SWOT of selected secondary/tertiary health facilities in EQ affected districts

Quality care at the secondary and tertiary level is an essential component in the pyramid of health care delivery. An assessment of services and structures is the first logical step towards improving and/or sustaining high quality services in an efficient and needs based way. A preliminary rapid assessment was conducted at four hospitals; DHQ Bagh and HQ !orward "ahuta in District Bagh; and DHQ Battagram and #H$ ha%ot in District Battagram he ob&ectives of this assessment are' (. o assess functionality of facilities with regards to services; material and human resources. ). o assess the management structures and decision ma%ing process of selected facilities and their interaction with the district management team *. o conduct a +,- analysis of selected facilities .. o develop recommendations for pertinent areas of interventions towards improving quality and efficiency of services he methodology included a structured questionnaire with chec%lists/ in0depth interviews with selected staff and observations. A total of )1 interviews in four hospitals were conducted/ a brea%down on which is provided in the anne2. his report is divided into three parts i.e. 3(4 +,- analysis of hospitals visited 3)4 general observations with regards to pertinent areas and 3*4 recommendations. he report comments specifically on the following areas' 1. Service provision: Types of services provided; barriers to effective functioning/ further needs and potential initiatives and affects of e2ternal agency support with a focus on sustainability. 2. Management str ct re/processes: "ey management posts and structures such as management team/ meeting schedule/ types of decisions made/ barriers and needs with regards to s%ill capacity; budgeting/ accountability and transparency and leadership issues. !. "r g proc rement and s pply: 5rocess of drug requirement pro&ections/ procurement and supply including barriers faced/ stoc% outs/ warehousing problems and corresponding prescription patterns. #. $eporting: ypes and content of regular monitoring including feedbac% and use for planning

%art 1: SWOT &'&()S*S

ST$E'+T,S 6ood equipment ,ell supplied 5rovision of multiple facilities for people 5rovision of high quality medicine Qualified and e2perienced staff +ufficient funds !uture funding prospects good !oreign interest in interventions Hard wor%ing 5resence of 7a%at fund and other social nets $ommitted staff WE&-'ESSES +enior management not serious 8anagement staff does not care 3does not even wear uniform4 9ot enough management meetings with staff 5lanning not needs based 9o staff feedbac% :ac% of communication 9o accountability or transparency oo much reporting 3not used ;nclear reporting structure 9o documentation 5oor wor% ethics +taff shortage Alleged corruption 3drug procurement4 $annot deal with emergencies :abs not reliable 3I dont believe4 ;nnecessary referrals Drug stoc% outs common <rrational prescription practices No drug protocols/treatment guidelines 9o community participation 5olitical nepotism 9o political commitment +hortage of staff residences +taff capacity low T,$E&TS :ocal staff de0motivated 3not rewarded/ discomfort/ no place to stay/ frustration4 5rivate practice of doctors :ac% of maintenance Thankless community :ac% of critical staff 3orthopedics4 +taff conflicts 3local versus outside/ senior management and staff4 Discrepancy in wages 38oH versus 96-s4 secretarial level do not want lower staff to benefit in any way $entrali=ed planning +hort term vision 3false sense of security4 !unctioning beyond capacity

O%%.$T.'*T*ES 5olitical will for improving quality -utside funding opportunities 9ew building structures $lient satisfied $ommunity support $omputer technology

