 MOPH/Policy and Planning Directorate

Background & Rational


Ensuring access to quality health services is one of the main functions of a health system

Since 2003 MoPH introduced innovative approaches such as BPHS and EPHS to increase access to health services

However there are still concerns about access to quality services and rational distribution especially in insecure provinces

The P&P Directorate with WHO support assigned HPRO to conduct a comprehensive assessment of all public HF in 14 provinces


Objectives

• Understand the level of HFs functionality

• Assess some factors for rationality and distribution of BPHS heath facilities

• Identify potential factors negatively affecting functionality of HF

HF

Working Hours

Access

Utilization

Catchment Pop

HF Mapping

Human Resources

Pharmaceuticals/Equipment

10/7/2015 5

Domains

HFRA Project coordination & management team

Project Director (Dr. Nadir Naadim)

Research Team Leader (Dr. Farooq

Mansoor)

Dr. Catherine Todd

Dr Asmat Malik

Anupama Sharma

Dr Saber Perdes

Design, Tools development, data

analysis and interpretation

Operation Team Leader (Rohullah

Zekria)

Field Operation Coordinator Ghaus

Sultani

Provincial Team Leader and surveyors

HPRO monitors GIS & Data

Management Expert (Jawed Mansoor)

10/7/2015

6

Policy and planning General Directorate (General oversight)

Research Department (Indicators and tools)

HIS GD (M&E HMIS GIS: consultation, field test, regular monitoring and feedback on quality)

GCMU (Data & consultation)

WHO

MOPH/Policy and Planning Directorate

Setting Conducted assessment in 14 provinces (Dec 2014 - May 2015)

Design: Cross sectional design using mix method (qualitative & quantitative) Universal sampling of public health facilities; (BPHS, Vertical program, PPP) in 14 provinces 10/7/2015 MOPH/Policy and Planning Directorate 9

Methods: Desk review of secondary data

– MOPH/HMIS reports, clinic names – Third party evaluations, – Peer reviewed articles

Primary data • Quantitative: exit interview and facility checklist (domains)

• Qualitative methods: key informant & FGD, to explain and

triangulate Q data

• GPS coordinates and mapping of HF


Tools development

• Tools were adapted by steering committee from:

– The WHO Service Availability and Readiness Assessment (SARA)

– DHS Service Provision Assessment (SPA) tool

– National Monitoring Checklist (NMCL)

• Qualitative tools were developed for FDGs & KII

• Field test done with M&E and P&P in facilities in Kabul and Parwan

10/7/2015 MOPH/Policy and Planning Directorate 11

Field operations

• Recruited local surveyors and supervisors (17 teams)

• Conducted 6 days training for survey staff in Kabul

– using tools and collecting accurate data and GPS

• Extra staff trained to fill any attrition and to cover insecure places


Quality assurance

• Steering committee input to the quality during tool design, training • Monitoring by P&P and M&E who provided feedback

• Monitoring by HPRO monitors

• Repeated assessment of HF with inaccurate data

• Team leaders regularly brought to steering committee for face to

face meetings

• Review of data by HPRO editing team for consistency and accuracy


Quality assurance • Follow up call to Health facility head for back check

• Letter of confirmation of visit of surveyors by HF head

• Signing the visit book by Survey team (to confirm their visit)

• Photo documentation and GPS coordinates of facilities visited (to

confirm their visit)

• Reassessment of 5% randomly selected health facilities showed 87% and 83% consistency with survey data


Data management and analysis

• Data cleaned, double-entered into MS ACCESS

• Epi Info version 3.5.4 software has used for cleaning.

