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1. CURRENT POJECTS: 1.1 Implementation of Basic Package Health Services (BPHS) in all districts of Takhar Province with support of USAID/ Partnership Performance based Grant (PPG) program, starting from May 2006 to April 2011, CAF is the leading agency and SHDP is our partner in this project. 1.2. Implementation of Essential Package of Hospital Services( EPHS) in Faizabad Provincial Hospital in Badakhshan Province with support of USAID/PPG program, starting from May 2006 to April 2008. .1.3. Implementation of BPHS in four districts of Badakhshan Province (Jurm, Khash, Yamgan and Kuran wa Munjan), with support of World Bank/ PPA program. SHDP is our partner in this project. 1.4. Implementation of BPHS in Kishm, Shahre Buzurg, and Faizabad district of Badakhshan province in partnership with Merlin International being the leading agency, starting from May 2006 to April 2011. 1.5. Implementation of BPHS in Baharak, Wardooj and Shuhada Districts of Badakhshan province in partnership with Aga Khan Foundation,the lead agency, starting from May 2006 to April 2011. 1.6. Implementation of BPHS in Ragh, Khwan, and Yawan Districts of Badakhshan province in partnership with Mediar, starting from May 2006 to April 2011. 1.7. Implementation of BPHS in Kundoz Province from June 21 2007 to April 30, 2009 It is in partnership with Merlin and funded by EC. 1.8. Establishment and application of EOC in CHC Jurm of Badakhshan started from ….2007 to 200….and is funded by UNFPA. 1.9. Implementation of micronutrient, Iodin, distribution and awareness project in Takhar and two districts of Badakhshan province,started from November first,2007 and ends in March 31,2008.It is supported by MICRONUTRIENT INITIATIVE ,a Canadian funded project.
2.1. The first activity of CAF was evaluation of therapeutic feeding units in provincial hospitals and pre-test of nutrition communication materials with the communities in seven provinces (Kabul, Logar, Kandahar, Kapisa, Balkh, Jawzjan, and Faryab) of Afghanistan. Donor of this project was Unicef. MoPH facilitated our evaluation of the provincial hospital. This project was started in Jun 2003 and last for two months. 2.2. In October 2003, CAF started implementation of BPHS in three districts of Takhar Province with financial support of USAID/REACH. 2.3. In December 2005, CAF started implementation of EPHS in Faizabad (centre of Badakhshan Province) provincial hospital with financial support of USAID/REACH. 2.4. Implementation of BPHS in Burka district of Baghlan province from December 2004 to April 2006 Supported by USAID/REACH 2.5. Implementation of BPHS for first time in six Sectors of Kabul City (SC number 4, 9, 10, 11, 15 and 16) from December 2004 to October 2006, supported by USAID/REACH. 2.6. Implementation of BPHS in Kishm, Shahre Buzurg, and Faizabad district of Badakhshan province in partnership with Merlin International being the leading agency,starting from December 2004 to April 2006, supported by USAID/REACH. 2.7. Implementation of Roll Back Malaria initiative from May 2005 to November 2005, Takhar Province, donor of this project was Unicef-Afghanistan. 2.8. Capacity building for Afghan Women from June 2004 to November 2004 Takhar Province funded by Swiss Cooperation and Development Agency (SDC). 2.9. Community Midwifery Education program with Merlin being the leading agency in Takhar Province, from July 2004 to April 2006, supported by USAID/REACH. 2.10. Capacity Building for Poverty Reduction , a community development project with an education and CBO components from January 2006 to January 2007, Khwajaghar District of Takhar Province, supported by Counter part International. 2.11. Implementation of Willingness to Pay Survey (study) for Family Planning and primary Health Care Products-Nov2006-May2007.It was a research project and implemented in partnership of CAF-SHDP This WTP Survey was for Health Products in Kabul and Takhar Provinces. This Project was funded by Future Group International under COMPRI-A Project. 2.12. Evaluation of Education Quality Enhancement Grants under EQUIP/Ministry of Education Project-April-Jun2007. It was a “Midterm Evaluation of an Education Project of Ministry of Education” and has been implemented with the partnership of CAF-SHDP in Kabul, Logar, Khost, Paktika, Kandahar, Bamyan, Badakhshan and Kapisa provinces of Afghanistan. This Project was funded by the World Bank. 2.13. Health and Hygiene Promotion Project (HHPP) funded by Shelter for Life (SFL) and implemented by CAF, started from 1st July 2007 and completed by 15th October 2007 in Taloqan of Takahar province. BPHS (Basic Package of Health Services) Project CAF with the financial and technical support of USAID /REACH implemented a BPHS Project, the new health package for Afghanistan, in six districts of Takhar Province ( Khojaghar, Yangi Qala, Darqad, Chal, Worsaj and Eshkamesh), from 1st Oct 2003 to 30th April 2006. An estimated population of 284800 is living in the catchment area of project of which around 54736 are women of CBA and 19904are children less than five, the target group of BPHS. CAF with the collaboration of Takhar Provincial Health