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Medical Report MERLIN Afghanistan(Kandahar) Medical Report JULY and AUGUST 1995. I: MEDICAL MERLIN expanded its programme to include theprovision of drugs to Qalat Hospital, in Zabul Province at the end of July. It is hoped tostart physical rehabilitation of one wing of the building and provision of food for the staff and patients inSeptember. WFP has agreed to provide food for work for the rehabilitation work anda daily provision of food for 20 staff and 15 patients. The medical work in Kandahar and Helmand Provincescontinued uninterrupted, despite the increased security precautions and tensions in the area. 1.1 Pharmaceutical Distributions M mthly pharmaceutical%.1 tributions have now been introduced to all the MERLIN health facilities and the Mirwais Hospital. These have beencalculated on past usage and prescribing habits but with a certain degree of flexibility to allow forchanging patient numbers. Due to the uncertain securty situation September'sallocation for both the district clinics and Lashkargah Hospital were delivered in the second lastweek of August. 1.1.1 Mirwais Hospital: The package of assistan,e signed by MERLIN andthe MoPH concerning the Mirwais Hospital has + +orked well during these two months. The provision of food to the in- patients has beencarried out to the satisfaction of WFP. MERLIN provides basic equipment andreagents for the laboratory and it is now providinga full range of simple examinations ona daily basis. Theseare free of charge. A minimum fee is being charged foran x -ray examination and the film continues to be supplied by WHO. Three doctors currently work in the male OPD andthey are now filling in their registration books as required and so allowing closer monitoring of drugusage and prescribing habits. Monthly drug quotas have been introduced for boththe out patient pharmacy and theemergency room pharmacy. These have been calculated generously to allow foran increase in consultations or war wounded. Demand for drugs continues to be high and this hasnot always been mirrored in increased patient numbers. On investigation some explanationsappear to be a. Unrecorded prescription of drugs by visiting doctors and other membersof the health care staff. h. Poor prescribing habits in particular prescriptionof unnecessary antibiotics or of two antibiotics simultaneously when only one is required. In an effort to tackle these problems printed prescriptionpads have been provided to the MoPH and MERLIN doctors and the monthly drugquotas are being adhered to more strictly.It is hoped also to do some training with the doctors (seepara 13). The MoPH introducedc,., sultation fees for the patients attending of 200 Afghanis the male OPDon 13/8/95. A fee per consultation is charged and thismoney is used for general running hospital. MERLIN introducedthis fee into its MCH in costs of the taken at the MCH clip tandem with the MoPHand the money e is also returned to the MoPH (seepara 1.2). This appears to have very little effect on the consultationrates. had 1.1.2 DoRahi Clinic: Dorahi clinic was previouslystaffed by one male and one female doctor v, orking 4 and3 hours respectively. Regretfully thefemale doctor isno longer able to attend the clinic hours of the clinic havetherefore been changed every day. The doctor from Saturday to 5.5 hours a day and it is staffedby the male to Wednesday and by bothdoctors on Thursday.Patients requiring consultation with the femaledoctor are either referredto the Mirwais Hospital Thursday. MERLIN is searchin g for another female doctor. or asked to return on Consultation feeswere introduced into the DoRahi Clinic on 26/8/95. These feesfollow the MoPH guidelines and themoney collected is given to the MoPH. of the female doctor The introduction of thisfee and the loss seem to have had little effecton the consultation rates which appear stabilised at around 600per v eek. to have UNICEF introducedan ORT corner into the DoRahi containers of prepared ORS Clinic during July. Thisconsists of two and two cups. These sitnear to the main entrance and the staff been asked to register thenumber of people using this have this slightly and the registrar service. MERLIN hasattempted to regulate now takes the patients with diarrhoeato the ORT corner and explains to them the benefits of ORS.She also gives and it's treatment. Further group health education sessions aboutdehydration health education is given bythe nurses in the MCHroom. 