• STATA 14 was used for analysis of quantitative data

• Produced descriptive statistics for tracer and composite indicators

• Grounded theory method used for qualitative data analysis using ATLASti 13


HF Functionality calculation

HR Infrastructure Access Services

Child H EPI Nutrition Disability Mental H MNCH

EMOC NBC

1.Prevention of ophthalmia of the newborn

2. Resuscitation of the newborn

3. Kangaroo care

4. Management of Omphalitis

5. Management of Neonatal sepsis

6. Management of Neonatal jaundice

7. Management of Neonatal tetanus

Family Planning

Blood Transfusion

Communicable Diseases

Laboratory

Pharmaceuticals Equipment Working Hours


Rationality Factor calculation • Rationality factor was produced by weighting

three domains: – Catchment Population (weighting against standard

population by type)

– Inverse of accessible days % to HF

– Utilization of services (OPD, Delivery, Penta3 and CS) based on assigning weight to lower and upper quartiles (0.8, 1, & 1.2)


Rationality Level Decile Actual score

Low rationality level First decile 0.64-0.91

Medium rationality level Decile 2-9 0.911-1.08

High rationality level 10th decile 1.081-1.17

Results (Coverage) Description Number %

Target HF 846 100%

Visited 828 98%

Not visited 17 2%

Not consented to participate 1 0%

GPS provided 792 94%

HF newly established or not on HMIS list 38 4%

HF on HMIS List but not functional 22 3%

HF found in different place than HMIS 7 1%

PPP HF assessed in 6 provinces 160


New and Closed HF

5

3

2 2

5

8

1

3

2 2

5

1

2 2 2

4

2 2

6

1

0

1

2

3

4

5

6

7

8

9

GZN LG

R

HLD KST

NG

R

UZN PK

T

LGN

KN

R

PK

A

KD

R

FHR

PK

T

KN

R

WD

K

Closed and new HF by province

New Closed

The bars in blue color depicts health facilities that were not in the HMIS list but were identified by the survey teams in the field.

Red bars show health facilities that existed in HMIS list but upon visit of the surveyors they were found closed.

Duration of closure ranged from 0.5-120 months


14 Provinces/new and closed HF.xlsx

Building types of health facilities by type

Most of higher level HF has concrete or half concrete (wood or steel ceiling) buildings while less than 50% of lower level HF have concrete buildings


96%

83%

68%

34%

56%

4%

7%

11%

10%

25%

9%

20%

54%

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DH CHC BHC SHC Other

Concrete Concrete & Woods Mud & Bricks Pre-Fabricated Other

Domain 1: % of HF with Infrastructure and amenities conditions by province (Tracer indicator)

Pro

vin

ce

Nam

e

% o

f H

F w

ith

St

and

ard

b

uild

ing

% o

f H

F w

ith

El

ectr

icit

y

% o

f H

F w

ith

R

oad

acc

ess

% o

f H

F w

ith

C

lean

wat

er

% o

f H

F w

ith

P

rop

er w

aste

d

isp

osa

l

Overall 64% 79% 90% 83% 75%

FRH 38% 78% 97% 100% 49%

GHZ 56% 67% 95% 79% 89%

HLD 61% 70% 92% 80% 48%

KDR 56% 91% 74% 81% 60%

KNR 72% 88% 87% 84% 91%

KST 82% 89% 86% 93% 77%

LGN 31% 81% 93% 78% 77%

LGR 63% 68% 86% 86% 47%

NGR 45% 88% 93% 83% 85%

NTN 58% 62% 89% 39% 58%

PKA 72% 63% 96% 85% 58%

PKT 73% 96% 91% 83% 78%

UZN 45% 93% 82% 85% 85%

WDK 73% 85% 98% 92% 86%

• Standard building: based on MoPH standard for HF type (number of rooms, toilets, waiting room….. for type of HF)

• Electricity: from one or more of the bellow sources: Generator, Solar plates and City/public power

• Road Access: Yes/No

• Water from clean source: piped inside building, tap, deep well , covered well,

• Waste disposal: incineration of non sharp and incineration and burial of sharps