Department took over from SCA 4 existed clinics in Dec 2003 and 3 more in Jan 2005. In addition to that, CAF established 12 new HFs included 1 CHC and 11 BHCs. (Attachment-1 List of Health Facilities) More ever CAF established a wide net work of Community Based Health Care (CBHC).Through a community participatory approach 115 female and 115 male CHWs were selected in the catchment of health facilities. All clinics and health posts were supplied regularly with essential drugs, logistics supply, transportation, medical and logistical equipment and other necessary items. A baseline household survey and a end of project survey was conducted to measure the impact of services on the households and their health status, knowledge, and practices. The survey shows a significant improvement in the household level. All activities were conducted in close coordination with the Provincial Health Department and Provincial health Coordination Committee at the province level as well as central MoPH in the national level. Community involvement and participation was a main component in the process and it was realized that this component is very useful and need more attention and improvement in the next programs. CME (Community Midwifery Education) Program The goal of the Community Midwifery Education Program is to develop high quality community midwife training programs that will prepare skilled rural providers of maternal and newborn health services, who possess the skills to manage normal and problem pregnancies, including life threatening complications of pregnancy, in order to promote health and reduce maternal and newborn morbidity and mortality. In Takhar province Merlin in partnership with Care of Afghan families took the responsibility of implementation of this project, which is aiming to increase access of local communities to skilled birth attendants by training of local community residents as midwives; this program is expecting the local community to introduce eligible women as students to be trained. This is to ensure access to health care providers and ensuring that all women receive appropriate care during pregnancy and childbirth. Meanwhile it provides the opportunity for local community to be involved in the process of identifying their needs, planning and implementation of projects. By considering CAF strong linkage in community and for better implementation of project, CAF has taken the responsibility of linking the program with community and involve community in this project management and implementation; community members make up essential part of this project and their interaction towards this project is fundamental. SDC project implemented by CAF in Takhar province OVERVIEW OF THE PROJECT: Takhar Province is located in the North-East of Afghanistan, the Taluqan City, which has 172,000 population that 84, 000 of the total population is women. Amongst the women 69,000 are living in rural area and 15,000 women are living in urban area. The women of Taluqan like other parts of Afghanistan suffered much injustice during two decades of factional war and instability, they did not have the opportunity of studying and working outside home, they could not participate or contribute in social activities. Besides aforementioned obstacles, there are some women who are eager to improve their knowledge and capacity, and make them ready to take part in activities outside home. CAF by realizing that fact designed this project that is aiming to improve the knowledge and capacity of women in English language, office tasks and computer operation skills through proper education program to ensure their active participation in office work and social service provision. This project was a course for English language and computer operating skills for women started in June 2004 in Taluqan City. After necessary arrangements such as hiring necessary staff and listing the trainees, the course was inaugurated on June 15 by deputy governor of Takhar Province and Director of cultural & information department and executive members of CAF. The course continued in different classes for computer and English language. 100 students were trained (50 in each part) through the course (See Annex 1, the list of Students). All participants (trainees) were female. The majorities were senior students of Takhar High School and some participants were employees of different governmental organizations. The total Cost of the project was 16,568 USD that 5,820 USD was contribution of CAF and 10,748 USD contribution of SDC. Achievements: One English Course was started and continued for six months to train 50 women in basic communication skills. One computer course was established for 50 women to train basics of office operations. 50 women were selected as trainees for English Language Course. 