S16169e PDF

The Essential Package
of Hospital Services
for Afghanistan
Islamic Republic
of Afghanistan
Ministry of Public Health
2005/1384
Islamic Republic of Afghanistan
The Essential Package of

Hospital Services
for Afghanistan
July 2005
Saratan 1384
Table of Contents
Abbreviations ..............................................................................................................iv
Foreword.......................................................................................................................v
Acknowledgments .......................................................................................................vi
1. The Hospital Sector in the Afghan Health System ........................................................... 1
1.1 Background: The Afghan Health System and Issues Facing Hospitals .......................... 1
1.2 Purpose............................................................................................................................ 2
1.3 Levels of Hospitals.......................................................................................................... 3
1.4 The Relationship between the BPHS and the EPHS....................................................... 3
1.5 The Role of Hospitals in the Health System ................................................................... 5
1.6 Organization of Hospitals ............................................................................................... 9
1.7 The Future of Hospitals in Afghanistan ........................................................................ 10
2. Services Provided by Different Levels of the Hospital Sector ....................................... 14
3. Diagnostic Services Provided by Different Levels of the Hospital Sector .................... 21
4. Staffing of Hospitals by Type of Hospital........................................................................ 23
5. Equipment for Hospitals by Type of Hospital ................................................................ 25
6. Essential Drugs for Hospitals by Type of Hospital......................................................... 32
Annexes
A. Hospital Policy for Afghanistan’s Health System ............................................................ 43
B. Staffing Assumptions for Advised Staffing Patterns ........................................................ 51
List of Figures
Figure 1. Link between the BPHS and Hospital Sector ............................................................ 4
Figure 2. Entry and Flow of Patients at the District Hospital.................................................... 5
Figure 3. Organizational Structure of Hospitals...................................................................... 10
List of Tables
Table 1. Summary of Services at a District Hospital ................................................................ 6
Table 2. Summary of Services at a Provincial Hospital ............................................................ 8
Table 3. Summary of Services at a Regional Hospital .............................................................. 9
Table 4. Standards for Hospitals ............................................................................................. 12
Table 5. Accreditation: Dimensions of Quality of Care.......................................................... 14
Table 6. Diagnosis and Treatment of Common Conditions, by Type of Hospital .................. 15
Table 7. Diagnostic Services, by Type of Hospital ................................................................. 21
Table 8. Staffing of District, Provincial, and Regional Hospitals ........................................... 24
Table 9. Equipment and Supplies List, by Type of Hospital................................................... 26
Table 10. Essential Drugs for Hospitals, by Type of Hospital ................................................ 33
iii
Abbreviations
ANC antenatal care
BHC basic health center
BPHS Basic Package of Health Services
CHC comprehensive health center
CHW community health worker
DH district hospital
DOTS Directly Observed Therapy, Short Course
DPT diphtheria pertussis tetanus
EC European Commission
ECG electrocardiogram
ENT ear-nose-throat
EPHS Essential Package of Hospital Services
EPI Expanded Program on Immunization
HMIS health management information system
HP health post
ICRC International Committee of the Red Cross
IMR infant mortality rate
IP inpatient
MMR maternal mortality ratio
MOPH Ministry of Public Health
MSH Management Sciences for Health
NEDL national essential drug list
NGO nongovernmental organization
OPD outpatient department
OT operating theater
PH provincial hospital
PHC primary health care
RH regional hospital
STD sexually transmitted disease
U5M under-five mortality
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
iv
Islamic Republic of Afghanistan
_____________________________________________________________________
Foreword
The Ministry of Public Health is pleased to present the Essential Package of Hospital
Services (EPHS). This document represents a key element in the development of the
Afghan health system. The EPHS establishes what each type of hospital in the Afghan
health system (district, provincial, and regional) should provide in terms of the services
offered at each level and the resultant staff, equipment, diagnostic services, and
medications required to provide those hospital services. This, in essence, establishes the
standards for the hospitals of our country. The EPHS will help us develop the clinical and
administrative standards by which our hospitals should operate and thereby improve
quality. The ultimate purpose for the development of the EPHS has been to improve the
quality of hospital services provided to the population of Afghanistan.
The EPHS is not a stand-alone document but clearly complements the Basic Package
of Health Services (BPHS). These two documents, the BPHS and the EPHS, define
the key elements of the health system Afghanistan’s Ministry of Public Health is
building. They illustrate where basic primary care and hospital services are provided
and the referral hospital system necessary to support the BPHS. Figure 1 in this
document illustrates the role the district hospitals play as the link between the BPHS
and the hospital sector. Afghanistan is building a health system based on basic health
services that address our major health problems and supported by our hospital system,
as represented in the EPHS.
I would like to express my appreciation to Dr. Shakohmand and the members of the
Hospital Management Task Force for development of the EPHS. The MOPH is also
grateful to the many other Ministry, NGO, and international staff who made
comments on earlier drafts and participated in the development of this document. We
are especially grateful to USAID, which, through Management Sciences for Health,
has provided funds and technical experts for the development as well as the
publication and distribution of the EPHS.
Let us all use this opportunity to recommit ourselves to the ongoing development of
the health system of Afghanistan for the benefit of our noble and deserving people.
Dr. Sayed Mohammad Amin Fatimie

Minister of Public Health
Kabul, Afghanistan
March 2005
v
Acknowledgments
The development of the Essential Package of Hospital Services was completed by the
MOPH Hospital Management Task Force. The members of the task force during the
time of its development in 2004 were:
Ministry of Public Health Task Force Members

Dr. Ahmad Shah Shakohmand, Director-General and Task Force Chairman
Dr. Abdul Hakim Aziz
Dr. Gyuri Fritsche
Dr. Ghulam Sarwar Hemati
Dr. Abdul Rab Kohistani, Wazir Akbar Khan Hospital
Dr. Abdul Basir Mansoor
Dr. Nasrin Oryakhil, Rabia Balkhi Hospital
Dr. Rohullah Rasekh, Indira Ghandi Children’s Hospital
Dr. Fahima Sekandari, Malalai Hospital
MOPH Partner OrganizationTask Force Members

Ms. Palina Asgeirsdottir, ICRC
Dr. Maurice Coenegrachts, EC
Dr. Abdullah Fahim, UNICEF
Dr. Abu Hashish, WHO
Mr. Craig Hostetler, US Government/Health and Human Services/LTS
Ms. Florence Morestin, Embassy of the Republic of France
Dr. William Newbrander, USAID/MSH
Dr. Moh’d Khakirah Rashidi, USAID/MSH
Dr. Katja Schemionek, EC
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The Essential Package of Hospital Services for Afghanistan 2005/1384
1. The Hospital Sector in the Afghan Health System

1.1 Background: The Afghan Health System and Issues Facing Hospitals
In March 2003, the Ministry of Public Health (MOPH) of Afghanistan released the
Basic Package of Health Services (BPHS), the culmination of a process that determined
priority health services to address the population’s most immediate needs. This package
included the most needed services at the health post and health center levels of the
health system.
After establishment of the BPHS, the MOPH’s Hospital Management Task Force saw
the need to develop a framework for the hospital element of the health system. The
Basic Package made clear the need for a primary-care-based health system, which
requires functioning hospitals in order to have an appropriate referral system where all
health conditions may be treated. Health services in Afghanistan operate at three levels:
health posts (HP) and community health workers (CHWs) provide service at the
community or village level; basic health centers (BHCs), comprehensive health centers
(CHCs), and district hospitals operate in the larger villages or communities of a district,
provincial and regional hospitals comprise the third level. In urban areas, due to a lack
of facilities offering basic curative and preventive services, urban clinics, hospitals, and
specialty hospitals provide the services that HPs, BHCs and CHCs provide in rural
areas.
Hospitals play a critical role in the Afghan health sector: they are part of the referral
system, which aims to reduce high maternal and early childhood mortality rates. In
addition, hospitals utilize many of the most skilled health workers and much of the
financial resources available in the health system. Hospital management must
dramatically improve to ensure that these scarce resources are used in an effective and
efficient manner and to enable hospitals to function more effectively as part of the
health system. Serious need for improvement exists at all hospital levels—district,
provincial and regional hospitals—as well as at Kabul’s tertiary and specialty hospitals.
Before it could begin to develop a national policy on hospitals that would define the
role of the hospital in the Afghan health system, the Hospital Management Task Force
needed to identify the key problems facing the hospital system. The Hospital
Management Task Force determined that the key issues facing hospitals could be
summarized by six problems and the resulting consequences:
1. Problem: Poor distribution of hospitals and hospital beds throughout the

country
Consequences: Lack of equitable access to hospital care throughout the
country: people in urban areas have access, but semiurban and rural populations
have only limited access. Kabul has 1.28 beds per 1000 people, while provinces
have only 20% of that amount (0.22 beds per 1000 population).
2. Problem: Lack of standards for clinical patient care
Consequences: Poor quality of care
3. Problem: Lack of management skills for operation of hospitals
Consequences: Inefficiently run hospitals, poorly managed staff, lack of
supplies, and unusable equipment due to lack of maintenance
4. Problem: A fragmented and uncoordinated hospital system that is not integrated
into the health system
1
Consequences: A referral system that does not work—people from rural areas
and basic health centers are not referred to hospitals for problems such as
problem pregnancies. Support for a BPHS-based system for secondary and
tertiary services is lacking; the roles of hospitals in a BPHS-based health system
have not been spelled out.
5. Problem: Limited financial resources for hospitals, and sustainability
Consequences: Virtually all hospitals in Afghanistan lack adequate financial
resources. A user fee system must be developed to help finance hospitals while
at the same time ensuring that exemption mechanisms allow the poor continued
access to care.
6. Problem: Lack of qualified personnel, especially female, in remote areas
Consequences: Difficulty in guaranteeing 24-hour coverage, problems with
quality of care provided to female patients.
Having reviewed the situation, the Hospital Management Task Force drafted a national
policy, the Hospital Policy for Afghanistan’s Health System, which was adopted in
February 2004 by the MOPH Executive Board (Annex A). This policy provided the
rationale, structure, and guidelines needed to complete the definition of a health system
appropriate for Afghanistan by
• identifying the needs of the hospital sector;
• establishing 10 key policies related to hospitals;
• setting 31 standards for hospitals in six major areas (responsibilities to the
community, patient care, leadership and management, human resource
management, management systems, and hospital environment);
• identifying the levels of hospitals in the system and the need for rationalizing
the distribution of hospital facilities and beds.
1.2 Purpose
The Essential Package of Hospital Services (EPHS) has three purposes: (1) to identify a
standardized package of hospital services at each level of hospital, (2) to provide a
guide for the MOPH, private sector, nongovernmental organizations (NGOs), and
donors on how the hospital sector should be staffed, equipped, and provided materials
and drugs, and (3) to promote a health referral system that integrates the BPHS with
hospitals. The EPHS defines, for the first time, all the necessary elements of services,
staff, facilities, equipment, and drugs for each type of hospital in Afghanistan. The
EPHS identifies, with tables, the following elements for each level of hospital so that
the inputs or resources needed at each level may be easily compared:
• diagnostic and treatment services for various conditions (Section 2)
• diagnostic tests (Section 3)
• staffing (Section 4)
• equipment and supplies (Section 5)
• essential drugs (Section 6)
Annex A provides the national hospital policy, and Annex B describes the assumptions
behind the staffing calculations.
2
1.3 Levels of Hospitals
Hospitals play a critical role in the Afghan health sector: they are part of the referral
system, which aims to reduce high maternal and early childhood mortality rates.
Hospitals are classified into three groups according to size of the referral population,
number of beds, workload, and complexity of patient services offered:
• district hospitals (part of the BPHS)
• provincial hospitals
• regional hospitals
Another group of hospitals, specialty hospitals, are referral centers for tertiary medical
care and are located primarily in Kabul. They provide education and training for health
workers and act as referral hospitals for the provincial and regional hospitals. A
separate category of specialty hospitals was not created for the EPHS because each of
these hospitals is unique, and it would be difficult in this document to characterize in
one group the unique services, staffing, equipment, and drugs required at each of these
hospitals.
Four core clinical functions will exist in each of the three levels of hospitals: medicine,
surgery, pediatrics, and obstetrics and gynecology. Mental health and dental health are
predominantly provided as outpatient services at various levels. Mental health services,
for instance, are provided as an outpatient service at the district and provincial
hospitals, while such services are provided on an inpatient basis at the regional level, if
required.
District hospitals (and where there are no district hospitals, provincial hospitals) support
the primary health services of the BPHS. District hospitals are typically staffed by
junior general medical officers. As compared to district hospitals, provincial hospitals
provide more sophisticated services for diagnosing and treating various conditions and
support the use of some specialist doctors. Regional hospitals are tertiary hospitals that,
in addition to the above, provide more advanced specialized care. Research, as well as
training of medical officers, midwives, and nurses, will be practiced at all three levels
of hospitals.
1.4 The Relationship between the BPHS and the EPHS
Hospitals provide increasingly sophisticated services in support of referrals from the

primary health care system. The health post, basic health center, and comprehensive
health center offer basic curative and preventive services. The level of sophistication
increases moving from district to urban hospitals. The district hospital (or provincial
hospital, where there is no district hospital) is the link between the BPHS and the
hospital referral system, as illustrated in Figure 1.
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Figure 1. Link between the BPHS and Hospital Sector
4
The district hospital is the entry point to the hospital system, as shown in Figure 2. The
flow would be similar for the provincial and regional hospitals in accepting patients
from the lower-level health facilities and hospitals.
Figure 2. Entry and Flow of Patients at the District Hospital
1.5 The Role of Hospitals in the Health System
Each level of hospital plays a role in providing a continuum of care from the health post
to regional and specialty hospitals. This section defines the purpose and role of each
level of hospital and summarizes its services.
District Hospitals
Purpose:
The district hospital (DH) brings professional inpatient and emergency services closer
to the population in rural areas. Its role in supplementing the health centers aims at
reducing the maternal mortality ratio (MMR), infant mortality rate (IMR), and under-5
mortality (U5M). The DH is mainly an emergency hospital where patients are assessed,
diagnosed, stabilized, and either treated or referred back to a lower level or referred to a
higher level of health facility. Provision of 24-hour comprehensive emergency obstetric
care service is a crucial aspect of a DH. As illustrated in Figure 2, there are two entry
points to the DH: the outpatient department (OPD) and emergency department.
5
Role:
• The DH is an important part of the referral system. It is the first point of entry
for referrals from the comprehensive health center and for self-referrals in case
of an emergency.
• The DH is part of the BPHS. It functions as a triage station where patients are
assessed, diagnosed, stabilized and treated, and referred, if needed, to a higher
hospital level.
• The DH OPD functions as the entry point to the health system where no BHCs
or CHCs are available.
• The health system promotes a two-way referral system in which patients who no
longer need DH care are referred back to the health centers.
• The DH is not to be the primary place for emergency surgery.
• The DH plays a role in building the capacity of health workers, providing
health education, collecting health management information system (HMIS)
data, and participating actively in improving the health of the population. This
role includes health education, immunization campaigns, information sharing
with partners, responsiveness to the changing needs of the community, and
appropriate use of materials and equipment.
Summary of services:
A DH should provide the following clinical, diagnostic, and administrative services.
See Section 2 for a more detailed listing of conditions diagnosed and treated at the
district hospital.
Table 1. Summary of Services at a District Hospital