Domain 1: % of HF type with Infrastructure and amenities conditions

Indic

ato

r

Sta

ndard

build

ing

Ele

ctr

icity

Road

access

Cle

an

wate

r

sourc

e

Waste

dis

posal

DH 59% 100% 100% 85% 89%

CHC 68% 98% 99% 95% 82%

BHC 63% 79% 97% 83% 75%

SHC 39% 58% 91% 77% 59%

MHT 50% 53%

Other 0% 100% 100% 100% 44%

Overall 64% 79% 96% 83% 75%

Note: Total of Standard building excludes MHT and SHC

This slide shows structure and

amenities of each type of Health facility

Of note is that all of DH and almost all

of CHCs have electricity

Building, Electricity and road access is

not calculated for MHT


Domain 2 & 3: Service availability by HF type and emergency response Prep

Indicators DH CHC BHC SHC MHT Other Total

27 163 308 173 45 16 732

OPD 100% 100% 100% 100% 100% 75% 100%

MNCH 96% 97% 83% 78% 38% 31% 81%

Child health 100% 100% 99.6% 97% 100% 80% 99%

EPI 100% 99% 98% 63% 63% 12% 84%

Nutrition 96% 91% 70% 46% 47% 13% 67%

Cmcble Disease 96% 98% 60% 31% 20% 25% 60%

Mental health 96% 96% 78% 86% 33% 50% 81%

Disability 93% 95% 87% 75% 73% 69% 85%

Lab 93% 94% 94%

Blood T 78% 42% 47%

C-Section 78% 36%* 63%*

Emergency response preparedness

Emergency plan 78% 60% 62%

Emergency bed 85% 58% 62%

Em Transport 89% 74% 76%

Em Committee 70% 49% 52%

Composite 48% 34% 36%

• This categorical analysis considers a lower level of 50% of the PBHS prescribed services (as yes)

• 14 Provinces\RF Table Sep 30.xlsx

• Laboratory and Blood T calculated for CHC and DH only

• C-Section for DH and CHC+ only

• TB/HIV, less available in low level Health facilities

• Emergency response preparedness is very low in DH and CHC

Go to slide: 47


14 Provinces/RF Table Sep 30.xlsx




14 Provinces/Checklist Defenition for HF Type.docx

Domain 3

Emergency response preparedness at DH and CHC by province

A composite indicator of Em Preparedness

• Emergency Plan

• Emergency Committee

• Emergency Bed

• Emergency Transport

Most provinces needs attention

Go to slide 48


36%

0% 0% 0%

4%

17% 18%

25%

33% 33%

67% 68%

75%

78%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

overall LGR PKT UZN KDR KST FRH GHZ PKA WDK NTN HLD NGR LGN KNR

% of (DH and CHC) having Emergency preparedness by province

Domain 4: HR Tracer indicator

• Midwives are the staff mostly available at all type of health facilities

• Staff performance review a key HR management task is practiced in less than half of HF

• go to slide 49


Female Technical staff DH CHC BHC SHC MHT Other Overall

% of HF with 1 F Technical staff 100% 95% 79% 78% 78% 38% 82%

% of HF with 1 Midwife 96% 94% 78% 76% 76% 31% 78%

% of HF with 1 F nurse 85% 55% 59%

% of HF with 1 F doctor 41% 12% 16%*

% of HF with 1 Surgeon 93% 71%** 85%**

% of fully staffed HF 4% 8% 61% 71% 22% 56% 47%

HR management

% of HF updated attendance sheet 96% 93% 95% 95% 60% 81% 92%

% of HF with signed, JD 89% 81% 82% 84% 49% 81% 81%

% of HF performance review 41% 50% 50% 45% 18% 44% 46%

Note: * calculated only for CHC and DH ** calculated only for DH CHC+

A provincial picture of categorical analysis of Human resources: % of fully staffed HF and % of HF with at least one technical female staff (Vaccinator, MW, Nurse, Doctor, pharmacist) go to slide: 48

Domain 4: Human Resources (tracer & composite indicator (Categories))


47% 44%

25%

33%

49%

59%

50%

58% 54%

23%

47%

69%

62%

43%

51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of HF with at least 1 Female staff and fully staffed by province

1 Fmle staff Fully staffed

Insecurity

Sociocultural constraints for Female staff

Less amenities in rural

Lack of back up plan by NGOs

Insufficient technical staff

(female)

shortage of

Qualified staff

Domain 4: HR challenges

Domain 5: Essential Medicine (tracer indicator)


96% 96% 95% 94% 93% 91% 91%

89% 87% 86%

74%

41%

33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of BPHS HF with availabile Essential medicine

Domain 5: Essential medicine

Less than 2/3 of Health facilities had 10 essential medicines at the time of assessment. Some provinces i.e. KNR NTN PKT FRH KDR and KST have poor availability of 10 essential medicines

stock out of essential medicines is very common in almost all types of health facilities with some provinces in dire situation Slide 50

