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Sustainability of international aid and development – hospitals

May 8, 2013

By Tim Foxley

Summary:  More evidence of poorly planned, un-sustainable and wasteful international reconstruction activity in Afghanistan

Photos of Afghan maps 006I have documented a few examples of where the construction, development and aid have been spent poorly in Afghanistan over the 12 years since 2001.  In essence, money has been thrown into the country with apparently little understanding of the longer-term sustainability of such projects, which include, roads, schools and, now, hospitals.  Although such projects look good and feel good, after international attention moves on, the projects start to look precarious – too expensive, not suited to the needs of local Afghans, high maintenance costs or no planning for maintenance requirements, and corruption and contractors both skimming off huge chunks of the value of the project.

I mentioned Canadian overall efforts in southern Afghanistan here (“All the projects have failed. None of them have been successful,”)

and here, British efforts (“…buildings in Helmand were constructed without enough consultation with the Afghan government and without thinking through how they would be maintained.”)

and here, USAID handing out biscuits in Afghan schools

A new report has arrived from the US Special Inspector General for Afghanistan Reconstruction (SIGAR) – who

“…provides independent and objective oversight of more than $89.5 billion provided to implement reconstruction programs in Afghanistan. SIGAR’s core value of excellence, independence, and integrity guide its audits, investigations, and inspections.”

SIGAR is becoming adapt at spotting the longer-term problems with reconstruction work – has now focused on the construction by USAID of two hospitals.  Their website is worth a look.  The report, sub-headed: “Health Services in Afghanistan: Two New USAID-Funded Hospitals May Not Be Sustainable and Existing Hospitals Are Facing Shortages in Some Key Medical Positions”, looks damning:

“WHAT SIGAR FOUND – The Afghan government may not be able to sustain two hospitals—

Gardez in Paktiya province and Khair Khot in Paktika province—currently being built with USAID funds. USAID’s $18.5 million investment in these new hospitals may not be the most economical and practical use of these funds. First, USAID did not fully assess MOPH’s ability to operate and maintain these new facilities once completed. Second, construction began on the new hospitals about 1 year before USAID coordinated the final design plans with MOPH. USAID’s late coordination resulted in the construction of facilities that are larger—Gardez hospital is 12 times larger than the facility being replaced—than can be sustained, and increased estimated operating costs for the new facilities that are disproportionate to current costs…

Hospital construction…maintenance costs could be over five times more than the annual operating costs for the hospitals they are replacing…neither USAID nor MOPH has committed to provide funding to cover the additional operating costs of the new hospitals. SIGAR also found that some provincial hospitals are experiencing staffing shortages for certain key medical positions. Specifically, four of the five provincial hospitals that SIGAR reviewed to determine whether they met medical staffing standards reported persistent vacancies, some lasting several years…”

Analysis and Outlook

The Time article that carried the hospital story plausibly suggests a major cause of the problem.  In the last 10 years, in the context of Afghanistan and Iraq, USAID had a 30% staff cut combined with a massive increased allocation of funding for development.  The result was that money had to be spent via contractors with little oversight applied.  Doubtless more of these stories will continue to emerge.  Over 12 years there ought to have been plenty of opportunity for lessons to be identified, learnt and applied.  I can’t help worrying about the Afghan army which is expected to carry the burden of holding the state together for the next decade – how much of the billions invested there have been thrown in without real thought to sustainability in the long-term?

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5 Comments leave one →
  1. May 8, 2013 10:52 am

    A quick response, before I take the time to think more deeply.

    Hospitals, anywhere, are the province. primarily, of physicians. The other allied professionals and support staff are partners to the physician in care of the physicians’ patients. This is a bit idealistic and may offend some professionals in the care of hospital patients. In any case, I now paraphrase a physician I met in Afghanistan who was from another country: “there is no profession of medicine in Afghanistan.” There is no accredited medical school in Afghanistan. Afghan physicians are trained elsewhere, mostly (I think) in Pakistan. I met a physician trained in Pakistan who felt unprepared to be clinical physician, so he focused primarily on general management in the two hospitals he was associated with.

    The point about there “being no profession” is that there is no standard of professional behavior enforced by other properly trained Physicians, as in other countries–medical boards and associations at the local and national level. I witnessed directly the business of one physician who treated patients at a public hospital (state/province-owned) and referred those with assets to his private practice where he had his own clinical laboratory and x-ray equipment.

