World J Surg DOI 10.1007/s00268-010-0406-7

Emergency and Essential Surgical Services in Afghanistan: Still a Missing Challenge

Sandro Contini • Asadullah Taqdeer • Meena Cherian • Ahmad Shah Shokohmand • Richard Gosselin • Peter Graaff • Luc Noel

Ó Socie´te´ Internationale de Chirurgie 2010

Abstract infrastructures, human resources, supplies, equipment, and Background In Afghanistan, the number of surgically interventions characterizing basic trauma, surgery, and amenable injuries related to civil unrest and ongoing con- anesthesia capacities. flict or consequent to road traffic accidents, trauma, or Results In 30% of the 17 facilities examined, oxygen pregnancy-related complications is rising and becoming a supply is limited and irregular; uninterrupted running water major cause of death and disability. This study was is not accessible in 40%; electrical power is not available designed to evaluate availability of basic lifesaving and continuously in 66%. Shortage of equipment and personnel disability-preventive emergency surgical and anesthesia is evident in peripheral health facilities: certified surgeons interventions representing most of the country. are present in 63.6% and certified anesthesiologists in 27.2%. Methods Evaluation was performed outside Kabul to rep- Continuous 24 h surgical service is available in 29.4%. resent a cross-section of the country. Data were collected Lifesaving procedures are performed in 17–42% of periph- from Afghanistan health facilities, using the WHO Tool for eral hospitals; 23.5% are without emergency obstetric Situation Analysis to Assess Emergency and Essential Sur- service. gical Care, covering case volume, travel distances, Conclusions Limited access to surgery is highly remarkable in Afghanistan, with a severe shortage of emergency surgical capacities in provincial and district hospitals, where availability of basic and emergency sur- gical care is far from satisfactory. A comprehensive S. Contini (&) approach for strengthening basic surgical capacities at the Department of Surgical Sciences, University of Parma, primary health care level should be introduced. Via Gramsci 14, 43100 Parma, Italy e-mail: [email protected]