10 essential items • Tetracycline

ointment, • Paracetamol, • Co-Trimoxazol

• Amoxicillin • Iron, • ORS, • Oxytocin, • Aspirin,

• Ampicillin Injection, and

• Chorloquine


% of HF with 10 Essential Med % of HF with history of Stock out of at least 1 EM in the past 3 months

% of HF with Expired Med

Province N % N % Overall 732 62% Overall 732 61% 6%

KNR 45 27% LGR 43 28% 5% NTN 26 46% UZN 34 44% 3% PKT 23 48% HLD 73 48% 4% FRH 37 54% LGN 45 49% 4% KDR 74 55% WDK 59 51% 10% KST 28 57% GZN 82 56% 6% HLD 73 62% NGR 116 61% 4% GZN 82 62% NTN 26 69% 4% PKA 47 62% KST 28 75% 14% LGN 45 64% PKA 47 77% 4% WDK 59 68% KNR 45 78% 4% UZN 34 74% KDR 74 82% 16% NGR 116 78% PKT 23 83% 4% LGR 43 79% FRH 37 84% 3%

Average stock out days for 10 Essential medicine in the past 3 months

Obs Mean Std. Dev.

511 10.36008 20.82437

526 7.980989 13.56535

490 7.055102 15.50444

490 6.081633 11.64934

454 5.53304 15.75818

462 6.199134 14.19401

510 9.852941 16.92013

449 3.18931 12.59809

482 6.966805 13.4207

427 2.222482 10.67464


Medicine name

• Tetracycline ointment

• Paracetamol,

• Co-Trimoxazol

• Amoxicillin

• Iron,

• ORS,

• Oxytocin,

• Aspirin,

• Ampicillin Injection

• Chorloquine

Domain 6: Equipment

Availability of equipment composites indicator

Lower level for availability of equipment is 50% of the prescribed equipment

Facilities having less than 50% of the equipment were categorized as having no equipment

Overall 85% of health facilities have 50% or more of the equipment.

Provinces HLD, PKA, KDR, LGR, PKT have the lowest % of HF that have the necessary equipment

Slide: 52


N Overall DH CHC BHC SHC MHT Other

27 163 308 174 45 16

Total 732 85% 100% 100% 91% 77% 36% 13%

HLD 73 70% 100% 100% 68% 69% 0%

PKA 47 70% 100% 100% 89% 39% 0%

KDR 74 77% 100% 100% 95% 75% 21% 100%

LGR 43 81% 100% 100% 88% 90% 40% 0%

PKT 23 83% 100% 100% 82% 75% 100% 0%

NTN 26 85% 100% 100% 100% 64%

UZN 34 85% 100% 100% 91% 80% 80% 0%

LGN 45 87% 100% 100% 94% 81% 50% 0%

WDK 59 88% 100% 100% 96% 74% 0%

GHZ 82 90% 100% 96% 93% 67% 100% 0%

KNR 45 91% 100% 100% 100% 93% 50% 0%

NGR 116 91% 100% 100% 93% 89% 67% 0%

KST 28 93% 100% 100% 100% 86% 0%

FRH 37 97% 100% 100% 100% 100% 50%

% Of HF with minimum equipment by province

Domain 7: Working hours

24 hours services= availability of health worker all the times at the health facility

On call services= the health worker may not stay at the health facility but can be called when the need arises

The slide shows some health facilities functions minimal hours and hence services availability might be in question

14 Provinces\LowWH_HF.smcl


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DH CHC BHC SHC MHT Other

Working hours by type as reported by HF head

< 5 HRS 5-8 HRS on call 24 HRs

14 Provinces/LowWH_HF.smcl



Functionality domains median score % based on BPHS standards

Domain Median score % Q1 Q3 IQR Range N

Overall 80.4 72.8 89.2 16.4 64.2 732

Services 74.6 60 83.7 23.7 84.9 732

Emergency Prep 75.0 25 100 75 100 191

Equip/Supply 81.3 64 92.3 28.3 92 732

Essential Med 84.6 76.9 92.3 15.4 92.3 732

Infrastructure 86.6 66.7 99.5 32.7 76.2 732

HR Management 87.5 75 93.8 18.8 87.5 732

Working Hours 100 100 100 0 50 732


Among the domains Services and emergency preparedness are the weakest.