Clinical and • Inpatient services (24-hour)
diagnostic - general surgical services (operating theater, anesthesia,
services recovery room services, and sterilization services)
- general obstetric and gynecology services
- general pediatric services (including therapeutic feeding
services)
- general medical services
• Emergency department open and staffed 24 hours
• Outpatient services (including vaccinations, mental health, and
dental services)
• Hospital pharmacy
• Physiotherapy services
• Basic laboratory and blood transfusion (no blood bank) services
• Basic x-ray and ultrasound services
Administrative • Management and administration team
and support - finance and accounting
services - procurement and medical stores
- human resources
- supervision of all support services and buildings
- security
• Central sterile supply
• Medical records and HMIS statistics
• Kitchen
• Laundry and tailor
6
• Waste management and cleaning services

• Maintenance services and workshop
• Vehicles: transportation for emergencies and transferring patients
Provincial Hospitals
Purpose:
The provincial hospital (PH) is the referral hospital for the provincial health system. In
essence, the PH is not very different from a district hospital: it offers the same clinical
services and possibly a few additional specialities (see Section 4 for staffing). In most
cases, the PH is the last referral point for patients referred from the districts. In some
instances, the PH can refer patients to higher levels of care—to the regional hospital or
to a specialty hospital in Kabul. The PH brings professional inpatient and emergency
services closer to the population in rural areas. In their supplementary role to the basic
and comprehensive health centres and the district hospital, PH aim to reduce the
maternal mortality ratio, infant mortality rate, under-five mortality rate, and other
diseases and conditions responsible for the high mortality and morbidity in Afghanistan.
Role:
• The PH is an important part of the referral system: it is the first point of entry for
referrals from the district hospital or comprehensive health center, and for self-
referrals for emergencies.
• The PH is supplementary to the BPHS and functions as a triage station where
patients are assessed, diagnosed, stabilized, and treated, or referred to a regional
hospital.
• The health system promotes a two-way referral system in which patients who no
longer need PH care are referred back to the health centers (similar to the referral
patterns shown in Figure 2).
• The PH outpatient department functions as the entry point to the health system
when no BHCs or CHCs are available.
• Because a PH is primarily an emergency hospital, it does not perform complicated
elective surgery (see Section 2).
• The PH’s role includes training health professionals, collecting HMIS health
information, and actively participating in improving the health of the population
through community outreach, health education, immunization campaigns,
information sharing with partners, responsiveness to the changing needs of its
community and province, and appropriate and efficient use of staff, buildings,
equipment, and materials.
A PH should offer the clinical, diagnostic, and administrative services described in
Table 2. (See Section 2 for a more detailed listing of conditions diagnosed and treated at
the PH.)
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Table 2. Summary of Services at a Provincial Hospital

Clinical and • Inpatient services
diagnostic - general surgical services (operating theater, anesthesia,
services recovery room services, and sterilization services)
- general obstetric and gynecology services
- general pediatric services (including therapeutic feeding)
- general medical services
• Outpatient services (including vaccinations, basic ear-nose-throat,
mental health, eye care, and dental services)
• Basic laboratory, blood transfusion services, and blood bank
• Basic x-ray and ultrasound services
- human resources
- security
• Kitchen
• Mortuary
Regional hospitals
Purpose:
The regional hospital (RH) is primarily a referral hospital with a number of specialities
for assessing, diagnosing, stabilizing and treating, or referring back to a lower-level
hospital. The RH provides professional inpatient and emergency services at a higher
level than is available at district or provincial hospitals, yet the overall objective
remains reduction of the high maternal mortality ratio, infant mortality rate, and under-
five mortality rate, and of other diseases and conditions responsible for Afghanistan’s
high mortality and morbidity.
Role:
The RH is an important part of the referral system, having many of the specialists
that are not present at other levels of the hospital system.
• The RH has a significant role to play in training health professionals, collecting
HMIS and medical research information, and conducting medical and health
system research.
8
A RH should have the clinical, diagnostic, and administrative services outlined in Table
3. (See Section 4 for a more detailed listing of specialist staff and Section 2 for the
range of conditions diagnosed and treated at the provincial hospital.)
Table 3. Summary of Services at a Regional Hospital

Clinical and • Inpatient services
diagnostic - general and specialized surgical services (operating theater,
services anesthesia, recovery room services, and sterilization
services)
- obstetric and gynecology services
- pediatric services (including therapeutic feeding center)
- general and specialized medical services
- ophthalmology and ENT services
- mental health and psychiatric services
- dental services
- forensic medicine
• Outpatient services
• Laboratory, blood transfusion services and blood bank
• X-ray and ultrasound services
• Endoscopy services
• CT scan (Kabul only at tertiary hospital level)
- human resources
- security
• Kitchen
• Mortuary
1.6 Organization of Hospitals
The way in which the general administration of hospitals in Afghanistan should be

organized is illustrated in Figure 3, “Organizational Structure of Hospitals.” Figure 3
shows the staff positions, the relationship among the various hospital departments, and
the necessary reporting relationships. As noted in the following section, hospital boards
will be introduced to make sure that hospitals are overseen by community members
who can identify the true needs of the community and ensure the accountability of the
hospital administration.
9
While the Hospital Director is responsible for the hospital’s operation and the day-to-
day management of the facility and its services, the Director is also expected to develop
a management team of key staff. Team members should meet on a weekly basis to
discuss and resolve the hospital’s major plans, problems, and budgets. By promoting
participatory management and teamwork, the Hospital Director will be able to improve
the quality of care, performance, operation, and management of the hospital.
Figure 3. Organizational Structure of Hospitals
1.7 The Future of Hospitals in Afghanistan
The top three priorities of the hospital sector in the coming years are to increase access
to hospital services, improve the quality of patient care, and to increase the efficiency of
hospital operation. Bringing about these improvements will require several initiatives.
The following three initiatives can be expected to be operational within the next five to
10 years.
10
First, standards must be established. Hospitals require standards for both clinical and
administrative operations in order to improve clinical and managerial performance and
to attain an acceptable level of patient care and hospital operation. Standards establish
what is expected of hospitals and their staff at all levels of operation; standards permit
the monitoring of operations and the measurement of performance. The national
hospital policy (Annex A) outlines the six areas for which basic standards need to be
developed. The standards for each of these areas are also presented in Table 4. Specific
elements of each standard must be developed and specified in greater detail by the
Ministry of Public Health.
Second, to strengthen community involvement and support, hospital boards must be

established. Community support for hospitals is often poor; communities using a
hospital tend to regard it as the “government’s hospital” or the “NGO’s hospital” rather
than “their” hospital. A hospital board will provide general direction and guidance for
the management and operation of the hospital, as well as serving as a link between the
community and hospital. Hospital community boards will be made up of volunteers
with diverse skills and experiences who will be responsible for the long-term viability
of the hospital and ensure that it meets the real and felt needs of the community. Their
responsibilities will include:
• ensuring that high quality services are provided;
• maintaining community and government relations and generating community
support for the hospital;
• serving as the policy and strategy-setting body of the hospital;
• supporting the leadership of the hospital;
• providing financial oversight;
• helping develop the hospital’s strategic plan.
Third, as the number of hospitals operated by government, NGOs and private entities
increases, hospital certification or accreditation will be needed to ensure that all
hospitals provide a basic standard of care. Accreditation is the process of assessing
health institutions against a commonly accepted set of standards in order to ensure and
improve the quality of health services. The goal of accreditation is to ensure that
providers, both the hospital as an institution and its physicians and nurses, provide high-
quality care to patients. Table 5 lists the elements of quality of care that would be
considered in an accreditation process.
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Table 4. Standards for Hospitals

Responsibilities • The hospital is responsive to the community’s (health) needs.
to the • Hospital services are accessible to the community.
Community • The hospital has a proper disaster preparedness plan to properly
respond in the event of natural or manmade disasters.
Patient Care • Patients are treated with dignity and have a right to be treated in a
respectful manner.
• Quality of clinical care to the patient is high and appropriate for
Afghanistan, including the proper staffing, equipment, and supplies.
• Quality of care is monitored and measured by agreed-upon
indicators (e.g., wound infections, length of hospital stay, operations
per patient, mortality rates, etc.).
• Women and children receive the basic package of health services at
hospitals, including immunization, outpatient care for conditions
such as pneumonia and diarrhea, and appropriate assistance at the
time of delivery.
• Hospitals are “mother and baby friendly” and encourage “rooming-
in” and immediate, exclusive breastfeeding.
• Care delivery is monitored by the hospital’s health care team to
ensure that care meets the needs of patients and to assist in the
improvement of care.
• Medical records are maintained for each patient and are kept
confidential and secure.
Leadership and • The hospital is effectively and efficiently governed, organized,
Management supervised, and managed to ensure the highest quality of care
possible for patients.
• To ensure the responsiveness of hospitals to the community, a
hospital board of directors or board of management is established at
each hospital to govern and oversee operation and management of
the hospital.
Human • Staff planning ensures a properly trained hospital staff and the
Resource appropriate number of staff.
Management • Staff are appointed through a recruitment, selection, and
appointment procedure that is consistent with the MOPH human
resources policy.
• In performing their duties, staff adhere to high ethical standards and
a code of conduct.
• A comprehensive program of staff development and in-service
training meets individual and hospital needs.
• Effective workplace relations are developed through use of teams.
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Management • Financial management policies and procedures are developed and

Systems adhered to in order to ensure accountability of the hospital’s
finances from all sources.
• Management information systems meet the hospital’s internal and
external needs.
• Patient care, management of services, education, and research are
facilitated by the timely collection and analysis of data.
• Information technology enhances the hospital’s ability to gather,
store, and analyze information and to communicate.
• Appropriate logistics and purchasing systems are maintained to
ensure clinicians have the proper equipment, supplies, and
pharmaceuticals to provide patient care.
• Buildings and grounds are maintained to ensure a safe patient care
and work environment for patients, staff, and visitors.
Hospital • Infection is effectively controlled throughout the hospital.
Environment • The physical environment of the hospital and its equipment are
properly maintained to ensure patient and staff safety.
• The hospital is accessible to all patients, including those with
physical disabilities.
• Buildings, grounds, plant, and equipment are regularly maintained
to ensure a safe environment for all persons in the hospital.
• Waste from the hospital is handled, contained, and disposed of
safely and efficiently.
• Occupational health measures are adopted to ensure the safety of
staff, especially those dealing with direct patient care.
• Clean water of sufficient quantity and quality is available for
patients and staff and for proper hospital functioning.
• Toilets in the hospital are kept clean for use by patients, staff, and
visitors.
Source: Ministry of Health, Hospital Policy for Afghanistan’s Health System, February 2004.
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Table 5. Accreditation: Dimensions of Quality of Care

Technical aspects • Accuracy of diagnosis
of quality • Efficacy of treatment (appropriateness of treatment)
• Excellence according to professional standards
• Necessity of care
• Appropriateness
• Continuity of care
• Consistency
Interpersonal • Patient satisfaction
aspects of quality - Time spent with provider
- Attitudes of provider and treatment by staff
• Community satisfaction
• Amenities
Social aspects of • Efficiency
quality • Accessibility
Source: W. Newbrander, MSH, “Report on Accreditation of Providers for the National Health Insurance Fund,”
Ministry of Health, United Republic of Tanzania, July 1999.
2. Services Provided by Different Levels of the Hospital Sector
The services provided by hospitals encompass diagnosis and treatment based upon the
diagnosis. The services provided by each level of hospital are identified in Table 6,
“Diagnosis and Treatment of Common Conditions, by Hospital Level.” To define the services
provided at each hospital level, Table 6 categorizes the major physiological conditions
treated. Within each category are listed the more specific conditions that may present and the
hospital level at which those conditions would be treated.
Particular hospital levels are not suited to treat all conditions, but in an emergency situation,
the clinicians’ only option may be to treat the patient as best they can. For instance, it would
be best to use a defibrillator to deal with a cardiac arrest. Table 6 shows that cardiac arrest is
primarily dealt with at the regional hospital level since that is the only level where a
defibrillator, electrocardiogram machine, advanced cardiologic drugs, and cardiologist are
available. However, if a patient at a district hospital has a cardiac arrest, referral is out of the
question. In such a case, even though a defibrillator is not available, the district hospital
clinical staff will make every attempt to resuscitate the patient as best it can using available
staff, equipment, and drugs. Table 6 notes such circumstances in italics.
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Table 6. Diagnosis and Treatment of Common Conditions, by Type of Hospital
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Diagnosis and Treatment of Common Conditions
1. ACUTE TRAUMA & SELECTED EMERGENCIES
1.1 Anaphylaxis X X X
1.2 Cardiac arrest (simple ABC resuscitation done at all levels, but defibrillator only available at RH) X
1.3 Abdominal trauma X X X
1.4 Bites and rabies X X X
1.5 Burns X X X
1.6 Natural disasters X X X
1.7 Head injury X X X
1.8 Multiple injury to patient X X X
1.9 Pneumothorax and hemothorax X X X
1.10 Poisoning X X X
1.11 Shock X X X
1.12 Tracheotomy (done at all levels in cases of emergency) X X X
1.13. Fluid and electrolyte balance X X
2. AIDS/HIV AND SEXUALLY TRANSMITTED DISEASES DH PH RH