A. Taqdeer Á P. Graaff Introduction World Health Organization (WHO) Country Office, Kabul, Afghanistan Available epidemiological information and experience M. Cherian Á L. Noel support the conclusion that basic surgical and anesthetic Department of Essential Health Technologies, services should be included into primary health-care Health Systems and Services, WHO, Geneva, Switzerland packages [1]. In 2004, the World Health Organization (WHO) established an Emergency and Essential Surgical A. S. Shokohmand Health Services Provision, Ministry of Public Health, Care (EESC) project—designed to build capacities for Kabul, Afghanistan health care providers in resource-constrained settings [2]to strengthen the delivery of surgical and anesthetic services R. Gosselin at primary-health facilities. A tool kit focusing on the Institute for Global Orthopedics and Traumatology, Department of Orthopedic Surgery, University of San Francisco, Integrated Management for Emergency and Essential California (UCSF), San Francisco, CA, USA Surgical Care (IMEESC) was developed for training, 123 World J Surg education, and policy guidelines [3], outlining WHO’s hospitals) were visited and assessed by persons not part of the minimum standards and technologies for EESC. hospital staff, or authors of this paper. None of the ques- In Afghanistan, the number of surgically amenable tionnaires was completed through telephone interview. injuries related to civil unrest and ongoing conflict or con- Validation of some subset for responses (infrastructures, sequent to road traffic accidents, falls, trauma, burns, or equipment, supplies) was performed by direct observation pregnancy-related complications is rising and becoming a during health facility visits. The data collected were entered major cause of deaths and disability. Nevertheless, the Basic into the WHO database. Package of Health Services (BPHS) released by the Afghan Ministry of Public Health (MoPH) in 2005 [4] does not Facilities surveyed include the basic and essential surgical care among its seven major elements. The distribution of hospital beds is poor, The surgical needs assessment was performed in govern- with only 20% of hospital beds located in the provinces [5]. ment civilian hospitals throughout the country. It was There is growing evidence of lack of access to essential addressed to the regional hospitals of the four main cities surgical services for a population that is more than 80% rural outside Kabul (referral hospitals) to provincial hospitals and the number of Afghans seeking basic surgical services (PH), district hospitals (DH), and comprehensive health from neighboring countries is still high. None of the previ- centers (CHC). In the Afghanistan health system, CHC are ous analyses and surveys of the Afghanistan health system part of the BPHS [5], covering a catchment area of 30,000– have specifically addressed the availability of emergency, 60,000 people and usually include procedures for assisted essential surgical, and anesthesia services [5–7]. This study normal deliveries. DH, serving a population of 100,000– was designed to offer a snapshot of the availability and 300,000, also are part of the BPHS. The cases referred accessibility of emergency and essential surgical interven- include major surgery under general anesthesia as well as tions at peripheral health facilities in Afghanistan, by using comprehensive emergency obstetrics care. DH are the link the WHO Tool for Situation Analysis Survey to Assess between the BPHS and the hospital system, which includes EESC [8]. provincial and referral hospitals. PH may be comparable, in terms of basic emergency surgical capacity, to DH, although serving a larger population. Materials and methods Methods of measurement Study design The evaluation was made by using the WHO Tool for In 2006, WHO and Afghan MoPH planned a joint evalu- Situation Analysis to assess emergency and essential sur- ation mission on IMEESC in the country to assess the gical care [8]. The questionnaire was already used for the quality of surgical care, especially at the first referral level evaluation of basic and essential surgical capacities in very health facilities. This evaluation was addressed outside poor countries [9]. It was developed in 2007 and can be Kabul to represent a cross-section of the country for the downloaded from the WHO site. It is part of the WHO availability of basic lifesaving and disability-preventive IMEESC tool kit and has the specific objective of assessing emergency surgical and anesthesia interventions, together the gaps in the availability of EESC at resource-constrained with the perceived hurdles (skills, infrastructure, and health facilities. equipment) to access this essential care in peripheral facilities (regional, provincial, district hospitals, and com- Outcome measures prehensive health centers). This three-page questionnaire covers the population served, Data collection number of admissions and patients referred, travel distances to the facilities, and the distance to the next higher level of During the years 2007 and 2008, data using the WHO Tool health facility if the service was not available. Furthermore, for Situation Analysis Survey to Assess EESC (question- infrastructures, human resources (medical discipline and naire) were collected through WHO country office Afghan- number), supplies, and equipment for management of life- istan, from the Ministry of Public Health (MoPH) health saving emergencies were analyzed and the availability of facilities, contacting key health providers and managers of guidelines on anesthesia, surgery, and pain relief at the health facilities and visiting some health facilities. Data were point of care were identified. Thirty interventions are listed obtained through the forms filled by the key leaders and to characterize basic trauma and general surgery capacities. managers of health facilities or by surgical providers in their For the purposes of this report, we classified them as life- absence. Most health facilities (except two regional saving, urgent, and nonurgent respectively (Table 1). 123 World J Surg

Table 1 Classification of the Procedures Regional Provincial District hospital surgical interventions according hospital (4) hospital (6) ? health centers (7) to the purposes of the paper and percentage of facilities in the Lifesaving procedures different groups, performing the different procedures Resuscitation maneuvers 100 100 100 Cricothyroidotomy 100 33 28 Chest tube insertion 100 100 28 Foreign body in the throat 100 17 42 Urgent procedures Surgery for strangulated hernia 100 100 57 C-section 100 100 71 Curettage 100 100 71 Appendectomy 100 100 86 Cystostomy 100 100 86 Emergency laparotomy 100 100 71 Neonatal emergencies 100 50 42 Management of open fractures 100 50 42 Emergency amputation 100 67 42 Nonurgent procedures Burn management 100 67 100 Abscess incision 100 100 100 Debridement 100 100 100 Suture of superficial wounds 100 100 100 Management of obstetric fistula 100 67 71 Management of hydrocele 100 100 71 Male circumcision 100 100 100 Urethral strictures 100 67 86 Congenital inguinal hernia 100 67 28 Cleft lip 75 50 28 Clubfoot 75 67 28 Skin graft/contraction release 100 50 42 Closed fractures 100 100 71 Joint dislocation 100 100 71 Osteomyelitis/septic arthritis 100 83 42 Superficial biopsies 100 67 57 Cataract surgery 50 50 28 Data are percentages