50 women were selected as trainees for computer language course. Three master trainers were hired to train the students in English language, computer skills and office basic tasks. Health and Hygiene Promotion Project (HHPP) funded by Shelter for Life (SFL) and implemented by Care of Afghan Families (CAF), started from 1st July 2007 and completed by 15th October 2007. The main goal of the project was to increase awareness and promote healthy behavior, hygiene and sanitation practices amongst IDPs and returnees living in Taloqan district and supported by SFL, providing shelters and latrine and other services for them. Totally 500 (447 female, 53 male) people received three days in-class training on following five topics: personal and environmental hygiene, basics of sanitation, water born diseases, prenatal-natal-postnatal care, and nutrition. Totally 19 classes held in 10 different locations. Each class contained on average 20-30 trainees, trained by one male and one female qualified trainer. I. Province Background: shan is a North -Eastern province of Afghanistan with total population of 805,500 (CSO 2005-2006). There are 28 districts in Badakhshan according to the new administrative division of districts by MoIA. The center of the province is Fayzabad with total population of 56400 (according to CSO 2005-2006). There is an airport for small air crafts at the center, Fayzabad, and a main road to Takhar with 7 hrs drive, 170 Km. The road access to districts is available with unasphalted roads that are usually closed during the 4-5 months of winter to half of the districts in the province. Very limited number of public transportation facilities from the villages to the district center is another challenge that has complicated the situation. This situation seriously affects the health situation of the people, limiting their access to secondary health services. The Education level of the people is not very bad. Most of the young generation is literate. The economic status of the people is very poor; the main source of their income is raising small cattle. Even most of the people cannot afford proper warming cloths for their children in cold season. The province is mountainous and people have a small plot of farm land which does not meet their nutritional requirements that affect the nutritional status of the people as well. Access to safe drinking water is another environmental challenge that affects the health of people especially the children; most of the people use water of stream and other unsafe sources. The province is mostly at the risk of floods, heavy snow avalanches, and road blockages that cause destruction of villages and limitation of access to life facilities. General security of the province is satisfactory but some occasions of clashes between tribes were observed which restricted the movement of the people for some days. II. Health Background: There is 1 PH (Fayzabad Provincial Hospital), 1 DH, 8 CHCs, 35 BHCs, 1 Sub-center and 334 HPs in the province, still the access of the scattered population is unsatisfactory. Merlin, Medair, AKHS and CAF are the organizations implementing the health projects in the province. Most health programs are mainly funded by USAID and only in four districts by World Bank. There are some other health facilities running by Kinder Burg, MSI, Emergency, ICRC and ARCS. The health indicators show the worst condition in the province. Crude mortality rate per 1000 population is 27 (25–29), Maternal mortality ratio per 100 000 live births is 6507 (5026–7988), Lifetime risk of maternal death is 1 in 3 (3–4) , Proportion of deaths among women of reproductive age due to maternal causes is 65%, Mortality rate in children under 5 years per 1000 livebirths is 323 (266–378) and Infant mortality rate per 1000 livebirths is 216·9 (178·0–256·8). III. Fayzabad Provincial Hospital Background Fayzabad Provincial Hospital, the only one referral point for the whole province of Badakhshan, was supported by government through the PPHO Badakhshan before Nov 2005. It was an 80 bed Hospital in a 2 story old building and a newly built 30 bed building for EOC. The EOC services were supported temporarily by UNICEF. The renovation of the 2 story building was under progress funded by USAID and implemented by IOM through a sub-contract with a private construction company. The supervision and monitoring of the construction was very poor that resulted in low quality works; poor electricity wiring, poor plumbing and drainage system and poor plaster lining. There was neither a Hospital Director nor a hospital management team. The PPHD directly managed the Hospital. The staffs were not committed to respect the official working hours and attend the OPD and IPD patients on a timely manner. A bilateral referral system form private clinics to the hospital was the only working management of cases. The knowledge of staffs on updates in medical and IP practices was insufficient. The hospital was in a poor infection prevention and waste management condition. The hospital did not have autonomy. There was no leading or managing body in the hospital. There was no planning for routine activities and the hospital development. The decision making of the hospital was carried out in the PPHO level. The financial support of the hospital was unclearly projected and followed from the PPHO level. Supervision and monitoring was not in place to have the staffs and the activities in a working track There was severe shortage of medical equipment and other pharmaceuticals. The patient flow and medical