Health Sector Assessment, Part One
American University of Armenia Center for Health Services Research and Development
HUMANITARIAN ASSISTANCE PROJECT, NAGORNO KARABAGH
HEALTH SECTOR ASSESSMENT, PART ONE:
HEALTH FACILITIES
Prepared for the United States Agency for International Development
FAR/AUA Contract # 111-1-00-02-00064-00, Task Order 2
Yerevan, Armenia, December 2003
Authors and Contributors Michael E. Thompson, MS, DrPH Alina Dorian, PhD Anahit Demirchyan, MD, MPH Gohar Hovhannisyan, MD, MPH Charles Dunlap, PhD Zaruhi Mkrtchyan, MPH Melanya Ohanyan, Arthur Karapetyan
Assessors Ira Khachatryan, MD Manushak Sargsyan, MD Nina Hovhannisyan, MD Lilia Babayan, MD
Center for Health Services Research and Development, December, 2003 i Table of contents
List of Acronyms...... iii Executive Summary...... iv 1. Background...... 1 1.1 Project Description...... 1 1.2 Health Services Structure in NK...... 1 1.3 Prior Interventions Related to the Project...... 3 1.4 Selection of facilities to be covered by the assessment ...... 4 2. Assessment Methodology ...... 4 2.1 Village ambulatory services assessment methodology...... 5 2.2 Village district hospitals assessment methodology...... 7 2.3 Central regional and republican hospitals assessment methodology...... 8 2.4 San-epi stations assessment methodology ...... 11 2.5 The Ambulance Center assessment methodology ...... 12 3. Data Analysis and Findings ...... 12 3.1 FAPs and Village Ambulatories ...... 13 3.2 Village District Hospitals...... 31 3.3 Central Regional Hospitals and Republican Dispensaries...... 36 3.4 San-epi Stations ...... 57 3.5 Ambulance Station...... 61 4. Summary of Needs ...... 62 4.1 FAPs and Village Ambulatories ...... 62 4.2 Village District Hospitals...... 72 4.3 Central Regional Hospitals and Republican Dispensaries...... 73 4.4 San-epi Stations ...... 81 4.5 Ambulance Station...... 83 5. Summary of Priorities/Recommendations...... 84 6. References...... 87 7. Appendices…………………………………………………………………………………….. 88
Center for Health Services Research and Development, December, 2003 ii List of Acronyms
ADM Adult Disease Management AMIC Armenian Medical International Committee ARC American Red Cross AUA American University of Armenia ASTP Armenia Social Transition Program ARCS Armenian Red Cross Society CHSR Center for Health Services Research and Development CRH Central Regional Hospital CRS Catholic Relief Services ECG Electrocardiogram EDL Essential Drug List FAP Village Health Post (Feldsher/Obstetrical Post) FAR Fund for Armenian Relief ICRC International Committee of Red Cross IMCI Integrated Management of Childhood Illnesses MSF Medicines sans Frontiers MOH Ministry of Health NK Nagorno Karabagh NGO Non-Governmental Organization PHC Primary Health Care RA Republic of Armenia SES Sanitary Epidemiological Station SHCMA School of Health Care Management and Administration STD Sexually Transmitted Diseases SVA Village Ambulatory SUB Village District Hospital USAID United States Agency for International Development WHO World Health Organization
Center for Health Services Research and Development, December, 2003 iii Executive Summary
A thorough assessment of selected health care facilities in Nagorno Karabagh (NK) was carried out by the Center for Health Services Research and Development (CHSR) in the scope of a USAID-funded humanitarian assistance project collaboratively conducted by the Fund for Armenian Relief (FAR) and the American University of Armenia (AUA). The assessment included a detailed physical assessment and inventory of equipment, supplies, pharmaceuticals, and personnel of each facility and was aimed to develop a strategy to renovate/reconstruct and equip/supply the health facilities of NK according to prioritization of their needs.
Out of 200 health facilities functioning in NK, 148 were covered by the assessment including 115 village health posts (FAP), 15 village ambulatories (SVA), 4 village district hospitals (SUB), 4 central regional hospitals (CRH), 2 republican dispensaries (Oncological and Skin/STD), 7 san-epi stations, and the Stepanakert Ambulance Station. Five facility-specific instruments and four different lists of essential drugs were developed to assess the target facilities combined in the following types: (1) Village primary health care facilities (FAPs and Village Ambulatories); (2) Village hospitals; (3) Central Regional and Republican Hospitals; (4) San-epi Stations; and (5) Ambulance Station. Standard listings of equipment and supplies for each facility group were included in the assessment tools to identify the existing needs and workload of each was measured to prioritize facilities in terms of those needs.
The assessment revealed that, of 130 PHC facilities, 62 needed varying degrees of physical renovation. These facilities were grouped into three priority categories by the extent of renovation needed. Almost all village PHC facilities need piped water and/or swage system to ensure minimal hygiene standards are maintained and excretions properly disposed of. The majority of facilities need furniture and equipment, and all facilities need periodic supply of drugs/disposables. Standard listings of furniture, equipment, and essential drugs/disposables for PHC level were developed and the cost for providing each facility in need with those items was estimated. The needs of the San-Epi and secondary/tertiary level facilities were also identified in terms of renovation/equipment/supplies and recommendations were made.
Given the largely rural distribution of the population outside of Stepanakert, the overall strategy is to provide maximal health to the population by improving the primary care system through · First, improving primary care services available at the village/ambulatory level; · Second, improving the capacity of San-Epi to o Promote health through vaccination and monitoring of food and water supplies o Protect health through disease surveillance and control programs by providing updated/expanded laboratory facilities in combination with Central Regional Hospitals, etc; and · Third, improving secondary and tertiary facilities ability to treat patients referred from primary facilities, especially for conditions related to IMCI/ADM illnesses, with emphasis on diagnostic and inpatient services. · In parallel with point three, local solutions will be sought to improve the ability of patients to be transported from villages to regional facilities and from regional facilities to national facilities through a sustainable transportation and/or ambulance system, possibly with support from this project.
Center for Health Services Research and Development, December, 2003 iv 1. Background
1.1 Project Description
USAID contracted the Fund for Armenian Relief and the American University of Armenia to carry out a humanitarian assistance project in Nagorno Karabagh. In the scope of the project, rehabilitation and construction activities will be conducted in schools, local health clinics, water systems, and shelter in NK.
The Center for Health Services Research and Development (CHSR) of the American University of Armenia is implementing the health component of the program, which includes revitalization of the health care system and infrastructure of NK to meet humanitarian demands. For this purpose, CHSR conducted a thorough assessment of the health care facilities, which included a detailed physical assessment and inventory of equipment, supplies, pharmaceuticals, and personnel, as well as utilization/service information from each facility. The assessment served to develop a strategy to renovate/reconstruct and equip/supply the health facilities of NK according to prioritization of their needs.
The facilities assessment included: · Reviewing/validating/updating existing information available from both official and unofficial sources to select the facilities that are to be covered with the assessment · Physical assessment/inspection of all selected facilities · Creation of an inventory/database that summarizes all facilities, their available personnel, equipment, pharmaceuticals, and consumable supplies, and their actual/projected needs.
The assessment: · Summarizes existing facilities and equipment · Estimates renovation needs, equipment, pharmaceuticals, and consumable supply needs · Recommends standards for each level of health facility in terms of equipment/pharmaceutical/consumable supplies · Develops a plan to address facility needs based on prioritization of those needs
This report summarizes the facility assessment and subsequent recommendations for renovation project.
1.2 Health Services Structure in NK
At present, the health infrastructure of NK, developed in Soviet period, contains 200 health facilities covering the entire country. The facilities include 4 hospitals, 4 dispensaries and 3 ambulatories and other health-related institutions in Stepanakert, while regions are covered by 5 central regional hospitals, 5 village district hospitals, 16 village ambulatories (SVAs), and 145 health posts (FAPs). There are 9 san-epi stations in NK, carrying out primarily preventive functions.
Center for Health Services Research and Development, December, 2003 1 Figure 1. Map of NK
This well-developed network of health facilities serves the population of NK (according to different estimations, ranging from 130,000 to 145,000.1,2) through 274 MDs and 837 middle- level health workers, which results in a ratio of approximately 1 provider per 130 people. Despite this high ratio, the once well-functioning health infrastructure of NK currently suffers from critical shortage of equipment and supplies, poor facility conditions, and under-utilization of services due to gradually declining visits. The main reason for this is the economic and political instability of NK during the last decade, which has almost driven the entire health care system into collapse.
In the Soviet period, the health care system in NK (as in other Soviet territories) was quite centralized. After the recent decentralization, medical posts ceased to be directly supervised by the Ministry of Health of NK. Instead, the communities they serve assumed responsibility for supervision and funding the health posts. However, being health care facilities, medical posts still operate according to MOH orders and protocols. Given this dual leadership, problems with coordinating the distribution of available supplies and drugs or communicating up-to-date information to the regional health posts often occur.3 Indeed, having extremely restricted resources, communities often cannot afford to address even the most basic needs, such as electricity and water supply, much less provide basic medications and supplies.
Center for Health Services Research and Development, December, 2003 2 1.3 Prior Interventions Related to the Project
Because Nagorno Karabagh is not politically recognized as an independent state, it receives a limited flow of humanitarian aid and credits from international financial institutions. Meanwhile, the continuing Azerbaijani blockade hinders post-war reconstruction in the area. However, Armenian Diaspora and international non-governmental organizations have recently addressed some of the health care problems in NK through humanitarian efforts.
Supported by USAID, "Family Care" has operated in NK since 1998 and conducted an extensive program to improve maternal health and pediatric facilities in Stepanakert (Maternity House), in three regions (Maternity units in Martakert, Martuni and Hadrout), and in some villages. The intervention included reconstruction, provision of furniture, equipment and essential drugs, and retraining of the personnel.
The International Committee of the Red Cross (ICRC), with support from USAID and the American Red Cross Society (ARCS), and in collaboration with the Ministry of Health (MOH), implemented a Primary Health Care project beginning in 1998. The project included renovation of medical posts in villages and provision of health facilities with essential drugs and training for personnel on Integrated Management of Childhood Illnesses (IMCI) and Adult Disease Management (ADM). The intervention covered 66 health facilities (partially or fully) in 3 out of 5 regions of Nagorno Karabagh.
The French organization of "Medicine sans Frontiers" (MSF) implemented the program "Fighting Tuberculosis" from 1997 – 2002. MSF Belgium conducted the program "Fighting Mental Illnesses". This organization was involved in the renovation of Mental Health Dispensary in Stepanakert, and provision of equipment, drugs, and supplies.
Beginning in 1999, Catholic Relief Services (CRS) implemented a comprehensive program in NK, the important components of which were providing villages with clean water and reconstructing damaged houses and some health facilities.
The post-trauma rehabilitation center operates in Stepanakert with the help of the International Christian Solidarity organization. It was opened by the initiative of the Vice Speaker of Great Britain House of Lords, Baroness C. Cox. Services at the center are provided to invalids and injured soldiers and officers.
The Armenian Diaspora makes certain investments in the NK health care. A children dental clinic operates in Stepanakert, sponsored by the "Karagesyan" fund. A unit of Armenian Dentists of Canada has opened a dental surgery center for adults and children in Shushi. The AMIC Health Projects Database (www.amicdatabase.org) developed by CHSR can provide more details on Diaspora investments in the NK health Sector.
These and many other programs conducted by non-governmental organizations in the collaboration with NK MOH help to solve urgent problems in the sphere of health care. However, the system in general is still in need of serious investments and improvements at all levels.
Center for Health Services Research and Development, December, 2003 3 1.4 Selection of facilities to be covered by the assessment
The following criteria were applied to select those health facilities assessed: · All health facilities located in the areas considered “Green” were excluded. All other primary-level facilities were included. · Those secondary/tertiary level facilities in Stepanakert that has been already renovated with the help of International and/or Diaspora organizations, were excluded from the assessment · Those secondary/tertiary level facilities in Stepanakert that have current or committed future partner supporting them in renovation, equipment and supplies, were excluded from the assessment · Those facilities having no direct relation with provision of medical services to the population (namely the Nursing school, the “Artsakhphamacia” drug-distributing company, and the Agency for Forensic Medicine Investigation) were excluded from the assessment.
As a result, out of 200 health facilities listed by the NK MOH, 148 were included in the assessment: · 115 village health posts in five regions: 25 in Martuni, 32 in Martakert, 32 in Askeran, 22 in Hadrut, and 4 in Shushi, · 15 village ambulatories in four regions: 4 in Hadrut, 4 in Askeran, 2 in Martakert, and 5 in Martuni, · 4 village district hospitals, · 4 central regional hospitals in four regions: Askeran, Martakert, Martuni, and Hadrut, · 2 republican dispensaries in Stepanakert: Oncological and Skin/STD, · 7 san-epi stations, and · the Ambulance Center in Stepanakert A complete list of assessed facilities is provided in Appendix 1.
2. Assessment Methodology
Five different (facility-specific) instruments were developed to assess the target facilities combined in the following types: (1) Village primary health care facilities (FAPs and Village Ambulatories); (2) Village Hospitals; (3) Central Regional and Republican Hospitals; (4) San-epi Stations; and (5) Ambulance Center. The facilities were combined on the basis of similarity of the activities they conduct. Accordingly, 4 different lists of essential drugs were developed to assess the situation with essential drug supplies/needs in the facilities belonging to four out of five above-mentioned groups (excluding the san-epi stations).
The tools were used to collect information to: (1) identify existing renovation/ furniture/equipment/supplies/drugs needs in the assessed facilities, and (2) prioritize facilities in terms of their needs to be renovated/furnished/equipped/supplied.
Center for Health Services Research and Development, December, 2003 4
To address the first purpose, efforts were made to find acceptable standards for equipment and supplies for each facility group and include those in the assessment tool, so that the existing resources in each facility could be compared with those standards and the deficiencies identified. Many RA standards were used. Others were adapted from other sources such as WHO, US sources, etc.
To address the second purpose, the volume of work conducted by each type of facility was measured to identify the significance of the impact each facility could have in maintaining the health and well being of population. The level of workload was then compared with the extent of need each facility had to prioritize those to be addressed first.
The development process for the assessment tools and the assessment process for each group of facilities will be detailed in the following section.
2.1 Village ambulatory services assessment methodology
2.1.1 Instrument development
The instrument used by the International Committee of the Red Cross (ICRC) to assess village outpatient health facilities in NK during the National Policlinic Project in 2000 served as a basis for developing the assessment tool for the FAPs and village ambulatories. However, this instrument was thoroughly revised and changed to address the purposes of the current assessment.
The final instrument consisted of the following domains: · Facility identification information (name, type, code, facility responsible) · Renovation status, conditions (water supply, electricity, heating), and resources (rooms, furniture, staff) of the facility · Workload information (including number of population served, indicators of population dynamics, rates of ambulatory, home and school visits, referrals and hospitalizations, indicators of immunization, pregnancy visits and outcomes, medical record keeping) · Information on compliance of existing equipment/supplies with the standards for primary level village health facilities · Information on distances from other health facilities and transportation availability · Information on recent staff training · Situation with drug supply (main sources, percent of needs covered, existence of drugs included in the Essential Drugs List [EDL] for Primary Level Village Health Facilities)
The instrument was pre-tested in two FAPs and in a Village Ambulatory of NK to check its adequacy to the local conditions. After pre-testing, several changes were introduced in the instrument. The final instrument is provided in Appendix 2.
2.1.2 Standards used in the instrument
The following standard listings were incorporated in the instrument:
Center for Health Services Research and Development, December, 2003 5 o List of standard equipment and furniture for village ambulatory facilities (based on the Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA) o List of Essential Drugs for Primary Village Health Services.
The latter was developed by a group of experts from NK based on the following considerations: ü Existing listings of essential drugs for primary health care4 ü Drugs/medications distributed to village ambulatory services by ICRC and Family Care during recent years were given priority, because of familiarity of the medical personnel with those drugs ü Cost-effectiveness within a given class of drugs.
The EDL developed for NK PHC facilities measured the current state of drug supplies in the assessed facilities. The second purpose of this listing was to identify the most critically needed and the most useful drugs in necessary quantities for this level of care.
2.1.3 Assessor training, data gathering and entry
Assessment of the selected health facilities was implemented in two phases. Village-level health facilities (both in- and out-patient), represented by 115 FAPs, 15 village ambulatories and 4 village district hospitals were assessed during the first phase of assessment.
A total of 8 short listed applicants, all local medical doctors, were interviewed to be trained as assessors for the first phase. Taking into consideration their relevant work experience, communication abilities and familiarity with PHC facilities, 4 physicians were selected and trained to conduct the assessment. Training was held at CHSR’s Stepanakert sub-office and lasted 2 days (17-18 July, 2003). During the training sessions, assessors were instructed on how to implement the assessment instruments (for FAPs/ambulatories and village hospitals), introduced to assessment principles and standards, facility coding system, and EDL form for PHC level. The theoretical training was followed by practical completion of assessment tools for those PHC facilities that the assessors were familiar with from their previous experience. Revisions and retraining followed.
Fieldwork started on July 21, 2003 and lasted 15 days. The assessments were carried out by 4 teams each consisting of a trained assessor and a driver. CHSR staff observed each interviewer during at least 3 assessments. All 4 assessors were deemed qualified to conduct independent assessments. Assessors delivered completed questionnaires to the CHSR sub-office the morning following the assessment.
Data were reviewed and entered into SPSS data file by CHSR sub-office local staff. Double entry was used to ensure the precision of the information entered. Data entry lasted from July 22 to August 12. Upon completion of the entry phase the data were cleaned. The analysis was carried out by CHSR staff using SPSS 11.0 software.
Center for Health Services Research and Development, December, 2003 6 2.2 Village district hospitals assessment methodology
2.2.1 Instrument development
Taking into consideration the differences in functions of village inpatient and outpatient health facilities, a different assessment tool was developed for village district hospitals (VDH or SUB). The development process followed the same general principles of making measurable both the conditions/property/equipment/supplies of the assessed facilities and their workload. The instrument for FAPs/SVAs served as a template to develop this tool. In the property-measuring portion of the instrument, additional items were included to measure the conditions, renovation status, and furniture of patient rooms. As VDH in NK carry out both in- and out-patient health services, the workload-measuring part of the VDH instrument consisted from 2 parts, the first measured the outpatient service-related activities of the facility (repeating the structure of the FAP instrument), the second inpatient service-related activities.
The following main topics were included in the final VDH assessment tool: · Facility identification information (name, type, code, facility responsible) · Renovation status, conditions (water supply, electricity, heating), and resources (rooms, furniture, staff), including conditions of patient rooms · Workload information on outpatient services · Workload information on inpatient services (including number of admissions, occupied beds, surgeries, and deliveries; indicators of treatment outcomes and medical record keeping) · Information on compliance of existing equipment/supplies with the standards for village health facilities · Information on compliance of Clinical Laboratory equipment/supplies with existing standards · Information on recent staff training · Situation with drug supply (main sources, percent of needs covered, existence of drugs included in the Essential Drugs List [EDL] for Primary Level Village Health Facilities)
The instrument is provided in Appendix 2.
2.2.2 Standards used in the instrument
The same list of standard equipment and furniture (based on the Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA) used for village ambulatory facilities was used in this instrument. The List of Essential Drugs was also the same as for village outpatient services.
In addition, the list of standard equipment and furniture for clinical laboratories (based on the Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA) was included in the instrument, since the VDHs have clinical laboratories in their infrastructure.
2.2.3 Assessor training, data gathering and entry
As mentioned above, the same assessors were used to assess village inpatient and outpatient health services and the training on both instruments and the EDL for PHC was incorporated into
Center for Health Services Research and Development, December, 2003 7 one. The fieldwork also took place in parallel with the assessment of FAPs and village ambulatories. However, a different database was constructed for Village District Hospitals and the data entered into this database by the staff of CHSR sub-office in Stepanakert. Analysis was done using SPSS 11.0 software.
2.3 Central regional and republican hospitals assessment methodology
2.3.1 Instrument development
Several considerations were made to develop this instrument. The general approach was the same as with the assessment of village health facilities and SES: to estimate the extent of hospital’s compliance with existing standards and to measure the significance of its impact on the health of population it serves. However, this task was more complicated here because of large number of departments and functional units and their diversity.
Central Regional Hospitals (CRH) usually consist of three main divisions: outpatient service or policlinic, inpatient service, and maternity ward. Each of these services has a number of sub- divisions and functional units. The assessment instrument was designed to reflect this structure so that all the divisions/subdivisions could be assessed in terms of conditions they have (room space, renovation status, hygienic conditions, furniture), compliance of equipment/supplies with existing standards, and the workload/work outcomes for each division. Also, since the assessed hospitals were different in terms of types of subdivisions/departments they consist of, the assessment tool was flexible enough to allow assessment of different departments in different facilities.
These issues were addressed through developing a multi-level tool, which included a general questionnaire for the whole hospital, division-level questionnaires for each division, and sub- division-level questionnaires for each sub-division. The listing of standard equipments/supplies were prepared for the whole range of possible departments and functional units that could exist in at least one of the target facilities. In each facility, those listings of equipment that corresponded to the departments/functional units in that facility were included in the instrument.
The final instrument included the following topics: · General information on the facility (identification information, renovation, electricity and water supply, vehicles, infrastructure, recent training of staff) · Service information on Outpatient Divisions (to measure workload/work outcomes) · Structural/furniture/equipment information on each functional unit of Outpatient Division · Service information on Inpatient Division, including Maternity Ward (to measure workload/work outcomes) · Structural/furniture/equipment information on each functional unit of Inpatient Division
The CRH/hospital assessment tool is provided in Appendix 2.
2.3.2 Standards used in the instrument
A total of 45 listings of standard equipment/furniture were included in the assessment tool. Some of these listings were introduced into the body of the instrument, while others were put in an
Center for Health Services Research and Development, December, 2003 8 attachment for assessors to choose and use those listings that correspond with the type of units assessed in a particular facility.
The following is the list of equipment/furniture standards used in the instrument (all the standards5 are based on the Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA): a) The standard listings incorporated in the body of the questionnaire o Standard equipment/furniture for procedural room of a policlinic o Standard equipment for disinfecting room of a policlinic o Standard equipment (combined) for following outpatient units: Therapy, Pediatrics, Neurology, Psychology, Cardiology, Endocrinology, Oncology, Phthysiology, Infectious, Immunization, Rheumathology, Allergology, Teenagers. o Standard equipment for Surgery outpatient unit o Standard equipment for Physiotherapy outpatient unit o Standard equipment for Skin/STD outpatient unit o Standard equipment/furniture for Disinfecting Department of a hospital o Standard equipment/furniture for Drug Store of a hospital o Standard equipment/furniture for Morgue of a hospital o Standard equipment/furniture for Admission of a hospital o Standard equipment/furniture for Nursing Posts of inpatient units o Standard equipment/furniture for Procedural Rooms of inpatient units o Standard equipment/furniture for Dressing Rooms of inpatient units o Standard equipment/furniture for Operating Rooms of inpatient units b) The standard listings attached to the questionnaire to be used whenever needed:
For outpatient departments o Standard equipment/furniture for Women consultation o Standard equipment/furniture for Ophthalmology o Standard equipment/furniture for ENT o Standard equipment/furniture for Med. Kinesotherapy (adult and pediatric) o Standard equipment/furniture for Dentistry mixed, general (based on the Decision of the Government of RA # 1662 on October 18, 2002 concerning the required standards of equipment for dentistry services in RA) o Standard equipment/furniture for X-ray o Standard equipment/furniture for Fluorography o Standard equipment/furniture ECG o Standard equipment/furniture Sonography (ultrasound)
For inpatient departmets o Standard equipment/furniture for Oncology o Standard equipment/furniture for Chemotherapy o Standard equipment/furniture for Radiation therapy o Standard equipment/furniture for Skin/STD o Standard equipment/furniture for Rehabilitation
Center for Health Services Research and Development, December, 2003 9 o Standard equipment/furniture for Physiotherapy o Standard equipment/furniture for Therapeutic unit o Standard equipment/furniture for Pediatric unit o Standard equipment/furniture for Neonatal unit o Standard equipment/furniture for Surgery o Standard equipment/furniture for ICU o Standard equipment/furniture for Infectious unit o Standard equipment/furniture for Maternity/Obstetrics o Standard equipment/furniture for Delivery room & neonatal ICU o Standard equipment/furniture for Admission on maternity o Standard equipment/furniture for Operating gynecology o Standard equipment/furniture for Conservative gynecology o Standard equipment/furniture for Lab-clinical o Standard equipment/furniture for Lab-serological o Standard equipment/furniture for Lab-biochemical o Standard equipment/furniture for Lab-cytological o Standard equipment/furniture for Lab-bacteriological
Another standard listing used to estimate the situation with drug supplies was the Essential Drugs List (EDL) for General (secondary level) Hospitals (Appendix 3), developed by a group of experts from NK. The latter was represented by a group of local medical doctors, a ministry official, and the CHSR Health Sector Manager. The list was based on existing listings of essential drugs for secondary (hospital) level6. Again, a cost-effective approach was applied when choosing a particular drug and within a chosen priority was give to those medications used in the secondary healthcare facilities of NK more widely.