Obviously, urgent procedures also may be lifesaving. The facilities correspond to 18.8% of the 90 Afghan health principle that defines a life-saving procedure is essentially facilities outside Kabul with beds, not specialized, as linked to the very short time that is usually available to reported in the Afghanistan Hospital National Survey [5]. avoid the death of the patient on arrival. The answers to the questionnaires were accurate and complete regarding infrastructures (availability of oxygen, water, electricity), human resources, emergency equip- Results ment, and supplies for resuscitation. About interventions, some peripheral hospitals refer to provide relatively com- Completed questionnaire were received from 17 health plex interventions but not simpler ones (Table 1). facilities: 4 regional, 6 provincial, 5 district, and 2 com- The overall number of beds in the facilities (1,750) is munity hospitals or comprehensive health centers (CHC) approximately one-fifth of the declared beds in Afghani- (Fig. 1). They represent 10 of the 34 (29.4%) Afghanistan stan hospitals [5]. Provincial hospitals report a mean provinces, distributed through the country and account for a number of 25 surgical beds, yet some have 5, with con- total catchment population of approximately 9 million in a sequent very low surgical load (approximately 30 surgical country population of 33.6 million (26.7%) [10]. These 17 patients treated yearly). Regional hospitals have the highest

123 World J Surg

Fig. 1 Afghanistan map high lightening the facilities evaluated and list of health facilities

Regional hospitals 3. Sar-i-Pol 4. Spin Boldak 1. Hirat 4. Maymana 5. Yakawland 2. Kandahar 5. Baharak Comprehensive health 3. Mazar-i-Sharif 6. Lashkar Gah centres 4. Jalalabad District hospitals 1. Waras Provincial hospitals 1. Andkhoy 2. Balkhab 1. Bamiyan 2. Shirin Tagab 2. Ghazni 3. Panjab number of surgical beds (range, 65–200) with more than 30% of the facilities. Uninterrupted running water was not 500 surgical procedures per year. accessible in 40%, whereas electrical power was not The average travel distance to the hospitals was available continuously in 10 of 17 hospitals (58%). approximately 100 km, but in case of referral to more Operative rooms are generally poorly equipped, espe- advanced surgical facilities, these distances may increase cially in district hospitals. Functioning anesthesia machines to more than 200 km, frequently on unpaved roads, poorly were not available in 7 of 17 (41%), a percentage that maintained, and at times impassable, especially during the increases to 63% considering only the 11 district and winter. provincial hospitals. Anesthesia is performed mostly with ketamine injection or spinal anesthesia, and regional Infrastructure, equipment, and supplies anesthesia is not available in 41% of the facilities (7/17). One-third of the hospitals surveyed were without a blood

Due to lack of oxygen (O2) cylinders or nonfunctioning O2 bank. Equipment and supplies for basic surgical emer- concentrators, oxygen supply was limited and irregular in gencies were uniformly available in regional hospitals, 123 World J Surg whereas incompletely and occasionally available, without a 100 customary replacement, in provincial and district hospitals. 90 80 Emergency rooms were not properly equipped in 23% Resuscitation 70 (4/17). Intubation equipment for pediatric patients was 60 available in 41% (7/17) of facilities examined but in none Cricothyroidotomy % 50 of the district hospitals and in only 50% of provincial 40 Chest tube 30 hospitals. Foreign body in the Written guidelines for surgical emergencies, standard 20 throat surgical practices, and anesthesia are present in regional 10 0 hospitals but rarely in the other hospitals. Reg Prov District

