Securing medical care for mothers and children The Mazar-e Sharif Regional Hospital, Afghanistan Published by
The Mazar-e Sharif Regional Hospital The Mazar-e-Sharif Regional Hospital is a beacon of hope for the people in northern Afghanistan. As a tertiary treatment centre, the Abu Ali Sina Balkhi Regional Hospital, with its specialised departments, takes care of the sick in the province of Balkh. It is also the only accredited institution in the region that offers medical and practical on-the-job training for health personnel. Together with the affiliated Institute of Health Science and the faculty of medicine at Balkh University, the hospital plays an important role as an institution that offers basic and further training for health professionals, medical assistants and doctors. It provides better health care not just for the population of Mazar-e Sharif and Balkh Province, but also for the roughly six million inhabitants of the provinces of Samangan, Takhar, Kunduz, Baghlan and Badakhshan in northern Afghanistan. The hospital has around 500 beds and 64,285 people were treated in 2016. 2 i Medical care in northern Afghanistan Medical care in northern Afghanistan is neither widely available nor up to standard. Maternal mortality is high; with 396 deaths per 100,000 live births, Afghanistan is ranked 22nd out of the 184 countries surveyed. Only 39 per cent of all births take place in a health facility in the presence of trained medical staff. As regards infant mortality (children under the age of one), with approximately 117 deaths per 1,000 live births, the country had the highest rate in the world (2016). Furthermore, over half (55 per cent) of all children under the age of five suffer from malnutrition. The lack of adequately qualified female medical staff primarily doctors, midwives and nurses is an additional challenge for Afghanistan s health sector. The Mazar-e Sharif Regional Hospital is the most important health care facility in northern Afghanistan The paediatric ward is temporarily housed in the main building
The competence centre for maternal and child health in the Regional Hospital Better care for mothers and children The Balkh Regional Hospital enjoys a good reputation. It has now received funds from German development cooperation for a new competence centre for maternal and child health. The German Federal Foreign Office (AA) has commissioned KfW Development Bank to construct the building for the centre. The Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH advises the hospital administration on technical, maintenance and management aspects and on staff training. Procedures and processes are consequently better regulated and patient care is in line with established standards for the health sector. The project also supports the Ministry of Public Health (MoPH) in its efforts to address the maternal and infant mortality rates, which are extremely high in northern Afghanistan. The new centre has yet to be built. The provision of seamless care for mothers-to-be, and later for their newborn babies, is of the highest priority. Therefore, while construction is under way, mothers, babies and children will be looked after in containers that have been provisionally set up on the compound. The paediatric ward will be temporarily relocated to the main hospital building. The four pillars of the mother and child health programme Fifty babies are brought into the world every day at the Balkh Regional Hospital. To ensure prenatal and post -natal medical care for mothers and their newborn babies or their children, GIZ supports the hospital administration and MoPH in the following four areas: 3 1. Providing ongoing care in the hospital s gynaecology and paediatric wards during construction 2. Performing quality assurance in the maternal and child clinic 3. Human resource development and management 4. Raising patients awareness about health issues Training personnel in the early detection of cervical cancer Newborn babies can be treated immediately after birth
Component 1 Ongoing care during construction The old building accommodating the paediatric and gynaecology wards has to make way for the new maternal and child health centre. Despite the planned construction work, medical assistance in this important field will continue without interruption. GIZ will advise the hospital management on how the hospital can continue functioning without its work being disrupted: a master plan was prepared in October outlining the organizational and logistical process to relocate the two departments. The paediatric ward was moved to the main building in November 2015. Since January 2016, the obstetrics ward has been located in a clinic placed in containers. 4 The allocation of space has therefore been finalised. It is equally important for the power and water supply and for the technical equipment to function properly. A competent technical team will ensure that all installations, systems and equipment work as they should. Thanks to this public-private partnership between the Public Health Directorate in Balkh and the service provider, the hospital is able to undertake all repair and maintenance work on its own. Results and impacts: A master plan for the temporary relocation to provisional accommodation during the construction work was drawn up in October 2015. Three technicians attended a two-week course in India on hospital maintenance and repair. This means that work can continue: between September and December 2016 alone, 18,325 children were treated on the paediatric ward and 24,587 mothers-to-be were admitted and treated at the mother and child clinic. The obstetrics ward was moved to containers in January 2016 The waiting room has been available to patients and families since December 2016