The EDL for Hospitals was also intended to identify the most critically needed and the most useful drugs for this level of care.
2.3.3 Assessor training, data gathering and entry
The assessment of four Central Regional Hospitals of NK was lead by the Project Health Advisor Dr. Alina Dorian. The four assessors trained to assess PHC facilities of NK were involved in the assessment process under the direction of the Health Advisor. The CHSR Health Sector Manager assessed the two dispensaries in Stepanakert. All the assessors received specific instructions for assessment of hospitals from the Health Advisor.
Fieldwork started on August 11, 2003 and lasted 6 full days (a day for each facility). The completed instruments were sent to the CHSR office in Yerevan for data entry and preliminary analysis. Taking into consideration the multi-level and complicated character of the assessment instrument, an Access database was created for data entry. As the assessed facilities were rather different from each other, a facility specific approach was applied when analyzing the data.
Center for Health Services Research and Development, December, 2003 10 2.4 San-epi stations assessment methodology
2.4.1 Instrument development
San-epi station (SES) assessment instrument consisted of four parts, each intended to collect data on following issues: · Facility identification information (name, type, code, facility responsible) · Information on facility structure, renovation status, conditions (water supply, electricity, heating), and resources (rooms, vehicles, staff) · Workload information (including indicators for drinking and irrigation water control, outbreak control, preventive screening, immunization, and precautionary and routine sanitary control of food objects, public and private facilities, and industrial enterprises) · Information on compliance of existing laboratory equipment with the standards.
The main items of the instrument (Appendix 2) were pre-tested/discussed with selected representatives of NK san-epi services so that the instrument better addresses the local specifics.
2.4.2 Standards used in the instrument
The following standards were incorporated in the instrument: o Standard list of equipment and furniture for laboratories of sanitary-hygienic departments (based on RA MOH standards for equipment of sanitary hygienic departments of SES confirmed on January 20, 1987) o Standard list of equipment and furniture for bacteriological laboratories (based on the Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA) o Standard list of equipment and furniture for parasitological laboratories (based on working standards kindly provided by the head of the Parasitological Laboratory of the Republican SES of RA) o Standard list of equipment and furniture for toxicological laboratories (based on Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA) o Standard list of equipment and furniture for serological laboratories (based on Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA)
These standard listings were attached to the SES instrument as appendixes and used to check the existence of needed equipment/furniture whose deficiency might jeopardize the work of these laboratories.
2.4.3 Assessor training, data gathering and entry
The same local assessor (Dr. Ira Khachatryan) was used to assess 7 SES to avoid inter-assessor bias. Before initiating this assessment, she participated in the first phase of the health facilities assessment (assessment of village ambulatories and FAPs) and was sufficiently experienced to undertake this task. She also received specific instructions/training for assessment from CHSR faculty.
Center for Health Services Research and Development, December, 2003 11 The fieldwork lasted 4 days: from 20 through 23 August 2003. The data was brought to the local project office in Stepanakert by the assessor and entered into database by the local project assistant. Upon completion of data entry, the data file was forwarded to CHSR in Yerevan for further analyses. The analysis was carried out through SPSS 11.0 software.
2.5 The Ambulance Center assessment methodology 2.5.1 Instrument development
Taking into consideration the unique character of functions carried out by this institution, a different assessment tool was developed to assess its needs and workload. The same approach described in the general part of this chapter was applied to develop this instrument. The final tool consisted of four parts, each intended to collect data on following issues: · Human and technical resources of the facility (staff, rooms, renovation, furniture, vehicles) · Organizational structure and workload (number/type of brigades, volume/outcome of services) · Training of staff (recent) · Equipment for ambulance brigades
The Ambulance Center assessment tool is provided in Appendix 2.
2.5.2 Standards used in the instrument
The following standard listings were incorporated in the instrument to measure the degree of compliance of the existing equipment with the standards: o Standard list of equipment for Linear brigade o Standard list of equipment for Feldsher brigade o Standard list of equipment for Pediatric brigade o Standard list of equipment for Cardio-resuscitation brigade
All these lists were based on the Decision of the Government of RA #1936 on December 5, 2002 concerning the required standards of equipment for health services in RA.
2.5.3 Assessor training, data gathering and entry
The ambulance center was assessed by one of the local assessors (Dr. Ira Khachatryan) instructed by the Health Advisor of the Project Dr. Alina Dorian. The assessment took place on 19 August 2003. An electronic version of the completed questionnaire was forwarded to CHSR for summarizing/analysis.
3. Data Analysis and Findings
Taking into consideration the large diversity of the assessed health facilities and the different instruments used to assess each type of institution, the findings are presented separately for each type of facility. This chapter includes the analysis methodology and assessment findings for FAPs/Village Ambulatories, Village District Hospitals, Central Regional Hospitals/Dispensaries, San-epi stations, and the Ambulance Center.
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3.1 FAPs and Village Ambulatories
3.1.1 Medical personnel
During this assessment, the principal respondent was usually the head of the facility. The staffing data gathered by the assessment tool reported filled positions, not authorized staffing levels. According to RA standards (Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment for health services in RA), the minimal acceptable staffing level for FAP includes a full-time mid-level medical personnel (nurse, feldsher, or midwife) and a full-time low-level personnel (sanitar). The minimal staffing level for village ambulatory includes also a full-time physician.
According to the data, no FAP had a physician as a staff member and only 8 (Karmir Shuka, Norshen, Sos, Astghashen, Aknaghbyur, Azokh, Mets Taghlar, Tumi) out of 15 assessed SVAs had physicians among their staff. Overall, 10.5 full time positions for physicians were in SVAs: one position in three SVAs, and 1.5 positions in the remaining 5 SVAs. The overall ratio of primary physicians per 1000 served population in the assessed villages was 0.2, while according to RA standards; this number should be 1 per 1000.
All the assessed facilities were staffed with mid-level health care providers (feldshers, nurses, or midwives). Of all village outpatient health facilities, 8.5 % had a part-time mid-level position, 40.8 % a full time position; the remaining 50.7 % more than one full-time position for mid-level personnel. The mean number of mid level positions in the assessed facilities was 1.6 (range 0.5- 6).
Low-level medical personnel (sanitars) were employed in 14% of the assessed facilities (mainly SVAs), with one part-time position in 8.6% and one full-time position in 5.4% of facilities.
3.1.2 Physical conditions of facilities
The assessment tool was designed to estimate the condition of each room of the assessed facilities in term of type of room (the purpose it serves), its size, lightning, renovation status, and any other significant specifics. From preliminary visits, however, it was clear that not all the rooms of the facility were in use reflecting either oversupply of rooms or lower than expected referral levels. Thus, only the condition of those rooms being utilized was assessed. In the 130 assessed facilities, out of 327 rooms 244 were utilized. The mean total number of rooms in the assessed FAPs/SVAs was 2.53 (range 0-20), the mean number of utilized rooms was 1.91 (range 0-11).
Renovation status: To estimate the renovation needs of each facility, two items were included in the assessment tool. One was item asked about the year of the last renovation of the facility and its coverage (full or partial). The other was observational assessment of each utilized room by assessors in terms of its renovation status. The findings generated through these two items were compared with each other to check the validity of data. The facility was considered recently renovated if the renovation covered the whole building and was conducted in/after 1999.
Generally, the renovation of the overwhelming majority of renovated facilities (93.0 %) occurred between 1998-2003 years, when international charitable organizations started their
Center for Health Services Research and Development, December, 2003 13 activities in Nagorno Karabakh. ICRC renovated 65.1 % of renovated village outpatient health facilities. CRS undertook sewage system reconstruction in 9.3 % of renovated facilities. Family Care renovated two maternity units. Renovation of 6 outpatient health facilities in the Askeran region was done by the Local Hands Foundation (7.0 %). Out of all renovated village outpatient health facilities, the renovation of 18.6 % was done by village administration efforts and 3.5 % by private donors.
Among the 130 assessed FAPs/Village Ambulatories, 62 (47.7%) were fully/recently renovated, 17 (13.1%) were partially/recently renovated and 51 (39.2%) were non-renovated. There was clear agreement between data collected through self-reports and the assessor’s estimation (Table 1).
Table 1. Assessor-estimated renovation status of rooms belonging to recently renovated and non-renovated facilities Self-reported: Recently renovated Recently non-renovated Assessor’s % agreement Number of % agreement Number of estimate: rooms rooms Room 1 90.2 61 71.5 57 Room 2 92.3 39 33.3 18 Room 3 93.3 15 30.0 10 Room 4 100.0 10 50.0 6 Room 5 100.0 8 60.0 5 Room 6 100.0 6 100.0 3 Room 7 100.0 6 50.0 2 Room 8 100.0 3 - -
Taking into consideration the high degree of agreement between renovation status of the facility and assessors’ assessment of the renovation state of each room in the facility, the self-reported renovation status of the facility was considered valid and in the most cases identified those facilities needing renovation. However, the few recently/fully renovated facilities that had rooms assessed by assessors as non-renovated were analyzed separately and the following picture was revealed:
· Aknakhbyur FAP in Hadrut region (code 5602) had only one room assessed as non- renovated · Dahrav FAP in Askeran region (code 4606) had only one room assessed as non-renovated · Hatsi FAP in Martuni region (code 2615) had two rooms both assessed as non-renovated · Mets Shen FAP in Mardakert region (code 3623) had two rooms both assessed as non- renovated · Nerkin Szeq FAP in Askeran region (code 4625) had only one room assessed as non- renovated
The other several facilities in this group (Chldran SVA in Martakert region, Kaghartsi FAP in Martuni region and Khandzadzor FAP in Hadrut region) had other renovated rooms along with the ones assessed as non-renovated by assessors. Thus, only the five facilities mentioned above were considered as needing renovation along with those identified as non-renovated through Item 13.
Center for Health Services Research and Development, December, 2003 14
Assessors assessed as adequately renovated the majority of facilities recently (since 1999) but partially renovated. There were only four exceptions:
· Ashan FAP in Martuni region (code 2601) had two rooms both assessed as non-renovated · Hin Shen FAP in Shushi region (code 6603) had only one room assessed as non-renovated · Khndzristan FAP in Askeran region (code 4614) had 10 rooms, out of each 5 were in use, and all these 5 were assessed by assessors as non-renovated. · Tsaghkashen in Mardakert region (code 3611) had only one room assessed as non-renovated
These findings indicated that in a limited number of cases renovation was incomplete or below existing standards. These facilities were included in the list of those in need of renovation.
Among those 51 facilities not-renovated since 1999, only two were assessed as renovated by assessors. One was Kichan FAP in Mardakert region, which had two renovated rooms. The other one was Nakhijevanik FAP in Askeran region, but it had only one room with a size of 10m2 and was included in the list of FAPs with unsatisfactory size (Table 7). Thus, 50 out of 51 facilities in this group were considered as needing renovation. Moreover, some of these facilities had no building or it was essentially destroyed. Table 2 lists 10 FAPs identified as having no facility at all. Some utilize or share rooms in other community buildings; some were using the building of a “neighboring” FAP. The next 4 facilities listed in the table were located in essentially destroyed/uninhabitable buildings. Some 14 facilities were described by assessors as having extreme need for renovation (Table 2).
Table 2. List of FAPs having no facility, located in destroyed/uninhabitable buildings, or assessed as having extreme need for renovation. Name of FAP Region Workload Facilities having no building Zardakhach Mardakert low Ghazanchi Mardakert low Madaghis Mardakert normal Mehmana Mardakert lowest Vardadzor Askeran normal Verin Szneq Askeran lowest Aygestan Hadrut normal Vardashat Hadrut low Hakaku Hadrut low Hakhullu Hadrut lowest Facilities having destroyed/uninhabitable buildings Khnushinak Martuni normal Karvin Martuni low Paravatumb Martuni low Hilis Askeran normal Facilities assessed as having extreme need for renovation Zardanashen Martuni low Haghorti Martuni Normal
Center for Health Services Research and Development, December, 2003 15 Facilities assessed as having extreme need for renovation Matchkalashen Martuni high Aghabekalinj Martakert low Tbghlu Martakert low Nerkin Horatagh Martakert high Shahmasur Martakert normal Astghashen (SVA) Askeran high Lusadzor Askeran normal Khachen Askeran high Tsaghkashat Askeran normal Madatashen Askeran lowest Moshkhumhat Askeran lowest Rev Askeran low
All the above-mentioned facilities were in critical need of renovation and/or construction.
Room size: The mean size of rooms in village outpatient health facilities was 16.9 m2 with a range of 2-36 m2. According to the standards used during this assessment, a FAP examination/ procedural room was considered as having satisfactory size, if the size was more than 12m2. Among 130 assessed, 18 FAPs were identified as having only one room with a size of 12m2 or less. The vast majority of these facilities were non-renovated (Table 3).
Table 3. FAPs having only one room with a size of 12m2 or less
Name of FAP Region Renovation Workload status Aghabekalinnj* Mardakert no Low Khnkavan Mardakert yes Low Mingrelsk Mardakert no Low Shahmasur* Mardakert no Normal Dahrav* Askeran no (assessed as) Low Tblghu* Mardakert no Low Tsaghkashen Mardakert no (assessed as) Normal Vardadzor Mardakert no Low Paravatumb* Martuni no Low Madatashen* Askeran no Lowest Mkhitarashen Askeran no Lowest Moshkhmhat* Askeran no Lowest Nakhijevanik Askeran no Normal Nerqin Szneq* Askeran no (assessed as) Low Jraghatsner Askeran no Low Qrasni Askeran no Low Rev* Askeran no Low Tsaghkashat* Askeran no Normal * These facilities are mentioned also in the above listings of those in urgent need of renovation
These undersized facilities should also be included in the renovation list with priority given to those with higher workload.
Center for Health Services Research and Development, December, 2003 16
Type of rooms: Rooms were analyzed also by type. In most village outpatient health facilities different services were provided in the same room because of limited number of rooms in facility. The most common type of room in a village outpatient health facility was examination/ procedural room. Of all assessed, a laboratory room was found in 2 SVAs. Unlike this, a labor/delivery room was found in 9 out of 15 SVAs, while according to the RA standards, the latter is not a requirement for village ambulatory services.
Natural lighting: Natural lighting of the rooms was analyzed using existing standards of proportion of glazing material in the window (on outside wall) not less than one-tenth of the floor area7. Satisfactory lighting of the rooms was observed in 64.4 % of rooms in village outpatient health facilities.
Lavatory/water supply/sewage system: According to the existing standards, all the village heath posts should have indoor toilets and hand washing stations with running water connected with sewage system8. There was no indoor toilet station in 94.6 % of village outpatient health facilities. Only 7 (5.4 %) health facilities (all SVAs) had renovated indoor toilets with sewage system. Running water was available in 13 health facilities (10 %), out of which only 8 had 24hour/day water supply. Pit latrines were found in 65 village outpatient health facilities (50.0 %), all situated outdoor. Only 3 pit latrines had running water, hence sewage system. Mean distance of pit latrine to water source was 147.4 m with a range of 0-900m. Out of 65 facilities having no toilet or pit latrine, 37 (56.9%) were renovated after 1999, mainly by ICRC (24 facilities) and need that specific renovation.
Hand washing stations were found in only 46.9% of village outpatient health facilities, out of which 78.7 % were situated indoor, and 54.8 % were renovated. Running water was found in 23.0 % of available hand washing stations. There was no hand washing station in four village ambulatories: Berdashen, Gishi, and Norshen in Martuni and Astghashen in Askeran. The mean distance of hand washing stations to water source was 69.2 m with a range of 0-600m. Of the 69 facilities having no hand washing station, 25 (36.2%) were renovated after 1999, again mainly with ICRC support (12 facilities).
According to the existing standards5, all those facilities having delivery rooms should be installed with shower facilities. However, shower facilities, all with sewage system, were installed in only 5 SVAs (Karmir shuka and Sos in Martuni, Azokh, Mets Taghlar, and Tumi in Hadrut). All these facilities were renovated either by ICRC, CRS, Family Care or two of the mentioned.
Electricity: A 24-hour electric supply is a standard requirement for all types of health facilities5. Of 130 villages, one (Aygestan, Hadrut) had no electricity at all. There was no electricity in 9 FAPs (6.9 %), although their villages had electric supply. Of these 9 facilities, one was renovated fully (Khramort in Askeran), another partially (Kherkhan in Martuni). The remaining 7 facilities were among non-renovated (Avdur and Karvin in Martuni, Varnkatagh or Hakob Kamari in Mardakert, Sarnaghbyur, Khancq, Hilis, and Hovsepavan in Askeran). All the other facilities (excluding those 10 with no building) had unrestricted (24hour/day) electric supply.
Center for Health Services Research and Development, December, 2003 17 Heating: Of all village outpatient health facilities, 89.2 % were heated during winter. Out of them, 88.8 % used combustion room heaters with flue. The vast majority of village outpatient health facilities (85.3 %) heated only one room during winter.
Scoring for renovation needs: To make the renovation needs as objective and measurable as possible, a scoring system was created. The following criteria was applied when calculating summative renovation need score: · Facilities assessed as non-renovated were assigned a score 2 · Facilities with destroyed or non-useable buildings were assigned a score 3 · Facilities assessed by the assessors as having extreme need for renovation were assigned a score 2 · Facilities lacking a dedicated space were assigned a score 3 · Facilities having only one room with a size 12m2 or less were assigned a score 1 · Facilities with no electricity supply were assigned a score 1
If several of above mentioned criteria existed in one facility, a sum of the scores was calculated for that facility, with higher summative scores indicating higher renovation need.
Although the existence of a hand washing station and indoor toilet are crucial characteristics for health facilities, the absence of these items was not considered in calculating the summative score on renovation needs. The reason for this was that these commodities were universally missing and thus, added no information to the scoring system. The summative renovation scores are provided in Appendix 4.
3.1.3 Furniture
The existence of the following furniture items in each room and in a facility as a whole was observed: sink with running water, desk, chair, medical cabinet, cabinet for instruments, examination beds, beds, bedside tables, cabinets for cloths, screen, swaddle table, procedural table (glass), and telephone. The furniture items included in the assessment tool were taken from existing listings of necessary furniture for primary health care services, the most important of which was considered the Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment and furniture for health services in RA The number and the appropriateness/functioning of each item was estimated and only those in satisfactory working status included in the furniture totals.
The data gathered through this item were utilized in two ways: a total furniture score was calculated for each facility as an indicator for its need to be furnished/supplied, and an inventory of existing furniture in proper state was developed for each facility to serve as a guide when selecting items to furnish the facilities.
To calculate the furniture score, the number of each type of existing furniture in good working state was considered along with the weight assigned to each type of furniture in accordance with its importance for ambulatory functioning whit higher weight indicating higher importance (Table 4).
Center for Health Services Research and Development, December, 2003 18 Table 4: Weights assigned to each type of furniture in FAPs/SVAs
Type of furniture Weight 1.Sink with running water 4 2.Desks 2 3.Chairs 1 4.Med. cabinets (glass) 2 5.Cabinets for instruments 2 6.Exam. Beds 3 7.Beds 1 8.Bed tables 1 9.Cabinets (for cloths) 1 10.Screen 1 11.Swaddle table 1 12.Procedural table (glass) 2 13.Telephone 3
For each furniture type, the number of items (excluding those assessed as inappropriate) in the health post/ambulatory was multiplied with the weight assigned to the item. The summative furniture score was computed through simple summation of these numbers for all types of furniture listed above. After calculating the weighted summative score for each FAP/Village Ambulatory, the facilities were categorized into 5 groups according to the range of summative furniture scores.
The group numbers for furniture were reversed so that the higher numbers reflected higher need. For some FAPs, the Summative Furniture Score was equal to 0. These were those FAPs having no building.
The ranges for the Summative Furniture Score were as the following:
Furniture score range Group Indicating: < 4 5 Highest need 5-10 4 High need 11-20 3 Normal need 21-30 2 Low need >31 1 Lowest need
The furniture scores for each assessed facility were incorporated in the per-facility summaries provided in Appendix 5. Also, Appendix 6 provides scores on furniture and equipment needs and workload scores for each FAP/SVA.
3.1.4 Equipment
The equipment items included in the assessment tool were taken from the RA standard listings of equipment for primary health care services (Decision of the Government of RA # 1936 on December 5, 2002 concerning the required standards of equipment and furniture for health services in RA). The number and the appropriateness/functioning of each item were considered and only those in satisfactory working status were included in totals for equipment.
Center for Health Services Research and Development, December, 2003 19 As with the furniture, the data gathered through the equipment item were utilized in two ways: a total equipment score was calculated for each facility as an indicator for its need to be equipped, and an inventory of existing equipment in proper state was developed for each facility to serve as a guide while selecting items to equip/supply the target facilities.
To compute the Equipment Score for each assessed FAP and Village Ambulatory, the equipments/supplies listed in the Village Outpatient Questionnaire were considered. Some of the items (mainly disposables) were recoded so that a score 1 was assigned to the item if it was found in the facility (for some items, in a sufficient quantity) and a score 0 if the item was absent (or, for some items, its quantity was insufficient) (Table 5).
Table 5. Recoding criteria for disposable items included in Summative Equipment Score
Name of items Ranges Scores Infusion set & IV cannula 2 or less 0 3 or more 1 Disposable syringes/needles 10 or less 0 11 or more 1 Non-disposal syringes/needles 2 or less 0 3 or more 1 Spatula (metal) absent 0 present 1 Spatula, wooden (boxes) absent 0 present 1 Gauze masks absent 0 present 1 Surgical thread (boxes) absent 0 present 1 Tube (nasogastric) absent 0 present 1 Surgical needles absent 0 present 1 Subject glasses absent 0 present 1 Bandages 2 or less 0 3 or more 1 Elastic bandages absent 0 present 1 Medical cotton wool absent 0 present 1 Tape, adhesive 2 or less 0 3 or more 1 Gloves, surgical, sterile absent 0 present 1 Examination gloves absent 0 present 1
Center for Health Services Research and Development, December, 2003 20
For the remaining items (mainly equipment) listed in the questionnaire, the revealed quantity of each was considered when calculating the Summative Equipment Score, unless the item was in poor working state. Also, a weight was assigned to each of these items in accordance with their value/importance for ambulatory functioning (Table 6). The weight of each item was then multiplied by its revealed quantity (excluding those being in inappropriate working state). The result was considered as a score for each particular item.