Personnel Fig. 2 Availability (expressed as percentage of the healthcare facilities evaluated) of lifesaving procedures in different levels of healthcare facilities Certified surgeons (with a national diploma) are working in 11 of 17 hospitals (64.7%). In the others, surgery is per- formed by general doctors (not specialized). Remarkably, a injury management and amputations are performed in continuous 24 h surgical service is available in only 29.4% 64.7% (11/17) of the facilities. (5/17) of the hospitals. Districts and provincial hospitals perform an average of Certified anesthesiologists (with a national diploma) are four cesarean sections (C-sections) weekly, but approxi- available in 5 of 17 (29.4%) centers but only in 27.2% of mately one-third of these hospitals did not perform even district/provincial hospitals; however, the presence of nurse one C-section per week. anesthetists allows 24 h anesthesia service in 76.4% of the 17 hospitals. Lack of skill or absence of anesthesiologists Nonurgent procedures (certified nurses and doctors) are the main reasons for the referral of patients who need general (inhalation) Several hospitals perform most nonurgent procedures but anesthesia. with great disparity and with some incongruence: for One-third of the hospitals did not have any certified instance, all hospitals affirm to manage acute burns, but gynecologist and also 30% of midwives are not certified only 41% (7/17) perform skin grafts; a complex task, such by a recognized school. Emergency obstetric service as obstetric fistula, was managed in 76.4% (13/17) of the was not available in 23.5% (4/17) of the examined hospitals, yet the difficulties, case volume, and outcomes facilities; this percentage increases to 80% (4/5) in dis- were not specified. trict hospitals.