Overall Functionality Score % by Province

Province Name N Median Q1 Q3 Iqr Range

Overall 732 80.4 72.87 89.2 16.4 64.2

HLD 73 74.9 66 86.9 20.9 58

NTN 26 75.2 63.3 85.3 22 49.2

PKA 47 76.4 65.1 85.7 20.6 50.1

KDR 74 76.8 64.8 81.4 16.6 57.9

LGR 43 77.1 70.7 81.8 11 42.7

GHZ 82 78.7 69.7 84.2 14.4 50.4

UZN 34 79 73.5 84.5 11 41.6

PKT 23 80.2 74.5 88.9 14.4 28.3

KST 28 80.6 72.7 85.1 12.4 33.2

FRH 37 83.7 80.8 88.1 7.3 30.7

KNR 45 84 80.9 90.7 9.8 38.9

WDK 59 87.9 81 90.1 9.1 34.5

LGN 45 87.9 78.5 94.2 15.7 46.6

NGR 116 89.9 84.3 94.3 10 64

This slide shows median score of functionality and the spread of scores within province.

Provinces circled in red have low median of functionality and wider disparity

Go to slide: 46


facility type N Median IQR Range

DH 27 92.2 85.5 95.3 57.5

CHC 163 85.3 78.2 92.5 38.7

BHC 308 82.9 74.8 89.5 54.0

SHC 173 78.2 69.9 83.9 50.3

MHT 45 65.4 54.8 78.7 54.8

OTHER 16 64.3 58.7 69.9 42.3

total 732 80.4 72.87 89.2 64.2

Functionality groups of Health facility by province

Functionality score was grouped into three categories 1. High functional = 80-100 score 2. Medium = 50-79 3. Low functional= 34-49 • Overall more than 50% of HF (Red

and blue bars) require attention, 2.5% urgent action

• Go to slide: 46


1 2 6 8

1 18

4 52

127

101

29 15

328

22 111

179

66

8

386

0%

20%

40%

60%

80%

100%

DH CHC BHC SHC MHT Other Total

% and Functionality level by HF type

Low Medium High

2 1

3 1 3

6

1 1 18

16

11 14

21

15

30

14

12

29 42

44

18

47

15

328

8

12 14

13

29

14

23

33

13

28 24

41

34

100

386

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NTN PKT KST UZN LGN PKA FRH KNR LGR HLD KDR WDK GHZ NGR Total

HF functionality groups by province

Low Medium High

Domain 8: Utilization of services

Number of OPD (four months, monthly average) by type of Health facility facility type N Median Q1 Q3 IQR Range

DH 27 5952 3623 7931 4308 12053

CHC 163 2880 2020 3654 1634 7540

BHC 308 1470 1000 1938 939 4817

SHC 173 839 574 1177 602 4200

MHT 45 572 74 1130 1055 1989

OTHER 16 524 314 754 440 1451

Number of Penta_3 (Tally Sheet)

DH 27 98.7 63.2 154.3 91 506

CHC 163 80.5 55.3 113.2 58 365

BHC 308 51.6 32 78.6 47 982

SHC 173 18.8 6.2 27 21 90

MHT 45 16.2 6 33.3 27 131

Other 16 0 0 6.5 6.5 6.5

This slide shows utilization of services by type of HF with summary statistics (Median and spread).

See the large disparity in the same type of HF.

This indicator can be used to gauge rationality of a health facility


Domain 8: Utilization of services


Number of Delivery/month by type of Health facility (four months, monthly average)

facility type N Median Q1 Q3 IQR Range

DH 27 88.7 41.5 108.5 67 561

CHC 149 17.6 9.8 31.1 21 379

BHC 288 4.3 1.2 9.2 8 353

SHC 175 3.7 1.2 5.7 4.5 57

MHT 46 0.8 0 4.7 4.8 16.5

OTHER 8 230.6 4.7 456.5 452 452

Number of C-Section/month by DH, CHC+ (four months, monthly average)

DH 27 2.3 0.8 3 2.2 12.5

CHC+ 14 0.8 0.3 1.3 1.1 1.25

This data on delivery and C-Section can likewise be used for rationality calculation