AIDS Prevention and Management
2.1 Universal precaution measures X X X
2.2 Needle-stick injury X X X
2.3 Mother-to-child transmission of HIV X
2.4 HIV screening by rapid test X X X
2.5 Confirmation of HIV infection (by two different Elisa tests) X X X
2.6 Stages and diagnosis of AIDS X
2.7 Information, education, and communication X X X
2.8 Voluntary counseling and testing X
Sexually Transmitted Diseases (STDs)
2.9 Gonorrhea and urethral discharge X X X
2.10 Genital discharge in the female X X X
2.11 Dysuria in the female X X X
2.12 Pelvic inflammatory disease X X X
2.13 Genital ulcer disease X X X
2.14 Buboes or swollen inguinal glands X X X
2.15 Venereal warts (genital) X X X
3. CARDIOVASCULAR CONDITIONS DH PH RH
3.1 Congenital heart disease X
3.2 Deep-vein thrombosis X X X
3.3 Heart failure X X
3.4 Hypertension X X X
3.5 Pulmonary edema X X X
3.6 Ischemic heart disease (symptomatic treatment only; refer to tertiary Kabul level if possible) X X X
3.7 Rheumatic heart disease X X X
4. CENTRAL NERVOUS SYSTEM DH PH RH

4.1 Cerebral palsy X
4.2 Seizure disorders X X X
15
5. DENTAL AND ORAL CONDITIONS DH PH RH

5.1 Abscess, periapical X X X
5.2 Acute necrotizing ulcerative gingivitis X X X
5.3 Alveolitis (dry socket) X X
5.4 Cellutitis (oral) X X X
5.5 Gingivitis X X X
5.6 Neoplasms, salivary gland, and hereditary/developmental disorders (refer to Kabul hospital) –– –– ––
5.7 Pericoronitis X X X
5.8 Periodontitis X X X
5.9 Pulpitis X X X
5.10 Temporomandibular joint disorders (refer to Kabul if necessary) X
5.11 Trauma (jaw trauma: refer to Regional or Kabul tertiary hospital level if necessary) X X
6. EARS, NOSE, THROAT CONDITIONS DH PH RH

6.1 Acute otitis media X X X
6.2 Otitis externa X X X
6.3 Chronic otitis media (CSOM) X
6.4 Epistaxis X X X
6.5 Foreign bodies in the ears X X X
6.6 Foreign bodies in the nose X X X
6.7 Mastoiditis X
6.8 Wax on ear X X X
7. ENDOCRINE SYSTEM DH PH RH
7.1 Diabetes mellitus X X
7.2 Thyroid diseases (for simple goiter; otherwise refer to Kabul hospital) X X X
8. EYE CONDITIONS DH PH RH
8.1 Common eye conditions (for most conditions a generalist may treat at all levels, but for trachoma and
cataracts and other complicated conditions, opthalmologist at RH required) X X X
8.2 Eye injuries (many conditions can be treated at all levels; for those that cannot, refer to opthalmologist at
RH required) X X X
9. FAMILY PLANNING DH PH RH
9.1 Hormonal contraceptives X X X
9.2 Intrauterine contraceptive devices (IUCDs) X X X
9.3 Barrier methods X X X
9.4 Surgical contraception X X X
9.5 Periodic abstinence (natural family planning) X X X
10. GASTROINTESTINAL CONDITIONS DH PH RH

10.1 Amoebiasis X X X
10.2 Diarrheal diseases X X X
10.3 Gastritis X X X
10.4 Peptic ulcer disease X X X
10.5 Upper GI tract bleeding (at all levels patient is stabilized with IVs and antipeptic drugs, but further
diagnosis and treatment requires referal for use of endoscope at RH level) X
10.6 Worms X X X
11. GYNECOLOGY DH PH RH
11.1 Uterus fibromyoma X X
11.2 Infertility (only basic treatment offered, advanced tests not available at any of the hospital levels) X X X
11.3 Pelvic masses X X
11.4 Menstrual disturbances X X X
11.5 Neoplasms (refer to Kabul hospital) –– –– ––
11.6 Vaginitis (vaginal discharge) X X X
11.7 Pelvic inflammatory disease (PID) X X X
11.8 Abscesses X X
11.9 Prolapse and transvaginal operations X
11.10 Fistulae X
11.11 Sexual assault X X X
16
12. IMMUNIZATION DH PH RH
12.1 Vaccination schedule X X X
12.2 Dosage and administration X X X
13. INFECTIOUS (SELECTED) & RELATED CONDITIONS DH PH RH

13.1 Acute rheumatic fever (ARF) X X X
13.2 Bacterial infections X X X
13.3 Leishmaniasis X X X
13.4 Malaria X X X
13.5 Measles X X X
13.6 Meningitis X X X
13.7 Poliomyelitis X X X
13.8 Tetanus X X X
13.9 Tuberculosis X X X
13.10 Typhoid fever X X X
13.11 Rabies (rather than refer with inherent dangers of transporting publicly, patients treated and isolated with
arrier nursing at all hospital levels) X X X
13.12 Viral hemorrhagic fevers X X X
14. MENTAL ILLNESS

(as a psyciatrist is only available at regional hospital level, common psychiatric conditions such as
acute psychosis, depression, sleep disorders and suicide attempts will have to be treated at all hospital
levels) DH PH RH
14.1 Acute confusion (Acute psychosis) X X X
14.2 Anxiety and stress-related disorders X
14.3 Childhood psychiatric disorder X
14.4 Conversion disorders X
14.5 Depression X X X
14.6 Mania X
14.7 Schizophrenia X
14.8 Suicidal ideation X X X
14.9 Substance abuse and dependency X
14.10 Post-traumatic stress syndrome and trauma-related problems X X X
15. MUSCULOSKELETAL CONDITIONS DH PH RH

15.1 Arthralgia, nonspecific X X X
15.2 Gout X
15.3 Osteoarthritis X X X
15.4 Osteomyelitis X X
15.5 Rheumatoid arthritis X X
15.6 Septic arthritis X
16. NEONATAL CARE & CONDITIONS DH PH RH

16.1 Neonatal asphyxia and resuscitation X X X
16.2 Care of the normal newborn X X X
16.3 Birth injuries X X
16.4 Congenital anomalies (simple conditions, such as sixth finger, may be treated at lower levels) X
16.5 Infants of diabetic mothers X X
16.6 Jaundice (complicated cases to be referred to higher levels) X X X
16.7 Preterm infant (major difficulty is lack of power supply for operating incubators, if none then refer) X X
16.9 Apnoeic attacks X
16.10 Respiratory distress X X
17. NEOPLASMS DH PH RH
17.1 Neoplasms in childhood –– –– ––
17.2 Adult neoplasms (refer to Kabul hospital) –– –– ––
17
18. NUTRITIONAL & HEMATOLOGIC CONDITIONS

18.1 Anemia X X X
18.2 Blood transfusion X X X
18.3 Failure to thrive X X X
18.4 Growth monitoring and nutrition X X X
18.5 Malnutrition—severe or moderate, acute/chronic X X X
18.6 Malnutrition—micronutrient deficiency diseases (Vitamin A, anemia, iodine, Vitamin C) deficiencies) X X X
18.7 Thalassemia (refer to Kabul) –– –– ––
19. OBSTETRICS DH PH RH
Antenatal Care and Complications (at present, many conditions will have to be treated at the hospital level where they
present due to lack of or poor transportation for referring patients)
19.1 Antenatal care X X X
19.2 High-risk pregnancy X X X
19.3 Anemia in pregnancy X X X
19.4 Antepartum hemorrhage (APH) X X X
19.5 Cardiac disease in pregnancy X X
19.6 Diabetes in pregnancy X X
19.7 Drugs in pregnancy X X X
19.8 Malaria in pregnancy X X X
19.9 Multiple pregnancy X X X
19.10 Pre-eclampsia X X X
19.11 Eclampsia X X X
19.12 Rhesus (Rh) incompatibility X X
19.13 Urinary tract infection in pregnancy X X X
19.14 Ectopic pregnancy X X X
Intrapartum Care and Complications
19.15 Normal labor and delivery (including assessment of low-birthweight infants) X X X
19.16 Complicated labor and delivery (including CS and uterus rupture) X X X
Postpartum Care and Complications
19.17 Postnatal care X X X
19.18 Complications of puerperium X X X
19.19 Postpartum hemorrhage (PPH) X X X
19.20 Puerperal infections X X X
19.21 Breast conditions X X X
19.22 Deep vein thrombosis (DVT) X X X
19.23 Puerperal psychosis (rare condition—it is difficult to refer such patients so basic treatment would have
to be done at all levels) X X X
19.24 Abortion (due to medical indication: a special committee is necessary) X
19.25 Incomplete abortion (and complications of abortion) X X X
19.26 Destructive operations X X
18
20. ORTHOPEDICS DH PH RH
Orthopedic Trauma Cases
20.1 Closed fracture and dislocation of all of minor joints and bones X X X
20.2 Supracondylar displaced fructures X X X
20.3 Old condylar and epicondylar fructures (complicated cases) FA X X
20.4 Volkmann's ischemia and compartment syndrome FA X X
20.5 V.I.C. X
20.6 Soft tissue injuries and crush injuries X X X
20.7 Spinal vertebrae fracture and trauma FA X X
20.8 Pelvic fracture without complication FA X X
20.9 Pelvic fracture with complication FA X X
20.10 Hip joint dislocation FA X X
20.11 Femur neck fractrue X
20.12 Femur fracture X
20.13 Knee joint dislocation X X
20.14 Knee joint inner lession X
20.15 Tibia and fibula closed fracture FA X X
20.16 Tibia open fractures X
20.17 Ankle joint dislocation and fractures X
20.18 Ankle bones open fractures X
20.19 Tarsal bones fractures and dislocations X X
20.20 Tarso-metatarsal joint dislocation X X
20.21 Skin graft and tendon injuries X X
Orthopedic Procedures
20.22 Acute osteomyelitis FA X X
20.23 Chronic osteomyelitis X
20.24 Pyogenic septic arthritis X X
20.25 Tuberculosis of bones and joints X X
20.26 Gout arthritis X X
20.27 Rheumatoid arthritis X X X
20.28 Congenital bone diseases X X
20.29 Osteogenesis imperfecta X
20.30 Bone tumors (benign and malignant) X
20.31 Pott's disease X
20.32 CDH, DDH X
20.33 Bone cyst X X
20.34 Carpal tunnel lession X
20.35 Hand flexors and extensors injuries X X
20.36 Amputation (open amputation) X X X
20.37 Scoliosis X
20.38 Menopausal osteoporosis X X X
20.39 Genu valgum and Genu varum X
Note: FA = First Aid
21. RESPIRATORY SYSTEM DH PH RH

Acute Upper Respiratory Tract Infections
21.1 Common cold (Acute Rhinitis, Coryza) X X X
21.2 Pharyngotonsillitis, tonsillitis X X X
21.3 Sore throat X X X
21.4 Sinusitis X X X
Lower Respiratory Tract Conditions
21.5 Approach to cough or difficult breathing in children X X X
22.6 Pneumonia—Infant age less than 2 months X X X
21.6 Pneumonia—Child age 2 months–5 years X X X
22.7 Pneumonia—Adults X X X
21.7 Acute epiglottitis X X X
22.8 Croup X X X
21.8 Acute bronchitis—Bronchitis (Tracheobronchitis) X X X
22.9 Wheezing & Asthma—Child under 5 years X X X
21.9 Bronchial asthma—Adults X X X
21.10 Chronic obstructive pulmonary disease X X X
19
22. SIGNS AND SYMPTOMS DH PH RH

22.1 Coma X X X
22.2 Fever X X X
22.3 Fever of unknown origin X X X
22.4 Hepatosplenomegaly X X X
22.5 Jaundice X X X
22.6 Lymphadenopathy X X
23. SKIN DISEASES DH PH RH

23.1 Atopic eczema X X X
23.2 Impetigo X X X
23.3 Ringworm (Tinea) X X X
23.4 Scabies X X X
23.5 Herpes zoster X X X
24. SURGICAL CARE AND CONDITIONS DH PH RH