Table 6. Weights assigned to equipment for computing Summative Workload Score Item Name Weight Item Name Weight Stethoscope 2 Tweesers (pincers) 1 Sphygnomanometer 4 Scissor 1 Thermometer 1 Forceps 1 Refrigerator 4 Scalpel 1 Cold Chain Igloo 3 Scalpel holder 1 Tongue holder 1 Tray for instruments 1 Height measurer–child 3 Needle holder 1 Height measurer– adult 3 Used instruments’ tray 1 Scale – child 4 Instrument cleaning jar 1 Scale – adult 4 Gynecological chair 2 Measure tape 1 Gynecologic. mirrors 1 Timer 2 Packer curved 1 Medical tourniquet 1 Kocher 1 Steriliz. cylinders (bixes) 2 Folkman spoon 1 Steriliz. boxes (for 2 Obstetrical stethoscope 2 instruments) Dry sterilization (for 4 Medical splints 3 dressing material) Autoclave 4 Stretchers 3 Sharp disposal 1 Myuso forceps 1 Dental set 3
A Summative Equipment Score was calculated through simple summation of scores of all items (recoded and non-recoded). Thus, the recoded items had 0 or 1 score while the score for non- recoded items varied depending from the weight assigned to the item and its quantity found in an acceptable working state.
The ranges for equipment were also reversed so that the higher ranges reflected higher extent of need in equipment. The ranges for the Summative Equipment Score were set as the following:
Equipment Score range Group Indicating: < 15 5 Highest need 16-30 4 High need 31-45 3 Normal need 46-60 2 Low need >61 1 Lowest need
Center for Health Services Research and Development, December, 2003 21
For only three FAPs (Karvin in Martuni Region, Vardadzor and Verin Szneq in Askeran Region) the Summative Workload Score was not possible to identify, because these FAPs had either no building (Vardadzor and Verin Szneq) or the building was not utilized due to its poor condition (Karvin). These facilities were placed in the highest need category.
3.1.5 Workload
To prioritize the needs of village health posts (FAPs) and village ambulatories (SVAs) in renovation, furniture, and equipment in accordance with their current condition and the degree of workload they have, some items in the assessment instrument were integrated in scores indicating the workload for each assessed facility.
To determine the summative Workload score, the following indicators were calculated for each facility/community it serves based on particular items in the assessment tool (numbers of which are mentioned in parenthesis next to each indicator):
· # of villages served · # of population served · mean birth rate during 2000-2002 per 1000 served population · mean death rate during 2000-2002 per 1000 served population · mean under 5 death rate during 2000-2002 per 1000 under-5 children served · rate of ambulatory visits during 2002 per population served · rate of home visits during 2002 per population served · number of referrals to other health facilities during 2002 · number of hospitalizations during 2002 · mean rate of pregnancies during 2000-2002 per 1000 served population · # of FAP/SVA deliveries during 2000-2002 · # of home deliveries during 2000-2002 · # of adverse pregnancy and/or birth outcomes during 2000-2002
The next step was setting ranges for each indicator and assigning scores to these ranges so that the range indicating lower workload receives lower score while the one indicating higher workload receives higher score. In general, the mean value for each indicator (or the quartile) served as a cut-off point for setting ranges. The scores to each range were assigned in accordance with the weight assigned to that indicator. The weights, ranges and scores for each indicator are provided in Table 7.
Table 7. Weights, ranges, and scores for indicators comprising Summative Workload Score
Name of indicator Weight Ranges Scores Number of villages served 1 one 0 2 or more 1 Number of population served 3 90 or less 0 91-180 3 181-360 6 361-540 9
Center for Health Services Research and Development, December, 2003 22 Name of indicator Weight Ranges Scores 541-750 12 751 or more 15 Mean birth rate during 2000-02 per 1000 1 25.0 or less 0 served 25.1 or more 1 Mean death rate during 2000-02 per 1000 1 15.0 or less 0 served 15.1 or more 1 Mean under-5 death rate during 2000-02 1 13.6 or less 0 per 1000 served 13.7 or more 1 Rate of ambulatory visits during 2002 per 1 2.97 or less 0 population served 2.98 or more 1 Rate of home visits during 2002 per 1 1.72 or less 0 population served 1.73 or more 1 Number of referrals to other health 1 23 or less 0 facilities during 2002 24 or more 1 Number of hospitalizations during 2002 1 10 or less 0 11 or more 1 Mean rate of pregnancies during 2000-02 1 18.88 or less 0 per 1000 served 18.89 or more 1 Number of FAP/SVA deliveries during 1 3 or less 0 2000-2002 4 or more 1 Number of home deliveries during 2000-02 1 2 or less 0 3 or more 1 Number of adverse pregnancy/birth 1 1 or less 0 outcomes during 2000-02 2 or more 1
A Summative Workload score was computed for each facility through simple summation of the scores of its indicators. For all assessed village ambulatory facilities, the mean Workload Score was 9.48 (SD 4.75) with a range of 1-21. All the assessed facilities were divided into five groups based on their Workload Score. The facilities with the highest workload (score >16) were assigned to group 5, those with the lowest workload (score <3) were assigned to group 1. The ranges for the Summative Workload Score were as the following:
Workload Range Group Indicating: <3 1 Lowest workload 4-7 2 Low workload 8-11 3 Normal workload 12-15 4 High workload >16 5 Highest workload
Thus, the higher the Workload group number of the facility, the more priority should be given to that facility during future intervention, given that other characteristics of the facility are similar to that of others.
Center for Health Services Research and Development, December, 2003 23 The following indicators of population dynamics and health status provide details that creates general impression of the health of the population served by these facilities.
Number of villages served: Most village outpatient health facilities served only one village (91.5%).
Size of population served: The size of population served by a PHC facility varied widely, with a mean of 358 and a range of 28-2375. On average, the number of population served by a SVA was 3.4 times more than that served by a FAP (961 vs. 280).
Age distribution of population served by PHC facilities: The assessment tool gathered information on the following 4 age groups: 0-12 months, 1-4 years, 5-14 years, and 15 years and over. The following figure displays age distribution of the rural population of NK served by PHC facilities (outpatient and inpatient) showing that children of all age groups constitute only one fourth of that population (Figure 2).
Figure 2. Age Distribution of Rural Population served by PHC facilities, NK, July-August, 2003
1-12 months 2% 15 years and 1-4 years over 6% 76%
5-14 years 16%
Population dynamics: The birth rate of population in villages (mean for the years of 2000-2002) was 17.56 per 1000 population (much higher than the birthrate in Armenia: 8.4 for 2001). The mean death rate for the same period was 9.92 per 1000 population (6.3 in Armenia for the year of 2001). Thus, with an assumption that emigration and immigration rates were equal, the natural growth in rural population of NK could be estimated as 7.64 per 1000 population (compared to 2.1 in Armenia for 2001).
The infant death rate among surveyed population (average for 2000-2002 years) was 15.2 per 1000 life births (15.4 in Armenia for 2001). The under 5 death rate (average for the same period) was 19.57 per 1000 life births or 4.12 per 1000 under 5 population. No maternal deaths among population served by the assessed facilities were registered during 2000-2002. Generally, these indicators are similar with that in Armenia and somewhat higher than the WHO goals set for 2000: to reach infant mortality rate of 12.3 and under-five mortality rate of 15.9.
Center for Health Services Research and Development, December, 2003 24 Utilization of health services: According to the records made in journals of home visits and ambulatory visits, infants were seen by a provider 18.7 times per year, children (under 15) 4.1 times per year (range 0.2-15.0), and adults 4.5 times per year (range 0.4-22.3). On average, the mean number of visits per person for general population was 4.69, including 1.72 home visits (sd 1.5) and 2.97 ambulatory visits (sd 2.1) per person per year. Figure 3 displays the mean number of visits per person for 3 defined age groups.
Figure 3. Mean Number of Visits per Person at theVillage Outpatient Health Facilities, NK, 2002
20 # of 18 visits 16 14 12 10 8 6 4 2 0 0-12 months 1-14 years old 15 years and over
Age groups
Although the number of visits per served infant was the highest, the percentage of infant visits out of all visits was the lowest (7.0 %), since infants comprised the smalest age group. The following figure shows proportions of visits made by PHC providers to each age group (Figure 4). Data did not allow assessing the individual level access to the services.
Figure 4. Proportions of Visits to the Village Outpatient
Health Facilities by Age Groups, NK, 2002
0-12 months 7% 15 years and over 72%
1-14 years 21%
Center for Health Services Research and Development, December, 2003 25 School visits: As a rule, health providers visited schools 1-2 times per month during the whole academic year (9 months) and examined all eligible children present in school at the time. The mean number of school visits made by a PHC provider during 2002 academic year was 19.9 with a range of 6-66. Of all examined children, 6.6% were identified as suffering from pediculosis and/or scabies.
Referrals to other health facilities: During 2002, the mean number of infants referred from a FAP to another health facility was 3.3 (6.5% of all visits made in this age group). For children aged 1-14 this number was 6.5 (3.9% of all visits for this age group) and for adults (15 and over) 12.9 (1.9 % of all adult visits). However, these figures varied largely (up to 10 times) between different FAPs.
Hospitalizations: During 2002, the mean number of hospitalizations among infants referred from a FAP to other health facilities was 1.2 (36.4% of the referrals), for children aged 1-14 this number was 3.5 (53.8% of the referrals), and for adults 5.1 (39.5% of all referrals for adults). According to assessors, patients sometimes applied directly to secondary (regional or republican) health facilities, bypassing PHC level. Thus, the numbers provided here on referrals and hospitalizations could be underestimated.
Preferred referral sites: Of all respondents, only 29.2 % mentioned 3 preferred referral hospitals for children. The rest mentioned 1 or 2 health facilities where they usually referred their patients. The most frequently mentioned referral hospitals for children were the local central regional hospitals followed by the Republican Pediatric Hospital. This was the case with the PHC facilities located in Hadrut, Martuni, or Mardakert regions. As for the PHC services in Askeran region, in most cases they referred their patients directly to Stepanakert omitting the Askeran CRH, because of the closeness of former. Only 36.1 % of FAPs/SVAs in Askeran region mentioned referring their patients to Askeran CRH.
Out of all village outpatient health services, 71.5 % mentioned the CRH as the first or second preferred site for referring pediatric patients. This was followed by the Republican Pediatric Hospital, mentioned by 68.5 % of facilities as the first or second preference for pediatric referrals. The third referral sites were nearby SVAs or SUBs, such as Aknaghbyur SVA, Getavan SUB, Sos SVA, etc.
The picture for the preferred referral sites for adults was similar to that for children. In Mardakert, Martuni and Hadrut regions the vast majority of respondents stated their CRHs as the first referral choice, followed by the republican facilities such as Republican Hospital, Stepanakert Polyclinic, Republican Diagnostic Center, etc. Overall, out of all village outpatient health facilities 66.2 % referred their patients to their CRHs first. Out of all assessed, 26.9 % of PHC services did not refer their patients to any republican health facility, but their neighboring health facilities, including military hospitals.
The frequency of mentioning republican health facilities as top referral centers was the following: Republican Hospital was mentioned in 53.1 % of cases, Republican Diagnostic Center in 32.0%, Stepanakert City Polyclinic in 10.2 % (Figure 5).
Center for Health Services Research and Development, December, 2003 26 Figure 5. Main Referral Clinics/Hospitals at National Level for Adults, Frequency of Being Mentioned by Village Outpatient HFs, NK, July- August, 2003
Republican Diagnostic Center 32% Stepanakert City Polyclinic 10% Republican Maternity House 2% Others 3%
Republican Hospital 53%
Top three diagnoses/reasons for referral: Diarrhea (63.1%), respiratory diseases (53.8%), and high fever (25.4%) were mentioned as the top three reasons for referring children to other clinics/hospitals. Traumas (16.9%) and infectious diseases (13.1%) were among other frequent reasons for referrals.
Top three diseases for referral for adults were cardio-vascular diseases (87.7 %), urinary tract diseases (20.8%), and arthritis (18.5 %). Among other frequently mentioned conditions were gastro-intestinal diseases (17.7%), diabetes mellitus (15.4 %), traumas (15.4%), and surgical diseases (14.6 %).
Immunization coverage: The purpose of this item was identifying possible deficits in vaccine supply through comparing doses of vaccines administered to 0-24 month old children during 2002 with that planned to be administered. The analysis showed that there was practically no deficit of Hepatitis B, DPT, Polio, Measles, and BCG vaccines. The proportion of administered doses out of planned was 79.2% for Hepatitis B; 98.0% for DPT; 98.3% for Polio; 98.1% for measles; and 100% for BCG. The slight inconsistency found between planned and administered doses of these vaccines was explained by medical contraindications to vaccination rather than vaccine deficit. The situation was different with Mumps vaccine. Because of its shortage, only a small proportion (4.8%) of planned doses was administered during 2002.
Among other vaccines/anatoxins needed, the most frequently mentioned items were antitetanus anatoxin (60 %), snake antivenom serum (29.2%), rabies vaccine/immunoglobulin (17.7 %), and DT -M vaccine (9.2 %).
Pregnancies/deliveries: Selected indicators on pregnancy/delivery services and outcomes were identified through gathering data for the last three years (2000-2002). The mean pregnancy rate per 1000 population served by the assessed PHC facilities was 18.9 (sd 8.57). The mean number of prenatal visits of pregnant women to the assessed facilities was 5.6 with a range of 1.0-18.0.
Center for Health Services Research and Development, December, 2003 27 However, all pregnant women were referred to secondary level facilities (mainly CRHs) for laboratory tests and consultations at least once during the pregnancy (mean 1.3; range 1-12.0).
The mean number of home deliveries during 2000-2002 was 0.69 per facility (sd 2.397, rage 0- 20). Of all facilities, 75.8% did not mention any home deliveries during this period, and 21.7% mentioned only 1-3 home deliveries. Only two outliers mentioned high number of home deliveries: Sos SVA in Martuni (20) and Khndzristan FAP in Askeran (16).
The mean number of deliveries in PHC facility was 3.2 (sd 9.4, range 0-73). Again, 75.2% of questioned did not mention any delivery in their settings during 2000-2003. High numbers of home/FAP deliveries (over 8 during the last three years) took place in 9 out of 15 SVAs and in 7 FAPs (Taghvard, Kolkhozashen, Matchkalashen, Sargsashen, Qert in Martuni, Ghazanchi in Martakert, and Hakaku in Hadrut).
The three-year (2000-2002) average rate of abnormal birth outcomes (premature birth, stillbirth, spontaneous abortion, neonatal death) per 1000 deliveries was 30.8 among the rural population served by the assessed facilities. This indicator is also similar with that in Armenia.
Medical records: Medical charts were not used in 22.5% of assessed PHC facilities. In 94% of those facilities using medical charts, less than 40% of served population (mainly children) had charts. Almost always (in 96.3% of cases) non-standard forms were used for medical charts.
Unlike the charts, journals for ambulatory visits were present in 95.4% of assessed facilities, journals for home visits in 75.4%, and immunization forms in 93.1%. The vast majority of pre- school-age children (88.4%) had immunization forms. The completeness of information recorded in these forms was assessed by assessors as generally satisfactory.
Transportation/roads: Of all facilities, 36.2% mentioned that there is no public transportation to Stepanakert, and 57.7% mentioned that there is no public transportation to the regional center. Only 4 respondents (3.1%) mentioned the availability of CRH ambulance for transporting patients to Stepanakert and only 11.5% mentioned CHR ambulance availability to transport patients to the regional center. In more than 70% of cases, there was no available public transportation connecting the facilities to nearby villages or the closest health facilities.
The roads to Stepanakert were characterized by respondents as “bumpy dirt or large holes dirty” in 73.7% of facilities. The roads connecting these facilities to the regional center or the closest village were characterized in the same way in 69% and 70.5% of cases respectively.
The mean distance from the assessed health facilities to the regional clinic was half that to Stepanakert (29.3km [range: 2-80) vs. 57.1 [range: 6-210]). The mean distance to the closest village was 4.1km (range: 5-15), and to the closest health facility where patients can be referred 8.4km (range: 1-65km).
The mean price of the bus (wherever is available) to Stepanakert was 548 AMD (range: 70- 1500), to the regional center 472 AMD (range: 60-3000), to the closest village 109 AMD (range: 30-600) and to the closest health facility 217 AMD (range: 50-1000). The mean prices of the bus
Center for Health Services Research and Development, December, 2003 28 to Stepanakert, regional center, closest village and closest health facility by each region are provided in Table 8. As it is evident from the table, the highest prices for transportation are in Hadrut region, exceeding others by 1.5-3 times.
Table 8. Mean bus prices by NK regions (in AMDs) Regions Stepanakert Regional center Closest village Closest facility Shushi 505 353 50 60 Hadrut 929 978 240 372 Askeran 298 163 75 152 Martuni 638 336 50 100 Mardakert 722 394 80 187
The main sources for drug supply: Regional governments were cited as the main source for FAPs/SVAs drug supply. They allocated finances to 76.6% of facilities to purchase drugs. By the frequency of being cited, ICRC was the next organization assisting with drugs 46.9% of the facilities. The NK Ministry of Health was reported as a source of drug supply by 25.6% of the facilities. Family Care was mentioned by 10.9% of them.
In terms of the percentage of needs covered by the drug delivery source, the first place was given to ICRC, which covered the needs of beneficiary PHC facilities by 55.1% in average. Family Care was the next covering the drug needs of beneficiaries by 25.9% in average. The local Governments and the NK Ministry of Health had much lower coverage of needs: 12.9% and 15.9% respectively.
The following types of drugs were mentioned most frequently as delivered or purchased through the help of the above-mentioned sources: first aid preparations, antibiotics, analgesics, hypotensives, spasmolitics, cardiac drugs, dressing material.
3.1.6 Findings on drug availability/use and principles of developing the list of recommended drugs to be supplied to PHC facilities of NK
As mentioned previously, an Essential Drugs List (EDL) for Primary Level was developed and used to assess the status of PHC facilities in terms of drug supply and the existing need in drugs. The following main principles were applied in developing this initial list of drugs: · The EDL list was developed based on IMCI and ADM algorithms Unlike the IMCI algorithm, which was introduced by WHO more than 10 years ago and practiced worldwide, ADM was developed by the local specialists of NK and introduced recently. One of the lessons learned since the introduction of the latter was that the range of drugs provided by ICRC was not enough to manage on primary level the five adult diseases included in the ADM. Hence, specialists involved into development of ADM offered to enlarge the existing list of drugs with several medications essential to providing qualified ADM care at PHC level. · Some drugs, such as No-Spa, Analgin, Dimedrol, Papaverin, etc. were also included in the EDL as the most commonly used preparations.
Center for Health Services Research and Development, December, 2003 29 The final list consisted of 99 drugs (Appendix 3). This list of drugs was used for both assessing the situation of PHC facilities in terms of drug supply/usage and estimating the extent of need for each drug included in the list, so that a short list of the most essential drugs can be developed and recommended as a regular supply to NK PHC facilities.
The EDL-based assessment instrument contained 3 questions measuring (1) the presence of the given drug in the facility at the time of assessment, (2) its needed quantity per month, and (3) the perceived degree of its necessity. The perceived degree of necessity of each drug was mainly considered for developing the short list of drugs for regular supply, since the answers to the second item (the needed quantity per month) were not reliable because of their subjective/ judgmental character and dependence on facilities current patient flow. As to the first question, the presence of a given drug mainly indicated that the facility was supplied with that drug recently, but was not informative in terms of the extent the drug was needed.
The drugs were divided into 4 categories in terms of their necessity: low (0-100 score), normal (100-150 score), high (150-200 score), highest (score 200 and over). These scores were simply calculated by summing up the necessity column for each drug (Appendix 7). Priority was given to those drugs with higher levels of necessity. In many cases, however, respondents found some drugs from the core list of medicines of IMCI and ADM unnecessary as a result of lack of training on these topics. For this reason, the IMCI and ADM core drugs were included in the recommended short list of drugs despite the results of the analysis and need for training/ retraining noted.
Another principle underlying the process of selecting drugs to be included in the short list was choosing only one representative of the same group of medications. Priority was given to the drug with the highest necessity score among those medications belonging to the same group. For instance, Dexamethasone was chosen among steroid hormones, and Ibuprofen among non- steroid anti-inflammatory drugs, since these items had the highest necessity scores in their groups and were cost-effective.
Some preparations were included in or excluded from the list for some specific reasons: · Chloroquine and Primaquine (antimalarial drugs) were excluded because of low demand, · Analgin, Dimedrol, No-Spa, Dibasol, and Papaverin were the most widely used drugs in PHC facilities, so they were included in the list, · Coffein, Cordiamin, Sulfocamphocain were the drugs widely used in urgent cases, so they were also included, · Magnesii Sulfas was the only option for hypertension disorders during pregnancy (pre- eclampsia, eclampsia) and so was included in the final list, · Oxytocin was also included as a drug of the only choice in obstetrical and gynecological practices, · Albucid was included as the only proposed antibacterial eye drop for neonates to prevent gonoblenorrhea, · Furadonin was included as the most cost-effective drug for urinal tract infections, while Furazolidone as an antihelmintic and antiprotozoal drug for alimentary tract.
Center for Health Services Research and Development, December, 2003 30 Out of 99 drugs included in the initial EDL and tested for necessity, 48 were selected for the final recommended drugs list (a long with some disposables) to be supplied to PHC facilities of NK (Appendix 8).
3.2 Village District Hospitals
As revealed during the assessment of the four village district hospitals (or so called SUBs), these facilities combined the functions of inpatient and outpatient primary health care services. Also, considerable part of their workload was connected with ante- and perinatal care (care for pregnancies and deliveries).
Figure 6. Mean Numbers of Population Served by Different Types of Health Facilities, NK, July-August, 2003
2750 2500 2250 2000 1750 1500 1250 1000 750 500 250 0 FAP SVA SUB
Types of health facilities
The outpatient component of their work was similar to that of FAPs/SVAs. However, unlike the village outpatient services, all the SUBs had physicians in their staff, which gave them more flexibility in addressing the health care needs of population they serve. The mean number of occupied physician’s positions in the assessed SUBs was 3.1 with a range of 2.0 – 4.25. The mean numbers of other occupied positions were like the following: 6.5 nurses (range: 3-8.5), 2.1 midwifes (range: 1-3.5), 0.5 lab assistants, 0.25 feldshers, and 3.0 sanitars.
All the assessed SUBs had their own served population, meanwhile serving as referral places for the nearby FAPs/SVAs. The mean number of core population served by SUBs was 2470.5 (range 1373-3920), which considerably exceeded that for FAPs (279.8) and SVAs (960.7) (Figure 6).
The detailed summaries of findings for each assessed SUB are provided in Appendix 5. In this chapter, some of the main findings that may help to create an overall impression of the physical status, equipment/supplies and workload of these services will be discussed.
3.2.1 Physical status of the buildings:
Of all assessed SUBs, three (Haterk, Getavan, and Hanq in Mardakert) were recently (since 2000) renovated. Only Vanq SUB was renovated partially (maternity and outpatient units and sewage system). Outpatient units of SUBs were renovated by ICRC, maternity/reproductive units by Family Care, and sewage systems by CRS. The fourth SUB (Chartar in Martuni) with a huge
Center for Health Services Research and Development, December, 2003 31 building consisting of 56 rooms of which less than half were in use, was renovated in 1996 by the local administration. However, the assessors assessed as satisfactorily renovated all the utilized rooms. Unlike this, the Haterk SUB, despite being recently renovated, had 2 patient and 8 non-patient rooms needing cosmetic renovation because of peeling plaster. All other rooms in use in the assessed facilities were assessed satisfactory in terms of renovation.
