Strengthening Referral Hospitals in Post-Conflict Afghanistan

Background: Soon after the fall of the Taliban, the Afghan MOPH made two key policy decisions: to contract out basic health services to NGOs and to introduce a Basic Package of Health Services (BPHS). Implemented in 2003, the BPHS defines specific primary care services by level and appropriate intervention. Provincial referral hospitals remained within the MOPH, inheriting all the problems associated with 23 years of war. By 2004 the BPHS was implemented nationally but the problems of poor quality and management in the referral hospitals remained. The USAID-funded Rural Expansion of Afghanistan's Community-based Healthcare (REACH) project was asked to address Provincial Hospital management improvements. Methods: REACH adapted a Standards Based Management/Performance Quality Improvement (SBM/PQI) tool for essential obstetric care and developed clinical standards for surgery, anesthesia, medicine and pediatrics plus management standards for community boards, pharmaceuticals, personnel, and facilities. The SBM/PQI process started in five hospitals with training programs, on-site mentoring and networking of hospitals to exchange experiences. Results: Baseline scores for each standard were very low but improved dramatically over the following 3 years. As the quality of services improved, so did the utilization of services, showing greater than a 50% rise in the same time period. Discussion: Combining clinical and management standards created innovation so that improvements were made throughout the hospital. Training, mentoring and networking are essential to sustaining the SBM/PQI process. The MOPH has adopted this quality improvement approach as the foundation of a national hospital accreditation system.