Discussion Procedures Emergency and essential surgical needs are increasing Life-saving procedure worldwide, especially in low- and middle-income coun- tries, and this fact is consistent with the growing volume of Standard resuscitation (intravenous access for intravenous injuries, accounting for a large amount of the disease infusion, O2 delivery, intubation) of patients with severe burden [11]. This growth often is unappreciated but brings injuries and in shock (hemorrhage) was apparently per- as a consequence a great need for public-health efforts to formed in all hospitals (Table 1). However, only 12 of 17 improve the monitoring, safety, and availability of surgical facilities (70.6%) could position a chest tube and 8 of 17 and anesthesia services. The disproportionate scarcity of (47%) perform cricothyroidotomy and remove a foreign surgical access in low-income settings suggests a large body from the throat. Results according to the various unaddressed disease burden. levels of hospital are shown in Fig. 2. The health status indicators of Afghanistan are among the worst in the world, which is not surprising considering Urgent procedures decades of war and environmental degradation. Main concerns are corruption, which may include corruption of Regional hospitals perform all urgent procedures, yet the health care system, widespread hunger and malnutri- 58.8% of hospitals (10/17) are able to treat neonatal tion, a heavily reduced access to clean water (22% of the emergencies and open fractures, a percentage reduced to population), and, as the war continues, an increasing dif- less than 50% in district and provincial hospitals. Mine ficulty to provide aid: only 60% of the country is now 123 World J Surg accessible to humanitarian response [12]. With the highest Hence, despite the reduced number of centers reached rates of children younger than aged 5 years mortality (191/ during the first 18 months of survey, we feel that this study 1,000), maternal mortality (1,600/100,000) (http://www.who. may be considered a preliminary but reliable evaluation int/hac/crises/afg/Afghanistan_Aug08.pdf), and injuries (war- and snapshot about the capacity of the Afghan health related, road traffic crashes, bombing), it is necessary to system to guarantee essential and emergency surgical care address the basic surgical capacity strengthening with a in the provinces outside Kabul. comprehensive integrated approach. Apart from the National Our data show a remarkable shortcoming of available Health System, NATO hospitals might provide treatment for surgical care. The number of surgical beds is very limited war injuries and civilians, but the number of patients treated is and unequally distributed, reflecting the already known unknown and interaction with the National Health Service is discrepancy in the allocation of beds in the country [5]. The problematic. Since 2003, the number of Non Governmental scarcity of surgical beds is further highlighted by the Organizations (NGO) health facilities has nearly tripled increased surgical needs due to the ongoing war and gives in 18 provinces (www.irinnews.org/Report.aspx?ReportId= explanation of the distances often required to be covered to 86542), yet their task in the field of emergency surgery is obtain even basic surgical treatment. It may have a definite quite limited and increasingly difficult because of the ongoing impact on the high maternal mortality rate of the country conflict. Because few or no data are available for many and on the poor clinical outcome of child victims of mine known health centers, an accurate denominator is impossible injuries, which frequently require referral to a higher level to calculate and only a best estimate is available. Moreover, of care. Moreover, usually patients are referred to the after some years of partnership with national or international hospitals by their own means of transportation, which are NGOs, alternatives are emerging to follow the policy of very primitive. Some hospitals have their own ambulance, increasing public provision of health services at central and but the equipment and the level of training of attendants are peripheral levels and to revive the dilapidated health infra- very low, if any. Transportation by military or NGO structure of Afghanistan, whose basic surgical resources need ambulances is quite uncommon. to be evaluated [13]. Basic amenities, such as running water, oxygen supply, A clear information system about the health situation and electrical power, often are unavailable in district and and outcome in Afghanistan is lacking. There are concerns provincial hospitals, making inaccessible any timely and about the completeness of the reports from the local Health even basic surgical interventions. Properly functioning Management Information System (HMIS) [14] and cur- anesthesia equipment is strongly needed in peripheral rently the Balanced Score Card, which is not specifically hospitals. Surgical care includes having anesthesia services focused on the availability of emergency and essential in place; the lack of experienced anesthesiology personnel surgical services, is the principal instrument for monitoring and safe anesthetic equipment is one of most urgent con- the health system’s performances [15]. Several analysis straints shown by this study and results in the use of and surveys about the Afghanistan health system have been inappropriate anesthetic techniques or time-consuming published [5–7]; only one addressed hospital capacities [7], referral to other facilities, with possible higher rate of and none of them specifically dealt with the accessibility of complications and death. essential surgical care in trauma and injury. The WHO The shortage of qualified medical personnel is evident. questionnaire, which has been used in previous surveys [9], A heavy brain drain has been observed in Afghanistan, due is easy and simple to complete within a short time. to low salaries, poor working conditions, limited opportu- This preliminary evaluation has some evident drawbacks. nities for professional development, unsafe environment, The number of facilities analyzed and the data are small; together with destroyed and degraded training facilities therefore, they may be skewed and may not give a compre- [16]. Appropriate teaching hospitals are present in Kabul hensive picture of the availability of emergency and essential and Jalalabad (Nangarhar province) only. Lack of training surgical care in the whole country. The increasingly difficult was apparent in this study. Simple lifesaving procedures, travel due to the ongoing conflict, the long time to answer, such as cricothyroidotomy or chest tube insertion, are sometimes the difficulty to obtain authorization to fulfill the performed in a small percentage of provincial and district questionnaire, etc., might underline how challenging could hospitals. Ad hoc training for nurses and midwives is have been any attempt to obtain a larger sample of facilities provided throughout the country, with varying curricula, and a more comprehensive evaluation. duration, and teaching methodologies, therefore, resulting However, the health facilities surveyed are spread in different levels and standards, often poor. This could be throughout the Afghan territory; more peripheral health overcome by incorporating WHO policies and standard facilities (13/17: CHC, PH, DH) or RH (4/17) show homo- tools on surgical services, within the existing education and geneous features within the groups, and they are rather con- training curriculum for frontline health providers and sistent in assuring (or not) basic and emergency surgical care. managers. Major constrains to the organization of training 123 World J Surg courses at this moment are the nonavailability of textbooks References (for doctors or nurses) in the country’s languages (Dari or Pashtu), as well as logistic and travelling problems for 1. Debas HT, Gosselin RA, McCord C et al (2006) Surgery. In: health personnel. The WHO-IMEESC textbook, Surgical Jamison D, Evans D, Alleyne G et al (eds) Disease control pri- orities in developing countries, 2nd edn. 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