Acute abdomen and traumatic abdomen. (Stabilize and refer. If a competent surgeon and anesthetic
24.1
service and appropriate equipment are available, then laporotomy can be performed at DH.) X X
24.2 Thyroidectomy (Refer to center) –– –– ––
24.3 Mastectomy (Refer to center) –– –– ––
24.4 Chest conditions (Chest tube at all levels) X
24.5 Hiatus hernia (Refer to center) –– –– ––
24.6 Esophageal operations (Refer to center) –– –– ––
24.7 Biliary tract and liver operations X
24.8 Pancreas operations (Refer to center) –– –– ––
24.9 Colon operations X
24.10 Proctological operations (perianal abcess at DH) X X
24.11 Hernioraphy (simple at DH) X X
24.12 Rectal prolapse, Crohn's disease, all malignancies (Refer complicated cases to center) X
24.13 Superficial abcesses, cysts, and tumors (Refer to center if suspected malignancy) X X X
24.14 Cavity abcesses X
24.15 Cystostomy X X X
24.16 Kidnay stones and nephrectomy X
24.17 Prostatectomy X
24.18 Pyeloplasty (Refer to center) –– –– ––
24.19 Circumcision X X X
24.20 Burns (pending distribution [%] and dept [°] ) X X X
Vascular and neurosurgery (Refer to center—life-saving procedures can be done by competent surgeons
24.21
at PH and RH level) –– –– ––
25. URINARY TRACT AND RENAL CONDITIONS DH PH RH

25.1 Urinary tract infections X X X
25.2 Renal disease signs and symptoms X X X
25.3 Acute glomerulonephritis X X X
25.4 Acute renal failure X X X
25.5 Chronic renal failure (only treatable at RH level if services are upgraded there) X
25.6 Hypokalemia X X
25.7 Nephrotic syndrome X X
20
3. Diagnostic Services Provided by Different Levels of the Hospital Sector
Laboratory and imaging departments support clinicians in their diagnoses of patient

conditions. Radiology, laboratory, and other diagnostic services that should be provided by
each type of hospital in the health system are identified in Table 7, “Diagnostic Services, by
Type of Hospital.”
Table 7. Diagnostic Services, by Type of Hospital
osp l
ita
l
ita
tal
os p
spi
H
lH
Ho
al
nci
na
ct
tri
gio
ovi
Dis
Diagnostic Tests Performed
Re
Pr
1. LABORATORY SERVICES
HEMATOLOGY
1.1 Hemoglobin X X X
1.2 Hematocrite X X X
1.3 Bleeding time and coagulation time test X X X
1.4 Prothrombine time X X
1.5 White blood count (WBC and differential) manual X X X
1.6 WBC automated X
1.7 Erythrocite sedimentation rate (ESR) X X X
1.8 Plateletes and reticulocyte X X
1.9 Malaria parasite smear (MPS) X X X
1.10 Histopathology (on Kabul level only in one institute) - - -
BIOCHEMISTRY
1.11 Blood sugar, glycometer X X X
1.12 Blood sugar advanced automated X
1.13 Electrolytes (Na+, K+, Ca++) X
1.14 Liver function tests (LFT) and liver enzymatic test X X
1.15 Kidney function tests X
SEROLOGY
1.16 Creactive protein X X
1.17 Toxoplasmosis (Kabul tertiary hospital level only) X
1.18 Anti-Streptolysine-O (ASLO) X X
1.19 Rubeola AG X
1.20 Typhoid AG (Widal) X X
1.21 CD 4 cell count X
1.22 Brucellosis X X
CULTURE
1.22 Culture and sensitivity testing X
GRAM STAIN
1.23 Body fluids X X X
21
DH PH RH
URINE TEST
1.24 Macroscopic X X X
1.25 Chemical X X X
1.26 Microscopic X X X
1.27 Pregnancy test X X X
STOOL TESTS
1.28 Macroscopic X X X
1.29 Microscopic X X X
SPUTUM TESTS
1.30 Acid fast bacil (AFB) Ziehl-Nielson X X X
BLOOD TRANSFUSION AND BLOOD BANK SERVICES
1.31 Blood grouping (Beth Vincent/Simonin) X X X
1.32 Cross matching X X X
1.33 HIV antibody (I and II) testing X X X
1.34 Hepatitis B surface antigene X X X
1.35 Hepatitis C virus X X X
1.36 VDRL testing (syphylis) X X X
2. IMAGING SERVICES DH PH RH
X-RAY
2.1 Chest X X X
2.2 Abdomen X X X
2.3 Skeletal X X X
2.4 IVP (KUB) X
2.5 Hystero salpyngography X
2.6 Barium enema and barium meal X
ULTRASOUND
2.7 Ultrasound (simple portable at DH/PH, doppler at RH) X X X
3. ELECTROCARDIOGRAPHY (ECG) X X
4. ELECTROENCEPHALOGRAPHY (EEG) X
5. ELECTROMYOGRAPHY (only in Kabul) X
6. ENDOSCOPY X
22
4. Staffing of Hospitals by Type of Hospital
A hospital’s most critical resources are its human resources. Because human resources for
health are scarce in Afghanistan, the critical skills needed must be identified, based on the
conditions that a hospital is expected to treat. However, while identifying the skills the staff
for each type of hospital must possess, the Hospital Management Task Force found it
impossible to specify the number of staff needed because (1) within each type of hospital the
number of staff will vary according to the number of beds and services provided, and (2) a
large difference exists between the number of staff required to operate a hospital and the
number of staff that would be ideal. To address this quandary, Table 8, “Staffing of District,
Provincial, and Regional Hospitals,” provides staffing figures within the following
guidelines:
1. Since for each type of hospital the number of beds may vary, the midpoint in the
range of number of beds was chosen to determine staffing. For instance, district
hospitals may have from 25 to 75 beds. The staffing for district hospitals in Table 8
therefore reflects staffing for a 50-bed hospital—the midpoint. While the range in the
number of beds is specified for each level of hospital, the allocation of those beds to
various clinical services is not specified (e.g., the number of surgical beds, the number
of pediatric beds, etc.). Instead, the hospital director is expected to allocate beds to
clinical services according to the needs of the community and situation. For instance,
in the event of an earthquake, many hospital beds should be shifted to serve as
surgical beds for the duration of the emergency.
2. Two staffing levels are given for each type of hospital—“minimum staffing” and
“advised staffing.” Minimum staffing reflects the minimum number of staff required
for a hospital of that type, size, and number of beds to operate in a responsible
manner. The number given as minimum staff may not be the desired or ideal number,
but it is the number of staff required for the hospital truly to function as expected. The
second staffing figure reflects the “best case” or ideal number of staff. Providing the
necessary training institutions, the proper training programs, and an intake of
qualified candidates adequate to reach such staffing levels will require a great deal of
effort. Thus the number in the “advised staff” column for each type of hospital may be
considered the number of staff Afghanistan aspires to in the medium term—five to 10
years. (See Annex B for the assumptions underlying the advised staffing patterns.)
23
Table 8. Staffing of District, Provincial, and Regional Hospitals
Minimum and advised staffing levels for hospital with midpoint number of
beds in each hospital category
District Hospital Provincial Hospital Regional Hospital

(25–75 beds) (75–250 beds) (300–450 beds)
Staffing for 50 Beds Staffing for 150 beds Staffing for 350 Beds
Minimum Advised Minimum Advised Minimum Advised
Position Staffing Staffing Staffing Staffing Staffing Staffing
1. MANAGEMENT
Hospital Director 1 1 1 1 1 1
Medical Director (duties performed by the hospital director at district
and provincial hospitals) — — — 1 1 1
Nursing Director/Chief Nurse 1 1 1 1 1 1
Administrator 1 1 1 1 1 1
Subtotal 3 3 3 4 4 4
2. PHYSICIANS
Surgeons (For regional hospital includes all other specialty surgeons) 2 2 2 5 4 8
Ophthalmologist — — — — 1 3
ENT — — — — 1 3
Anesthesiologist doctor (includes reanimation) — 1 1 2 2 4
Obstetrician and Gynecologist 1 2 2 4 4 6
Pediatrician 1 1 2 2 4 4
Medical specialists (internal medicine, psychiatry, dermatology, and
cardiology) — 1 2 3 4 5
General practitioners (nonspecialized—malaige ) 3 3 7 13 14 28
Radiologist (medical imaging including X-ray and ultrasound) — — — 1 1 2
Dentist — — 1 1 1 3
Subtotal 7 10 17 31 36 66
3. NURSES/MIDWIVES
Operating theater and sterilization 2 3 5 6 10 12
Midwives 3 4 8 9 12 15
Ward nurses 8 8 12 24 28 58
Anesthestic nurses 2 2 2 3 4 5
ER (emergency room) and OPD (outpatient department) nurses 2 2 4 7 8 12
Subtotal 17 19 31 49 62 102
4. TECHNICAL STAFF
Psychologist — 1 — 2 1 4
Physiotherapist 1 1 1 4 2 6
Pharmacist 1 2 2 2 2 3
X-Ray technician 1 2 2 2 2 4
Laboratory technician 2 2 4 3 4 5
Blood-bank echnician 2 2 3
Dental technician 1 1 1 2 3 4
Vaccinator 2 2 2 2 2 2
Nutritionist/Cook — 1 — 2 — 3
Technical assistants (x-ray, lab, pharmacy, physiotherapy) — — 2 3 4 5
Subtotal 8 14 14 24 20 39
5. SUPPORT STAFF
Administration (procurement, accounting, human resources, medical
records, clerks) 2 2 3 4 6 8
Storekeeper — 1 1 2 2 3
Maintenance 1 2 2 4 4 6
Cleaners, waste management, and grounds (gardeners) 5 8 16 20 20 34
Laundry 2 2 2 4 4 8
Cook 2 2 4 4 4 5
Drivers 1 1 2 2 3 4
Guards (and porters) 4 5 5 10 8 15
Tailor — — — 2 — 4
Mullah — — — 1 — 1
Subtotal 17 23 35 53 51 88
TOTAL STAFF
Administration 3 3 3 4 4 4
Physicians 7 10 17 31 36 66
Nursing/Midwives 17 19 31 49 62 102
Technical 8 14 14 24 20 39
Support 17 23 35 53 51 88
TOTAL 52 69 100 161 173 299
24
5. Equipment for Hospitals by Type of Hospital
If doctors and nurses lack the equipment necessary to provide patient care, their knowledge
and skills are wasted. If quality of care is to improve, the basic equipment necessary for each
level of hospital—district, provincial, and regional—must be clearly identified. Table 9,
“Equipment and Supplies List, by Type of Hospital,” lists the equipment and supplies needed
by each level of hospital. When specialized equipment is required, such as ultrasound
machines, maintenance and operational training plans should be included.
Great care was taken in selecting appropriate technology equipment for all levels of hospitals.
Choices have been informed by (1) grassroots-level experience in Afghanistan, (2) the
necessity to offer appropriate technology to help lower maternal, neonatal, infant, and child
mortality, (3) cost-effectiveness considerations, and (4) recurrent cost considerations.
For instance, appropriate technology neonatal incubators, such as the Van Hemel Neonatal
Incubator,1 have been added at all three hospital levels. However, at the DH level (and quite
frequently, at the PH level as well), such an incubator can be used for only short periods of
time due to the absence of 24-hour electricity. Caring for a premature neonate at delivery or
following a caesarean section may require other methods, such as kangaroo care.2
Ultrasonography was considered important at all levels, although the exact type of ultrasound
machine would differ at each hospital level: portable ultrasounds for DH and PH levels and a
larger machine, perhaps with echo Doppler functions, for the RH level. Oxygen concentrators
were deemed indispensable for all three levels of hospitals. However, ventilators and
anaesthetic machines, for use during operations, will be available only at the RH level: at the
DH and PH levels, local, spinal, and ketamine anesthesia will be practiced.
1
The Van Hemel Neonatal Incubator costs about US$385 and is easy to maintain.
http://www.clinicalresearch.nl/incubator/INFO.HTM (accessed 9 Sept. 04).
2
http://www.prematurity.org/baby/kangaroo.html (accessed 9 Sept. 04).
25
Table 9. Equipment and Supplies List, by Type of Hospital
tal
al
l
pita
ospi
spit
Ho s
l Ho
ial H
rict
iona
vinc
Dist
Reg
Pro
Equipment and Supplies
1. NONMEDICAL EQUIPMENT
1.1 Administration DH PH RH
Office furniture X X X
Office equipment X X X
Computer X X X
Stationary X X X
1.2 Communications DH PH RH
Radios X X X
Telephone (type depends on level) X X X
1.3 Medical maintenance and power DH PH RH

Generator (including backup for OT, lab/blood bank, and maternity) X X X
Solar X X X
Emergency lights (back-up lighting in key areas) X X X
Voltage stabilizer for all electronic equipment X X X
Tools and spare parts X X X
Fuel and oil X X X
1.4 Water Supply (24/7) DH PH RH

Water source for safe drinking water at 100 liters per patient per day X X X
Water pump X X X
Storage reservoir, holding tank X X X
Water purification chemicals/filters X X X
Utility sinks with taps X X X
Hand washing sinks with taps X X X
Surgical scrub sinks in operating theater X X X
1.5 Waste Disposal DH PH RH

Incinerator/burial pit X X X
Septic tanks X X X
Drainage systems X X X
Sanitation facilities for patients and families X X X
Sharps containers (in all locations where sharps are used) X X X
Rubbish bins (in all rooms) X X X
1.6 Safety and Security DH PH RH

Fire extinguishers X X X
Water hoses and buckets X X X
Spotlights X X X
1.7 Vehicles DH PH RH
Vehicle, 4-wheel drive 1 1 2
Ambulance, 4-wheel drive 1 2 4
Fuel and oil X X X
26
1.8 Medical stores DH PH RH