Unlike village outpatient health facilities, all four village inpatient health facilities had clinical laboratories. Also, all the SUBs had delivery rooms. There were separate procedural rooms in two SUBs, the rest 2 had no procedural rooms as such. Instead, the night nursing rooms served as procedural rooms besides their direct purpose. Antenatal care units were observed in all SUBs. There were separate pediatric examination rooms in two SUBs and a separate therapeutic examination room in one SUB.
The mean number of utilized rooms in the assessed facilities was 13.3 with a range of 7-26. The number/state of patient and non-patient rooms (in use) was assessed separately. The mean number of patient rooms in village inpatient health facilities was 6 with a range of 2-16. On average, there were 3.2 beds in each patient room (range of 3-5). The mean size of patient rooms was 14.3m2 with a range of 9-28. Out of all patient rooms the size of 2 (both in Chartar SUB, Martuni) was charged as unsatisfactory (3 beds in a 9m2 room) taking into consideration the applied standards9. The natural lighting of patient rooms was satisfactory in 72.7 % of cases (according to the applied standards). The mean number of non-patient rooms in the assessed SUBs was 7.25 (range 4-10). Only 64.0% of them met the applied standards in terms of natural lighting.
All of the assessed facilities had sewage system, but only one of them, namely Haterq SUB had 24 hours/day running water supply. Out of all 4 SUBs only in Getavan SUB the facility had no indoor toilet. Outdoor pit latrines were observed in all 4 SUBs. No one of them had running water, but in Vanq SUB there was sewage system in pit latrine. The mean distance of pit latrines to water source was 68.8 m with a range of 25-100.
There were hand washing stations in 3 SUBs, let alone Chartar SUB. All of them were located indoor. Shower facility was observed in 2 SUBs (Haterq and Vanq). Both of them were renovated.
In all 4 SUBs, electricity was available 24 hours/day. The primary heating source in all 4 facilities were room heaters with flue. The mean number of rooms heated during wintertime in the facility was 6.0 with a range of 4-8.
3.2.2 Furniture/equipment/supplies
Furniture/equipment of patient rooms in village inpatient health facilities was analyzed in mean numbers for several items. The figure for beds was obtained for each village inpatient health facility on the whole, as well as for each patient room separately. The mean number of beds in each patient room was 3.2 (range 3-5), whereas the same indicator for each SUB was 8.75 (range 6-11). Mean numbers of the rest of furniture items that were assessed in each patient room, as
Center for Health Services Research and Development, December, 2003 32 well as the percent of inappropriate items out of all available ones are presented in the table below (Table 9.).
Table 9. Mean numbers of items in each patient room and percent of inappropriate items in village inpatient health facilities, NK, July-August, 2003 ¹ Name of item Mean # (range) % of inappropriate 1. Running water sink - - 2. Beds 8.75 (6-11) 8.6 % 3. Bed tables 4.25 (2-6) 70.6 % 4. Tables 0.75 (0-2) 100.0 % 5. Chairs 2.75 (0-11) 45.5 % 6. Folding screen - - 7. TV - - 8. Armchair/sofa - - 9. Refrigerator - - 10. Heater 0.50 (0-2) 0.0 % 11. Electrical outlets 1.75 (0-4) 71.4 % 12. Toilet (private) - - 13. Shower (private) - - 14. Telephone - -
Such luxury/convenience items as a sink with running water, toilet, shower, TV, telephone, refrigerator, folding screen, armchair/sofa or others were observed in no one patient room.
Furniture/equipment of non-patient rooms in village inpatient health facilities was also analyzed in several items. Particularly, sink with running water which is of crucial need for inpatient health facilities, was not observed in the 92.9% of all non-patient rooms in village inpatient health facilities. The rest of items were analyzed by mean number of items in the facility, percentage of inappropriate items out of all available, and percent of the rooms having the item. The results are shown in the Table 10.
Table 10. Furniture of non-patient rooms in village inpatient health facilities, NK, 2003 ¹ Items Mean # % of inappropriate % of rooms having the (range)* items** item 1. Running water sink 0.5 (0-2) 0.0 7.1 2. Desk 6.5 (5-8) 0.0 75.0 3. Chair 16.5 (12-21) 0.0 75.0 4. Medical cabinet 1.8 (0-5) 0.0 21.4 5. Instrument cabinet 3.3 (0-6) 0.0 39.3 6. Examination bed 4.0 (3-6) 0.0 57.1 7. Bed 2.3 (0-4) 22.2 14.3 8. Bed table 2.8 (0-7) 0.0 25.0 9. Cabinet for clothes - - - 10. Folding screen 1.0 (0-2) 0.0 14.3 11. Swaddle table 0.8 (0-1) 0.0 10.7 12. Procedural table 1.5 (1-3) 0.0 14.3 13. Telephone 0.8 (0-2) 0.0 7.1 * mean number of the item in facility ** percentage of inappropriate items out of all available
Center for Health Services Research and Development, December, 2003 33
As it is evident from Tables 9 and 10, non-patient rooms in the village inpatient health facilities were generally better equipped than patient rooms.
The assessment of the available equipment in the village inpatient health facilities showed lack of some important items and unequal distribution of some others resulting in excess amounts of those in some SUBs and deficit in others. For instance, there was no refrigerator, bactericid lamp, and height measurer (both child and adult) in Getavan hospital. Oxigen (cylinder or bag) was absent in Getavan and Haterk hospitals. Medical splints were present only in Vank hospital. No one village hospital had electrocardiograph or ultrasound. Meanwhile, several items were found in excess amounts in Chartar hospital (scalpels - 80, forceps, scissors, tweezers, gynecological mirrors - 20-30 each, etc.), while being rather few (1-2) in the other village hospitals. Almost all hospitals had some items in excess amounts showing that these items were supplied abundantly and rarely used (for instance, elastic bandages and examination gloves).
All the assessed village hospitals mentioned ICRC as one of the main sources of their drug supply covering 40% of their needs (range: 20-70). Family Care was mentioned as the second source by three out of four facilities (excluding Getavan) covering 32% of needs in drug supplies (range: 15-50). No one SUB mentioned the regional government as a source for drug supply. NK MOH was mentioned by three out of four facilities, but covered only a small proportion (5%) of their needs in drugs. Only Vank SUB mentioned a private organization (named “Artsakh Bishoprik”) helping them to cover 15% of their needs in drug supplies. Among the types of drugs provided by these sources first aid drugs, antibiotics, and dressing materials were mentioned most frequently.
Among crucial needs mentioned most frequently were running water supply, diagnostic equipment, equipment for clinical laboratory, drugs, and TV-set.
3.2.3 Workload
In general, the workload of village district hospitals was significantly higher than that of ambulatory services because of the higher numbers of population they serve, as well as the diversity of functions they provide through combining outpatient, inpatient, and maternity services, and serving as referral center for nearby FAPs.
The mean service indicators of village hospitals concerning their outpatient functions were almost similar with that of village ambulatory services. The numbers for 2002 were the following: mean # of infant visits per year: 20.9 (range 16.4-30.4), mean number of child (1-14 years old) visits per year: 5.1 (range 2.3-12.2), mean number of adult visits per year: 3.1 (range 1.3-7.3), mean number of general population visits per year: 3.8 (range 2.0-8.4), mean number of school visits per year by health providers: 25.5 (range 16-33).
The percentage of referrals from village inpatient health facilities to other health facilities was lower (1.1% of all visits) than that from village outpatient health facilities. The reason for this could be provision of health services by physicians in these facilities. The main reasons for children referrals from village hospitals were surgical diseases (since there was no surgical department in these hospitals), complicated cases of diarrhea or pneumonia, etc. The adults were
Center for Health Services Research and Development, December, 2003 34 referred to other health facilities only in the case of complicated diseases, when specialized help was needed, such as complicated oncological, surgical, gynecological pathology, and diabetes mellitus.
The immunization coverage of 0-24 month children served by these facilities was also similar with that in village outpatient services (for the year 2002, coverage with Hepatitis B – 66.7%, DPT – 99.4 %, polio – 100.0 %, measles 99.2 %, mumps – 0 %, BCG – 97.3 %). The lack of coverage by mumps vaccination was explained by the lack of vaccine. The same vaccines and anatoxins as in outpatient services were reported as needed (antitetanus anatoxine, snake antivenom serum, rabies vaccine, mumps vaccine).
Figure 7. Proportions of Deliveries in SUBs, Other Maternal Hospitals/Departments and Home, NK, 2002
Other Maternal Hospitals/ Departments 22,4% SUBs 77,0%
Home 0,7%
The mean number of prenatal visits per pregnant woman in village inpatient health facilities was 7.4 with a range of 3.0-14.9. Since all 4 SUBs had clinical laboratories and prenatal care services provided by physicians, pregnant women were referred to other health facilities for lab tests and consultations only in complicated cases. Overall, 166 pregnancies were registered in 4 village inpatient hospitals during 2002, out of which 152 gave deliveries. Only 22.4% of the pregnant women were referred to Stepanakert Maternity Hospital or maternity departments of CRHs to give deliveries. Figure 7 displays the proportion of deliveries given by women primarily served by village hospitals in SUBs, other referral centers and home during 2002.
The main indicators for inpatient services for 2002 were as follows: mean number of hospital beds: 11.25 (range: 10-15), mean number of occupied beds per day: 4.8 (range: 2.7-7.8), mean number of admissions per year: 176 (range: 106-236). The mean duration of patient stay across the assessed hospitals was 10 days. No cases of deaths were registered in the hospitals during last three years (2000-2002). During this period, only one patient was transferred to some other health facility.
The situation with medical record forms was much better in village hospitals when comparing with village outpatient services. All the assessed hospitals had medical record forms, journals for outpatient and home visits, immunization forms and annual report forms. The mean percentage
Center for Health Services Research and Development, December, 2003 35 of served population having medical charts was 59.3 in SUBs, while only 16.2 in FAPs/SVAs. The assessors assessed all the records as complete.
3.3 Central Regional Hospitals and Republican Dispensaries
3.3.1. Central Regional Hospitals
The cities of Askeran, Hadrut, Mardakert and Martuni each house a Central Regional Hospital (CRH). The main purpose of the CRH is to serve as the first referral level for the entire region and to provide primary care services at the secondary level. It is responsible for providing and/or supervising all the curative, preventive, and promotive health activities within its region. Each CRH has both outpatient and inpatient divisions and employs a staff of physicians, nurses, and sanitars. All have electricity 24 hours/day but have varying levels of water supplies. The following section will highlight key findings from the assessment. For greater detail regarding the field assessment findings for each CRH specifically see Appendix 5.
Population
The four CRHs each serve between approximately 11,700 and 22,300 people. The CRHs are the primary referral site for all of the inhabitants within each region, as well as both the primary source for outpatient care and referral site for the population within their respective city limits.
The population distribution among the four regions is fairly consistent, with Askeran having a lower percentage of children in the population and a higher percentage of adults in the urban population. The urban population stratified by age distribution, as well as the number of births, deaths and the total regional population are shown in Table 11 below:
Table 11: Population distribution for Askeran, Hadrut, Mardakert, Martuni, showing age (with percent of city population in parentheses for 2002), number of births and number of deaths as well as regional population totals
CRH Year 2000 Year 2001 Year 2002 Askeran Population: City of Askeran 2147 Infants - - 28 (1.3%) Children - - 373 (17.4%) Adults - - 1746 (81.3%) Births 32 22 28 Deaths 10 10 10 Total Regional Population - - 14,465 Hadrut Population: City of Hadrut - - 3008 Infants - - 52 (1.7%) Children - - 806 (26.8%) Adults - - 2150 (71.5%) Births 56 60 54 Deaths 36 23 31 Total Regional Population - - 11,712
Center for Health Services Research and Development, December, 2003 36 CRH Year 2000 Year 2001 Year 2002 Mardakert Population: City of Mardakert - - 3791 Infants - - 77 (1.9%) Children - - 902 (22.7%) Adults - - 2812 (70.8%) Births - 35 47 Deaths - - - Total Regional Population - - 19,652 Martuni Population: City of Martuni - - 4448 Infants - - 66 (1.5%) Children - - 1111 (25.0%) Adults - - 3271 (73.5%) Births 89 77 71 Deaths 34 19 40 Total Regional Population - - 22,287
Facilities
In Askeran, one unit (ECG) of the facility was renovated in 2000 by the regional administration. Unlike the other regions, the outpatient division of the CRH in Askeran has not been renovated. The CRH has one functioning vehicle, which is used for the general needs of the hospital. Electricity is supplied 24 hours/day, but there is no direct water supply. Although, there is an outdoor water tap that supplies water for two hours per day to the facility.
The facility in Hadrut was renovated in 2002 by the ICRC and in 2000 by Family Care; the renovated areas were the polyclinic and the maternity unit. The CRH has one functioning vehicle used for general hospital needs. Electricity and water are both supplied 24 hours per day.
The Mardakert facility was renovated in 2000 by Family Care and in 2001 by the ICRC; the renovated areas were also the polyclinic and the maternity unit. The CRH has two functional vehicles. Electricity and water are both supplied 24 hours per day.
The facility in Martuni was renovated in 1999 by the ICRC and in 2000 by Family Care; the renovated areas were again, the polyclinic and the maternity unit. The CRH has two vehicles for hospital general use. Electricity is supplied 24 hours per day, but water is only supplied 1 hour per day.
Outpatient Division
The CRH in Askeran has five outpatient units, which occupy a total of eight rooms. In Hadrut, there are nine outpatient units, which occupy 18 rooms. In Mardakert, the CRH has 10 outpatient units with 17 rooms and in Martuni there are 14 outpatient units, occupying a total of 22 rooms.
Center for Health Services Research and Development, December, 2003 37
Table 12: Outpatient division and number of rooms per unit in the CRH in Askeran, Hadrut, Mardakert and Martuni.
Division Askeran Hadrut Mardakert Martuni Women’s Consultation 2 rooms 1 room 1 rooms 4 rooms Primary Care 2 rooms 1 room 1 room 3 rooms Pediatrics 1 room 1 room 2 rooms 3 rooms Surgery 2 rooms 1 room 1 room 2 rooms Dermatology/STD - - 1 room - Pulmonary - 1 room - 1 room Infectious Disease - - - 1 room Immunization - 1 room 1 room 1 room Ophthalmology - - 1 room 1 room Neurology - 1 room - 1 room Psychology/Psychiatry - 1 room 1 room 1 room Dentistry 1 room 1 room 1 room 1 room Minor Procedures - 2 rooms 1 room 1 room Medical Record - 1 room 1 room 1 room Other - 6 rooms 5 rooms 1 room
Inpatient Division
Inpatient services are used to provide continuity of care to rural and urban populations in these four regions through an organized system of health care. Table 13 demonstrates the number of rooms in each of inpatient divisions of four CRHs.
Table 13: Inpatient division and number of rooms per unit in the CRH in Askeran, Hadrut, Mardakert and Martuni.
Division Askeran Hadrut Mardakert Martuni Medicine 5 rooms 7 rooms 13 rooms 20 rooms Pediatrics Yes 4 rooms 6 rooms 3 rooms Surgery Yes 10 rooms 15 rooms 15 rooms Infectious Disease - 13 rooms 19 rooms 21 rooms Gynecology/Obstetrics Yes 10 rooms Yes 11 rooms
Auxiliary Services: Diagnostic: Diagnostic: Diagnostic: Diagnostic: ECG X-ray X-ray X-ray Clinical Flurography Flurography Flurography Lab ECG ECG ECG Kitchen Physical Physical Physical Laundry therapy therapy therapy Medical Clinical Lab Clinical Lab Clinical Lab records Delivery Room Kitchen Kitchen Kitchen Laundry Laundry Laundry Medical Medical Morgue records records Medical Pharmacy Pharmacy records Admissions Admissions Pharmacy
Center for Health Services Research and Development, December, 2003 38
As it is evident from the table, the CRH in Askeran has five inpatient units, occupying a total of 11 rooms. In Hadrut, the CRH has four inpatient units and 66 rooms for inpatient care. In Mardakert, the inpatient division has four main units and several auxiliary units, which occupy 76 rooms. In Martuni, the inpatient division has four main units and several auxiliary units, occupying a total of 91 rooms. In all four hospitals, the inpatient units are in dire need of renovation.
Inpatient Utilization
Utilization of health care services in each of the four CRHs is critical in raising and maintaining the health status of the population. Effective and efficient utilization of services will allow the CRH to cover the optimum inpatient treatment needs of the people, especially those at risk. Utilization rates can be compared by examining mean length of stay in number of days per person in each inpatient unit, and the mean number of patients in each unit per day throughout the year.
In all four of the regions, Askeran, Hadrut, Madakert, and Martuni, the shortest mean length of stay in 2002 occurred in either the gynecology or maternity unit. Additionally, in Hadrut, Madakert, and Martuni the gynecology or maternity unit maintained the lowest mean number of patients per day. In the CRH in Askeran, the lowest mean number of patients was in the pediatric and the surgery unit.
For the CRH in Askeran, Hadrut and Mardakert the mean length of stay in 2002 was longest for patients in the medicine unit, as well as in the surgery unit in Askeran. Similarly, the medicine unit in Askeran, Hadrut and Mardakert maintained the highest mean number of patients per day. In Martuni, both the mean length of stay and the mean number of patients per day was highest in the infectious disease unit. It should be noted that in NK there were several communicable disease outbreaks in 2003.
In comparison to other central Asian republics, where from 1990 to 1998 the average length of stay for all inpatient divisions combined ranged from 12-13 days,10 NK has slightly shorter lengths of stay on average in each of the four CRHs. In 2002, the average length of stay for all inpatient divisions in Askeran was 8.8 days, in Hadrut was 9 days, in Mardakert was 8.2 days and in Martuni was 9.2 days.
The structural capacity for increased levels of inpatient care are already in place in all of the CRH’s in NK. Provisions, however, are needed to increase the functionality of the available resources for improved inpatient care. The inpatient utilization rates by specific unit are shown in the Table 14.
Center for Health Services Research and Development, December, 2003 39
Table 14: Inpatient utilization indicators for the CRH in Askeran, Hadrut Mardakert, and Martuni in 2002 by mean length of stay and mean number of patients by unit unit.
Mean length of stay per Mean number of patients per Askeran person in number of days day Pediatrics 8 2 Medicine 10 5 Surgery 10 2 Gynecology 7 - Hadrut Pediatrics 11 5 Medicine 12 6 Surgery 8 3 Gynecology 5 2 Mardakert Pediatrics 4 - Medicine 15 15 Surgery 9 10 Infectious Disease 10 6 Maternity 3 0.4 Martuni Pediatrics 7 8 Medicine 10 8 Surgery 8 7 Infectious Disease 15 15 Gynecology 6 0.7
Hospitalizations: Bed Occupancy Rates and Bed Index
Bed occupancy rates, which are the percentage of beds in each unit occupied by patients during the year, have consistently increased in Hadrut, Mardakert, and Martuni between 2000 and 2002. This demonstrates a need for improved inpatient services.
The WHO sets the minimum desired bed occupancy ratio at 70% to achieve acceptable efficiency in hospitals. Only the CRH in Martuni approximates this minimum guideline. The information gathered in NK will be used to establish a framework for prioritizing health services and decreasing the quantity of beds per unit, while increasing the quality of care provided for emergency and referral inpatient services.
Based on the a study published in the Eastern Mediterranean Health Journal in 2000, the countrywide bed occupancy rate in Iran from March 1997 to March 1998 was found to be 57.44%11, which is within the range of bed occupancy rates for the four CRHs in NK in 2002. In Iran, the bed occupancy rate of 57.44% was used to support the argument that overall the beds per population were not being occupied appropriately.
Center for Health Services Research and Development, December, 2003 40
The bed index is used to show the number of hospital beds available per 1,000 people. Bed index is an indicator that can be used to detect inappropriate geographical distributions of health care services with regard to hospital beds. In NK, the CRH in Askeran has the lowest bed index (at 0.7 hospital beds per 1,000 people) of the four regions, this is most likely related to its near proximity to Stepanakert.
Overall, the bed index for Askeran, Hadrut, Mardakert and Martuni combined, is only 2.8 hospital beds per 1,000 people, with 190 beds and 68,096 people. This figure is one of the lowest in the world, based on the 1998 World Bank figures, where the bed index per 1,000 people was 8.9 in Australia, 5.4 in Canada, 2.1 in Egypt, 9 in France, 16.2 in Japan, 6.5 in Sweden, and 4.2 in the United States.12
In other central Asian republics, such as Uzbekistan and Kyrgystan, the average number of hospital beds per 1,000 people has seen a sharp decline between 1992 and 1999. In 1999 Uzbekistan had the lowest average number of beds among hospitals in former Soviet Union republics at 5.4 per 1,000 people and Kyrgystan had the highest bed index at 7.5.13 The bed index in NK is significantly lower than in central Asian republics.
Table 15: Hospitalization indicators for the CRH in Askeran, Hadrut, Mardakert and Martuni for 2000-2002 by number of occupied bed days, number of people hospitalized per year, number of hospital beds, bed occupancy rate, and bed index per 1,000 people based on the total regional population shown in Table 11.
Year 2000 Year 2001 Year 2002 Askeran
# Occupied Bed Days 2464 2163 2241 # Hospitalized 170 199 237 # of Surgeries - - - # of Beds 10 10 10 Bed Occupancy Rate 67.51% 59.26% 61.40% Bed Index - - 0.7 Hadrut
# Occupied Bed Days 5764 6273 10290 # Hospitalized 642 652 876 # Surgeries 85 62 58 # of Beds 50 50 50 Bed Occupancy Rate 31.58% 34.37% 56.38% Bed Index - - 4.3 Mardakert
# Occupied Bed Days 10483 10252 12574 # Hospitalized 1030 1056 1122 # Surgeries 261 222 182 # of Beds 70 70 70 Bed Occupancy Rate 41.03% 40.13% 49.21% Bed Index - - 3.6
Center for Health Services Research and Development, December, 2003 41
Year 2000 Year 2001 Year 2002 Martuni
# Occupied Bed Days 10088 10043 14951 # Hospitalized 1050 1053 1483 # Surgeries 224 111 91 # of Beds 55 55 60 Bed Occupancy Rate 50.25% 50.03% 68.27% Bed Index - - 2.7 Overall
# of Beds - - 190 Bed Index* - - 2.6
Medical Personnel
In Askeran, there are eight FTE physicians, seven FTE nurses, and two FTE sanitars who work in the outpatient division. The polyclinic of the CRH serves as the primary source for outpatient services within the city of Askeran. The ratio of health care providers (physicians and nurses combined) for the Askeran city population of 2147 people is therefore approximately 1 outpatient provider per 143 people. This is the highest outpatient provider per person ratio among the four regions.
The inpatient division in Askeran has six FTE doctors, 11 FTE nurses, four FTE sanitars and two FTE non-medical personnel. The inpatient division of the CRH serves as the emergency care and primary referral site for the entire region of Askeran, which has an estimated population of 14,465 people. The ratio of inpatient health care providers to people is therefore 1 provider per 851 people, which is the lowest inpatient provider per person ratio among the four regions.
In Hadrut, there are ten FTE physicians, ten FTE nurses, and three FTE sanitars who work in the outpatient division. The Hadrut city population has an estimated 3008 people and therefore the ratio of outpatient health care providers per person is approximately 1:150.
The inpatient division in Hadrut has nine FTE physicians, 33 FTE nurses, nine FTE sanitars and three FTE non-medical personnel. The total regional population is estimated at 11,712 people and therefore the ratio of inpatient health care providers to people is approximately 1: 279. This is the highest inpatient provider per person ratio among the four regions.