Component 2 Quality assurance Standards for better care How do we provide patients with the best treatment in accordance with their needs? What are the individual treatment steps and processes? What does the patient need by way of medicines? What is the dosage and at what time intervals? Patient care is in line with recognised standards. Besides medical care, the system also includes nursing and ancillary services. In the future, medical cases will be documented in forms and handover reports will be compiled. For patients at risk there are guidelines in place to ensure swift and adequate treatment in an emergency. With the help of a cardiotocography (CTG), the foetal heartbeat and uterine contractions can be recorded at the same time. The resultant curve charts should be analysed early so that any risk to the mother and child can be detected early, during pregnancy itself. Training courses will ensure that the hospital personnel is familiar with the standards developed and knows how to apply them. Results and impacts: Documentation of the care provided, including forms for monitoring and handover, has been introduced in the paediatric ward as a pilot project. The forms have been modified and adapted for the gynaecology department. Eight senior doctors, seven junior doctors and one midwife have been instructed in how to fill in the forms. One doctor has attended a 42-day training course in India on electroencephalography (EEG) and electromyography (EMG). 20 male and female doctors have received basic training in Mazar-e Sharif and 10 of them attended a further training course in Freiburg, Germany, on accurate CTG reading and analysis. An experienced doctor will train other junior doctors and nurses in using the technology. A CTG form has been introduced in the maternity ward. Forms for washing hands and dealing with waste have also been introduced. Training in how to maintain basic hygiene by washing our hands helps us greatly in our daily work. It ensures that we carry virtually no bacteria and are therefore less likely to infect patients. Member of the nursing staff in the mother and child clinic 5 Information about patients is documented in forms and handed over at the change of shift Experienced doctors learn techniques to enable them to pass on standards to colleagues Standards of hygiene applied to the sterilisation of instruments are specified and the staff is trained
Component 3 Human resource development developing and strengthening capacities Doctors, nurses, midwives, carers, cleaning staff the employees at the mother and child clinic receive training with a view to providing comprehensive medical treatment and care. Included here are basic hygiene measures as well as courses on how to use the new CTGs, which were introduced in 2016. The focus is not always on saving lives. Sometimes simple surgical interventions can help in correcting birth defects, such as cleft palates and cleft lips. Doctors in training as specialists, medical students and students of the nursing and midwifery school are also given practical training at the mother and child clinic. The basic and further training measures are underpinned by an HR strategy. As part of this strategy, training needs are identified based on the ward requirements and training is tailored to the skills of the personnel. The measures are a preliminary contribution to capacity development for improving levels of care for women and children even before and during construction of the new maternal and child competence centre. In an exchange programme with other hospitals in northern Afghanistan, individual training courses are also open to other hospital personnel. In addition, medical professionals have the opportunity to acquire knowledge at universities and hospitals abroad. International partnerships will be established and maintained with university clinics and hospitals in Europe (Germany) and Asia (India) for training and exchange programmes. 6 i Well connected cooperation with other hospitals International cooperation arrangements with the Johannes Wesling Hospital in Minden and the University Medical Center Freiburg (both in Germany), combined with training at the Apollo Hospital in Delhi, India, help in the transfer of medical knowledge to Afghanistan. Study trips or on-site hospital visits allow doctors to gain insights into the medical care provided at specialised centres outside Afghanistan. Individual staff members attend two-month training courses in India in specific fields and share their knowledge with their colleagues. Training in the surgical correction of birth defects in newborn babies is also important Medical staff practises life-saving measures initially on baby dolls
Results and impacts: Training and exchange: Two cleaning for cleaners courses have been held for the cleaning staff. Two doctors and 40 midwives have attended a language course in medical English. This makes it easier for them to participate in an international exchange of experience and information and to understand professional literature in English. 127 individuals, including 59 women, from different professions such as doctors, nurses, midwives, as well as medical students, have attended an advanced course on life-saving measures for newborns and infants. In addition to presentations, videos and practical exercises, the ethical aspects of lifeprolonging measures were also addressed. Six doctors, five nurses and seven medical students have been trained in newborn care and neonatal resuscitation for the paediatric ward. Another 16 doctors, nurses and midwives have been given a theoretical and practical introduction to infant care. 18 doctors and nurses have been given prevention training to avoid infections. Obstetrics courses have been held for 12 junior doctors and midwives. The director of the orthopaedic ward did a three-week residency in the hospital in Minden. The focus was on treatment and surgical techniques for children in order to provide surgical care for diseases and to be able to treat physical defects that occur before or after birth, such as cleft lip and palate. One ENT doctor attended a four-week training course in India on ear treatment and surgery. 