Refrigerators X X X
Cool boxes X X
Vaccine carriers X X
Shelves X X X
Padlocks X X X
1.9 Kitchen
Ovens X X X
Cooking stove X X X
Cooking pots and utensils X X X
Dishes, cups, cutlery X X X
Dishwasing machine X
Refrigerators X X X
Shelves X X X
1.10 Laundry DH PH RH
Washing equipment X X X
Washing machine X X
Basins X X X
Irons X X X
Water heater (electrical/diesel/wood) X X X
Wash detergent/powder X X X
Sewing/repair kits X X X
1.11 Housekeeping DH PH RH
Mops X X X
Brushes X X X
Brooms X X X
Soap and disinfectant X X X
Buckets X X X
1.12 Mortuary DH PH RH
Mortuary fridge X X
2. MEDICAL EQUIPMENT
2.1 Basic Equipment Sets for Medical and Nursing Examinations DH PH RH
Sphygmomanometer X X X
Stethoscope X X X
Vision chart X X X
Thermometer X X X
Dressing (Lister) scissors X X X
Torch/flashlight X X X
Adult scale X X X
Pediatric and infant scales X X X
Height measuring scale (and height board for infants and young children) X X X
Fetal stethoscope Pinard (specifically for OB/GYN) X X X
Ophthalmoscope and otoscope set (specifically for ER) X X X
Reflex hammer (specifically for ER) X X X
Tourniquet X X X
Hand washing facilities (container or running water) X X X
Sharps container (in all rooms) X X X
Wall clock X X X
27
2.2 Emergency equipment DH PH RH

Basic examination set (see 2.1) plus ophthalmoscope and otoscope set and
reflex hammer X X X
Defibrillator X
Electrocardiography (ECG) X X
Examination lamp X X X
Patient separators/dividers X X X
Suction machine (foot/pedal operated) X X X
Fetal stethoscope (Pinard) X X X
Oxygen (concentrator) X X X
Oxygen cylinder (various sizes) X X X
Ambu bag, masks, guedel (oropharyngeal airway, adult and child) X X X
Drip (IV) stands X X X
Kramer splints, different sizes X X X
Suture set X X X
Wound dressing set X X X
Bowls and bassins X X X
Examination trolleys, stretchers, and wheelchairs X X X
Dressings trolley X X X
Bed pan X X X
2.3 Operating Theater/Room DH PH RH

Operating table with accessories (lithotomy poles—stirrups & arm rests) 2 2 4
Instrument sets for each operating table, consisting of
- wound set 5 10 15
- minor set 1 2 4
- laparotomy set 2 4 6
- caesarian section set/hysterectomy set 2 4 6
- gynecology set 1 2 4
- obstructed labor set 1 1 1
- episiotomy set 1 2 3
- suture set 5 7 10
- amputation set 1 1 2
- arm and leg pneumatic tourniquet X
- diathermy set X X
Suction machine (foot/pedal operated) one per OR table X X X
Bucket for decontamination, one for each table X X X
Heating and cooling equipment X X X
2.4 Anesthesia
Basic examination equipment (see 2.1) X X X
Oxygen (concentrator)—if oxygen, then oxygen saturation monitor advisable X X X
Ventilator machine X X
Anesthetic machine X X
Laryngoscope set (handle and different size blades, spare bulbs) X X X
Magill forceps X X X
Nontoothed artery forceps X X X
Endotracheal introducer (malleable) X X X
Ambu bag, masks (0–5), guedel (oropharyngeal airway), adult and child X X X
Suction machine (foot operated) X X X
Refrigerator, lockable X X X
Pedal waste bin X X X
28
2.5 Sterilization equipment DH PH RH

Autoclave (approximately 60–70 L per OT/OR table), electric or gas heated
team/pressure autoclaves X X X
Each autoclave (high pressure steam sterilizer) with:
- autoclave carts X X X
- metal instruments trays (rigid containers/perforated trays or pans) X X X
- metal wire baskets X X X
- cloth/linen for sugical wraps (woven textiles) X X X
- dry steriliser Poupinel (electric) X X
- metal instrument containers with lid for dry sterilizer X X
- sterilization drums and boxes X X X
Indicators for both steam and dry heat (consumables):
- indicator tape X X X
- chemical indicators (time/temperature/pressure and time/temperature) X X X
- biological indicators X X X
High-level disinfection:
- boilers for boiling items (electric) or pots with lids X X X
- electric/gas/kerosene stoves X X X
- plastic containers with lids for chemical HLD and rinsing (endoscopes) X
- tables for instrument preparation and for wrapping (dedicated) X X X
- shelves/cabinets for with doors for storage X X X
2.6 Obstetrics and Gynecology DH PH RH

OB/GYN examination table X X X
Doppler (small, portable, battery operated) X X X
Fetal heart monitoring machine X
Dilatation and curettage set X X X
Delivery table X X X
Dressing trolley X X X
Bed pan X X X
Manual vacuum aspirator (for D&C) X X X
Vacuum extractor (for childbirth) X X X
Infant mucus aspiration pear X X X
Infant cot X X X
Infant warmer X X X
Incubator, neonatal, Van Hemel X X X
Nebulizer X X X
Infant emergency resuscitation equipment X X X
Speculum (all sizes)-retractor vaginal X X X
Intravenous (IV) poles X X X
Scale, infant, with tray X X X
Apron and boots (and masks and caps) X X X
29
2.7 Medical DH PH RH
Electrocardiogram (ECG) machine X X
Examination table X X X
Medicine storage cabinets or cupboards X X X
Table and chairs X X X
2.8 Pediatrics DH PH RH
Infant scale X X X
Photo therapy equipment X
Circumference measurement tape X X X
Height measurement board /mat for infants and young children X X X
Children height measurement board X X X
Growth monitoring charts X X X
2.9 Specialist (ENT, Ophthalmology, etc.) DH PH RH

Highly specialised equipment X
Bronchoscopes and endoscopes X
ENT mirror or lamp X X X
Nasal speculum X X X
Ear speculum X X X
Dental specialized equipment X X
2.10 Nursing wards DH PH RH

Ventilators/AC/Bukharies (where appropriate) X X X
Beds with mattresses and pillows, and bedside tables X X X
Stretchers on wheels X X X
Intravenous (IV) stands X X X
Dressing trolleys X X X
Bedpans and urinals X X X
Pedal waste bin X X X
Patient and bed linen X X X
2.11 Outpatient Department (OPD)

X-ray viewer X X X
Scales, infant and adult X X X
Pedal wastebin X X X
Table and chairs X X X
30
2.12 Orthopedics and Physiotherapy (equipment only if physiotherapist

present) DH PH RH
Brown frame with pulleys and weights X X X
Weights for traction X X X
Thomas splint X X
Blocks for relevating beds X X X
Pillows (various sizes and shapes) X X X
Bed frames for traction X X
Walking frames X X X
Treatment bench X X X
Measuring tape and goniometer X X X
Pulley system X X X
Floor mattress X X X
Weights: 0.25–5kg X X X
Dumb-bells: ½–5kg X X X
Walking bars X X X
Steps X X X
Crutches X X X
Wheelchairs X X X
2.13 X-Ray/Radiology DH PH RH
X-ray machine (fixed and/or mobile) X X X
X-ray developing machine (manual) and darkroom equipment X X X
X-ray protection material (e.g., lead aprons and protective walls) X X X
X-ray wall viewer X X X
Ultrasound machine (small, portable with voltage stabilizer at DH and RH
level) X X X
Voltage stabilizer for x-ray machine X X X
2.14 Laboratory DH PH RH
Microscope (electric where electricity through grid available) X X X
Distiller machine X X X
Hemoglobinometer (Sali method at DH and PH and Haemacue and RH) X X X
Hermatocry + D290t (HCT) centrifuge (electric) X X X
Centrifuge (hand and electric) X X X
Glucometer X X
Glycostrips X
Urine strips X X X
Pregnancy test X X X
Water bath X X X
Counting chamber X X X
ESR rack, (automated) pipette and tube X X X
Spirit lamp X X X
Timer/stop watch X X X
Slide rack X X X
Measuring jug and cylinders X X X
Fridge (absorption type) X X X
Rotator for syphilis test X X X
Sterilizer (dry heat) X X X
Balance X X X
Spectrophotometer (colorimeter on PH level) X
31
2.15 Blood Bank/Transfusion Service DH PH RH

Blood donor beds X X
Refrigerator X X
Deep fridge X
Water bath X X
Autoclave X X
Automated pipette, adjustable (10–100 micro liter) X X X
Stethoscope X X
Sphygmomanometer X X
Adult scale X X X
Crystallizing dish X X X
Cool box X X X
Lens mirror X X X
Shaking machine (vs 1–2 kg scale for manual stirring of blood bag) X X X
Transfusion bags X X X
Cross match test X X X
HIV tests X X X
Hepatitis B and C tests X X X
VDRL test X X X
2.16 Infection Prevention DH PH RH

Buckets for general waste, one for each treatment area X X X
Buckets for contaminated waste, one for each treatment area and one for each
bed in DR X X X
Buckets for decontaming instruments, one for each treatment area, OT table,
and delivery bed X X X
Sharps containers X X X
Impermeable aprons X X X
Utility gloves (for housekeeping staff) X X X
Eye protection or face shield X X X
6. Essential Drugs for Hospitals by Type of Hospital
Drugs are necessary for treating most patients in hospitals, and they can be very expensive. It
is important that hospitals have the necessary drugs, but only those absolutely necessary for
the types of conditions diagnosed and treated at that level of hospital. In 2003 the MOPH
defined the National Essential Drug List (NEDL) for Afghanistan. Table 10, “Essential Drugs
for Hospitals, by Type of Hospital” is a subset of the complete NEDL. Each hospital must
adhere to this list and not add to its formulary expensive and “exotic” drugs that benefit very
few patients. Table 10 identifies the basic drugs needed by each level of hospital based upon
the conditions diagnosed and treated at that level (see Table 6).
32
Table 10. Essential Drugs for Hospitals, by Type of Hospital
al
al
sp i t
l
sp i t
pita
o
ial H
l Ho
Hos
iona
vinc
rict
Dist
Reg
Pro
Drug Dosage
1. Anesthetics and Oxygen DH PH RH
1.1 General Anesthetics and Oxygen
Halothane cylinder X
Ketamine injection 50mg (as hydrochloride)/ml in 10ml vial X X X
Sodium thiopental powder for injection, 0.5g, 1g (sodium salt) in ampoule X
Oxygen inhalation X X X
1.2 Local Anesthetics
Lidocaine injection 1%, 2%( hydrochloride) in vial X X X
Lidocaine topical forms 2%, 4% (hydrochloride) X X X
Lidocaine + Adrenaline injection 1%–2% (hydrochloride) + epinephrine 1:200 000 in vial X X X
Lidocaine dental cartridge, 2% (hydrochloride) + epinephrine 1:80 000 X X X
Bupivacain (not in EDL but critical for hospitals) X X X
2. Analgesics, Antipyretics, Nonsteroidal Anti-inflammatory Drugs (NSAID) Medicines Used to Treat

Gout DH PH RH
2.1 Nonopioid Analgesics / Antipyretics / NSAID
Acetaminophen tablet 325mg, 500mg, syrup 120mg/5ml X X X
Acetaminophen suspension, drop 100 mg/ml X X X
(Paracetamol)
Acetyl Salicylic Acid 500 mg X X X
Ibuprofen tablet 200mg, 400mg X X X
2.2 Opioid Analgesics
Morphine injection, 10mg (hydrochloride or sulfate) in 1ml ampoule X X X
Pethidine injection, 50 mg (hydrochloride) in 1ml ampoule X X X
Pethidine tablet 50mg, 100mg X X
2.3 Medicines Used to Treat Gout
Allopurinol tablet 100mg X
Colchicine tablet 500 microgram X
3. Anticonvulsant /Anti-epileptics DH PH RH
Carbamazepin tablet 100mg, 200mg X
Diazepam injection 5mg/ml in 2ml ampoule X X X
Ethosuxamid capsule 250mg, syrup 250mg/5ml X
Magnesium Sulphate injection 500mg/ml in 2ml ampoule X X X
Phenobarbital tablet 15mg 100mg, injection 200mg/ml ampoule capsule or tablet,
25mg, 50mg, 100mg X X X
Phenobarbital (sodium salt) injection 50mg (sodium salt)/ml in 5ml vial X X X
(Complementary)
Valproic acid enteric-coated tablet, 200mg, 500mg (sodium salt) X
4. Antidotes and Other Substances Used in Poisonings DH PH RH