1.1.3 District Clinics: The work in the 5 districtcliïa.. continues and anaverage of 1100 patients wereseen each week. Around 20 to 25% of thesepatients are seen by the female as women travel longer and longer doctor and this numbercontinues to rise distances to consult witha female medical worker. It was necessary to discontinuethe employment of the for reasons of health worker working inMaywand Clinic gross misconduct. The clinicwas closed for one week whilst found but is now functioningwell. a replacement was Consultation fees are beingintroduced into the district the MoPH and the Minimum clinics this week. This is inline with both Primary Health Care Planfor Afghanistan. A charge for consultation witha health worker and 200 afghanis of 100 afghanis introduced. for consultation witha doctor is being 1.2MCH The weekly attendance figures for the MCH clinics forJuly and Augustare shown below. The decrease in the attendanceat the Mirwais clinic in week 3 forbidding all women from was caused by the enforcement ofa rule travelling in rickshawsunescorted and the in week 9 by the MoPH registeringsystem for consultation fee. confusion in Attendance at the MCH clinics 400T 300°s.-` ° Mirwais 200 DoRahi 100 s __--.----_.. Districts 1 0 1 1 1 1 1 1 1 1 1 2 3 4 5 6789 Week N° The graph below shows the number of malnourished children attending the MCH clinics. The decreases in weeks 3,4 <<rid 9 correspond with the decrease in the total number of children attending the clinics on these days. Malnourished Children Attending the MCH Clinics Mirwais / ` O DoRahi :._.,,,,,i.,...._ ,,;,:: -....2'/ Districts o 1 I 1 1 -r 1 "' ! 1 2 4 5 6 7 8 9 Week N° Discussions were held with all medical, paramedical and nursing staff to improve the system of care for malnourished children and pregnant women. The number of pregnant women attending the clinics stabilised at between 30 and 60 at week and around 25% of these women are attending for their second and third visits. The low number ofre- attendees remains a problem for good ante natal care and appears to be mainly caused by the problems for women moving outside their homes. However it is hoped to discuss with thewomen in more detail the reasons for their reluctance to attend. Consultation fees have been introduced into all the clinics as mentioned above. These apply only to the patients attending the doctors. Patients attending the MCH clinic only and those referred by the nurses to see the doctor are exempt from payment. No severely sick patient will ever be refused consultation for lack of money. Health education continues to be a main feature of the MCH work. Practical training sessions have been held with the clinic staff to improve teaching methods. 1.3 Helmand Province The pha, maceutical distribution to Lashkargah Boost Hospital continues without any problems. Basic reagents and a microscope have been supplied to the laboratory which is working to it's full capacity. After the original surge in numbers of out patients following MERLIN' provision of drugs the numbers of consultations have stabilised at around 1150 a week. All the staff continue to work 4 hours a day receiving only a minimum daily supply of food. The medical staff substitute their salaries with earnings from there private clinics. This is not, however, possible for the chowkidars and cleaners and for this reason it is difficult to get adequate numbers of people to work in these positions. This leads to problems with hygiene and crowd control within the hospital. In an effort to increase safety in the hospital and relieve some of the pressure on doctors an attempt was made by the MoPH to ban guns from the hospital. This was supported by the Governor of Helmand Province and was successful for some weeks. However with the increased Taliban presence in the town this ruling has again broken down. An MCH clinic has now been set up in the hospital. The clinic has been set up by the staff along the same lines as the previous MCH clinic which closed after the invasion of the Russian forces. The clinic is ; `.erefore concerned purely with preventative medicine, ante -natal care, health education and monitoring of nutritional status in children. The female and child OPD is a seperate clinic. There was much initial confusion over the provision of food to the children by the clinic. The previous policy in the 1970's had been to distribute food to all pregnant and lactating women and all children under six years of age and this was still the expectation of all the staff and mothers. Attempts have been made to emphasise the importance of health education and the mother's understanding of her problems. Unfortunately due to staff abscences and the disturbances due to the presence of work men for physical rehablitation of the building the clinic has not been able to work on a very regular basis and was operating for only 20 days between the 10th of July and the end of August. 1.4 'Training MERLIN started training Traditional Birth Attendants (TBA's) in the villages in July. Four groups (thirty seven women) have completed their training in Daman and Dand districts and fourteen women are currently receiving training in Arghandab district. The course covers the WHO TBA teaching material but is adjusted according to the needs of the community.
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