DOMAIN 4:

Domain 9: catchment population of HF Catchment Population by estimation of Health Worker from CSO or CAAC (62% of HF reported to have conducted CAAC) This is another good measure to gauge rationality of a HF. (However CSO and CAAC figures are always questionable??? But this is all what we have and what we can use)


Catchment population by type of HF

HF Type N Median Q1 Q3 Min Max BPHS range

DH 27 46325 28000 72099 6352 156000 100,000-300,000

CHC 163 28000 20000 37000 6188 166979 30,000-60,000

BHC 308 11165 11400 22500 1810 70401 15,000-30,000

SHC 173 6061 5000 10000 1280 25200 3,000-7,000

MHT 45 15500 5500 25320 2950 36747

No accurate data on

catchment population

•Exaggeration in account of population by the communities

•Underestimation of population overloads the health centers

Different meaning for redefinition

of catchment population

•Community: It is upgrading the local health center

• PHD: redefining the needs and shifting one center to another place

• Policy makers: a comprehensive rationalization with downgrading and closing down;

It has become a political issue

CHALLENGES OF CATCHMENT POPULATION

Rationality factor and groups

Rationality factor was developed by weighting catchment population, utilization and seasonal, geographical and security hinderer of access

HF was scored on the bases of:

• OPD/other services which were summarized by type of HF

Minimum-Q1 0.8

Q1-Q3 1

Q4 1.2

• Inverse of % of accessible days/year

• Catchment population was weighted against BPHS prescription for each type

The three weightings were averaged which give rationality score (0.64-1.167)

This score was then grouped to three:


15

31

22 1 1

70

12

124

264

129

43 16 588

8 22

43

1

74

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DH (27) CHC (163) BHC (308 SHC (173) MHT (45) Other (16) Total (732)

% of Rationality level by HF type

Low Medium high

Rationality Level Decile Actual score

Low rationality level First decile 0.64-0.91

Medium rationality level Decile 2-9 0.911-1.08

High rationality level 10th decile 1.081-1.17

Access: client (Care Seeker) perspective (exit interview)


70%

54%

48%

43%

23%

8%

4% 3% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Lack oftransport

Poor roadcondition

Inscurity Distance of HF Climate barrier Absentism HF closed Improperlocation

Other barrier

Factors affecting access to health facility N=1051

insecurity

Economic barriers

Other barriers

Key health workers can’t attend the clinic

Clinics are closed down Referral is disrupted

People don’t want to go to clinic

Transportation is affected hence no supervision and no timely supply

Unable to pay for medicine

Low salary of health workers

can’t afford transportation

poverty

Poor coordination on pharmaceutical distribution

Medicine stock out

Women’s limitation

Absenteeism of HW

Go to Slide 53

Challenges for rationalization of HF

geographical

challenges

No accurate

population data

Political influence against evidence

based rationalization

Go to slide 54

Mapping

• Mapping


14 Provinces/14-HF-Map.pdf

Discussion • This study showed median score of functionality as 80% which

means about 366 HF are functional below 80% functionality score with the Minimum score of 34%

• Among provinces NTN &HLD 75% and PKA 76%, KDR & LGR 77%, GZN & UZN 79% have the lowest functionality scores. Lower level HF (MHT 65%, SHC 78%) are least functional as compared to DH 92% and CHC 85%

• Expert opinion suggests 80% and above is an acceptable level of

functionality however HF with below 80% score requires attention.

• Our grouped data showed about half (47%) of HF are less than 80% functional and require attention for improvement, among which 3% require urgent attention. Go to Slide 36


Discussion • Services in general and emergency preparedness are two areas that are

the weakest among the functionality domains. The two directly affect functionality of HF. – Among the services EPI, Nutrition and communicable disease (HIV /TB / Malaria) are

poorly available especially at lower level HF (MHT and SHC 63%, about 46% and 20-31% respectively). This is in spite of the focused support they get from GFATM/GAVI…..etc.

– Blood transfusion is only available in 47% of DH and CHC, C-Section in only 63% of DH and CHC+.

– PKA 57%, WDK 61%, LGR 64% KST 69% GZN& HLD 70% have the lowest median score of service availability.