$ommunity participation difficult

%art 2: +eneral O/servations

Despite the peculiar differences between each of the four hospitals/ the issues are more or less of similar nature and have been presented here as such. Service provision: he greatest strength as perceived by the staff is the level and types of services being provided by the hospitals. <n fact all institutions visited are providing the essential services li%e -5D/ emergency/ gynecology and obstetrics/ pediatrics/ surgery and laboratory services. Having said that/ we cannot comment on quality of services at this point though some observations point towards areas where improvement is warranted 3for e2ample -5D practices including client e2amination/ privacy/ communication etc.4. +ome services/ however/ are generally less available despite the demand for e2ample orthopedics. <t also seems that most hospitals are functioning well beyond their capacity with regards to staff and space available and the population see%ing access for care. <n one hospital which is being supported by an e2ternal agency/ serious deficiencies in staffing and subsequently quantity and quality of service provision are e2pected once the agency withdraws its support. <n this particular case/ the local staff seems to be little concerned and is confident that a >third party? will come and support them when the current supporting agency leaves. All facilities though seemed to be well equipped though equipment may not be used 3for want of technical e2pertise/ electricity or maintenance4. he assessor came across high tech/ e2pensive machinery unused that included an 20ray machine/ dental chairs/ a huge donated generator/ ventilators and incubators to name a few. At DHQ Bagh/ a huge pile of relatively sturdy hospital beds lying in open under a parachute cover and rusting. ,hile laboratories were functioning at each facility/ several doctors commented that they do not ta%e the results too seriously due to the poor quality of labs/ low capacity of staff and a general dissatisfaction of clinicians with the service. Barriers to effective service provision as quoted by staff included conflict of interest vis0 @0vis the private practice of most physicians/ lac% of maintenance of equipment and supplies/ burn out of health wor%ers due to high case loads and a waning interest by the funding community. Management str ct re/processes: <n all facilities visited/ management is at best ad0hoc and unscientific. here is little input from staff and manager meetings are rare. ,hile policy issues are centrali=ed at the D6 level/ micro0management of individual facilities is centered on one individual i.e. the 8edical +uperintendent. 8ostly these are political appointments and not supported by the necessary s%ills/ competencies or aptitudes. !or e2ample/ in one facility/ the previous 8+

who was one of the few personnel with some management training was replaced by the pathologist. $onsequently both areas; management and pathology/ have suffered. As such there is no functioning management structure. Any >management teams? are on paper only and all decisions of any importance are made by the 8+/ or another senior clinician appointed by him. <t is worth noting that the 8+ was absent in three out of four facilities visited. ,hile tal%ing to staff/ there was a lot due to the >high0handedness? of management. At one facility/ the nurses complained that they > did not have a voice? and are >treated so badly?. <nfact/ after the conclusion of the interview/ the assessor overhead the ward doctor on duty reprimanding the nurses in a very insulting way in front of the patients in the ward and saying >you are supposed to work here not give interviews like movie stars . he head nurse reported that she had >been begging for phenol for the wards but the !" #ust laughs at us?. ransparency is also an issue and rumors rife regarding embe==lement of funds. ,hile management s%ills are obviously wanting/ staff reported that they > dont need training. $e #ust do what we are told? Staff Morale: +taff morale was generally poor with visible differences between the clinical staff 3particularly doctors4 and the lower staff. ,hile senior clinicians seemed mostly satisfied/ other cadres/ including lower staff/ were unmotivated and resentful. According to one wor%er/ >we also worked endlessly in the earth%uake despite our personal losses but no one has given us any reward or shown appreciation?. $onflicts are common and commonly revolve around local staff versus staff from outside 3>the local people do not work and #ust come in to pick their pay why am I the one shouted at.. I am here all the time ?4. $onflicts were reported at every level and revolve around >nepotism?/ >overwork? and >une%ual treatment? and >no reward&. here is no sense of organi=ational or institutional identity. 5erhaps the frequent transfers and high staff turnover may be one reason for this. 8ost people view their &obs as essentially >to put bread on the table&. hey did not seem to see the prospect of career development as realistic. -n the other hand/ the assessor did come across some remar%ably motivated individuals but these were rare individuals/ and/ we suspect/ not supported by the institution. -ther issues reported included staff absenteeism 3especially local staff4/ >attached staff? 3staff being paid from the hospital budget but serving elsewhere4/ lac% of incentives and no accountability. "r g proc rement and s pply:

$urrently/ the drug stoc% situation in all facilities was up to par. <n fact/ in one facility/ they had an over supply of drugs. hese stoc%s included both governmental supplies as well as private donations. -n the other hand/ clients at two facilities complained that they were prescribed drugs that were not available in the stores and very e2pensive. his was corroborated by store %eepers at three facilities who reported that doctors often prescribed medicines not as per any guidelines 3none e2ist4 promoted by drug representatives without considering the cost/ cheaper alternatives or availability of stoc%s in the mar%et. ,hile drug procurement was local/ as per lists and guidelines provided by the authorities/ all decisions regarding specific generics and quantity was centrali=ed. 5rocurement quantification was done based on the previous years records of drugs dispensed by the hospital pharmacy and supported by rough estimates by senior clinicians. !urther there is little storage space/ poor or non0e2istent warehousing protocols and frequent stoc% outs. A huge amount of drugs e2pired before usage and are supposedly disposed off by >throwing away?. <t seems that the communitiesA perspective to quality care lin%ed to the provision of drugs is shared by clinicians also. -ne clinician reported >'ow do you e(pect us to do anything when we dont have any drugs?. $eporting: #eporting is perhaps considered the least important of all functions by hospital staff. o start with there is little culture of documentation and staff has been resistant to initiating proper documentation in the one facility supported by 8+!. +econdly/ the hospitals produce a myriad of cumbersome reports on a monthly/ quarterly and annual basis that >nobody even looks at?. Despite the feeling that reporting is unnecessary/ many decisions li%e procurement of drugs and supplies/ staff transfers and such decisions are made based on these reports. However/ little of the information collected is utili=ed for day to day management of the facility or for planning purposes. 0lient satisfaction All seven clients spo%en to seem to be satisfied with the services provided. he absolute determinant of satisfaction is the availability of drugs at the facility. his is followed by the presence of a doctor. :ong waiting times/ inappropriate waiting facilities and perceived quality of care were considered secondary. ;ltimately/ it seems that for clients/ health care is a priority and they can spend a lot of money towards this. -ne man had spent over 5#" (B/BBB on hospital bills in two wee%s for a prostrate operation. He claimed that e2cept for drips he had to get all other medicine from the mar%et. $osts related to his attendantAs lodging and meals were around 5"# .BB per day. hough it was a lot of money for him/ he was satisfied with the results of his surgery.

$lients did complain about staff attitude 3especially local ward staff4/ lac% of water in the toilets and frequent power brea%downs.

%art !: $ecommendations
he situation reported here cannot be generali=ed to other facilities/ but does point towards some cross cutting issues across the secondary and tertiary health care system/ and generally the >institution? in 5a%istan. ,hile most of the issues are structural in nature/ the negative affects are magnified due to the softer issues of human relationships/ wor% place environment and individual aspirations of the wor% force. Any intervention designed must be needs based and developed in close coordination and involvement of staff. -b&ectives need to be realistic and achievable. -ne methodology that may be used in conducting interactive and facilitated +,- sessions with prior formed health management teams to include a cross section of all staff cadres 3and including nurses4. hese sessions may be used to develop three to five year strategic plans for the hospital in line with departmental goals and ob&ectives. !urther/ %ey individuals must be identified and supported and groomed as the >agents of change?. he whole process and subsequent improvement needs to documented and disseminated. ;ltimately/ the process can be used for advocating further devolution of power to the hospital/ but not until the necessary capacity/ transparency and accountability are in place. he following are some areas where intervention is warranted. Management Cstablishing management committees 3H8 4 with clearly defined -#s and a system of accountability #evision and/or development of -#s for managerial staff #estructuring of 8<+ system $apacity building with regards to management s%ills for selected individuals <nitiating improved financial management practices and financial audits Service provision Cstablishing standard treatment protocols and minimum standards of quality of care #eview of health personnel and transfers to be based on needs #egular clinical audits "r g proc rement 9eeds0based drug procurement $apacity building for warehousing s%ills 5rovision of appropriate space for drug storage Cstablishing specific prescription guidelines and protocols 5rocurement to be based on multiple client load and specific morbidity patterns. Others <nterventions for proper hospital waste management $ommunity involvement Hospital based community outreach and active public health information campaign <ncome generation for hospital &nne1: 2rea3do4n of intervie4ees

!acility DHQ Bagh

D of interviewees ()

DHQ !orward "ahuta

DHQ Battagram

#H$ ha%ot

<nterviewee brea%down 8oH administrator Hospital Administrator 38+!4 :ogistics 38+!4 +tore %eeper E) 38oH4 !emale doctor 38oH4 9urses E) 38oH and 8+!4 echnician Cmergency department 38+!4 - technician 38oH4 $lients E) 8+ and doctor 38oH4 B officer 38oH4 :HF 38oH4 $lient Doctor -5D male 9urse 8edical echnician 3ward4 $lients E) 8edical echnician :HF +weeper ,atchman $lients E)