4.1 Nonspecific Antidotes
Activated Charcoal powder/tablet 500mg, 1g X X X
4.2 Specific Antidotes
Acetyl Cystein injection, 200mg/ml in 10ml ampoule X
Atropine Sulphate injection, 1mg (Sulfate) in 1ml ampoule X X X
BAL (Dimercaprol) injection in oil 50mg/ml in 2ml ampoule X
Deferoxamine powder for injection, 500 mg (mesilate) in vial X
Diphenhydramine injection [dosage], cap/tab 25mg, 50mg; syrup 5mg/5ml X X X
Methylen Blue injection 10 mg/ml in 10ml ampoule X
(Methylthioninium)
Naloxone injection 400 microgram (Hydrochloride) in 1ml ampoule X X X
Calcium gluconate injection 1 gram, 10% in 10ml ampoule X X X
Protamine Sulphate injection 10mg/ml in 5ml ampoule X X
(Complementary)
Flumazenil injection 100 micrograms/ml ampoule X X X
33
5. Antihistamines DH PH RH
5.1 H1 Receptor Antagonists
Chlorpheniramine Maleate tablet 4mg, injection 10mg/1ml X X X
Promethazine tablet 25mg, injection 25mg/ml X
Promethazine syrup 5mg/5ml X
Hydrochloride
5.2 H2 Receptor Antagonists
Ranitidine tablet 150 mg, 300mg, injection 50mg/2ml ampoule X X X
6. Anti-infective Medicines DH PH RH
6.1 Anthelmintics
6.1.1 Intestinal Anthelminthics
Mebendazole chewable tablet 100mg X X X
(Complementary)
Albendazol chewable tablet, 200mg, 400mg X X X
6.1.2 Antifilarials
Diethylcarbamazine tablet 50mg, 100mg (dihydrogen citrate) X X X
6.2 Antibacterials
6.2.1 Beta Lactam Medicine
Amoxycillin tablet 500mg and 250mg (anhydrous) X X X
Amoxycillin powder for oral suspension, 125mg (anhydrous)/5ml, 250 mg/5m X X X
Amoxycillin syrup X X X
Ampicillin powder for injection 1g and 500mg (as sodium salt) in vial X X X
Benzathine Benzyl powder for injection, 1,2 million IU & 2.4 million IU in 5ml vial X X X
Benzyl Penicillin G powder for injection 1 million IU and 5 million IU (sodium or X X X
(Crystal) potassium salt) in vial
Cloxacillin vial 500mg for injection X X X
Cloxacillin capsule/tablet 500mg, 250mg (as sodium salt) X X X
Phenoxy Methyl Penicillin tablet 250mg, 500mg (as potassium salt) X X X
Procaine Penicillin powder for injection, 2 million IU and 4 00 000 IU in vial X X X
(Complementary)
Amoxicillin + Clavulanic tablet 500mg + 125 mg X
Acid (restricted indication)
Amoxicillin + Clavulanic for oral suspension 125mg, 31.25mg/5ml X
Acid (restricted indication)
Ceftriaxone (restricted vial 1 gram, 500mg X X
indication)
6.2.2 Other Antibacterial
Chloramphenicol capsule 250mg X X X
Chloramphenicol oral suspension 125mg (as palmitate)/5ml X X X
Chloramphenicol powder for injection 1 gram and 500 mg (sodium succinate) in vial X X X
Doxycycline capsule/tablet 100mg (hydrochloride) X X X
Erythromycin tablet 400mg/200mg (ethyl succinate) X X X
Gentamicine injection 20mg, 40mg, 80mg (as sulfate)/ml in 2ml vial X X X
(Complementary)
Ciprofloxacin (restricted tablet 500 mg 250mg (as hydrochloride) X X
indication)
Ciprofloxacin (restricted injection 2mg/ml, 50ml bottle X X
indication)
6.2.3 Antileprosy medicines (in speciality facilities only)
Clofazimine capsule 50mg, 100mg -- -- --
Dapsone tablet 25mg, 50mg, 100mg -- -- --
Rifampicin capsule or tablet 150mg, 300mg -- -- --
34
6.2.4 Antituberculosis medicines

Ethambutol tablet 400mg X X X
INH tablet 100mg, 300mg X X X
Pyrazinamid tablet 500mg X X X
Rifampicin capsule or tablet 150mg, 300 mg X X X
Rifampicin syrup 100mg/5ml X
Streptomycin powder for injection 1g (as sulfate) in vial X X X
(Complementary)
Thiacetazon +Isoniazid tablet 50mg + 100mg & 150mg + 300mg X
6.3 Antifungal medicines
Benzoic acid+ Salicylic cream or ointment 6% + 3% X X X
Griseofulvin capsule or tablet 125mg, 250mg X X
Ketoconazol tablet 200 mg, topical cream 2% X X X
Nystatin tablet 100 000 IU, 500 000 IU X X X
Nystatin vaginal tablet 100 000 IU X X X
6.4 Antiviral Medicine
Aciclovir opthalmic ointment 3% X X
6.5 Antiprotozoal medicines
6.5.1 Anti-amoebic and Antigiardiasis medicines
Metronidazol tablet 250mg, 400mg X X X
Metronidazol injection 500mg in 100ml vial X X X
Metronidazol oral suspension, 200mg (as benzoate)/5ml X
6.5.2 Antileishmaniasis
Meglumine Antimonate injection, 30%, equivalent to approx. 8.1% antimony in 5ml X X X
ampoule
Stibogluconate Sodium injection 100mg/ml ampoule X X X
6.5.3 Antimalarial
Chloroquine tablet, base 150mg (as phosphate or sulfate) X X X
Chloroquine syrup, base 50mg (as phosphate or sulfate) /5ml X X X
Pyrimethamin +
Sulfadoxine (Fansidar) tablet 25mg + 500mg X X X
Quinine tablet 300mg (as bisulfate or sulfate) X X X
Quinine injection, 300mg (as dihydrochloride)/ml in 2ml ampoule X X X
(Complementary)
Artesunate tablet 50 mg (Note: Provided ony in malarial endemic areas) X X X
Artemether 80mg/ml 2ml Ampule (for IM only) X X X
6.6 Sulfonamide/Related
Co-Trimoxazole suspension 200mg + 40mg/5ml X X X
(Sulfamethoxazole+Trimeth
oprime)
Co-Trimoxazole tablet 100mg + 20mg & 400mg + 80mg X X X
(Sulfamethoxazole+Trimeth
oprime)
6.7 Urinary and Intestinal Antiseptics
Nalidixic Acid tablet 250mg 500mg, 250mg/5ml Syrup X
Nitrofurantoin tablet 100mg X X X
Furazolidon tablet 100mg, Syrup 125mg/5ml X
7. Antimigraine Medicines DH PH RH
Acetyl Salicylic Acid tablet, 300mg 500mg X X X
Acetaminophen tablet 325mg X X X
Ergotamine tablet 1mg (tartrate) X
Propranolol tablet 20mg 40mg (hydrochloride) X X X
35
8. Antiparkinsonism Medicines DH PH RH
Biperidin tablet 2mg (hydrochloride) X
Biperidin injection, 5mg (lactate) in 1ml ampoule X
Levodopa + Carbidopa tablet 100mg + 10mg X
Levodopa + Carbidopa 250mg + 25mg X
Trihexylphenidyl tablet 2 mg X
9. Medicines Affecting the Autonomic System DH PH RH

9.1 Parasympatomimetics
Pilocarpine solution (eye drop), 2%, 4% (Hydrochloride or Nitrate) X
9.2 Parasympatholytics
Atropine solution (eye drop) 0,1%, 0,5%, 1% (sulfate), X
Atropine tablet 1mg (sulfate), injection 1mg (sulfate) in 1-ml ampoule X X X
Hyoscine-N-butyl bromide tablet 10mg, injection 20mg/ml X X X
9.3 Sympathomimetics
Adrenaline injection 1mg (as hydrochloride or hydrogen tartrate) in 1-ml X X X
ampoule
Salbutamol tablet 2mg, 4mg (as sulfate) X X X
Salbutamol inhalation (aerosol), 100 microgram (as sulfate) per dose X X
Salbutamol respirator solution for use in nebulizers 5mg (as sulfate)/ml X X X
Dopamine Hydrochloride injection, 40 mg/ml, 5ml ampoule X
9.4 Sympatholytics
Methyldopa tablet 250mg X X X
Atenolol tablet 50mg, 100mg X
Propranolol tablet 10mg, 40mg X X X
Timolol solution (eye drop), 0.25%, 0.5% (as maleate) X
9.5 Muscle Relaxants (Peripherally acting) and Cholinesterase inhibitors
Alcuronium injection, 5 mg/ml in 2ml ampoule X
Suxamethonium (Succinyl injection, 50mg (chloride)/ml in 2ml ampoule X X X
Choline)
9.6 Autonomic Agents, Other
Bromocriptine tablet 2.5 mg (as mesilate) X
10. Medicines Affecting the Blood DH PH RH

10.1 Drugs Used in Anemia
Ferrous Sulphate tablet, equivalent to 60 mg iron, oral solution X X X
Folic Acid tablet, 1mg and 5 mg/tablet X X X
Ferrous Sulphat+Folic Acid tablet, equivalent to 60 mg iron + 400 microgram folic acid X X X
(Nutritional Supplement for
use during pregnancy)
Hydroxocobalamine injection, 1mg in 1-ml ampoule X X
(Complementary)
Iron Dextran injection equivalent to 50mg iron/ml in 2-ml ampoule X
10.2 Drugs Affecting Coagulation
Vit.K (Phytomenadione) injection 10mg/ml ampoule, tablet, 10mg X X X
Sodium Heparine injection 1000 IU/ml, 5 ml and 5000 IU/ml, 1 ml X X
Enoxaprin (low molecular sc injection X X X
weight Heparine) restricted
indication only for DVT
11. Blood Products and Plasma Substitutes DH PH RH

Dextran 70 Injectable solution 6% X
36
12. Cardiovascular Medications DH PH RH

12.1 Anti-anginal Medicines
Atenolol tablet, 50mg, 100mg X
Glyceryl Trinitrate tablet, (sublingual), 0.5 mg X
Isosorbide Dinitrate tablet, (sublingual), 5mg, 10 mg X X X
Verapamil tablet, 40 mg, 80 mg (hydrochloride) X
12.2 Anti-arrhythmic Drugs
Atenolol tablet 50mg, 100 mg X
Digoxin tablet 0.25 mg, injection 0. 5 mg/2ml X X X
Lidocaine injection, 20 mg (hydrochloride)/ml in 5ml ampoule X
Procainamide injection 1000 mg /10 ml, cap/tab 250mg X
Verapamil tab 40mg, 80 mg, injection, X
Verapamil 2.5mg (hydrochloride)/ml in 2ml ampoule X
12.3 Anti-hypertensive Agents
Atenolol tab 50mg, 100mg X
Captopril tablet 25mg X
Hydralazine tablet 25mg, 50 mg (hydrochloride), powder X
Hydralazine for injection, 20mg (hydrochloride) in ampoule X X X
Methyl dopa tablet 250 mg X X X
Nifedipine capsule/tablet 10mg X X X
12.4 Cardiotonics
Digoxin tablet 0.25mg, injection 0.5 mg/2ml X X X
12.5 Platelet Aggregation Inhibitors
Acetyl Salicylic Acid tablet 100mg X X X
13. Dermatological Medicines (topical) DH PH RH

13.1 Anti-infective, Topical
Methyl Rosanilinium
Chloride (Gention Violet) aqueous solution, 0. 5%, 1% X X X
Neomycine+Bacitracine ointment, 5mg neomycin sulfate + 500 IU bacitracin zinc/G X X X
Silver Sulfadiazine cream 1%, in 500-gram container X X X
13.2 Antifungal, Topical
Benzoic Acid + Salicylic ointment or cream 6% + 3% X X X
Acid
Nystatine ointment 100 000 U/gram, vaginal tablet X X X
Nystatine 100,000 U, drop 100 000 U/ml, coated tablet 500,000 U X X X
Tolnaftate topical cream 1%, topical solution 1% X
13.3 Anti-inflammatory and Antipruritics, Topical
Calamine-lotion lotion X X X
Hydrocortisone ointment or cream, 1% (acetate) X
13.4 Anti-infective/Anti-inflammatory Combination, Topical
Betamethasone-N topical cream/ointment Betamethason (as Valerate) 0.1%+ X X X
Neomycin Sulfate 0.5%
13.5 Sun Protectants/Screen
Zinc Oxide topical ointment 20%, powder X X X
13.6 Keratolytics/Caustics
Benzoyl Peroxide lotion or cream, 5% X
Coal Tar solution, 5% X
Fluorouracil ointment, 5% X
Resorcinol-S topical cream Resorcinol 2% + sulphur 8% X
Salicylic Acid solution, 5% X X X
13.7 Scabicides/Pediculocides
Lindane lotion 1% X X X
13.8 Local Anesthetics, Topical
Lidocaine gel 2 %, 4% X X X
37
14. Diagnostic Agents DH PH RH

14.1 Radio Contrast Media
Barium Sulfate aqueous suspension X
Meglumine Compound 76% injection 20 ml, 100ml (Meglumine diatrizoate 66% + sodium X
diatrizoate 10%)
Meglumine Compound 76% oral solution (Meglumine diatrizoate 66% + sodium diatrizoate X
10%)
15. Disinfectants and Antiseptics DH PH RH

Methanol solution, 70% (denatured) X X X
Chlorhexidine solution, 5% (digluconate) for dilution X X X
Chlorine releasing comp. powder for solution, 1 gram per liter X X X
Hydrogenperoxid solution 6% ( = approx. 20 volume) X X X
Iodine Polyvidone solution, 10% X X X
Gentian Violet aqueous solution 0, 5%, 1% X X X
Potassium Permanganate aqueous solution, 1:10 000 X X X
16. Diuretics DH PH RH
Furosemide tablet 40 mg, X X X
Furosemide injection, 10 mg/ml in 2-ml ampoule X X X
Hydrochlorothiazid tablet 25 mg 50mg X X X
Mannitol injectable solution, 10%, 20% X
Spironolactone tablet 25 mg X
17. Gastrointestinal Medicines DH PH RH

17.1 Antacids
Aluminum hydroxide + chewable tablet aluminum hydroxide 200mg + magnesium X X X
Magnesium Hydroxide hydroxide 200mg
17.2 Laxatives
Bisacodyl tablet 5mg X X X
17.3 Drugs Used in Peptic Ulcer
Histamine H2 Receptor tablet 150 mg, 300mg, injection 50mg/2ml X X X
Antagonist Ranitidine
(Complementary)
Omeprazol capsule 20mg X X
17.4 Anti-emetics
Metoclopramid tablet 10mg (hydrochloride), X X X
Metoclopramid injection 5mg (hydrochloride)/ml in 2-ml ampoule X X X
17.5 Antimuscarinics/Antispasmodic
Atropine injection 1 mg (sulfate) in 1-ml ampoule X X X
Hyoscine –N- Butyl tablet, 10 mg, X X X
Bromide
Hyoscine –N- Butyl injection 4 mg/ml in 5-ml ampoule X X X
Bromide
17.6 Antihemorrhoid Drugs
Anti-Inflammatory ointment or suppository X X X
Astringent/Local Anesthetic
Drugs
17.7 Oral Rehydration Salts (ORS)
Oral Rehydration Salt powder, 27,9 g/l X X X
(for Glucose Electrolyte sodium chloride (3.5 G/L), trisodium citrate dihydrate (2.9 G/L),
solution) potassium chloride (1.5 G/L), glucose (20 G/L); trisodium citrate
38
18. Hormones, Other Endocrine Medicines, and Contraceptives DH PH RH