In Mardakert, there are ten FTE doctors, nine FTE nurses and five FTE sanitars working in the outpatient division. The Mardakert city population has an estimated 3791 people and therefore the ratio of outpatient health care providers per person is approximately 1:200.
The inpatient division in Mardakert has six FTE physicians, 25 FTE nurses, 18 FTE sanitars and four FTE non-medical personnel serving in the primary referral site for the entire regional population of approximately 19,632 people. The ratio of inpatient health care providers per person is therefore approximately 1:633.
Center for Health Services Research and Development, December, 2003 42 In Martuni, the outpatient division has ten FTE physicians, 12 FTE nurses and three FTE sanitars who serve the Martuni city population of approximately 4448 people. The ratio of outpatient health care providers per person is approximately 1:202.
The inpatient division of Martuni has nine FTE physicians, 38 FTE nurses, 15 FTE sanitars and six FTE non-medical personnel. These health care workers serve the total regional population of approximately 22,287 people. The ratio of inpatient health care providers per person is approximately 1:475.
Figure 8: Ratio of medical staff per capita for the CRHs by number of overall medical staff (includes both nurses and doctors), mid-level staff (includes nurses only), and doctors by i. outpatient unit for the corresponding city population only, and ii. inpatient unit for total regional population.
OUTPATIENT DIVISION
3,500
3,000
2,500
2,000 Overall Staffing/Capita 1,500 Mid-level/Capita Doctors/Capita 1,000 268 301 379 445 307 500 301 Doctors/Capita 421 143 371 150 0 200 Mid-level/Capita 202 Askeran Hadrut Overall Staffing/Capita Mardakert Martuni
INPATIENT DIVISION
3500.0 3272.0 3000.0 2410.8 2500.0 2476.3
2000.0 Staff/Capita Ratio 1301.3 Overall Staffing/Capita 1500.0 1315.0 Mid-level/Capita 1000.0 Doctors/Capita 785.3 500.0 354.9 586.5 Doctors/Capita 850.9 278.9 0.0 633.3 Mid-level/Capita 474.2 Askeran Overall Staffing/Capita Hadrut Mardakert CRH Region Martuni
Center for Health Services Research and Development, December, 2003 43
Lavatory/Water/Sewage
There is no water supply in the CRH building in Askeran. The hospital staff collects and keeps water in water tanks. There is an outdoor water tap, which is used by the hospital staff as the primary water source. The water supply for this outdoor tap functions for only two hours per day. The Askeran CRH has only one pit latrine, which is located in the inpatient division. There are two water sinks, one located in the inpatient division and the other located in the outpatient division. There is no sewage system or running water available in the CRH.
In Hadrut, the CRH outpatient units have access to three toilets, one pit latrine, and 31 hand washing sinks. The inpatient units have access to four toilets, 76 hand washing stations and one shower. The hospital has a built-in sewage system, which is in need of urgent renovation. Water is supplied to the hospital through the water tanks located outside the building.
In Mardakert, the entrance/admissions room of the CRH has one hand washing sink and one shower. The administration has access to one pit latrine and one hand washing sink. Water is supplied from the water tanks. The sewage system is built-in the hospital. The outpatient division has three toilets and 15 water sinks inside the building, where the majority of the sinks are located inside of the rooms. There is a built-in running water system, however water is only supplied for four hours per day. The toilets and water sinks are linked to the sewage system. All of the outpatient units, except the Women’s Consultation unit, have access to this water source. The water and toilet source for the Women’s Consultation unit is separate. The inpatient pediatric unit has one toilet, three hand washing sinks and one shower, although there is no running water. In the surgery division, there is only one functioning toilet, one functioning pit latrine, six hand-washing sinks and one shower. In the Infectious Disease division there are two non-functioning pit latrines and two functioning hand washing sinks inside the department. In the medicine division there is one toilet and two hand washing sinks. In the maternity division there are five toilets, 20 hand washing sinks and three showers. In all of the inpatient divisions there is a built-in sewage system and the water is supplied through water tanks.
In Martuni, the outpatient division of the CRH has access to ten toilets, 57 hand washing sinks and two showers, while the inpatient division has access to 14 toilets, four pit latrines, 49 water sinks and four showers. There is a built-in sewage system in the building but it is in need of urgent renovation. There is no running water in the building, and water is only supplied once every two days. The hospital staff gets water from the tanks. All toilets and sinks are located inside of the building.
Ambulatory and Home Visits
During 2002, the CRH in Askeran made 10,865 ambulatory visits; 980 home visits and 27 school visits. Out of 334 children that were screened for illness, nine sick children were identified during school visits. In Hadrut the CRH made 9,596 ambulatory visits, 1,473 home visits and 20 school visits. Out of 2000 children that were screened five sick children were identified. In Mardakert, the CRH made 17,189 ambulatory visits and 572 home visits. In Martuni, the CRH made 16,427 ambulatory visits, 1,679 home visits and nine school visits. Out of 1,200 children screened, 15 sick children were identified.
Center for Health Services Research and Development, December, 2003 44 The number of ambulatory, home and school visits conducted by each CRH are shown in the Figure 9 below:
Figure 9: Number of ambulatory, home, and school visits for each the CRH in Askeran, Hadrut, Mardakert and Martuni in 2002.
18000 17189 16427 16000
14000 10865 12000 9596
10000 School 8000 Home Ambulatory
6000
4000 980 2000 1473 Ambulatory 572 27 1679 0 20 Home
Askeran 9 Hadrut School Mardakert Martuni
Hospitalizations
In Askeran, Hadrut, Mardakert, and Martuni the absolute numbers for hospitalization of infants and children are shown for 2000, 2001 and 2002 in the table below. The number of adult hospitalizations has been on the rise throughout the three years in all four of the regions. The number of infant/children hospitalizations has increased throughout the three years in Hadrut as well, and has shown an overall increase in Mardakert and Martuni from 2000 to 2002, but with a decline in 2001.
Table 16: Number of hospitalizations by age group for Askeran, Hadrut, Mardakert and Martuni from 2000 to 2002.
Age Group Year 2000 Year 2001 Year 2002 Askeran Infant/Children 20 25 31 Adult 150 174 206 Total 170 199 237 Hadrut Infant/Children - - 77 Adult - - 779 Total 642 652 876
Center for Health Services Research and Development, December, 2003 45 Age Group Year 2000 Year 2001 Year 2002 Mardakert Infant/Children 207 184 226 Adult 823 872 892 Total 1030 1056 1118 Martuni Infant/Children 216 182 322 Adult 834 871 1161 Total 1050 1053 1483
Immunization Coverage
The outpatient division at each CRH vaccinated children in 2002 for hepatitis, DPT/Dt, polio, measles and BCG. Vaccinations for mumps were not provided, although they were needed. (Table 17, below)
Table 17: Immunization coverage in 2002 for Askeran, Hadrut, Mardakert and Martuni for hepatitis, DPT/Dt, polio, measles, BCG, and mumps by number of administered doses, with number of needed doses stated in parentheses when applicable.
Askeran Hadrut Mardakert Martuni Hepatitis 9 29 37 22 DPT/Dt 90 165 239 185 Polio 90 165 239 185 Measles 27 191 83 59 BCG 1 121 (124) 147 (149) 152 (153) Mumps 0 (27) 0 (257) 0 (83) 0 (59)
Pregnancies and Deliveries
In Askeran, in 2002, there were 279 pregnancies, out of which one was terminated by spontaneous abortion. Additionally, 17 women in 2002 were referred to other health care facilities.
In Hadrut, in 2002, 20 pregnant women out of 82 were referred to other health care facilities. Overall, there were 1,249 pregnancy visits, three of which ended through spontaneous abortions.
In 2002 in Mardakert the CRH had 1,580 pregnancy visits with 221 pregnancies and three spontaneous abortions. The number of pregnancies decreased in the years 2000 to 2002, however the number of pregnancy visits increased. Pregnancy referrals also increased from 41 in 2000 to 118 in 2002. No maternal or early neonatal deaths occurred in the facility in last three years. Additionally, all deliveries were in the hospital in the years 2000, 2001 and 2002.
In Martuni, 45 pregnant women out of 479 were referred to other health care facilities, the overall number of pregnancy visits was 1262 (2.6 visits per pregnancy). Two pregnancies ended with spontaneous abortions. No maternal or early neonatal deaths occurred in the facility.
Center for Health Services Research and Development, December, 2003 46 Table 18: Number of pregnancy visits, # of pregnancies, and # of deliveries by year for 2000 to 2002 for Askeran, Hadrut, Mardakert and Martuni.
Askeran Year 2000 Year 2001 Year 2002 Pregnancy Visits - - 631 # Pregnancies - - 279 # Deliveries - - 1 Hadrut Pregnancy Visits - - 1249 # Pregnancies - - 82 # Deliveries 127 132 126 Mardakert Pregnancy Visits 1180 1547 1580 # Pregnancies 229 227 221 # Deliveries 161 155 149 Martuni Pregnancy Visits - - 1262 # Pregnancies 160 152 479 # Deliveries 159 152 155
Main Sources of Drug Supplies
In Askeran, 60% of the drug supply of the CRH is provided by the MOH. Family Care supplies another 20% of the essential drug supply. In the CRH in Hadrut, the MOH provides 50% of this supply, while Family Care covers 30% and the ICRC covers the remaining 20% of all supplied drugs. In Mardakert, the MOH of NK supplies 50% of all drugs, Family Care supplies 30% and the ICRC supplies 20%. In Martuni, the drug supply of the CRH is provided by the MOH of NK, which covers 60%, Family Care provides 30% and the ICRC contributes 10%. These relationships are depicted in Figure 10 below:
Figure 10: Main sources of drug supply to the CRHs by region (Askeran, Hadrut, Mardakert, and Martuni).
Askeran Hadrut
25 % 30 %
Ministry of Ministry of RedHealth RedHealth FamilyCross FamilyCross 0 Care 50 Care % %
75 20 % %
Center for Health Services Research and Development, December, 2003 47
Mardakert Martuni
30 30 % %
Ministry of Ministry of RedHealth RedHealth FamilyCross FamilyCross 50 Care Care % 60 % 10 20 % %
Equipment/Supplies
Since the polyclinic and maternity units have been renovated and supplied with equipment and essential pharmaceuticals through prior USAID projects, discussions will focus on the inpatient unit. However, since Askeran has not undergone any significant renovations, both the inpatient and outpatient units will be discussed for this region. For a list of available equipment for the outpatient division of each CRH see Appendix 5.
In general, all of the CRHs are in dire need of equipment and supplies. Essential equipment is non-existent, outdated, or inoperable. Below are a few highlighted examples for each CRH. A detailed list of all available equipment for the inpatient divisions by department in each CRH can be found in Appendix 5.
In Martuni, Mardakert, and Hadrut, the pharmacy has no distillator, technical laboratory scale, or refrigerator. Further, there is no laboratory glassware. In order for simple pharmaceuticals to be prepared these essential items are mandatory. Currently, it is impossible for the pharmacy in these three CRHs to address the hospitals’ needs.
There is no running water in any of the patient rooms within the medicine/pediatrics units in Askeran, Hadrut and Martuni. Mardakert has one patient room with a running water sink. In all four of the CRHs, there are no working toilets or heaters in any of the patient rooms. In contrast, the majority of patient rooms located within the renovated Gynecology/Obstetrics units of these facilities have running water sinks and heaters. Furthermore, toilet and shower facilities are conveniently located for both the patients and staff in these units.
Basic equipment and furniture is also missing for both the pediatrics and medicine divisions in all four CRHs. The entire medicine division in Mardakert has no sphygmomanometer and only one patient thermometer. Askeran does not have a single chair in any patient room in either unit. Further, the equipment assessment list for the pediatrics division in Askeran only lists the availability of 10 disposable syringes. Every other item is missing.
Center for Health Services Research and Development, December, 2003 48
The surgery division, much like the other inpatient units within the four CRHs, also has no available running water sinks, toilets, or heaters. Each of the CRHs has only one sphygmomanometer, one stethoscope, and one thermometer in this division. Surgical instruments are also very scarce. Further, sterilization equipment is minimal and/or missing, which creates a large risk to the inpatient population. These findings are summarized in Table 19, below.
Table 19: Equipment in patient rooms by medicine (and pediatrics in parentheses) and surgery divisions for the CRH in Askeran, Hadrut, Mardakert and Martuni.
Askeran Hadrut Mardakert Martuni Medicine # Patient rooms 2 5 (2) 7 5 (7) Running water sink 0 0 1 0 Beds 11 (0) 5 21 13 Bed tables 3 0 7 9 Tables 0 (0) 2 4 1 Chairs 0 (0) 0 2 1 Screen 0 0 0 0 TV 0 0 0 0 Armchair/Sofa 0 0 0 0 Refrigerator 0 0 0 0 Heater 0 0 0 0 Electrical outlets 2 4 5 8 Toilet (private) 0 0 0 0 Shower (private) 0 0 0 0 Surgery # Patient rooms - 10 15 15 Running water sink 0 0 0 0 Heater 0 0 0 0 Toilets (private) 0 0 0 0 Sphygnomanometer 0 0 0 0 Stethoscope 0 0 0 0 Thermometer 0 0 0 0
Laboratory and Diagnostics: The laboratory in all four CRHs is very deficient. Most do not even possess a binocular microscope, the most basic, low-tech piece of equipment that is essential in any laboratory. The Mardakert laboratory does not have a centrifuge and the Askeran laboratory does not have a laboratory table.
Only the Martuni CRH has an operating, yet very outdated, x-ray machine. The other CRHs cannot do any basic radiographic tests for inpatient or outpatient populations. Further, no basic ultrasound or doppler machines are available.
Askeran Outpatient Division: As mentioned previously, the Askeran CRH has not been incorporated into any of the USAID funded projects. Therefore, unlike the other CRHs, its polyclinic and reproductive health service departments have not renovated or supplied with equipment and furniture. All of the units are in dire need of renovation. Basic medical equipment and supplies are unavailable in Askeran.
Center for Health Services Research and Development, December, 2003 49 Drug Availability and Use
As stated in the other sections, an Essential drug list for the CRHs was developed and used to assess the status of the facilities in terms of availability and unmet need of the drug supply. The drug list, containing 202 items, was developed using WHO recommendations, the essential drug list of the Republic of Armenia, drug list corresponding to accepted guidelines, and an advisory group of local experts. The advisory group was comprised of the following:
· Pediatrician: Deputy Executive Director, Republican Pediatric Hospital · Internal Medicine Specialist: Chief Specialist, Ministry of Health, NK · Cardiologist: National Polyclinic · Cardiologist: Republican Hospital · Neonatologist: Chief Neonatologist, Republican Maternity Hospital
The drugs were divided into 3 categories in terms of their perceived necessity: low, normal, high. These scores were calculated by summing up the values recorded for each drug. The final drug list included drugs with high perceived necessity scores as well as drugs necessary to adequately implement accepted guidelines for primary care and referral level care. The recommended essential drug list for the CRHs consists of 68 items (Table 37).
3.3.2. Oncology Dispensary
General information
The Oncology dispensary is located in Stepanakert. It has an outpatient and an inpatient division as well as auxiliary laboratory and diagnostic services. The services provided by the dispensary are shown in detail in the table below. Additionally, see Appendix 5 for greater detail regarding the field assessment findings on the Oncology dispensary.
Table 20. Description of units in the Oncology Dispensary by i. type of service, ii. division, iii. number of rooms, iv. mean length of stay per patient in number of days, and iv. mean number of patients per day.
Service Division Rooms Mean length of stay Mean number in days of patients Outpatient Oncology (General 2 - - and Women’s) Medical Records 1 - - Inpatient General Services - - - Oncology 24 14 22 Auxiliary X-ray 1 Clinical Lab 1 Kitchen 1 Laundry 1 Medical Records 1 Disinfecting 1
Center for Health Services Research and Development, December, 2003 50 Electricity is supplied in the facility 24 hours/day, but water is supplied only two hours per day. The last renovation of the facility was done in 2001 by hospital general funds. The renovation covered only the basement. The oncology dispensary has one functioning vehicle, which serves all general needs of the dispensary. Drugs are supplied from the MOH of NK and they cover 50% of all needed medications.
Outpatient Services
The oncology division occupies two rooms and employs two FTE physicians, one FTE nurse and one FTE sanitar. In 2002, the outpatient unit of the dispensary made 576 home visits. The outpatient unit is equipped with a sterilization room, which has one water distillator, two autoclaves and two bactericide lamps. Visits to the outpatient unit of the dispensary by age group are shown in Figure 11 below:
Figure 11: Age distribution of patient visits to outpatient unit of Oncology Dispensary in 2002 by count and percentage.
148, 4%
Adults Children
3367, 96%
Outpatient Services: Oncology Division The general oncology room is 13.7m2 and the women’s oncology room is 14.5m2. Both rooms are heated with portable electric devices.
Water, Toilet and Sewage System in the Outpatient Oncology Unit The Oncology outpatient division in the hospital has two pit latrines and one hand washing station. Both are outside the room but inside the building. There is a running water system in the building, but the water system has not been renovated.
Inpatient Services
The oncology unit employs six FTE physicians, 11 FTE nurses, seven FTE sanitars and eight FTE non-medical professionals. Overall 0.5 FTE physician, one FTE nurse and four non- medical professionals are employed in the auxiliary units of the dispensary. Specific inpatient data from 2000 to 2002 is shown in Table 2 below:
Center for Health Services Research and Development, December, 2003 51 Table 21: Inpatient count for i. number of hospitalizations for adults per year, ii. number of available beds, iii. number of bed days per year, iii. number of surgeries per year and iv. number of deaths per year in 2000, 2001 and 2002. 2000 2001 2002 Adults Hospitalized 394 429 460 Hospital Beds 30 30 30 Bed Days 7389 6792 6286 Surgeries 107 88 101 Deaths 4 7 7
Inpatient Services: Oncology Unit The oncology inpatient unit has nine patient rooms. Eight of the rooms have four beds and one room has three beds. The size of the rooms varies between 16m2 and 18.3m2. The natural light is sufficient in all of the patient rooms. All the rooms have been renovated. Water, Toilet and Sewage System in the Inpatient Oncology Unit The oncology inpatient subdivision of the dispensary has one toilet, three pit latrines and one hand washing station. There is a built-in running water and sewage system in the unit, however water is only supplied 1.5 hours per day.
The oncology unit has 15 non-patient room, however only 11 rooms are currently used. These rooms are not renovated, but the natural light is satisfactory.
Equipment/Supplies
The rooms are equipped with the following operable equipment and/or furniture.
Table 22: List of supplies/equipment by number of items in the i. outpatient Oncology ii. inpatient Oncology and iii. Surgery divisions.
Departments Supplies Quantity Outpatient Oncology Desks 2 Chairs 6 Cabinets for instruments 1 Examination beds 2 Bed tables 1 Cabinets for clothes 2 Screens 2 Stetho/phonendoscope 1 Sphygnomanometer 1 Tape measure 1 Sharp disposal 1 Instrument cleaning jar 2 Multichannel ECG 2 Stretcher 5 Inpatient Oncology Bed tables 35 Tables 9 Chairs 35 Heater 9
Center for Health Services Research and Development, December, 2003 52 Departments Supplies Quantity Electrical outlets 9 Sphygmomanometer 1 Stethoscope 1 Patient thermometer 1 Procedural pillow 1 Stand 4 Oxygen bag 2 First aid drugs kit 1 Anti-shock drugs kit 1 Operating Room Bactericide lamp 1 Equipment for general anesthesia 1 Small set of surgical instruments 1 Large set of surgical instruments 1 Electric knife 1 Sterilization equipment 1 Table for sterile instruments 2 Sterilization cylinders 4
3.3.3. STD Dispensary
General Information
The STD dispensary is located in Stepanakert. The dispensary has one outpatient and two inpatient divisions; dermatology and STD, as well as clinical and serological laboratories. Electricity in the facility is supplied 24 hours per day, but water is only supplied one hour per day. The facility has not been renovated in the last several years. The dispensary has one functioning vehicle, which serves all general needs of the dispensary. Drugs are supplied by the MOH of NK and cover 5% of all needed medications. Additionally, see Appendix 5 for greater detail regarding the field assessment findings on the STD dispensary. The services provided by the dispensary are shown in detail in Table 23 below:
Table 23: Description of division by i. type of service, ii. division, iii. number of rooms, iv. mean length of stay per patient in number of days, and iv. mean number of patients per day per division.
Service Division Rooms Mean length of stay Mean number of in days patients per day Outpatient: Minor Procedures 2 - - Dermatology/STD Examination Room 1 - - Inpatient: Dermatology 6 17 1.3 STD 5 20 0.3 Clinical Lab 1 - - Serological Lab 1 - - Kitchen 2 - - Laundry 1 - - Admissions 1 - -
Center for Health Services Research and Development, December, 2003 53 Outpatient Services
The outpatient unit has two rooms for Dermatology and STD patients. There are two FTE physicians, three FTE nurses and three FTE sanitars employed by the dispensary. In the 2002, 21918 patients visited the dispensary. The age distribution is shown below in Figure 12:
Figure 12: Age distribution of patient visits to outpatient unit of STD Dispensary in 2002 by count and percentage.
110, 1%
7308, 33% Adults Children (1 to 15 years) Infants (under 1 year) 14500, 66%
In 2002 the dispensary conducted 36 school visits, where 15,387 students were screened and 212 sick children were detected. The facility generally has had very few referrals to other health care facilities. In 2002, two children (1-15 years old) and one adult were referred to other health care facilities. Hospitalization rates increased over the past three years and are shown in Table 25 below:
Table 25: Inpatient count for i. number of hospitalizations for adults per year, ii. number of available beds, iii. number of bed days per year, and iii. number of occupied bed days per year in 2000, 2001 and 2002.
2000 2001 2002 Adults Hospitalized 132 392 292 Hospital Beds 25 25 25 Occupied Bed Days 1344 3863 4427
Outpatient Services: Dermatology/STD Division The dermatology/STD division of the outpatient unit has three rooms. The two examination rooms are 16m2 and 14m2 and the one minor procedures room is 12m2. The natural lighting is sufficient in all three of the rooms, however none of the rooms have been renovated. All three outpatient rooms are heated in the winter by built-in electric heaters.
Water, Toilet and Sewage System in the Outpatient Dermatology/STD Division The Dermatology/STD outpatient division in the dispensary has one pit latrine and one hand washing station. Both are outside of the room, but inside of the building. There is no running water in these stations and they have not been recently renovated, however they both have a sewage system built within the stations. Water is available only one hour per day in the facility.
Center for Health Services Research and Development, December, 2003 54 Inpatient Services
There are four FTE physicians, eleven FTE nurses and five FTE sanitars employed by the inpatient division of the hospital. There is no sterilization department in the facility, so the instruments are sterilized in a drying cabinet. Additionally, the facility has a pharmacy.
Inpatient Services: Dermatology Unit The dermatology unit has five patient rooms, which are each 15m2. Three of the rooms have two beds each, one room has three beds, and the other room has four beds. The natural light is satisfactory in all of the patient rooms; however none of them have been recently renovated.
Water, Toilet and Sewage System in the Inpatient Dermatology Unit The dermatology inpatient subdivision of the dispensary has two pit latrines and one hand washing station. There is no running water for the pit latrine or hand washing station. General water is supplied one hour per day. The pit latrine and hand washing stations both have a sewage system.
The dermatology unit has one non-patient room (30m2), which is the minor procedures room. The natural light in this room is satisfactory, however the room has not been renovated and the walls are cracked.
Inpatient Services: STD Division The three patient rooms of the STD division are 16m2, 10m2 and 10m2. The natural light in the rooms is sufficient, however, none of the patient rooms have been renovated.