record system was not working. The medical staffs were not oriented to the MoPH HMIS reporting. The hospital was fragmented and uncoordinated with other BPHS or EPHS higher facilities to ensure patient referral system. Coordination with and the support of community form the hospital was in its lower level. The sense of ownership and the hospital credibility was severely affected by the poor ethics of the personnel In conclusion the insufficient financial resources, poor human resources, weak management, lack of knowledge and existence of quality standards and guidelines, shortcoming of medical equipment and other pharmaceuticals and poor commitment of staffs all resulted in a low quality of patient care and patient safety. The whole province, with limited access to outside, was struggling to receive secondary health services in a difficult situation. MSH,REACH had assessments of hospital standards in Fayzabad Hospital in August 2005 that resulted in 15% average (shown in chart below). IV. Implementation of EPHS in Fayzabad Provincial Hospital: An assessment was done by CAF which provided a whole picture of the existing problems and suggested areas for intervention. Considering these facts, CAF took on the responsibility of implementation of EPHS in Badakhshan hospital by financial and technical support of MoPH and MSH-REACH in October 2005. In order to successfully implement the EPHS strategy in Faizabad hospital the following three objectives were set. I. Successful implementation of the Essential Package of Hospital Services (EPHS) at Badakhshan Provincial Hospital, II. Overall Performance Quality Improvement in Badakhshan Provincial hospital through using the Standard Based Management Approach. III. Increased capacity of the Provincial Hospital and CAF staff in hospital management. 1. Objective 1: Successful Implementation of EPHS: Hospital Management Team Initiation: Ahead of starting the activities in Faizabad Provincial Hospital, the management team of the hospital was selected through an open competition by a selection committee comprising of Badakhshan PPHD, representative of active partners like AKHS, Mediar, Merlin and representative of WHO. The hospital management team is composed of three persons; Hospital director, Medical director and Admin/finance director. This way the hospital was given a leading/managing body that were delegated the overall responsibility of the hospital management. The team was refreshed with EPHS guideline and oriented on the project work plan and budget plan. The CAF policy and operational procedures were trained to them. In coaching of the CAF HQ management the hospital management team started with a draft of operational day to day, weakly, monthly, and project-long action plans. Hospital Hand Over: After selection of the hospital management team, under the guidance of MoPH standard handing over guideline a hand over committee comprising of representative from hospital management, representative of Provincial health office, representative of mastufyat and representative from CAF-Badakhshan office was formed. This committee was assigned to facilitate the hand over process by preparing necessary documents and inventory for hospital assets, equipments, building and property and ease smooth handing over of hospital to the hospital management team. The committee started to work on documentation of the handing over process and after preparing necessary documentation the hospital was officially taken over from Badakhshan PPHD at the beginning of November 2005. Beside the asset inventory for the security and hand over purpose, an assessment of needed equipment and furniture was carried out, through which a plan for purchase and procurement was prepared. Recruitment Committee Establishment: Following the selection of the hospital management team, a recruitment committee by the membership of representative from provincial public health office, representative of hospital management team, and CAF-Badakhshan was created. Meanwhile all allocated positions in the hospital were announced as vacant, and application forms were distributed to hospital staff and were asked to apply for the positions. Different categories of staffs were interviewed and hired according to the requirement of EPHS and hospital need. One aim of assigning this committee was to standardize the staffing and recruitment procedure and systems and avoid over staffing and encourage management by minimum staffing. The allocation of the staff to each department of the hospital was based on staff proficiency, type of services and work load. All staffs were provided with job description relevant to their job requirements, meanwhile the staffs were introduced with new standards of staffing pattern according to EPHS guideline. Establishment of Hospital Community Board: Mostly the communities do not feel connected to the hospital—lack of ownership, and do not view the hospital as “their hospital” and a community resource. On the other hand the hospital leadership lacks accountability to act in the interest of the community and there is lack of information flow from the hospital to the community about the hospital and its