– Emergency preparedness a very important factor for responsiveness of the HF given

the active widespread conflict in the country, is available in only 48% of DH and 36% of CHCs.

– LGR, PKT and UZN has 0% & KDR 4%, KST 17% GZN 18% PKA and WDK 33% of DH and CHC are prepared to respond to emergency



Discussion • Human resources is in general OK with overall median score of 87%. Availability of at least one Female

staff and fully staffed HF has improved between 2006-11 and this assessment (Newbarnder et.al. 2008 and BSC 2012/13), from <80 to 83% , and 24% to 47% respectively however there are still problems with availability of female technical staff and HF being fully staffed. – 17% of overall HF, 4% of CHCs and more than 20% of BHCs, SHCs and MHTs do not have even a single

female technical staff. This directly affect functionality of HF and service utilization by women and children.

– Less than half (47%) of HF are fully staffed based on the BPHS which is a minimum package. DH (4%) and CHCs (8%) are the worst in terms of being fully staffed.

– Among the provinces, KDR 27%, KST 32%, HLD 42% and PKT 43% are on the lowest side of the spectrum of HFs being fully staffed.

– On the other hand PKT, KNR, KST, and HLD with only 65%, 71% and 75% HF respectively having at least one female staff are again on the lowest side.

• Thanks to the efforts by MOPH and partners to establish CME program at province level which has improved availability of this cadre at almost every level of HF, albeit with some short falls still available. The same approach for training other key cadre such as female nurse could be a viable solution when importation of skilled staff from cities does not work due to the widespread insecurity


Discussion

• Essential pharmaceutical availability at all health facilities is very poor.

– Overall less than 2/3 or 62% of health facilities had 10 selected essential medicine on the day of the assessment.

– 61% of HF had run out of at least one of the essential medicines (average 2-10 days) over the past 3 months from the assessment.

– 6% of the HF had expired essential drugs on the shelves.


Discussion

• Provinces such as KNR 27%, NTN 46%, PKT 48%, FRH 54%

and KDR 55% have the lowest HF that have 10 essential medicine

• Lack of essential medicines make the services utilization very difficult especially the poor may not be able to purchase medicine from the market.

• Availability of minimum equipment to facilitate services provision is 81% (Max 100 Min8%). This also directly affect functionality of HF – HLD 63%, PKA 65%, NTN 75% and LGR and UZN 76% have

lowest median of equipment and supplies


Discussion

• Infrastructure and amenities are not conducive enough for service provision: – 22% of health facilities function in mud houses, – More than a third (36%) of health facilities function in sub-

standard building (not meeting the service needs)

• Access to water from clean source is not optimal – 17% of HF do not have access to water from clean sources, in

some provinces this access is worse: – NTN 39%, LGN 78%, GHZ 79% and KDR 81%

• Waste management is generally poor; – 75% of HF practice some level of proper waste management; – LGR 45%, HLD 48%, FRH 49% and NTN 58% have the poorest

waste management practices


Discussion Adherence to prescribed working hours is a very important factor for service availability & utilization

• About 6% of (42) health facilities are not open as per the prescribed time – 6% of BHC, SHC and MHT are open less than 5 hours

during working days

– 7% of DHs and CHCs do not provide 24 hours or on call services.

• Cases referred from low level HF after open hours, may not get the services they need.


Discussion: Utilization of services • This study showed considerable variation in utilization of

services by the same type of HF. For example: – An average DH provide 5900 OPD consultations/ month

however this ranges between 1030 in NTN and 13080 in NGR – On average CHCs provide about 2900 consultations/ month

but the range is 373-7539 – On average BHCs provide 1560 OPD/month and range is 160-

4817

• Data from community reveals there are factors such as insecurity, cultural issues that affect utilization of services.

• There might be some factors that this study did not explore but generally this variation warrants further exploration


Catchment population • There is considerable variation in population served by a same level of

HF for example: – On average 50% of DHs serve 46000 or less population; this number ranges

between 6352 in NTN and 156000 in HLD. BPHS prescribes a DH should cover 100-300,000 people.