Water, Toilet and Sewage system in Inpatient STD Unit The facility’s STD department has two toilets and one hand washing system, which are both connected to the sewage system. The toilets and hand washing systems have not been renovated. Water is available only one hour per day and there is no running water available in the unit.
The facility has two used non-patient rooms; a procedures room with area 9m2 and a doctor’s office that is 15m2. Both rooms have satisfactory natural light, although neither of them has been renovated.
Equipment/Supplies
The rooms by division are equipped with the following operable equipment and/or furniture.
Table 26: List of supplies/equipment by number of items in the i. outpatient Dermatology ii. inpatient Dermatology and iii. STD division.
Departments Supplies Quantity Outpatient Dermatology Desks 4 Chairs 8 Medical cabinets 1 Cabinets for instruments 3 Examination beds 1 Bed tables 3
Center for Health Services Research and Development, December, 2003 55 Departments Supplies Quantity Screens 1 Gynecological chairs 1 Illuminating lamps 1 Forceps 5 Vaginal speculum 5 Disposable syringes 20 Microscope sliders 30 Inpatient Dermatology Beds 13 Bed tables 11 Tables 3 Chairs 3 Electrical outlets 5 Microscope 2 Mobile lamp (electric torch) 1 Medical scales 1 Tonometer 2 Sterilization cylinder (drum) 4 Device for press 3 Vaginal speculum 20 Set of probes 5 Set of catheters 5 Packer 15 Forceps for the nails 2 Volkmann’s spoons 10 Scissors 10 Set of tongs (nippers) 15 Lancets of various size 10 Phonendoscope 2 Spatula 40 Disposable syringes 200 Syringes for cavities’ lavage 2 Measuring glasses 40 Eye dropper 5 Medical thermometer 5 Disinfection glasses 5 Cover-slide 200 Microscope slide 100 Gynecological chair 1 STD Beds 12 Bed tables 3 Tables 2 Chairs 3 Electrical outlets 5
Center for Health Services Research and Development, December, 2003 56 3.4 San-epi Stations The sanitary-epidemiological service is a parallel system within the healthcare system of NK. The San-Epi service has to reach 2 main objectives are o ensure health by: 1) assuring sanitary/hygiene conditions are kept and 2) providing epidemiologic monitoring, surveillance, and disease prevention and control services.
Sanitary control is divided into precautionary and routine control. Precautionary control applies during the design and construction of new establishments or the renovation/expansion of existing structures. The scope of coverage is broad, encompassing public facilities, children’s and teen’s institutions, food vendors, industrial enterprises, and any location utilizing X-rays/radiation or engaged in toxic chemical storage. Routine control (monitoring and surveillance) is carried out once facilities are operational.
Epidemiologic control focuses on preventive and population-level curative measures for environmental hazard and infectious disease control. Water quality monitoring and population immunization are among the most important preventive measures. Outbreak investigations and response is the second-most important activity.
The Republican San-Epi Station coordinates the functioning of the whole system, which consists of a city (Stepanakert) SES and 7 regional services, including Antiplague station, situated in Hadrut (Figure 13).
Figure 13. Structure of San-Epi Services in NK
Ministry of health of NK
Republican San Epi Station
Stepanakert City San Epi Station Hadrut Regional San Epi Station
Askeran Regional San Epi Station Hadrut Antiplague Station
Martuni Regional San Epi Station Qashatagh Regional San Epi Station
Mardakert Regional San Epi Station Shushi Regional San Epi Station
Center for Health Services Research and Development, December, 2003 57
Water quality monitoring
The aim of the water quality assessment and monitoring is to provide safe drinking water for hospitals, schools, and community water systems, as well as to provide acceptable water for irrigation systems, reducing the potential for salinization from water supplies with high salt content.
Water quality is typically assessed in two steps: 1) broad-spectrum screening for chemical and microbiological pollutants before a water source is chosen as a supply for drinking or irrigation; and 2) ongoing monitoring of key contaminants to verify continued suitability for use over time. This report therefore reviews both initial screening and ongoing monitoring requirements for water sources and distribution systems in FAR/AUA project areas.
Drinking water quality must be free of pollutants in four general categories: 1) pathogens; 2) inorganic chemicals (e.g. toxic metals such as lead and arsenic; molecular ions such as nitrates and cyanide); 3) organic chemicals (e.g. biocides and their breakdown products, petrochemicals, and solvents); and 4) radionuclides.
The US EPA regulates 3 specific pathogenic organisms and two broad categories. The US EPA also regulates over 40 inorganic chemicals, over 170 organic chemicals, and four categories of radionuclides. By contrast the Soviet GOST standards regulate only 20 inorganic chemicals and two broad categories of pathogens. The GOST standards do not directly regulate organic chemical concentrations, although they make reference to other health standards that do so.
The initial Assessment has shown that Soviet-era screening has not taken place for decades; the Soviet GOST standards do not conform to modern norms in many areas; and the laboratory techniques and quality assurance practices in Soviet-era labs are known to have been uneven or non existent. Because screening may have been inadequate and is by now outdated, retesting of water for pollutants in all four categories is necessary to assure the safety of public water supplies in the region. Such efforts should not duplicate ongoing monitoring that has verifiable accuracy; it should supplement those results with a well-chosen set of pollutants that have not been included in ongoing monitoring.
Irrigation water must be screened for its total alkalinity index in order to avoid use of water that will lead to soil salinization and a reduction in crop productivity. Irrigation water can be monitored for gross fluctuations in quality using inexpensive equipment intended for each regional water quality monitoring station (San-Epi stations in regional centers).
Immunization
The effectiveness of immunization depends on the cold chain maintenance for vaccines. Once the vaccines are received, they are immediately placed in freezers and stored at the Republican san-epi station until distribution. All the regional san-epi stations have refrigerators where vaccines can be kept for no more than 1-3 days. All the medical facilities that are supplied by vaccines have Cold Chain Igloos. So, the existing equipment for cold chain maintenance can be assessed as satisfactory for effective immunization thanks to “MERLIN” British NGO. However, there is no possibility to keep vaccines in the regional SESs and PHC facilities for more than 24-
Center for Health Services Research and Development, December, 2003 58 72 hours because of lack of freezers, and this limitation does not allow any flexibility in the immunization schedule in the case of temporary contraindications to a particular vaccination.
The main outbreaks during 2002 reported by the san-epi service were Hepatitis A, tuberculosis, and dysentery. Analysis of the immunization service and vaccines distributed by the Republican San-Epi Station during 2002, found that vaccination was conducted against Hepatitis B, DPT, Polio, Measles and BCG. Hepatitis A is not among the vaccines currently imported into NK or the region. Consequently, Hepatitis A reached epidemic proportions in 2002 and 2003. In addition, there was no vaccination against mumps (part of the usual MMR vaccine). Thus, vaccines against Hepatitis A and mumps are of pressing need in NK.
Facilities/vehicles/supplies
Taking into consideration the small number of facilities, the analysis includes detailed per- facility summaries (Appendix 5). Analysis revealed that none of the facilities has been recently renovated. Electricity was supplied 24 hour/days for all the facilities. Water supply varied in a range of 0-24 hour per day across facilities.
The Republican San-Epi service was established in 1936. The building where the service is located now, was constructed in 1982 and has not been renovated since. It was planned to serve 1.5 million people and employ over 560 FTE staff. During the Soviet period, the center served about 180,000 people including the population of the surrounding Azerbaijani regions. The building currently being utilized by the service is too large considering the decreased population size it serves (145,000), and the decreased number of specialists employed. According to the executive director’s statement, the building did not meet the sanitary-hygienic standards from the first day of its functioning, despite the fact that the service located there was responsible for sanitary-hygienic control.
The structure of the Republican SES includes the following departments/laboratories: 1. Administration and supportive services department 2. Sanitary-hygiene department 3. Epidemiological department 4. Particularly dangerous infectious diseases department 5. Bacteriological laboratory 6. General san-hygienic laboratory 7. Serologic laboratory 8. Toxicological laboratory 9. Parasitological laboratory
Republican San-Epi service is responsible for coordinating the activities of the city and regional services. Besides supervising, it provides both methodological and practical support to these facilities. A key obstacle in carrying out its preventive functions is the lack of transportation. Indeed, since the main laboratories are centralized at the Republican San-Epi Station, transportation becomes of crucial importance for timely delivery of samples to the center to identify outbreaks and coordinate preventive activities.
Center for Health Services Research and Development, December, 2003 59 Since Stepanakert SES is located in the same building with the Republican SES, the laboratories are shared by both facilities. So, the latter has only 3 departments:
1. Administration and supportive services department 2. Sanitary-hygiene department 3. Epidemiological department
The structure of the regional san-epi stations is similar with that of the city SES. Each consists from the following departments/laboratories:
1. Administration and supportive services department 2. Sanitary-hygiene department 3. Epidemiological department 4. Bacteriological laboratory 5. Parasitological laboratory
Only the Mardakert SES lacks a parasitological laboratory. As it can be seen from the SES structure, the Republican san-epi station is currently responsible for all tests except common bacteriological and parasitological tests. Thus, transportation to/from regional san-epi facilities is of primary importance. All the SESs except Martuni have one car (all of which need repairs). The Stepanakert san-epi station also has no car, but uses the two cars of the Republican san-epi station. These two vehicles also need repairs.
The number of rooms in each department/laboratory varied and was generally too many for the volume of work and size of staff. The Republican san-epi station, for instance, the general san- hygienic laboratory occupied 25 rooms (not required by the equipment), and only 8 FTE staff was employed there.
The vast majority of specialists (sanitary inspectors, epidemiologists) were concentrated in Stepanakert, at the Republican/City San-Epi Stations. At regional stations there were 1-2 specialists, mainly epidemiologists. The Askeran region had no specialist.
Unlike the satisfactory coverage of the vaccines supply, the needs for drugs and reagents were covered at only 20-30 % of the level needed to carry out routine monitoring and surveillance. The list of necessary drugs/reagents/disinfectants is provided in Appendix 11. The regional san- epi stations receive vaccines, reagents and drugs from the Republican san-epi station, which in its turn is supplied by the MOH of NK (85%), and by the MOH of RA (12.5 %).
Having studied the lists of crucial needs for each facility the priority was given to the following:
· Provision of laboratories with appropriate modern equipment, reagents/drugs, furniture · Transportation · Building renovation/reconstruction, · Urgent need of sanitary inspectors and epidemiologists, · Personnel training. (The latter two items are addressed in the training report).
Center for Health Services Research and Development, December, 2003 60
The Antiplague station previously operated under the Azerbaijany health ministry. Curretly the Antiplague station is included in the San-Epi system of NK, although it differs from the common san-epi stations by its structure and activities. It is situated in Hadrut due to the geographical location, which is a prime breeding ground for mosquitoes. While the building is sound, it lacks trained personnel. It is no longer clear if a separate plague station is needed or these functions can be incorporated within the regional SES.
3.5 Ambulance Station Ambulance station is a unique facility in Stepanakert, which provides first aid/primary health care services in case of emergency. Despite the important role it plays in the healthcare system of NK, it has no other sponsors than the government of NK, which addresses only the minimal routine needs of the facility. However, the Ambulance station needs serious capital investments to continue functioning. The summary of findings of this facility assessment is provided in Appendix 5. The following is a short description of main issues/problems revealed during the assessment.
Medical personnel: A total of 45 people were employed in the facility, including 8 doctors, 16 nurses, 5 sanitars and 16 non-medical staff. The facility operated through 10 linear (general) brigades, each staffed with a physician and a nurse, meaning that the number of physicians was not enough to staff all brigades. According to the head of the Station, all 8 physicians and 16 nurses attended a training on first aid organized by the MOH of NK during the period since 1994.
Physical condition of facility: The Ambulance station had 17 rooms, out of which 15 were utilized, and 10 garages. The facility have not been renovated for many years. All the rooms and garages were assessed by assessors as needing renovation. The lightning and/or size of many rooms did not meet the standards, including dispatcher’s room (4m2), procedural room (9m2), three physicians rooms (all 3m2), accounting room (7.5m2) and driver’s room (7.5m2).
The facility had a sewage system, but poor water supply (2 hour/day) and few sanitary commodities: an indoor pit-latrine and a hand washing station, both non-renovated. Electricity was available in the facility 24 hour/day, and portable electric heaters were used to heat rooms during winter.
Vehicles/equipment/supplies: Ambulance station operated with 6 vehicles, 5 Kia-Bestas and one Reno, all produced in 1997. All the vehicles were not functioning properly and needed repair. The station was furnished somewhat satisfactory, but experienced crucial need in equipment/supplies. Out of 19 types of items necessary to ensure satisfactory level of functioning of a linear brigade, only 9 were found in the station. Among lacking/out of order items were really crucial ones, like defibrillator and portable electrocardiograph. Due to lack of equipment and specialists, no brigades other than linear (like pediatric, cardio-resuscitation) were functioning.
Center for Health Services Research and Development, December, 2003 61 MOH of NK was the only source supplying the station with fuel, drugs and disposables. According to the Executive Director of the station, this covered 100% of station needs in fuel and 90% needs in drugs. Although out of 95 drugs included in the EDL for ambulance services only 42% were present in sufficient quantities, over 85% of those drugs considered by the respondent as very important for the ambulance functioning were present in sufficient quantities (Appendix 9).
Workload: Ambulance station served only the Stepanakert population. The mean number of ambulance calls per day was 28. During 2002, 10,021 calls were received, including 9,035 (11.2%) calls for adults and 986 (9.8%) for children. Out of all cases 948 (9.5%) were hospitalized and 62 (0.6%) died. Cardio-vascular, respiratory diseases, and traumas were reported as the top three reasons for ambulance calls. The republican hospitals (adult, pediatric, and maternity) were claimed as the primary referral sites for the ambulance.
Medical forms of the station included ambulance form, journal for calls, and annual reports. All these records were on standard forms and were assessed as complete.
4. Summary of Needs
4.1 FAPs and Village Ambulatories The detailed assessment of PHC facilities of NK yielded the following conclusions: · Out of 130 assessed facilities, 62 need different extent of facility renovation. These facilities are grouped into several categories in terms of the extent of renovation they need. The range of renovation varies from cosmetic inner renovation of a generally good-state building to construction of a new building in the place of destroyed or non-existing one. Table 11 provides the prioritized listing of facilities needing renovation. The following factors were considered while developing the listing: the Renovation Score of the facility (the most important factor), the workload score of the facility (assigned a weight 3), and the scores in furniture and equipment needs (each assigned a weight 1). The weighted sum of the latter three scores was called Summative Need of a facility. The Priority Score was calculated by multiplying the Summative Need Score for each facility with its Renovation Score. Table 11 provides the Renovation Score, Summative Need, and Priority Score for each facility needing renovation. The Priority Score is provided in descending order, meaning that the facilities are to be approached according to the prioritized order. Meanwhile, 2 cut-off points are set at the priority levels of 65 and 35 (mentioned in the table by solid lines) to group the facilities according to their priority level. The first 20 facilities having priority score more than 65 are included in the highest priority group to be renovated first. The second priority group includes the next 28 facilities with a priority score ranging from 35 to 65. The third priority group includes the last 14 facilities with a priority score less than 35. Those facilities needing new building are indicated in the table with a “!” sign. All the buildings included in this table are lacking indoor piped water and swage system. The renovation cost estimates for each facility that include also the costs for construction of these commodities are provided in Appendix 10.
Center for Health Services Research and Development, December, 2003 62
Table 27. List of PHC Facilities of NK by Priority of Need in Being Renovated/Supplied
Ren. Sum. Priority Engineering # ID Name Type Region Score Need* Score** Assessment 1. 4619 Hilis ! FAP Askeran 6 18 108 2. 5603 Aygestan ! FAP Hadrut 6 18 108 3. 2612 Karvin ! FAP Martuni 6 16 96 4. 4633 Vardadzor ! FAP Askeran 5 19 95 5. 3621 Madaghis ! FAP Mardakert 5 19 95 6. 4616 Tsaghkashat FAP Askeran 5 18 90 7. 2624 Paravatumb ! FAP Martuni 6 14 84 8. 3627 Nerqin Horatagh FAP Mardakert 4 21 84 9. 4612 Seydishen FAP Askeran 4 21 84 10. 3619 Ghazanchi ! FAP Mardakert 5 16 80 11. 3630 Shahmasur FAP Mardakert 5 16 80 12. 5623 Vardashat ! FAP Hadrut 5 16 80 13. 5616 Hakaku ! FAP Hadrut 5 16 80 14. 3601 Aghabekalinj FAP Mardakert 5 15 75 15. 3606 Zardakhach ! FAP Mardakert 5 15 75 16. 3608 Tblghu FAP Mardakert 5 15 75 17. 4629 Rev FAP Askeran 5 15 75 18. 4609 Lusadzor FAP Askeran 4 18 72 19. 2609 Khnushinak ! FAP Martuni 5 14 70 20. 2618 Machkalashen FAP Martuni 4 17 68 21. 4634 Verin Szneq ! FAP Askeran 5 13 65 22. 3626 Mehmana ! FAP Mardakert 5 13 65 23. 4623 Moshkhmhat FAP Askeran 5 13 65 24. 5626 Hakhullu ! FAP Hadrut 5 13 65 25. 2614 Haghorti FAP Martuni 4 16 64 26. 4504 Astghashen SVA Askeran 4 16 64 27. 4621 Madatashen FAP Askeran 5 12 60 28. 3611 Tsaghkashen FAP Mardakert 3 19 57 29. 2606 Zardanashen FAP Martuni 4 14 56 30. 2602 Avdur FAP Martuni 3 18 54 31. 4610 Khantsk FAP Askeran 3 17 51 32. 3625 Mingrelsk FAP Mardakert 3 16 48 33. 4611 Khanabad FAP Askeran 2 23 46 34. 3635 Vardadzor FAP Mardakert 3 15 45 35. 4604 Badara FAP Askeran 2 22 44 36. 4606 Dahrav FAP Askeran 3 14 42 37. 4628 Jraghatsner FAP Askeran 3 14 42 38. 6605 Qarin tak^ FAP Shushi 2 21 42 39. 2601 Ashan FAP Martuni 2 20 40 40. 4625 Nerqin Szneq FAP Askeran 3 13 39 41. 2615 Hatsi FAP Martuni 2 19 38 42. 4506 Avetaranots SVA Askeran 2 19 38
Center for Health Services Research and Development, December, 2003 63 Ren. Sum. Priority Engineering # ID Name Type Region Score Need* Score** Assessment 43. 3617 Varnkatagh (H.K.) FAP Mardakert 3 12 36 44. 4614 Khndzristan FAP Askeran 2 18 36 45. 4620 Hovsepavan FAP Askeran 3 12 36 46. 4622 Mkhitarashen FAP Askeran 3 12 36 47. 4630 Sardarashen FAP Askeran 2 18 36 48. 4637 Qrasni FAP Askeran 3 12 36 49. 4602 Aghbulagh FAP Askeran 3 11 33 50. 5602 Aknakhbyur FAP Hadrut 2 16 32 51. 6603 Hin Shen FAP Shushi 2 16 32 52. 3623 Mets Shen FAP Mardakert 2 15 30 53. 3615 Kusapat FAP Mardakert 2 14 28 54. 2629 Qarahunj FAP Martuni 2 13 26 55. 3620 Ghzarahogh FAP Mardakert 2 13 26 56. 4632 Skhnakh FAP Askeran 2 13 26 57. 4605 Berqadzor FAP Askeran 2 12 24 58. 6604 Mets Shen^ FAP Shushi 2 11 22 59. 4615 Khramort FAP Askeran 1 17 17 60. 4624 Nakhijevanik FAP Askeran 1 17 17 61. 2608 Kherkhan FAP Martuni 1 12 12 62. 3610 Khnkavan FAP Mardakert 1 12 12 * Summative Need = 3 * Workload Score + Furniture Need Score + Equipment Need Score ** Priority Score = Summative Need * Renovation score ^ Has hand washing station with running water ! No building or the building is destroyed
The map of NK in Figure 14 provides renovation need of each assessed PHC facility according to the priority group it belongs.
Center for Health Services Research and Development, December, 2003 64 Figure 14.
Center for Health Services Research and Development, December, 2003 65
· Almost all village PHC facilities (excluding 3 out of 130) need piped water and/or swage system to ensure the existence of running water and proper disposal of excretions. The list of those facilities assessed as renovated is provided in Table 28. For each facility, the existence of indoor piped water supply and swage system are mentioned. For all those facilities having no indoor piped water supply, sewage system, or both (the vast majority of renovated facilities, as it is evident from the table), these commodities should be installed/constructed.
Table 28. Renovated Facilities Needing Running Water Supply & Sewage System HW st. IT with Cost # ID Name Type Region Workload with RW RW Estimate 1. 2507 Berdashen SVA Martuni 5 2. 2508 Gishi SVA Martuni 5 3. 2509 Karmir Shuka SVA Martuni 5 yes - 24h. yes - 24h. 4. 2512 Norshen SVA Martuni 4 5. 2514 Sos SVA Martuni 5 yes - 24h. yes - 24h. 6. 2605 Yemishchan FAP Martuni 3 7. 2607 Tagahavart FAP Martuni 5 8. 2610 Tsovategh FAP Martuni 3 9. 2611 Kaghartsi FAP Martuni 3 10. 2613 Kolkhozashen FAP Martuni 3 11. 2616 Her-Her FAP Martuni 4 12. 2617 Ghavakhan FAP Martuni 3 13. 2619 Myurishen FAP Martuni 3 14. 2621 Mushkapat FAP Martuni 4 15. 2622 Nngi FAP Martuni 3 16. 2623 Shekher FAP Martuni 5 17. 2626 Sargsashen FAP Martuni 3 18. 2627 Spitakashen FAP Martuni 4 19. 2630 Gert FAP Martuni 5 20. 3505 Arachadzor SVA Mardakert 5 21. 3513 Chldran SVA Mardakert 4 yes 22. 3603 Garnaqar FAP Mardakert 2 23. 3604 Drmbon FAP Mardakert 2 24. 3605 Zaglik FAP Mardakert 2 25. 3607 Talish FAP Mardakert 4 yes - 24h. 26. 3612 Tsmakahogh FAP Mardakert 3 27. 3613 Kichan FAP Mardakert 2 28. 3614 Kochoghot FAP Mardakert 4 29. 3616 Harutyuna- Gomer FAP Mardakert 3
Center for Health Services Research and Development, December, 2003 66 HW st. IT with Cost # ID Name Type Region Workload with RW RW Estimate 30. 3622 Maghavuz FAP Mardakert 3 31. 3624 Mokhratagh FAP Mardakert 4 32. 3631 Chapar FAP Mardakert 3 33. 3632 Poghosagomer FAP Mardakert 2 34. 3633 Janyatagh FAP Mardakert 3 35. 3634 Vaghuhas FAP Mardakert 5 36. 3636 Verin Horatagh FAP Mardakert 4 37. 3637 Qolatak FAP Mardakert 3 38. 4503 Aknaghbyur SVA Askeran 5 yes 39. 4511 Noragyugh SVA Askeran 5 yes 40. 4601 Aygestan FAP Askeran 5 41. 4608 Khnatsakh FAP Askeran 3 42. 4613 Khachmach FAP Askeran 3 43. 4617 Karmir Gyugh FAP Askeran 2 44. 4618 Harav FAP Askeran 2 45. 4627 Shosh FAP Askeran 5 46. 4631 Sarushen FAP Askeran 3 47. 5501 Azokh SVA Hadrut 5 yes - 24h. yes - 24h. 48. 5510 Mets Taghlar SVA Hadrut 5 yes 49. 5515 Togh SVA Hadrut 4 yes - 24h. 50. 5516 Tumi SVA Hadrut 5 yes - 24h. 51. 5604 Araqel FAP Hadrut 2 52. 5605 Arevshat FAP Hadrut 2 53. 5606 Banadzor FAP Hadrut 2 yes 54. 5607 Drakhtik FAP Hadrut 3 55. 5608 Taghaser FAP Hadrut 4 56. 5609 Taghut FAP Hadrut 3 57. 5610 Khandzadzor FAP Hadrut 3 58. 5612 Tsakuri FAP Hadrut 2 59. 5613 Tsamdzor FAP Hadrut 2 60. 5614 Karmrakuch FAP Hadrut 2 61. 5611 Khtsaberd FAP Hadrut 3 yes - 24h. 62. 5617 Hin Taghlar FAP Hadrut 2 yes - 24h. 63. 5618 Mayramadzor FAP Hadrut 3 yes 64. 5619 Mokhrenis FAP Hadrut 2 65. 5622 Jrakus FAP Hadrut 3 66. 5624 Ukhtadzor FAP Hadrut 4
Center for Health Services Research and Development, December, 2003 67 HW st. IT with Cost # ID Name Type Region Workload with RW RW Estimate 67. 5625 Qyuratagh FAP Hadrut 3 68. 6601 Yeghtsahogh FAP Shushi 3 Total Cost HW st. - Hand washing station, RW - Running water, IT - Indoor toilet
· The majority of facilities need furniture and equipment. The number/character of needed equipment/furniture differs from facility to facility and needs to be adjusted specifically for each facility taking into consideration the existing furniture/equipment in each. The standard listings of equipment/furniture included in the assessment tool (Appendix 2) were used as a guide to estimate the need in these supplies for each facility. The estimated costs to provide each facility with the standard lists of equipment and furniture for PHC level are provided in Tables 29 and 30. The price for equipment is calculated considering obstetrical services or without their consideration, since only minimal obstetrical services are provided in the majority of FAPs (unlike SVAs and SUBs), thus, they do not need obstetrical equipment.