18.1.Adrenal Hormones and Synthetic Substitute
Hydrocortisone powder for injection X X X
Prednisolone tablet 5mg X X X
18.3. Contraceptives
Hormonal Contraceptives
Ethinylestradiol + tablet 30 microgram + 150 microgram X X X
Levonorgestrol
Ethinylestradiol + tablet 50 microgram + 250 microgram X
Levonorgestrol
Ethinylestradiol + tablet 35 microgram + 1.0mg X
Norethisterone
(Complementary)
Medroxy Progesterone depot injection, 150mg/ml in 1-ml vial X X X
50mg/ml in 3ml vial
18.4 Intrauterine Devices
Copper-containing device X X X
18.5 Barrier Methods
Condoms with or without
spermicide (Nonoxinol) X X X
18.6 Estrogens
Ethinylestradiol tablet 10 microgram, 50 microgram X
18.7 Progestines
18.8 Ovulation Inducers
Clomiphene (Clomifen) tablet 50 mg (Citrate) X
18.9 Insulin and Other Antidiabetic Agents
Glibenclamide tablet 5mg X X
Insulin injection (soluble) injection, 40 IU/ml in 10ml vial X
Insulin injection (soluble) 100 IU/ml in 10ml vial X X
Intermediate-acting insulin injection, 40 IU/ml in 10-ml vial X
Intermediate-acting insulin 100 IU/ml in 10ml vial (as compound insulin zinc suspension or
isophane insulin) X X
Metformine tablet, 500mg (hydrochloride) X X
18.9.1 Thyroid Hormones and Antithyroid Medicines
Levothyroxine tablet, 50 microgram, 100 microgram (sodium salt) X
Potassium Iodide tablet, 60mg X
Carbimazole tablet, 5mg X
19. Immunologicals DH PH RH
19.1 Diagnostic agents
Tuberculin, Purified Protein injection X X X
Derivative (PPD)
19.2 Sera and Immunoglobulins
Anti–D immunoglobulin
(human) injection, 250 microgram in single-dose vial X X
Antitetanus injection, 500 IU, 1500U, 3 000U ampoule X X X
Immunoglobulin (human)
Pertussis Antitoxin X
Diphtheria Antitoxin injection, 10 000 IU, 20 000 IU in vial X X
Rabies Immunoglobulin injection, 150 IU/ml in vial X X
19.3 Vaccines
BCG X X X
DPT X X X
Hepatitis–B X X X
Measles X X X
Poliomyelitis X X X
Tetanus X X X
39
19.4 For Specific Group of Individuals

Mumps vaccine X X X
Rabies vaccine (inactivated: X X X
prepared in cell culture)
Rubella vaccine X
20. Ophthalmological Preparations and Drugs Used in ENT DH PH RH

20.1 Antiglaucoma and Miotics
Acetazolamid tablet, 250mg X
Pilocarpine solution (eye drop), 2%, 4% (hydrochloride or nitrate) X
Timolol solution (eye drop), 0.25%, 0.5% (as maleate) X
20.2 Anti-infective, Topical:
Aciclovir (Acyclovir) ophthalmic ointment 3% X X X
Chloramphenicol solution (eye drop) 0.5% X X X
Gentamicine solution (eye drop) 0.3 % (as sulfate) X
Sulfacetamide solution (eye drop) 10%, 20% X
Silver Nitrate solution (eye drop) 1% X
Tetracycline eye ointment, 1% (hydrochloride) X X X
20.3 Anti-inflammatory Topical Agents
Prednisolone solution (eye drop), 0.5% X
20.4 Local Anesthetics
Tetracaine solution (eye drop), 0.5% ( hydrochloride) X X X
20.5.Mydriatics
Atropine solution (eye drop), 0.1%, 0.5%, 1% ( Sulfate) X
Tropicamide solution (eye drop) 0.5%, 1% X
20.6 Drugs Used in E.N.T
20.6.1 Decongestant
Naphazoline solution (nasal drop) 0.05% X X X
20.6.2 Removal of Ear Wax
Glycerin Boric solution 5% X
21. Oxytocics and Antioxytocics DH PH RH

21.1 Oxytocics
Ergometrine tablet 200 microgram (hydrogen maleate), X X X
Ergometrine injection 200 microgram (hydrogen maleate) X X X
Oxytocin injection, 10 IU in 1ml ampoule X X X
21.2 Antioxytocics
Salbutamol tablet 4mg (as sulfate) X X X
Salbutamol injection, 50 microgram (as sulfate)/ml in 5ml ampoule X X X
22. Psychotherapeutic Medicines DH PH RH

22.1 Medicines Used in Psychotic Disorders
Chlorpromazine tablet 100mg (hydrochloride), X
Chlorpromazine syrup 25mg (hydrochloride)/5ml X
Chlorpromazine injection 25 mg (hydrochloride)/ml in 2ml ampoule X
Haloperidol tablet 2mg, 5mg, injection 5mg /1ml ampoule X X X
22.2 Medicines Used in Depressive Disorders
Amitriptyline tablet, 25 mg (hydrochloride) X
Fluoxetine capsule, 20mg X X X
22.3 Medicines Used in Generalized Anxiety and Sleep disorders
Diazepam tablet 2mg, 5mg, 10mg; injection 5mg/ml in 2ml ampoule X X X
Alparazolam tablet 0.5mg X X
22.4 Medicines Used in Vertigo
Dimenhydrinate tablet 50mg X
40
23. Medicines Acting on the Respiratory Tract DH PH RH

23.1 Anti-asthmatic Medicines
Aminophylline injection, 25mg/ml in 10-ml ampoule X X X
Aminophylline tablet 100mg X X X
Beclometasone inhalation (aerosol), 50 microgram, 250 microgram (dipropionate)
per dose X
Epinephrine (Adrenaline) injection 1mg (as hydrochloride or hydrogen tartrate) in 1ml X X X
ampoule
Salbutamol tablet 2mg, 4mg (as sulfate) X X X
Salbutamol inhalation (aerosol), 100 microgram (as sulfate) per dose X
Salbutamol syrup, 2mg (as sulfate)/5ml X
Salbutamol injection, 50 microgram (as sulfate)/ml in 5ml ampoule X
Salbutamol respirator solution for use in nebulizers, 5mg (as sulfate)/ml X X X
24. Solutions Correcting Water, Electrolyte, and Acid-base Disturbances DH PH RH

24.1 Oral
Oral Rehydration Salts (for for composition see section 18. 7 X X X
glucose-electrolyte solution)
Potassium Chloride Powder for solution X
24.2 Parenteral
Glucose injectable solution, 5% isotonic, 10%, 50% hypertonic X X X
Glucose with Sodium injectable solution, 4% glucose, 0.18% sodium chloride (equivalent X X
Chloride to Na+30mmol/l Cl-30mmol/l)
Potassium Chloride 11.2 % solution in 20ml ampoule, (equivalent to K+1.5mmol/ml, cl- X
1.5mmol/ml)
Sodium Chloride injectable solution, 0.9% isotonic (equivalent to Na+154 mmol/l, Cl- X X X
154 mmol/l)
Sodium Hydrogen injectable solution 1.4% isotonic (equivalent to Na+167mmol/l, X
Carbonate HCO3-167 mmol/l)
Sodium Hydrogen 8.4% solution in 10ml ampoule (equivalent to Na+ 1000 mmol/l, X
Carbonate HCO3-1000 mmol/l)
Compound Solution of injectable solution X X X
Sodium Lactate (Ringer
lactate)
24.3 Miscellaneous
Water for injection 5ml, 10ml ampoule X X X
25. Vitamins and Minerals DH PH RH

Iodine iodized oil, 1ml (480mg iodine) X
Iodine 0.5 ml (240 mg iodine) in ampoule (oral or injectable) X
Iodine 0.57 ml (308 mg iodine) in dispenser bottle X
Iodine capsule, 200 mg X
Multimicronutrients capsule X X X
Pyridoxine tablets 25 and 40 mg, injection (dosage) X X X
Cholecalciferol ampoule 600,000 IU/ml X X X
Phytomenadione injection, 10mg/ml ampoule X X X
(Vitamin K)
Phytomenadione tablet, 10mg X
(Vitamin K)
Retinol sugarcoated tablet, 10 000 IU (as palmitate) (5.5mg) X X X
Retinol capsule 200 000 IU (as palmitate) (110mg) X X X
Retinol oral oily solution, 100 000 IU/ml in multidose dispenser (as X
palmitate)
Retinol injection, 100 000 IU (as palmitate) (55mg) in 2ml ampoule X
41
42
Annex A. Hospital Policy for Afghanistan’s Health System
Islamic Transitional Government

of Afghanistan
Ministry of Health
Policy Statement
Hospital Policy for

Afghanistan’s Health System
February 2004
43
Ministry of Health
Policy Statement
Hospital Policy for Afghanistan’s Health System

Approved by the MOH Executive Board, February 2004
The Basic Package of Health Services (BPHS) is being expanded throughout Afghanistan.
The BPHS is an important element in the redevelopment of the health system because it deals
with the priority health problems of the country. Hospitals have an important role in this
PHC-focused strategy because district, provincial, and regional hospitals are required to form
an integrated referral system providing a range of needed services: from health promotion to
disease prevention to basic treatment to disability care to specialized inpatient care. This
policy establishes the guidelines for the redevelopment of hospitals as a key element of the
Afghan health system.
Issues: The Need for a Hospital Policy
The major problems facing Afghanistan’s hospitals which must be addressed to ensure that
hospitals are part of an integrated health system and providing quality patient care are:
• The lack of standards for clinical patient care and management of hospitals. The
consequence is poor quality of care for patients.
• The lack of equitable access to hospital services throughout the country. People in
many parts of the country have no access to a hospital and its services, while other
areas, such as Kabul, have a disproportionate number of hospital beds relative to the
population. The problem of the skewing of hospital beds and services toward certain
areas is often compounded by donors.
• The concentration of financial resources and health workers at hospitals. The result is
the potential for hospitals to be allocated a disproportionate share of new health
workers and financial resources which will reduce the ability of the health system to
address basic health problems.
• The lack of hospital management skills for the operation of hospitals. As a result, the
hospitals are inefficient.
• The lack of necessary staff, equipment, supplies and pharmaceuticals in many
hospitals. The result is the hospital is often ineffective in the treatment it provides.
• The referral system does not work. The hospital system is fragmented and
uncoordinated.
As a consequence, there is a need to address the role of hospitals in the health system, the
organization and management of hospitals, standards for hospitals and the financial and
human resources allocated to hospitals so the Afghan health system is properly planned to
address the health problems of the country for the long-term. That is the purpose of this
policy.
44
MOH Hospital Policies
The hospitals of Afghanistan will provide a comprehensive referral network of secondary and
tertiary health facilities. The policies guiding the hospital sector are:
1. Hospitals, as part of a unified national health system, will provide necessary curative
and emergency services, which complement the Basic Package of Health Services,
that includes disability care, offered at basic and comprehensive health centers.
2. Hospitals must be rationally distributed so their services are accessible on an equitable
basis for the entire population.
3. The MOH will carefully plan the number of hospitals, their location, hospital beds,
and types of hospital beds to ensure that the resources committed to hospitals result in
the maximum impact on the population’s health status. Because Afghanistan does not
have unlimited resources to finance hospitals, so health planning, resource allocation
and financial management of hospitals will be undertaken by MOH for the entire
hospital sector as a means for maximizing the impact and effectiveness of hospitals on
the country’s health status.
4. Provision of hospital care must be based on need for hospital care and not on ability to
pay.
5. Hospitals must be managed in an efficient manner that adheres to basic clinical and
managerial standards that ensure the provision of quality care to all patients, including
patients with disabilities.
6. The proportion of the government’s annual operational budget for hospitals will not
exceed 40% of the total health budget.
7. To ensure budgetary accountability and transparency, the MOPH will develop the
appropriate financial systems and develop proper mechanisms, such as empowering
financial management of hospitals to their board of directors.
8. Equitable cost-sharing strategies which are appropriate for Afghanistan, will be
developed to help make the operation of hospitals more financially sustainable.
9. Hospitals also have a role within the health system to provide supervision of lower
level health facilities, a place for professional training of physicians, nurses,
midwives, and other health providers as well as supporting necessary national medical
and health systems research.
10. Private hospitals are permitted and are part of the health system and must comply with
all standards for providing good quality care, be accredited and adhere to all MOH
policies.
Standards for Hospitals
Standards are required to improve the clinical and managerial performance to attain an
acceptable level of operations for hospitals. Standards establish what is expected of hospitals
and their staff at all levels of operation. It is the establishment of such reasonable standards
which permits the monitoring of hospital operations against which hospital performance can
be measured. This is required to improve the standard of care and management of hospitals in
Afghanistan. The following provide the framework of the basic standards. Specific details,
elements and components of each standard must be developed and specified in greater detail
by the MOH. The following provides a structure and direction for development of detailed
standards for hospitals, which will be used for accreditation, ultimately.
45
1. Responsibilities to the Community