20 employees from the hospital in Kunduz participated in a three-day first-aid training programme at the Balkh Regional Hospital. We are now in a position to take better care of newborn babies and to revive them in an emergency. Doctor from the mother and child clinic 7 Hygiene is vital cleaning staff receive training and learn about the importance of hospital hygiene Emergency medical equipment requires thorough training The English course enables doctors and midwives to take advantage of further training using literature in English
Component 4 Raising health awareness There is little public awareness of health issues, such as mother and child health. Many patients from rural areas can neither read nor write and have no access to information. Among women, the lack of knowledge owing to a number of social taboos that prevent them from using the medical services on offer leaves them particularly exposed to health hazards. The mother and child clinic, with its large number of visitors, offers excellent opportunities to increase health literacy by creating awareness and providing information. Consequently, the curative care services offered by the Regional Hospital have been expanded to include preventive health awareness: the obstetrics and paediatric wards are particularly useful in this context. Not only the in-patients but also their families are sensitised to the issues of breastfeeding, prenatal care, newborn care and hygiene. Simple preventive measures are routinely presented and explained: Washing hands with soap is the most effective way of avoiding and preventing the spread of infectious diseases, is one of the key messages for patients and their visitors. 8 Each and every opportunity is used. Waiting times are good opportunities in this vein. Doctors, nurses and midwives repeatedly make patients aware of the importance of hygiene for a healthy life. Materials such as posters and video clips, developed for these encounters, are used. In a further step, doctors, midwives and nursing staff are taught about health issues during the training itself. They can then pass on their knowledge to the people at their subsequent place of work, be it in the city or in the village. Results and impacts: Between May and December 2016 alone 24,022 people were made aware of the various options for health care in the mother and child clinic. Five nurses were trained for awareness-raising measures. Training materials such as posters and videos were also developed. In the training courses I learned about better breastfeeding for babies. I can now share my knowledge with mothers. Midwife, mother and child clinic
Mothers are given important information about optimal care for their newborn babies 9 Premature babies in particular require good care mothers learn everything about the correct way to breastfeed and about hygiene The personnel is the first to be sensitised and trained hand washing is one of the most effective weapons against infection
Outlook A stronger health system boosts public confidence The competence centre for maternal and child health is still under construction. The contract for the construction of the new building has been officially signed and the ground-breaking ceremony was held in December 2016. The shift into the new maternal and child centre with a 250-bed capacity is scheduled for mid-2018. Signing of contract for the construction of the maternal and child health competence centre with Dr Ferozuddin Feroz (right), and the Minister of Health (MoPH) The new maternal and child competence centre is not just another high-quality hospital wing. With its medical equipment, it can carry out operations that cannot be conducted in other hospitals in the region. This makes it the only facility in the north capable of providing neonatal emergency care. For an efficient health sector, project support is not confined to the hospital itself. MoPH too is advised on strategies and financial needs with the aim of enhancing the quality of the services in the sector. The state-run hospital takes care of public health. Through its contributions in the health sector, the state can build public trust. 10 The new maternal and child competence centre is under construction
With their solid training, they can pass on their knowledge to their colleagues 11
Imprint As a federal enterprise, GIZ supports the German Government in achieving its objectives in international cooperation for sustainable development. Published by: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Registered offices Bonn and Eschborn, Germany Programme: Capacity Development for setting up a Competence Centre for Maternal and Child Health in the Regional Hospital in Mazar-e Sharif Afghanistan I www.giz.de Text: Viola Reinhard Eschborn viola.reinhard@t-online.de Design and layout: Barbara Reuter Oberursel barbarareuter-grafik@web.de Photo credit: GIZ Mother and child health programme Published in: January 2017 GIZ is responsible for the content of this publication. Commissioned by the Federal Foreign Office All rights reserved. No part of this publication may be reproduced without the permission of GIZ. Non-commercial use is permitted provided the source is acknowledged.