Table 29: Estimated cost to provide each facility with a standard list of equipment Equipment for FAPs/SVAs Average Quantity Average Average price per per price with Price item middle- OB service without OB size FAP service 1. Stethoscope $1.60 1 $1.60 $1.60 2. Sphygmomanometer $5.86 1 $5.86 $5.86 3. Thermometer $0.53 3 $1.59 $1.59 4. Refrigerator $307.07 1 $307.07 $307.07 6. Tongue holder $3.44 1 $3.44 $3.44 7. Height measurer-child $22.05 1 $22.05 $22.05 8. Height measurer-adult $17.20 1 $17.20 $17.20 9. Scale-child $194.00 1 $194.00 $194.00 10. Scale-adult $162.26 1 $162.26 $162.26 11. Measure tape $0.26 2 $0.53 $0.53 12. Timer $10.58 1 $10.58 $10.58 13. Sterilization cylinder (bix) $20.28 1 $20.28 $20.28 14. Sterilization box for instruments $34.39 1 $34.39 $34.39 15. Dry sterilization $307.76 1 $307.76 $307.76 16. Non-disposable syringe/needle 5,0 $0.35 5 $1.76 $1.76 17. Spatula (metal) $0.97 3 $2.91 $2.91 18. Tweeser (pincer) $1.32 2 $2.65 $2.65 19. Scissor $1.76 2 $3.53 $3.53 20. Forceps $3.17 2 $6.35 $6.35 21. Scalpel $0.16 2 $0.32 $0.32
Center for Health Services Research and Development, December, 2003 68 Equipment for FAPs/SVAs Average Quantity Average Average price per per price with Price item middle- OB service without OB size FAP service 22. Scalpel holder $1.85 1 $1.85 $1.85 23. Tray for instruments $7.50 1 $7.50 $7.50 24. Needle holder $2.65 1 $2.65 $2.65 25. Surgical needle $0.11 5 $0.57 $0.57 26. Used instruments’ tray $5.29 1 $5.29 $5.29 27. Instrument cleaning jar $8.82 1 $8.82 $8.82 28. Gynecological chair $432.10 1 $432.10 29. Gynecological mirrors $3.17 2 $6.35 30. Packer curved $4.67 2 $9.35 31. Kocher $4.41 2 $8.82 32. Folkman spoon $2.38 2 $4.76 33. Obstetrical stethoscope $7.05 1 $7.05 34. Subject glasses $0.04 50 $1.85 35. Medical splints $13.23 1 $13.23 $13.23 36. Stretchers $119.05 1 $119.05 $119.05 Total $1,735.35 $1,265.07
Table 30: Estimated cost to provide each facility with a standard list of furniture Furniture for FAPs/SVAs Average Quantity Average price price per per per needed item middle- items size FAP 1. Sink with running water $30.86 1 $30.86 2. Desk $98.44 2 $196.88 3. Chair $21.16 4 $84.66 4. Medical cabinet (glass) $95.65 1 $95.65 5. Cabinet for instruments $118.73 1 $118.73 6. Examination Bed $78.38 1 $78.38 7. Bed $126.15 1 $126.15 8. Bedside table $22.26 2 $44.53 9. Cabinet for cloths $141.09 1 $141.09 10. Screen $148.41 1 $148.41 11. Swaddle table $79.15 1 $79.15 12. Procedural table (glass) $59.37 1 $59.37 13. Telephone $17.32 1 $17.32 Total $1,221.17
Center for Health Services Research and Development, December, 2003 69 According to the priority scores for equipment and furniture, up to 90 PHC facilities had highest, high, or normal need in furniture and equipment. If all these facilities are provided with furniture and equipment according to the standard listings given below (without considering the items they already have), the cost for one-time supply with equipment and furniture will be $223,762.
· All facilities need to be periodically supplied with the most necessary drugs/disposables. The current needs in drug/disposable supplies are insufficiently covered by MOH of NK and Regional Governments. ICRC and Family Care are going to terminate their activities soon. Meanwhile, village administrations and/or communities lack resources to cover the minimum needs of PHC facilities in terms of drugs/disposables. The lists of drugs and disposables to be supplied to village PHC facilities of NK along with estimated prices for each item and the estimated monthly costs of supplies (for all facilities) are provided in Tables 31 and 32. The tables show that the monthly supply of all facilities with both disposables and drugs will cost $11,921.85, meaning that the cost for annual supply will be $143,062.
Table 31: Estimated monthly cost of disposable supplies for PHC facilities
Disposable Supplies for FAPs/SVAs Average Estimated Cost for price per monthly monthly item need supply 1. IV Cannula, G18, 1,2 x 45mm, teflon, with inj.site, green $0.51 134 $68.54 2. Infusion set, min. 150cm, with air intake $0.42 134 $56.48 3. Disposable syringe/needle 5,0 $0.06 670 $42.54 4. Disposable syringe/needle 2,0 $0.05 670 $34.27 5. Spatula, wooden (box) $0.02 134 $2.13 6. Surgical thread (boxes) $0.69 67 $46.08 7. Sterile bandages 7x14 $0.23 402 $92.17 8. Elastic bandages $0.96 134 $128.09 9. Medical cotton wool 100g $0.37 268 $99.26 10. Tape, adhesive 1x500 $0.39 268 $104.46 11. Gloves surgical, sterile $0.32 134 $43.01 12. Examination gloves $0.11 134 $14.65 13. Gauze mask $0.16 134 $21.74 14. Tube (nasogastric) $1.59 67 $106.35 Total $859.77
Center for Health Services Research and Development, December, 2003 70 Table 32: Estimated monthly cost of drug supplies for PHC facilities Drugs for FAPs/SVAs Form Average Estimated Cost for price per monthly monthly item need supply 1 Acetylsalicylic Acid (Aspirin) 500mg x 10 tab $0.09 256 $23.48 2 Albucid 30%, 1.5ml (Sulfacyl-Natrii) x 2 item $0.26 128 $32.96 3 Alcohol 250ml bottle $0.74 134 $99.73 4 Alum. hydroxide 250mg + Mag Trisilicate 500mg tab $1.28 26 $33.29 5 Amoxycillin 250mg x 10 tab $0.62 4122 $2 551.71 6 Ampicillin 1.0g amp $0.43 1026 $436.10 7 Analgin 50%, 2ml x 10 jar $0.51 103 $52.32 8 Baralgin 5ml x 5 amp $3.28 103 $337.88 9 Benzyl benzoate 90%, 1l (20% 100ml) bottle $0.48 134 $64.28 10 Benzylpenicillin 1MU (=600mg) x 10 flac $0.93 103 $95.92 11 Brilliant green bottle $0.25 134 $34.03 12 Chloramphenicole 1,0g x10 flac $0.59 52 $30.81 13 Chlorhexidine 0.5%, 1l (4% 1l) bottle $14.67 52 $763.03 14 Coffein 10%, 1ml x 10 amp $0.51 52 $26.69 15 Cordiamin 25%, 2ml x 10 amp $1.06 16 $17.02 16 Dexamethasone 4mg, 1ml x 25 amp $5.46 5 $27.28 17 Dibasol 1%, 5ml x 10 amp $0.89 103 $91.56 18 Dimedrol 1%, 1ml x 10 amp $0.35 103 $36.51 19 Epinephrine (Adrenaline) 1mg/ml, 1ml amp $0.53 257 $135.98 20 Erythromycin 250mg x 10 tab $1.26 257 $324.08 21 Ferrous Sulfate 200mg + Folic Acid 0.4mg x 100 tab $2.41 15 $36.14 22 Furadonin 0.05g x 10 tab $0.04 257 $11.33 23 Furazolidone 0.05g x 10 tab $0.04 134 $5.67 24 Gentamycine 40mg/ml, 2ml x 10 amp $1.34 52 $69.79 25 Glyceryl Trinitrate 500mg -sublingual x 40 tab $0.61 26 $15.87 26 Ibuprofen 200mg x 100 tab $1.07 52 $55.58 27 Magnesii Sulfas 25%, 10ml x 10 amp $0.75 52 $39.25 28 Mebendazole 100mg x 10 tab $1.76 514 $906.53 29 Methyldopa (Dopegit) 250mg x 50 tab $3.71 15 $55.61 30 Nalidixic Acid 250mg x 56 tab $7.60 20 $152.06 31 Nifedipine 10mg x 50 tab $0.62 20 $12.49 32 No-spa 2ml x 25 amp $8.45 21 $177.41 33 Nystatine 0.5g x 20 tab $0.66 26 $17.29 34 Oral Rehydration Salts (ORS) 27.9g/1l sachet $0.55 1541 $845.24 35 Oxytocin 10IU, 1ml x 10 amp $1.66 52 $86.39 36 Papaverin 2%, 2ml x 10 amp $0.43 52 $22.10 37 Paracetamol 0.1g (0.2g x 10) tab $0.05 257 $11.78 38 Paracetamol 0.5g x 10 tab $0.08 154 $12.77 39 Permethrin 5%, 25g sachet $2.65 103 $273.03 40 Polyvidone Iodine 10%, 200ml drop. $5.29 134 $708.99
Center for Health Services Research and Development, December, 2003 71 Drugs for FAPs/SVAs Form Average Estimated Cost for price per monthly monthly item need supply 41 Promethazine Hydrochloride 25mg tab $1.39 129 $178.83 42 Ringer-Lactate, 1l (500ml) plastic $0.58 52 $30.26 43 Salbutamol 4mg x 10 (2mg x 24) tab $0.53 248 $131.22 44 Salbutamol aer, 10ml item $2.54 165 $418.76 45 Sulfocamphocain 10%, 2ml x 10 amp $0.62 52 $32.28 46 Trimetoprim-Sulfamethoxazole (480mg) x 20 tab $0.79 1500 $1 182.54 47 Ung Tetracyclini 1%, 5g tube $0.53 514 $271.96 48 Validol 0.06 x 10 tab $0.08 155 $12.57 49 Water for injection, 5ml(2ml) x 10 amp $0.28 155 $43.19 50 Zinc Oxide 10%, (25g) jar $0.23 134 $30.49 Total $81.55 $11,062.08
4.2 Village District Hospitals The assessment of the four village district hospitals of NK showed that priority should be given to these facilities, since they carry out dual functions of primary health care facility and referral center for surrounding health posts. Indeed, the population size they serve is much higher and the range of activities they conduct is wider than that of FAPs/SVAs. The assessment pointed out the need for the following interventions: · Addressing apparent renovation needs of these facilities, particularly, o In Chartar SUB, Martuni: installation of an indoor hand washing station and toilet connected with a swage system, renovation of the rooms in use and reallocation of patient rooms with small size into other rooms with appropriate size/conditions. o In Vank SUB, Mardakert: renovation of the inpatient part of the facility o In Haterk SUB, Mardakert: cosmetic renovation of 2 patient and 8 non-patient rooms with peeling plastering of walls, renovation of the roof
· Providing some important equipment to these facilities to ensure the maintenance of medications and antiseptic conditions in these facilities and to address diagnostic/treatment needs they have, particularly: o Provision of Getavan SUB, Mardakert with refrigerator, bactericid lamp, height measurer: both child and adult, and oxygen cylinder o Provision of Haterk SUB, Mardakert with oxygen cylinder o Provision of Haterk, Getavan and Chartar SUBs with sets of medical splints o Provision of all four SUBs with electrocardiographs and cardiac defibrillators (and ultrasounds [$8,000] if possible)
The price estimates for above-mentioned supplies are provided in Table 33. As table shows, the overall cost for providing all four SUBs with the needed equipment will be $7,434.50 without ultrasounds, and $39,603.81 with the latter.
Center for Health Services Research and Development, December, 2003 72
Table 33: Needed equipment for SUBs Equipment Item cost # of each item Total cost per item Elevtrocardiographs $703.70 4 $2 814.81 Cardiac defibrillators $1 005.29 4 $4 021.16 Refrigerator $307.07 1 $307.07 Bactericid lamp $100.53 2 $201.06 Height measurer: child $22.05 1 $22.05 Height measurer: adult $17.20 1 $17.20 Oxygen cylinder $12.35 2 $24.69 Set of medical splints $13.23 2 $26.46 Ultrasounds (optional) ($8,042.33) 4 ($32,169.31) Total (without ultrasounds) $7,434.50
· Equipping the patient rooms of all SUBs with appropriate furniture, the standard listing of which with price estimates is provided in Table 34. The total cost of furnishing all 12 patient rooms in use (in all four SUBs) will be $10,578.
Table 34: Price estimates of furniture for patient rooms in SUBs Item Price for one Mean # of items Total price per item* in room item 1.Running water sink $30.86 1 $30.86 2.Bed $126.10 3 $378.31 3.Bed table $22.22 3 $66.67 4.Table $59.96 1 $59.96 5.Chair $21.16 4 $84.66 6.Refrigerator $202.82 1 $202.82 7. Heater $38.80 1 $38.80 8. Telephone $19.40 1 $19.40 Total $881.48 * Average cost estimates
· Providing all the assessed SUBs with the standard listing of drugs and disposables for primary level (Tables 15 and 16)
4.3 Central Regional Hospitals and Republican Dispensaries
Central regional hospitals
A hospital at any level, whether serving an urban or a rural population, is an integral part of the health system, with a key role to play in achieving health for all. Hospitals throughout the world represent the largest concentration of health care investments, resources, and professional skill. Anytime someone suffers a physical or mental ailment that cannot be managed on an ambulatory basis admission to an inpatient facility is sought.
Center for Health Services Research and Development, December, 2003 73 Findings from this assessment pointed out the need to strengthen the Central Regional Hospital’s role in developing partnerships with primary and post-discharge care providers and supporting the referral services. While the availability of inpatient services exists at all four of the CRHs, none of the regions are able to effectively provide quality emergency care and primary referral level care to their corresponding regional population. Along with training and procurement of essential drugs and equipment the restructuring and renovating of the inpatient units of the four Central Regional Hospitals is a priority.
This assessment highlighted that a significant burden of diseases in NK is caused by time- sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhea, intentional and unintentional injuries, and acute myocardial infarction. Emphasis must be placed on the strengthening of triage and emergency care within the context of the integrated management of childhood illnesses and management of adult illnesses. Health programming in NK to date has focused on the first level primary care provider. However, in order to build upon the success of previously USAID funded projects, it is vital to strengthen primary care services at the secondary level. This will ensure continuity of care for patients referred from primary care units.
The detailed assessment of the CRHs of NK highlighted the following priorities:
Renovation of CRH facilities
All four of the CRHs are in dire need of restructuring and renovation. The maternity and polyclinic units of the Martuni, Mardakert and Hadrut CRHs have been renovated. Therefore activities will focus on the inpatient units for the above mentioned CRHs. The CRH in Askeran is different than the other three facilities, in that it has not been included in either Family Care or the ICRC program. Therefore, no significant renovation activities have occurred in the facility.
· Planning for each CRH will require that a functional space program be formulated for each facility to provide the necessary services to the intended population. The functional space program describes the most effective use of the available space within the building. Renovation recommendations for each specific CRH will be made according to clinical, systematic, and structural needs in order to create a “building” that is responsive to the health care needs. The design of the renovation of the inpatient units will incorporate the previously renovated spaces (polyclinic and maternity) and create a macro plan for patient flow and service provision throughout the building. Therefore ensuring appropriate patient movement and referral through the system as well as the facility. This type of functional space planning allows for space, equipment and resources to be shared by both inpatient and outpatient units. For example, simple diagnostic and laboratory capabilities are necessary for both the Regional polyclinic and inpatient division. During the functional space planning, essential diagnostic and laboratory facilities will be designed and located in the building in order to maximize their utilization.
Uncoordinated follow up, disconnected planning activities, and a lack of norms, standards and locally adapted protocols and methodologies can lead to inappropriate design and utilization of the regional hospitals. This field assessment highlighted the need to create a better integrated health care delivery system in NK as a strategy to deal with current and
Center for Health Services Research and Development, December, 2003 74 projected health care service demands. Therefore, detailed planning of the renovation for each structure is a priority for the project health and engineering teams
· Since a regional approach has been adopted for program implementation, CRH functional space planning and renovation activities will commence in Askeran. The functional space plan for this CRH will differ from the remaining three facilities. During construction activities in Askeran, the planning team will turn its attention to the other three CRH facilities. Each facility will undergo functional space planning and a detailed implementation plan will be compiled. Based on construction activities in the other sectors, the construction timeline for the remaining three facilities will be prioritized.
· Due to the large structures left behind from a Soviet legacy, it is not possible or even desirable to renovate entire buildings. Further, renovation activities for each building will vary. Standards will be applied to protect specific space or technical requirements. However, a standardized functional space plan will not be applied to all the facilities. Due to differences in building architecture, renovation needs and prior renovation activities, each facility will need a unique functional space plan.
· Planning and renovation activities for each CRH will largely focus on the pediatrics and medicine units, as well as diagnostics and laboratory. Surgical units will also be included however as a secondary priority. Restructuring the inpatient division more in terms of levels of care will ensure that the CRH is providing effective emergency care and primary referral care to its corresponding regional population.
· In order to increase the effectiveness and efficiency of the CRH, the strategy will be to use fewer hospital beds more intensively, with shorter average lengths of stay, reflecting the changing patterns of disease and clinical management. Day-care interventions and short stay acute care should account for more of the total district hospital activities as is recognized globally. The Sanitary epidemiologic stations for each region will be relocated into the CRH facilities if they presently reside in other buildings. This integration of space and sharing of facilities will trim the system of redundancy and waste.
· Inpatient divisions are more costly to renovate then outpatient units, due to specific structural and material requirements. Each CRH facility will need to renovate between 1,000 – 1,700 sq. meters in the inpatient division. The cost of renovation for each sq. meter within an inpatient facility is estimated at $250. Therefore, the construction budget is estimated at $250,000 – 425,000 per facility.
· Renovation of each facility will include the water and sewage systems to ensure the availability of running water and proper waste disposal. The structures have indoor piped water supplies and sewage systems. However, most are dilapidated and inoperable. Securing these commodities is a priority in the renovation activities.
Center for Health Services Research and Development, December, 2003 75 Equipment and Supplies
The CRH has a strong community- oriented role. It is responsible for providing and/or supervising all the curative, preventive and promotive health activities for its regional population. As such, it has a very pivotal role in the continuum of primary care service provision. In order to ensure appropriate service delivery, investments in training and essential equipment and supplies are necessary.
· The purchasing decisions made for the newly planned National Adult Polyclinic in Stepanakert was based on a macro-assessment of needs, equipment cost analysis, available support capacity and long-term effects of acquired technology on the health system. The National Polyclinic program is developing in-house services for routine maintenance and repair of purchased equipment. Equipment engineers are being trained in Armenia and NK by medical equipment and technology providers. To keep in line with established standards and to utilize the resources created by the National Polyclinic project, the list of essential diagnostic, laboratory and medical equipment for the CRHs will be modeled after the polyclinic list. Table 35 provides the list of equipment for the National Polyclinic that is to be sponsored by USAID.
Table 35: List of essential diagnostic, laboratory and medical equipment needed for the National Polyclinic.