1.1. The hospital is responsive to the community’s needs
1.2. Hospital services will be accessible to the community.
1.3. Hospitals will have a proper disaster preparedness plan so it can properly respond
in the event of natural or man-made disasters.
2. Patient Care
2.1. Patients will be treated with dignity and have a right to be treated in a respectful
manner.
2.2. Quality of clinical care to the patient that the hospital serves is high and
appropriate for Afghanistan, including the proper staffing, equipment and
supplies.
2.3. Quality of care will be monitored and measured by agreed indicators (e.g. wound
infections, length of hospital stay, operations per patient, mortality rates etc).
2.4. Women and children will receive the basic package of health services at hospitals,
including immunization, outpatient care for conditions, such as pneumonia and
diarrhea, as well as appropriate assistance at the time of delivery.
2.5. Hospitals will be “mother and baby friendly” and encourage “rooming-in” and
immediate, exclusive breast feeding.
2.6. Care delivery is monitored by the hospital’s health care team to ensure that care
meets the needs of patients and to assist in the improvement of care.
2.7. Medical records are maintained for each patient and are kept confidential and
secure.
3. Leadership and Management
3.1. The hospital is effectively and efficiently governed, organized, supervised and
managed to ensure the highest quality of care possible for patients.
3.2. To ensure the responsiveness of hospitals to the community, a hospital board of
directors or board of management will be established at each hospital to govern
and oversee the proper operation and management of the hospital.
4. Human Resource Management
4.1. Staff planning ensures a properly trained hospital staff and the appropriate number
of staff.
4.2. Staff are appointed through a recruitment, selection and appointment procedure
that is consistent with the MOH human resources policy.
4.3. In performing their duties, staff adhere to high ethical standards and a code of
conduct.
4.4. A comprehensive program of staff development and in-service training meets
individual and hospital needs.
4.5. Effective workplace relations are developed through use of teams
5. Management Systems
5.1. Financial management policies and procedures are developed and adhered to in
order to ensure accountability of the hospital’s finances from all sources.
5.2. Management information systems meet the hospital’s internal and external needs
5.3. Patient care, management of services, education and research are facilitated by the
timely collection and analysis of data
46
5.4. Information technology enhances the hospital’s ability to gather, store and analyze
information and to communicate.
5.5. Appropriate logistics and purchasing systems are maintained to ensure clinicians
have the proper equipment, supplies and pharmaceuticals to provide patient care.
5.6. Buildings and grounds are maintained to ensure a safe patient care and work
environment for patients, staff and visitors.
6. Hospital Environment
6.1. Infection is effectively controlled throughout the hospital
6.2. The physical environment of the hospital and its equipment are properly
maintained to ensure patient and staff safety and that there are no physical barriers
for those with disabilities.
6.3. The hospital is accessible to all patients with including those with physical
disabilities.
6.4. Buildings, grounds, plant and equipment are regularly maintained to ensure a safe
environment for all persons in the hospital.
6.5. Waste from the hospital is handled, contained and disposed of safely and
efficiently
6.6. Occupational health measures are adopted to ensure the safety of staff, especially
those dealing with direct patient care.
6.7. Clean water of sufficient quantity and quality is available for patients and staff
and for proper hospital functioning.
6.8. Toilets in the hospital are kept clean for use by patients, staff, and visitors.
Levels of Hospitals
There are three levels of hospitals: district (as a part of the BPHS), provincial, and regional,
including specialized hospitals. Differentiation of hospital levels is based on the patient
services offered. Five core clinical functions will exist in each level of hospital: medicine,
surgery, pediatrics, obstetrics and gynecology, and mental health. An escalating level of
sophistication will exist from district to urban hospitals. The health post, basic health center
and comprehensive health center will offer basic curative and preventative services.
Hospitals in conjunction with the Provincial Coordination Committees (PCC) will ensure the
enforcement of a well-functioning referral system. A two-way referral mechanism will be
established maintaining a functional link between hospitals and primary health care facilities.
First line referrals will stem from health centers to district hospital outpatient departments
from where consultation will define whether patients need to be further referred to higher
levels or treated at that level. Similarly patients are referred back to primary health care
facilities for follow-up. The following general specification of services for various hospital
levels will be supplemented by the Basic Package of Hospital Services, to be developed by
MOH, will identify, in detail, the clinical services provided at each level, the equipment and
supplies required, and the minimum staffing required.
District Hospital
Each district hospital will have from 30 to 75 beds and serve a population of 100,000 to 300,000,
covering from one to four districts. The basic services offered at a district hospital are:
47
• surgery
• medicine
• pediatrics
• obstetrics and gynecology
• mental health (outpatient)
• dental services
The district hospital will also have nutrition, physical therapy, laboratory, radiology, blood
transfusion, and pharmacy services.
Provincial Hospital
A provincial hospital serves a province and will have from 100 to 200 beds. In addition to the
services offered at a district hospital, the provincial hospital has:
• physical therapy and rehabilitation services;
• nutrition services;
• infectious disease medicine.
Regional Hospital
A regional hospital serves several provinces and will have from 200 to 400 beds. In addition
to the services offered at a provincial hospital, the regional hospital has:
• surgery with ENT, urology, neurosurgery, orthopedics, plastic surgery, and
physiotherapy;
• medicine with cardiovascular, pulmonary, endocrinology, and dermatology;
• forensic medicine.
Diagnostic services include:

• laboratory: hematology, parasitology, bacteriology, virology, allergy and
immunology, biochemistry, toxicology, cytology, and pathology;
• blood bank/transfusion services: Provides for the taking, preserving, and
distributing blood to patients and the diagnosis of blood related diseases (hemophilia,
thalessemia, leukemia, and viral diseases—hepatitis, HIV/AIDS);
• imaging: routine and specialized radiography, ultrasonography.
Rationalization of Hospital Services
There will be rationalization of services, such as polyclinics, where specialized diagnostic

and curative services are provided on an outpatient basis. These facilities will be linked to
regional and specialized hospitals for referral of complicated cases requiring inpatient care in
order to reduce the burden on these hospitals and to give quality services at an outpatient
level. They will not have beds as this duplicates what exists in hospitals and is expensive for
the health system.
While there may be a need for some additional specialized diagnostic services for the
country, these services are too expensive and for too few patients to be available at every
regional hospitals. Further rationalization of services will occur at the urban level where
specialized clinical and diagnostic services and equipment will be centralized. These include:
pathology and forensic medicine, histology, bio-technical support, centralized statistics
center, and research. Equipment and services such as CT-scan and radiotherapy will be
48
located at only one hospital in the country to provide the services for the entire the country
rather than being provided at each regional hospital.
Specialized hospitals will be combined into regional hospitals with multiple specialties, as
much as possible. As current specialized hospitals are rehabilitated and new facilities
planned, the MOH will seek to combine them with other major hospitals in order to
rationalize the number and type of hospitals. The current specialized hospitals include eye,
mental health, disabilities, tuberculosis, chest, oncology, orthopedic and prosthesis,
maternity, pediatrics, and emergency hospitals.
49
Annex B. Staffing Assumptions for Advised Staffing Patterns

The assumptions related to the advised staffing patterns for the hospitals are:
• Related to the % of beds per service based on (1) Mirwais Kandahar, (2) JPHH-1
Jalalabad, and (3) Ghazni hospitals, however modified: surgery to 40% (58%; 57%;
37%); medical to 25% (24%; 28%; 37%) and OB/GYN increased to 20% (5%; 5%;
9%) and pediatrics to 15% (10%; 8%; 15%).
• Staffing doctors: 1:5 (total medical doctors versus total hospital beds: Regional
Hospital Afghan standard)
• Staffing nurses 1:5 (with one head nurse/midwife in each ward/department)
• Staffing midwives 1:4
• Staffing psychiatry nurses/psychologists/anesthesiologists: estimate, unexplored area
in Afghanistan
• Staffing operating theater 1 table: 2 nurses (OT tables 50 beds = 1 then 1 for every
100 beds)
• Staffing sterilization 1: table (OT tables 50 beds = 1 then 1 for every 100 beds)
• Staffing anesthesia 1: table + 1 night (OT tables 50 beds = 1 then 1 for every 100
beds)
• Staffing for outpatient department (morning shift only):
- 50 beds: 1
- 100 beds: 1
- 150 beds: 2
- 200 beds: 2
- 250 beds: 3
- 300 beds: 4
- 350 beds: 4
- 400 beds: 4
• Staffing for emergency room (shifts: morning + night + sleep)
- 50 beds: 1 + 0 + 0
- 100 beds: 1 + 1 + 1
- 150 beds: 2 + 1 + 1
- 200 beds: 3 + 2 + 2
- 250 beds: 3 + 2 + 2
- 300 beds: 4 + 2 + 2
- 350 beds: 4 + 2 + 2
- 400 beds: 5 + 3 + 3
• Staffing laboratory and blood bank are based on recommendations of lab and BB
experts.
• Staffing X-ray technicians are per X-ray machine covering 24 hrs (not per bed). If
mobile machines are used or fluoroscope in the OT, an increase can be considered.
• Staffing physiotherapists covering both OPD and IPD is an estimate based on ICRC
experience in Afghanistan.
• Staffing dental technicians and vaccinators are estimates.
• Staffing technical assistants: important for physiotherapy, X-ray, sterilization/OT and
pharmacy: preferable to using cleaners
51
• Staffing pharmacist: estimate based on ICRC experience in Afghanistan

• Staffing administration: estimate
• Staffing storekeeper: estimate
• Staffing maintenance: at minimum, a plumber and an electrician are needed. When
hospitals become bigger, other professions may be needed (e.g., a welder and a
carpenter). In addition, the plumber and the electrician may need to be available 24
hours a day.
• Staffing kitchen: both cooks and helpers are included in this estimate
• Staffing laundry: depends on if laundry machines are used or hand washing is
practiced, whether staff uniforms are washed, etc.
• Staffing drivers: estimate
• Staffing guards: outside guards 24 hours and inside (ward) guards
• Staffing cleaners: includes administration (1), wards (1–2 per ward), corridors (1:50
beds), OT (1: table), and waste management
• Staffing porters for emergency room and OT during day time and 1 per night (> 100
beds): added to guards
52
Great Massoud Road
Kabul
Afghanistan
This publication was prepared by the Ministry of Public Health

with technical and financial assistance from the United States
Agency for International Development under the Rural Expan-
sion of Afghanistan’s Community-based Health Care (REACH)
Program, Contract Number EEE-C-00-03-00015-00.

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The Essential Package

The Essential Package of

Dr. Sayed Mohammad Amin Fatimie

Ministry of Public Health Task Force Members

MOPH Partner OrganizationTask Force Members

1. The Hospital Sector in the Afghan Health System

1. Problem: Poor distribution of hospitals and hospital beds throughout the

1.3 Levels of Hospitals

1.4 The Relationship between the BPHS and the EPHS

Hospitals provide increasingly sophisticated services in support of referrals from the

Figure 1. Link between the BPHS and Hospital Sector

Figure 2. Entry and Flow of Patients at the District Hospital

1.5 The Role of Hospitals in the Health System

Table 1. Summary of Services at a District Hospital

• Waste management and cleaning services

Table 2. Summary of Services at a Provincial Hospital

Table 3. Summary of Services at a Regional Hospital

1.6 Organization of Hospitals

The way in which the general administration of hospitals in Afghanistan should be

Figure 3. Organizational Structure of Hospitals

1.7 The Future of Hospitals in Afghanistan

Second, to strengthen community involvement and support, hospital boards must be

Table 4. Standards for Hospitals

Management • Financial management policies and procedures are developed and

Table 5. Accreditation: Dimensions of Quality of Care

2. Services Provided by Different Levels of the Hospital Sector

Table 6. Diagnosis and Treatment of Common Conditions, by Type of Hospital

2. AIDS/HIV AND SEXUALLY TRANSMITTED DISEASES DH PH RH

4. CENTRAL NERVOUS SYSTEM DH PH RH

5. DENTAL AND ORAL CONDITIONS DH PH RH

6. EARS, NOSE, THROAT CONDITIONS DH PH RH

10. GASTROINTESTINAL CONDITIONS DH PH RH

13. INFECTIOUS (SELECTED) & RELATED CONDITIONS DH PH RH

14. MENTAL ILLNESS

15. MUSCULOSKELETAL CONDITIONS DH PH RH

16. NEONATAL CARE & CONDITIONS DH PH RH

18. NUTRITIONAL & HEMATOLOGIC CONDITIONS

21. RESPIRATORY SYSTEM DH PH RH

22. SIGNS AND SYMPTOMS DH PH RH

23. SKIN DISEASES DH PH RH

24. SURGICAL CARE AND CONDITIONS DH PH RH

25. URINARY TRACT AND RENAL CONDITIONS DH PH RH

3. Diagnostic Services Provided by Different Levels of the Hospital Sector

Laboratory and imaging departments support clinicians in their diagnoses of patient

Table 7. Diagnostic Services, by Type of Hospital

5. ELECTROMYOGRAPHY (only in Kabul) X

4. Staffing of Hospitals by Type of Hospital

Table 8. Staffing of District, Provincial, and Regional Hospitals

District Hospital Provincial Hospital Regional Hospital

5. Equipment for Hospitals by Type of Hospital

Table 9. Equipment and Supplies List, by Type of Hospital

1.3 Medical maintenance and power DH PH RH

1.4 Water Supply (24/7) DH PH RH

1.5 Waste Disposal DH PH RH

1.6 Safety and Security DH PH RH

1.8 Medical stores DH PH RH

2.2 Emergency equipment DH PH RH

2.3 Operating Theater/Room DH PH RH

2.5 Sterilization equipment DH PH RH