services and from the community to the hospital on their perceived needs. For this purpose to advocate for community needs, monitor management and ensure quality, oversee accounting for user fees and their use by the hospital and assist with resolution of problems between the hospital and community , a board of the owner’ agents; the Provincial Public Health Director , Local government representative, the civil organization members, the religious organizations, the customers of the hospital (business and schools), Business Owner/Operator, women affairs and Physicians and medical groups affiliated with the hospital (organized medical staff) was established. This board could provide advice and support to hospital management, provide guidance on management decisions affecting community, acted as a channel for complaints from community and advocated for the hospital and its services. The very recent noteworthy achievement of the board in Fayzabad is the funds raising for building a kindergarten for the hospital that is successfully under the process these days. The board has got regular monthly base meetings at the hospital. Establishment of CAF supportive team: for better implementation of Standard based management approach, a supportive team of CAF comprising of two technical supervisors; one male and one female, and two operational supervisors; one admin/finance and one logistic, was created. This team worked closely with the management team and other staff members of the hospital to support them to establish an accountable, transparent, and standard management system. The supportive team of CAF worked only as supporters not interfering in the management of the hospital. This supporting team linked the hospital management, CAF office and REACH controlling, on-time and reporting and capacity building activities. After the REACH time, while the support was handed over to PPG program, the support approach was changed and a hospital manager was selected instead of the supportive team. The hospital manager was designated as being accountable for all aspects of the hospital’s performance, and also formally delegated the resources necessary to fulfill this responsibility. This was a direct support to the hospital management team with an increase of an additional position to the management team members. Hospital Department setting: In order to define the pattern of service provision through Faizabad Provincial Hospital, and provide required clinical, diagnostic, administrative and supportive services according to the EPHS guideline, four core clinical departments, nursing department, administrative department and other diagnostic departments as laboratory, blood bank, ultrasonography and X-Ray were identified. The core clinical departments were general medicine, surgery, pediatrics, and obstetrics & gynecology. These departments offered both out-patients and in-patients services. Meanwhile some other small departments like the basic ear-nose-throat, eye care and dental services that provided only outpatient services were also established. The staffing pattern of each department was carried out according to the requirement of EPHS Provision of Essential Drug, medical equipments and supplies and furniture: During the whole project the hospital was provided with enough items of essential drugs for the provincial level of the hospitals by MSH/REACH or Tech Serve. Meanwhile some those needed drug items that were not provided by MSH were procured through using money collected from cost recovery. The distribution of drugs to both OPD and IPD is done as exemption to all. The medical equipments proposed after the existed equipment assessment of the hospital at the beginning of the project were procured, delivered to the hospital, and installed in the relevant wards. The medical supplies provision to the hospital was done in a regular base each quarter, furniture was provided and the hospital is equipped with adequate computer systems to modernize the physical structure and the system in the hospital functioning departments. CAF in partnership with Merlin provide a high-quality, cost-efficient and culturally acceptable Basic Package of Health Services in Kunduz province, Afghanistan. Replicating previous successful BPHS implementation in Takhar and Badahkshan provinces Merlin’s technical and managerial expertise will be combined with CAF’s strength in community-based approaches to health service provision. The project will support 1 DH, 12 CHCs and 26 BHCs across seven administrative districts. 275 HPs will be established in order to provide immediate access to health services and reduce dependency on distant, facility based care. Reductions in maternal and under 5 morbidity and mortality will be achieved through the strengthening of reproductive health, neonatal and child-health services. Disability & mental health services will be programmatic priorities. One existing Community Midwifery Education school will graduate 20 community midwives. This project is emphasising upon three principle performance areas: expanding access; improving quality; and strengthening sustainability.
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