Item Description # Price per item Total
Rehabilitation / Physical Therapy Paraffin Bath 1 $ 300.0 $ 300.0 Treadmill, 1 $ 1,000.0 $ 1,000.0 UHF therapy 2 $ 450.0 $ 900.0 Ultrasound therapy 2 $ 500.0 $ 1,000.0 Muscle therapy 2 $ 450.0 $ 900.0 Electrotherapy 2 $ 450.0 $ 900.0 Inhalator 2 $ 250.0 $ 500.0 Magnitotherapy 1 $ 500.0 $ 500.0 UV -therapy 2 $ 75.0 $ 150.0 Table, Physical Therapy 12 $ 250.0 $ 3,000.0 Stair, Exercise 1 $ 350.0 $ 350.0 Scale, Stand-On, Patient 2 $ 380.0 $ 760.0 Table, Exam/Treatment, Manual 11 $ 250.0 $ 2,750.0 Ward Screens 10 $ 180.0 $ 1,800.0 Sphygmo Aneroid, Adult, Wall Mtd 10 $ 90.0 $ 900.0 Stethoscope 4 $ 50.0 $ 200.0 Stair, Exercise 1 $ 350.0 $ 350.0 Exerciser, Dumbbell Set 1 $ 200.0 $ 200.0 Exerciser, Upper Body Ergometer 1 $ 1,200.0 $ 1,200.0 Exerciser, Bicycle, Ergometer 2 $ 350.0 $ 700.0 Scale, Stand-On, Patient 2 $ 380.0 $ 760.0 Table, Exam/Treatment, Manual 11 $ 250.0 $ 2,750.0 Total $ 21,870.0
Center for Health Services Research and Development, December, 2003 76 Item Description # Price per item Total Adult Primary Care Scale, Stand-On, Patient 4 $ 380.0 $ 1,520.0 Table, Exam/Treatment, Manual 18 $ 250.0 $ 4,500.0 Ward Screens 22 $ 180.0 $ 3,960.0 Wardrobe/shelves 22 $ 250.0 $ 5,500.0 Sphygmo Aneroid, Adult, Wall Mad 22 $ 90.0 $ 1,980.0 Stethoscope 45 $ 50.0 $ 2,250.0 Oto/Ophthalmoscope 20 $ 450.0 $ 9,000.0 Stool, Adjustable 34 $ 160.0 $ 5,440.0 ENT / Audiology $ - Chair, Exam/Trt, ENT w/ Light 1 $ 4,000.0 $ 4,000.0 Cabinet, ENT Treatment 1 $ 2,000.0 $ 2,000.0 Audiometer 1 $ 5,500.0 $ 5,500.0 Ophthalmology $ - Slit Lamp / Complete Set 1 $ 5,500.0 $ 5,500.0 Stool, Ophthalmic 1 $ 150.0 $ 150.0 Chair, Ophthalmic, Powered 1 $ 450.0 $ 450.0 Stand, Instrument, Ophthalmic 1 $ 3,000.0 $ 3,000.0 Mirror Set, Projector, Projector Screen Ophthalmic 1 $ 2,000.0 $ 2,000.0 Ophthalmoscope 1 $ 1,600.0 $ 1,600.0 Total $ 58,350.0
General Procedure Room Table, Exam/Trt, (surgical) 1 $ 6,500.0 $ 6,500.0 Stretcher, Procedure 1 $ 800.0 $ 800.0 Light, Procedure, Ceiling Mtd. 2 $ 1,250.0 $ 2,500.0 Pump, Suction 3 $ 500.0 $ 1,500.0 Refrigerator /, Upright 1 $ 450.0 $ 450.0 Refrigerator, Undercounter 1 $ 950.0 $ 950.0 Scale, Stand-On, Patient 2 $ 380.0 $ 760.0 Table, Exam/Treatment, Manual 2 $ 500.0 $ 1,000.0 Ward Screens 2 $ 180.0 $ 360.0 Wardrobe/shelves 4 $ 250.0 $ 1,000.0 Sphygmo Aneroid, Adult, Wall Mad 1 $ 90.0 $ 90.0 Stethoscope 2 $ 50.0 $ 100.0 Electrosurgical unit 1 $ 6,000.0 $ 6,000.0 Autoclave, Table Top, 15l 1 $ 4,000.0 $ 4,000.0 Light, Exsamenation, Mobile 2 $ 300.0 $ 600.0 Surgical Instrument Set,Small 2 $ 400.0 $ 800.0 Drug Cabinet 4 $ 250.0 $ 1,000.0 Total $ 28,410.0
Diagnostic Unit Cart, Emergency (Crash) Adult 1 $ 3,500.0 $ 3,500.0 Spirometry System 1 $ 1,800.0 $ 1,800.0 Analyzer Pulmonary Function 1 $ 5,500.0 $ 5,500.0 Analyzer, Blood Gas 1 $ 20,000.0 $ 20,000.0 ECG, 3 Channel, Interpretive 4 $ 2,500.0 $ 10,000.0
Center for Health Services Research and Development, December, 2003 77 Item Description # Price per item Total Monitor, Physiologic, Transport 2 $ 5,000.0 $ 10,000.0 Defibrillator/Monitor 1 $ 7,000.0 $ 7,000.0 Ultrasound Scanner (7.5 & 3.5) 1 $ 20,000.0 $ 20,000.0 Ultrasound Scanner ( 3.5) portable 1 $ 9,000.0 $ 9,000.0 Ultrasound doppler / Echocardiograph 1 $ 55,000.0 $ 55,000.0 Treadmill, Stress Test (entire unit) 1 $ 15,000.0 $ 15,000.0 Viewbox, 1-Film, Surfaced 2 $ 150.0 $ 300.0 Viewbox, 2-Film, Surfaced 7 $ 250.0 $ 1,750.0 Chair, Phlebotomy 2 $ 700.0 $ 1,400.0 Centrifuge 2 $ 1,500.0 $ 3,000.0 Refrigerators 2 $ 300.0 $ 600.0 Microscopes 2 $ 1,200.0 $ 2,400.0 Total $ 166,250.0
Sterilizer, Autoclave, Ctr.Top (15L) 1 $ 4,000.0 $ 4,000.0 Sterilizer, Autoclave, Horizontal (100L) 1 $ 8,000.0 $ 8,000.0 Sterilizer, Hot air 1 $ 1,500.0 $ 1,500.0 Stainless steel holloware/ Sterilization drums 1 $ 4,500.0 $ 4,500.0 Cleaner, Ultrasound, OR Instruments 1 $ 2,500.0 $ 2,500.0 Total $ 20,500.0
Project Total $ 295,380.0
· The quantity of equipment and furniture necessary for each CHR differs with each facility. As was previously stated, in order to increase the effectiveness and efficiency of the CRH, the strategy will be to use fewer hospital beds more intensively, with shorter average lengths of stay. It is estimated that at least a 15% reduction in the number of beds per facility in Mardakert and Hadrut would better serve the regional needs of the populations. The bed index for both regions is supportable. In Martuni, and especially Askeran, the bed index is very low. Therefore, a reduction in the number of beds may not be optimal. During the functional space planning, these figures will be worked out in detail.
· Currently, Askeran has ten beds. The estimated cost to furnish five rooms for 10 beds, assuming double occupancy, with the recommended standard basic furniture is shown in detail by number of items and estimated cost in Table 36. In Hadrut, there are 50 beds and therefore a 15% reduction would result in 43 beds and 22 rooms. In Mardakert, there are 70 beds and so the reduction would result in 60 beds and 30 rooms. In Martuni, there are 60 beds, therefore, 30 patient rooms. The total cost for furnishing the patient rooms in all four regions is estimated to be $60,759.93.
Center for Health Services Research and Development, December, 2003 78 Table 36: Estimated cost for equipment per inpatient room assuming double occupancy and total cost of room by estimated optimal number of beds and including total estimated cost by region (after a 15% reduction in number of beds).
Item Cost Askeran Hadrut Mardakert Martuni Optimal # of beds 10 43 60 60 Optimal # inpatient rooms 5 22 30 30 Sink with running water $30.86 $154.30 $678.92 $925.80 $925.80 2 chairs $42.32 $211.60 $931.04 $1,269.60 $1,269.60 2 beds $252.30 $1,261.50 $5,550.60 $7,569.00 $7,569.00 2 bedside tables $44.52 $222.60 $979.44 $1,335.60 $1,335.60 1 dresser $141.09 $705.45 $3,103.98 $4,232.70 $4,232.70 1 screen $148.41 $742.05 $3,265.02 $4,452.30 $4,452.30 1 heater $38.89 $194.45 $855.58 $1,166.70 $1,166.70 TOTAL $698.39 $3,491.95 $15,364.58 $20,951.70 $20,951.70
· Supply of pharmaceuticals and disposable supplies is integral to the success of any health system. All of the facilities will need to be periodically supplied with essential drugs and consumables. At present, the current pharmaceutical needs are not being met by the MoH of NK and the regional administrations. With the termination of the Family Care and ICRC programs, a larger unmet need is going to result. The list of essential pharmaceuticals for the CRH level is provided in Table 37.
Table 37. List of essential pharmaceutical for the CRH level. Per-item Price Medicines Form Estimates (US $) Albucid 30%, 1.5ml (Sulfacyl-Natrii) x 2 item $0.26 Almagel bottle $1.28 Amoxicillin 250mg x 10 caps $0.62 Ampicillin 1.0g flac $0.43 Analgin 50%, 2ml x 10 amp $0.51 Aspirin 0.5g x 10 tab $0.09 Atropine 0.1%, 1ml x 10 amp $0.39 Baralgin 5ml x 5 amp $3.29 Benzylpenicillin 1MU (=600mg) flac $0.10 Calcium Chloratum 10%, 10ml x 10 amp $0.97 Captopril 25mg x 24 tab $0.90 Cefazolin 1g flac $0.93 Chlorhexidine 5%, 1l (4% 1l) for dilution $14.70 Coffein 10%, 1ml x 10 amp $0.51 Cordiamin 25%, 2ml x 10 amp $1.07 Dexamethasone 4mg, 1ml x 25 amp $5.47 Diazepam 5mg/ml, 2ml x 10 amp $2.28 Dibasol 1%, 5ml x 10 amp $0.89 Dicynon 12.5%, 2ml x 50 flac $10.40 Digoxine 0.25mg x 50 tab $0.90 Digoxine 250mcg/ml, 2ml (1ml x 10) amp $3.74 Dimedrol 1%, 1ml x 10 amp $0.36
Center for Health Services Research and Development, December, 2003 79 Per-item Price Medicines Form Estimates (US $) Epinephrine (Adrenaline) 1mg/ml, 1ml x 10 amp $0.53 Euphyllin 2.4%, 5ml x 10 amp $0.65 Ferrous Sulfate 200mg + Folic Acid 0.4mg (Ferroplex) x 100 tab $2.41 Furadonin 0.05g x 10 tab $0.04 Furazolidone 0.05g x 10 tab $0.04 Furosemide 10mg/ml, 2ml x 10 amp $1.01 Gentamycine 40mg/ml, 2ml x 10 amp $1.34 Glucosa 5%, 500ml flac $0.66 Glyceryl Trinitrate (Nitroglycerin) 500mg - sublingual x 40 tab $0.61 Heparin sodium 5 000 IU/ml, 5ml flac $1.34 Hydrochlorothiazide (Hypothiazide) 25mg x 20 tab $1.81 Indometacin 25mg x 30 tab $0.23 Insulin biphasic 100IU/ml, 10ml flac $4.59 Isosorbit dinitrate (Nitrosorbit, Isodinit) 10mg - sublingual x 50 tab $0.56 Liniment Vishnevsky 30g tube $0.40 Magnesium Sulfate 25%, 5ml x 10 amp $0.76 Mebendazole 100mg x 10 tab $1.77 Methyldopa (Dopegit) 250mg x 50 tab $3.73 Metoclopramide 5mg/ml, 2ml x 10 amp $3.66 Metronidazole 250mg x 20 tab $0.35 Natrium Chloratum 0.9%, 500ml flac $0.61 Nifedipine 10mg x 50 tab $0.73 Nitrong 6.5mg x 100 (25) tab $5.17 No-spa 2ml x 25 flac $8.46 Novocainum 0.5%, 250ml flac $0.83 Oral Rehydration Salts 27.9g/1l x 1 sachet $0.55 Oxytocin 10 IU, 1ml x 10 amp $1.66 Panangin 5 ml (instead of Asparcam) (10ml x 5) amp $2.51 Papaverin 2%, 2ml x 10 amp $0.43 Paracetamol 0.5g x 10 tab $0.08 Phenylephrin (Mesatonum) 1%, 1ml x 10 amp $1.65 Polyvidone iodine 10%, 200ml bottle $5.30 Propranolol (Obsidan, Anaprilin) 10mg, (40mg) x 50 tab $0.28 Proserinum 0.05%, 1ml x 10 amp $0.36 Ranitidine x 10 tab $0.33 Ringer-Lactate, 500ml plastic $0.58 Salbutamol 4mg x 10 tab $0.53 Salbutamol aer, 10ml item $2.54 Sulfocamphocain 10%, 2ml x 10 amp $0.62 Suprastine 2%, 1ml x 5 amp $2.33 Trimetoprim-Sulfamethoxazole (Co-Trimoxazole 480mg) x 10 tab $0.79 Vitamin B1, 1ml x 10 amp $0.30 Vitamin B12 500mcg/ml, 1ml x 10 amp $0.33 Vitamin C 5%, 1ml x 10 amp $0.30 Vitamin K1, 10mg/ml, 1ml x 10 amp $0.31 Water for injection, 2ml amp $0.28
Center for Health Services Research and Development, December, 2003 80 Republican Dispensaries Most of the secondary and tertiary care centers have never been included in large-scale humanitarian activities in NK. The Oncology and STD Dispensaries are no different. Unfortunately, resources for this project do not allow for these facilities to be included as a top priority.
Chronic diseases, particularly cancers, are a major contributor to morbidity and mortality in NK. STDs and other communicable diseases, not addressed in IMCI and ADM, also contribute to NK’s disease burden. However, this program’s main objective is to build upon the success of previously funded USAID’s projects, which have mainly focused on strengthening primary health care. This program will expand primary care services both geographically as well as to the referral level. Limited resources do no presently allow the scope of the program to be expanded in order to include these dispensaries.
Conclusions
WHO has been actively promoting integrated care worldwide in order to improve outcomes, accessibility and cost-containment. Following the Alma-Ata global primary care campaign, WHO recognized the need for hospital integration into the primary health care approach. Thus, international guidelines for the integration and strengthening of primary health care were developed and the functions of hospitals as referral levels were delineated and incorporated in to the primary health care continuum.
Throughout the years of USAID’s involvement in NK, the focus has been in principle that primary care should be the lynchpin to a well responsive and performance focused health care system. A series of guidelines, such as IMCI and ADM, have been put into place to increase the performance of primary care. However, it is important to note that both protocols assume the availability of referral services.
Based on this assessment, the disease burden for referral signals the strong need for implementing referral level activities. Further, the vast majority of respondents stated that their CRH was their first referral choice, followed by the republican facilities located in Stepanakert. Sixty-six percent of village outpatient health facility staff referred their patients to the CRH prior to referral to Stepanakert. Therefore, the intent of the program is to make full use of existing lower-level facilities and to encourage users to follow the desired referral pattern. Continuing to strengthen the reliability, quality and responsiveness of services at lower-level facilities as well as at the referral level is the key objective. More effective and efficient utilization of the limited resources will allow the CRH to cover the optimum inpatient treatment needs of the people, especially those at risk. Enhancing a health system’s responsiveness to people’s needs and expectations leads to improved utilization of services and better health outcomes.
4.4 San-epi Stations While structurally outside the medical services system, the San-Epi service performs essential primary health care functions and has not been targeted for support in past programs. An effective San-Epi services complement primary health care by protecting health and responding
Center for Health Services Research and Development, December, 2003 81 to community/population-based health threats. These efforts are on par with efforts to improve the delivery of health services at the village/community level in terms of both importance and cost-effectiveness. Thus, addressing the needs of the San Epi services is the second priority within this program.
Specific activities recommended under the framework of this project are:
Republic Level
After detailed planning and architectural review, the Republican level San-Epi facility should be renovated to a level (number of rooms, layout, equipment) consistent with its function. Given the co-location of the regional/city San-Epi service in the same building, those laboratories, etc., which use common equipment, can be expanded to simultaneously meet the needs of both services, without needlessly duplicating space or equipment. The Republican San-Epi services must be prepared to · monitor water quality to safeguard the population (drinking water quality) and agriculture (salinization, etc) (Appendix 12) o Water quality monitoring laboratory for routine and periodic surveillance · Monitor and diagnose disease outbreaks from nuclear, chemical, or biological sources through o Microbiology/culture laboratory o Serology laboratory o Chemistry laboratory (physical and wet) · Promote disease prevention through vaccination and control activities o Sanitary/hygiene laboratory o Equipment to maintain cold chain (on site and for field delivery) o Transportation services to deliver materials/collect samples from throughout NK o Equipment/software needed for effective disease surveillance and outbreak investigations o Ensure vaccine supply is adequate for all recommended/required immunizations · Support needs of regional SES · Provide space, shared equipment and resources to Stepankert regional SES
The Republican SES annual requirements in drugs/reagents are provided in Appendix 11.
Regional Level
Stepankert/Soushi/Askeran. Currently, the region encompassing Soushi (Green town), Stepanakert, and Askeran each have small regional SES. In practicality, only one service is needed to serve the entire region. This service is most efficiently provided in coordination with the Republican SES office based in Stepanakert. In combination with expanding the capacity of the Stepanakert SES to absorb the increased demand by assuming responsibility for the Soushi and Askeran areas, those other facilities will be closed. This results in a more efficient operation based in Stepanaket. {The alternative is to locate the regional SES in Askeran as outlined below and closing the Stepankert SES.}
Center for Health Services Research and Development, December, 2003 82 Remaining regions. For the remaining regions, the SES will be housed in conjunction with the laboratory areas of the Central Regional Hospitals. The CRHs have laboratory needs that complement and overlap the needs of the regional SES. Thus, both facilities can benefit from a shared, expanded space without the needless duplication of capacity at adjacent facilities. In addition, this approach improves SES’s ability to monitor disease patterns by providing direct access to patient populations to detect trends in illnesses, etc.
While SES analyses at the regional level are less complex than at the Republican level, the added demands for meeting CRH needs results in similar capacity being available at the regional as at the Republican level. These combined facilities will need adequate laboratory facilities to meet the needs of both the regional SES and the CRH. This includes: · Water quality monitoring (See Appendix 12 for details) · Bacteriological laboratory · Chemistry laboratory · Serology laboratory · Sanitary/hygiene laboratory · Cold chain facilities (on site and for field delivery) · Transportation services for collecting routine samples and for field monitoring/outbreak investigations
For the Hadrut region, this approach means consolidating the efforts of the anti-plague station, which operates separately from the SES and the CRH, with the SES and locate all services at the CRH facility. This renovated facility will need additional capacity beyond that provided to the other regional facilities for dealing with the added plague monitoring and surveillance function.
4.5 Ambulance Station The Ambulance station in Stepanakert is the only facility providing ambulance services to the city population. It works with high workload and needs urgent support to sustain its functioning on satisfactory level. The assessment of this facility pointed out the need for the following interventions: · Renovation of the facility · Repair of the facility’s 6 vehicles · Provision of facility with two new ambulance vehicles ($ 13,800 each) · Provision of the facility with an ambulance vehicle equipped with the necessary equipment for cardio-resuscitation brigade ($19,000) · Provision of the facility with a portable electrocardiograph ($700) and defibrillator ($1,000).
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5. Summary of Priorities/Recommendations
Taking into consideration the findings of the assessment, as well as the principle of approaching primary healthcare facilities as the main services that ensure the health and well being of the population they serve, first of all through preventive measures, the following priorities can be derived:
First Priority · Village health posts/ambulatories are the main community-oriented healthcare structures with dual functions of prevention and first level disease management. Thus, these services are considered the first priority. The project will ensure their compliance with existing standards in terms of physical layout, furniture, equipment, drugs, disposable supplies, and provider performance level. A piped water supply and sewage system must be installed in these facilities to ensure minimal hygiene/safety.
Second Priority · San-epi services which promote health through their vaccination and sanitation/water monitoring functions and protect health through their surveillance and disease control functions are considered the second priority. San-epi serves to protect the basic health of the population, which is the most cost-effective approach in ensuring health and well being of population. The basic needs of these services in terms of laboratory capabilities, equipment, and drugs/reagents should be addressed to ensure appropriate quality and continuity of their functioning. At the regional level, this should be accomplished by locating the San-epi units within the CRH hospitals to provide for expanded and complementary lab services that meet the needs of the CRHs and the San-Epi while providing San-Epi direct access to surveillance and monitoring of the patient population.
Third Priority · Third priority is given to the secondary level facilities, such as Central Regional and Republican Hospitals, because they serve as the main referral services for primary level facilities and are necessary to ensure timely referral and continuity of care, especially for the conditions included in IMCD and ADM training modules. A proper referral system will guarantee secondary prevention of many complications and health hazards related to these conditions. To serve this purpose, secondary level facilities should be renovated, equipped and supplied in an extent that allows them to function in accordance with the existing standards. Taking into consideration the results of the assessment of these facilities and the purpose they serve, a special emphasis should be given to strengthening diagnostic and inpatient services of these facilities.
· As resources permit, other special needs of secondary-tertiary level facilities (units an functions outside the domain of primary care/support)
· Local leaders/organizations/businesses should be encouraged to develop sustainable transportation links/ambulance services to ensure patients have access to the CRHs from
Center for Health Services Research and Development, December, 2003 84 rural areas and CRH patients have access to national referral centers, possibly with support from this project.
In sum, the approach of the health facility renovation component of this project, supported by the proposed training program, is to ensure local primary care and preventive services are effectively and efficiently implemented, with appropriate referrals made to equipped and prepared secondary and tertiary facilities. It is hoped that by meeting these humanitarian needs, these efforts will result in improved primary and preventive care, improved access to primary and preventive care, improved quality of care, and reduced demand (both appropriate and inappropriate) for secondary and tertiary care.
The budgetary implications/estimates of these recommendations are summarized in Table 38.
Table 38. Estimated cost to implement facility renovation/supply efforts, by priority Priority 1 Village Health Posts/Ambulatories (130 facilities) Renovation: Equipment/furniture: $224,000 Drugs/disposables (annual): $144,000 Village district Hospitals (4 facilities) Renovation: Equipment/furniture: $18,000 Drugs/disposables (annual): $11,000
Total - priority 1: Renovation: Supplies: $397,000
Priority 2 San Epi Stations (7 facilities) Renovation: Drugs/reagents (annual): $40,000 Vehicles (4): $40,000 Water monitoring: $140,000 Lab establishment (4): $200,000
Total – priority 2: Renovation: Supplies: $420,000
Priority 3 CRHs Renovation: $1,100,000 ? (4 facilities) Equipment/Furniture: $657,300 Drugs/disposables (annual): $33,300
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Ambulance Station Renovation: Equipment/vehicles: $48,300 Drugs/disposables (annual): $11,100
Total – priority 3: Renovation: Supplies: $750,000
TOTAL – PROJECT: Renovation: Supplies: $1,567,000
Conclusion
At this stage of analysis, preliminary cost estimates have been made for the various priority tasks. These estimates are very general and must be developed in detail for each project. While a general approach is possible for the village level facilities and the San Epi, a facility-specific approach should be applied to the secondary/tertiary level facilities.
The priority recommendation is for renovation and equipping of village level facilities (FAPs, SUBs, SVAs).
Second priority is given to improving the capacity of the San-Epi service to promote and protect the public’s health. Basic strategies are outlined for both the republican and regional level facilities
Of the remaining funds, priority is next given to expanding diagnostic and treatment capacity of secondary facilities. This is beyond the laboratory capacity provided to CRH under the San-Epi initiative. As each facility is somewhat unique, more customized detailed planning is needed, as well as more accurate estimates of the remaining funds available.
These priorities may provide difficult to partial out by regional allocations in block with other sectors of this project unless additional planning and costing is completed to ensure adequate funds are reserved to complete the first and second priorities.
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6. References
1 Kirsti Lattu, David Garner, Dennis Culkin. Humanitarian Needs Evaluation for victims of the Nagorno Karabagh conflict. January,1998 (Prepared for the United States Agency for International Development, Bureau of Europe and New Independent States)
2 Office of the Nagorno Karabagh Republic in the United States. Country Overview. www.nkrusa.org/position_papers/us_assistance.html Accessed at 5 August, 2003
3 Communications with MOH officials (Z. Lazaryan, G. Hovannissyan), 2003
4 The listings included the following: WHO Model List of Essential Medicines (revised April 2002); The List of Main Drugs of the Republic of Armenia (approved by MOH by Order #16 on January 11, 2002); Medications Used in Primary Pediatric Care, Ambulatory Kit, MOH, 2003; Drug List for Primary Health Care, UMCOR; Drug List for Primary Health Care, OXFAM; List of drugs Provided to the 66 Health Facilities Covered by the ICRC PHC Program
5 The only exclusion is the standard list of for equipment/furniture for dental services (the source of the latter is provided next to it in parenthesis).
6 The List of Main Drugs of the Republic of Armenia (approved by MOH by Order #16 on January 11, 2002); Essential Drugs List Hospital Adults, Copyright 1998, The National Department of Health; WHO Model List of Essential Medicines (revised April 2002)
7 General Standards of Construction and Equipment for Hospitals, Chapter 3-07-02.1, General Authority NDDS 23-01-03 (3)(4), 28-32-02
8 Construction Standards and Rules, Part II: Blueprinting Norms, Chapter 69: Health Facilities, Moscow Stroyizdad 1978
9 General Standards of Construction and Equipment for Hospitals, Chapter 33-07-02.1, Effective April 1, 1994, General Authority NDCC 23-01-03(3)(4), 28-32-02
10 WHO, Restructuring hospital systems in the central Asian republics.
11 Khatani SM et al. National university hospital discharge survey in the Islamic Republic. of Iran. Eastern Mediterranean Health Journal, 2000, Vol. 6, Issue 2/3: 402-403.
12 World development indicators 1998. Washington DC, World Bank, 1998.
13 WHO, Restructuring hospital systems in the central Asian republics. Khatani SM et al. National university hospital discharge survey in the Islamic Republic.
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