– Likewise average catchment population of CHC is 28000 (Min 6180 Max 166900). BPHS prescribes 30-60,000

– BHC is 11165 (Min 1800 and Max 70000) BPHS prescribes 15-30,000

• Only population may not be a sole factor for rationalization of a HF,

however the considerable variation in catchment population at the same type of HF is an issue to be considered.

• We also learned from qualitative data that the quality of population reported by HF is not accurate and that there are geographical and political challenges in the face of evidence based rationalization.


Discussion

• Rationalization of health facility based on evidence is constrained by the vested interest of influencing people

• It is already understood that only about 65%-68% of population have access to BPHS services (Strong et. al. 2004, New Brander et.al. 2008); this study did not assess the white areas


Limitations of the findings • Calculating rationality factor only considered Utilization (OPD, Penat3, delivery, and

CS), Catchment population and some geographical/seasonal/security barriers, while there are many other factors (cultural, spatial…..) that have role in rationalization of a health facility

• This study was limited to Health facility; hence identification of white areas was not within the scope of this assessment.

• Provincial Equity analysis and distribution of HF was not part of the scope of this project.

• HMIS records were not consistent; a number of health facilities could not substantiate their reports with registers, especially newly recruited staff were not responsive for past records..

• 17 HF overall and 10 only in Paktika could not be assessed hence the data for Paktika may not give a full picture

• No consent by a DH to participate did not allow to assess and hence data on that is lacking


Recommendations

Rationality of HF • The data from this study provides a short list

of HF that should be further explored and rationality determined by looking at other factors such as:

– White areas,

– Provincial equity analysis,

– The sociocultural context of each province

Functionality

• All HF that scored less than 80% score of functionality need attention, 3% (34-49% score) needs urgent action

• Provinces such as KDR, PKA, NTN, LGR, UZN, GHZ and HLD needs special attention

• Focus is needed on improving Services availability by targeting specific areas and the proxy factors such as the HR, EM, equipment & supplies


Recommendations

• Support EPI services in SHC & MHT • Improve capacity (diagnostic, treatment, counseling,

and follow up) for communicable disease at lower level HF (BHC…..)

• Improve blood Transfusion and C-Section services availability at DH and CHC/+

• Improve emergency response capacity at DH and CHC level in all provinces with special attention to provinces with no or poor preparedness

• Improve waste management practices at all Health facilities in all provinces with some special focus on LGR, FRH, HLD and NTN 10/7/2015 MOPH/Policy and Planning Directorate 60

Recommendation HR • Proper work force planning and developing strategy at

province level especially for female health workers.

– Replicate CME program for training other cadre especially female HW (nurse, lab technicians and pharmacist)

– Rotation and mandatory rural employment mechanism for key medical staff

– Creation of a comprehensive incentive package : living house, education package for family members, remuneration

– Recognition mechanism for good performance of HW

• Build capacity of HF staff on proper waste management at all HFs level


Recommendations

• Secure funding to build more standard building for HF (currently 36% of DH, CHC and BHC are functional in sub-standard buildings)

• An advocacy package is needed to be developed for parliamentarians and politicians to support evidence based rational distribution of HF

• An accurate population census would solve some aspects of planning in rationalization of health facilities

• If MoPH is going to downgrade or close down a center it should be carefully approached investing plenty of advocacy efforts in advance

• Work with other sectors to improve roads to clinics


Recommendations

• Stock out in any instance is not accepted and both MoPH and NGOs are bound legally to ensure proper availability of essential medicine at all times

• Regular and adequate provision of medicine to the health clinics based on realistic needs

• Buffer stocks to avoid stock-outs should be predicted and prepared


Recommendations

• Enforcement (incentivize) working hour policies on the health workers

• Improve code of conducts and ethical values among the health sector employees, through leadership .

• Last but not least: perform similar assessment in the remaining 20 provinces


Acknowledgement • The study was financially supported by WHO

• Thanks to the steering committee for their tireless efforts for the success of this study

• Key informants at MOPH, PHOs, and partner organizations for their participants

• PHD, NGOs for facilitation this study in HF

• HF staff for their cooperation and participation

• Community for providing invaluable information in exit and FGDs



Vertical program

14 Provinces/Vertical programs results.pptx

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P&P General Directorate MoPH, WHO HPRO

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