    Physicians with professional credibility and with certain other gifts of leadership are necessary to help a community (local and national) define its needs and set the standards, especially with respect to the establishment and configuration of a hospital..

    Bottom line: there is no leadership, therefore there is chaos.

    I am not a physician, but I worked alongside of them in the general management of hospitals and their group practices for around 40 years. I have seen weak physicians properly identified and guided by their peers and, where necessary, their privileges (in a hospital) limited to those the others felt comfortable with–with respect to patient care and safety.

    There’s more, bit I won’t dwell further on it except to say that a hospital”s organized medical staff needs a qualified board of directors, with lay people from the community and some physicians, to govern the affairs of the medical staff as well as the management. Given the general atmosphere of the country, I wonder if such people are available and willing?

  2. May 11, 2013 5:31 am

    Further comments, quoting this report (linked in your article) as a point of departure:

    “…only one of the five hospitals met the minimum staffing standards for all five key positions reviewed. In addition, none of the five hospitals met the “advised” staffing standards, except for the general practitioner and pediatrician positions; and three of the five hospitals had no anesthesiologist, one had no pediatrician, and two had no obstetrician/gynecologist.

    My Comments:
    1. A hospital is not a building; it is a team of people. The building and its equipment are their tools.
    2. A hospital building, even with all the equipment one could wish for, is useless without properly trained personnel (and certainly not only physicians) to operate it and maintain it.
    3. Hospitals are very expensive tools to build and maintain. They need to be designed and operated to certain standards of efficiency, infection control, general and special safety considerations, security, etc.
    4. Even if the entity which governs the hospital could find all the physicians needed by the local population, including specialists (note: OB-GYNs need to be female in Afghanistan), where do all the competent nurses, lab techs, radiology techs, physical therapists, hospital maintenance technicians, etc. be found?
    5. What about supplies? Where do all the medical, surgical, laboratory, x-ray imaging, and building supplies come from? Where are they securely stored?
    6. The hospital building is essential a hotel: laundry and linen functions, food service functions, buildings and grounds maintenance, etc. It should have an emergency power supply, constantly tested, if the main supply goes out (which it often does in Afghanistan).
    7. How about the general management of a hospital. Who is available to manage all the specialized personnel, equipment and supplies.
    8. How about financial management? Who keeps the books, manages cash flow, pays the bills, collects the revenue, audits the processes so stuff doesn’t go mysteriously missing?

    There’s more, but perhaps this is enough to make a final point: it’s stupid to “build a hospital” without a team of qualified people involved in the planning, especially physicians, who are going to use it. But first, you need an organized hospital governing board–a group of trustees to garner and carefully spend the assets of the organization with a mind toward service to an identified community. And, there needs to be a basis for the expectation that adequate personnel and supplies with be available ALL THE TIME.

    I remember one of our professors in graduate school who had worked with USAID in Southeast Asia (this was in the 1950s and 60s). He told us about the plan to provide privies with all the underground plumbing into leaching fields and holding tanks, etc., keep a clean water supply available in the village wells. They were nice bamboo enclosures (although the people preferred to “shit in the woods, under a nice tree”) supplied with biodegradable toilet paper. After a while the toilet paper was used up and there was no more available. The people started stripping off parts of the bamboo enclosures to use instead. The privies got clogged up and useless, so the people returned to their former habits of human waste disposal.

    But I suppose USAID could report that it had done a useful thing for the people before it moved on to other good works.

  3. May 13, 2013 4:39 pm

    Ron, some spot on useful thoughts, for which many thanks. Guess it shows that even big organisations with a long history and supposedly extensive experience can make pretty big (and basic) mistakes. You’re right of course that it would be good to get a USAID defence of the allegations. Don’t suppose you fancy turning your comments into a blog article for either you or me? 😉

    • May 13, 2013 4:58 pm

      Hadn’t thought of it (article), but if I do will you please be a close editor of it. Not everything I say may be directly pertinent to the article to which I responded. It may get stale, however, as i am about to fly to California for 7 weeks to be with some important family occasions (and boy, will my arms be tired). This doesn’t my preclude working on the article once i’m over jetlag (usually a week).

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