SWOT of selected secondary/tertiary health facilities in EQ affected districts

Quality care at the secondary and tertiary level is an essential component in the pyramid of health care delivery. An assessment of services and structures is the first logical step towards improving and/or sustaining high quality services in an efficient and needs based way. A preliminary rapid assessment was conducted at four hospitals; DHQ Bagh and THQ Forward Kahuta in District Bagh; and DHQ Battagram and RHC Thakot in District Battagram

The objectives of this assessment are:

  1. To assess functionality of facilities with regards to services; material and human resources.
  2. To assess the management structures and decision making process of selected facilities and their interaction with the district management team
  3. To conduct a SWOT analysis of selected facilities
  4. To develop recommendations for pertinent areas of interventions towards improving quality and efficiency of services

The methodology included a structured questionnaire with checklists, in-depth interviews with selected staff and observations. A total of 27 interviews in four hospitals were conducted, a breakdown on which is provided in the annex.

This report is divided into three parts i.e. (1) SWOT analysis of hospitals visited (2) general observations with regards to pertinent areas and (3) recommendations.

The report comments specifically on the following areas:

  1. Service provision: Types of services provided; barriers to effective functioning, further needs and potential initiatives and affects of external agency support with a focus on sustainability.
  2. Management structure/processes: Keymanagement posts and structures such as management team, meeting schedule, types of decisions made, barriers and needs with regards to skill capacity; budgeting, accountability and transparency and leadership issues.
  3. Drug procurement and supply:Process of drug requirement projections, procurement and supply including barriers faced, stock outs, warehousing problems and corresponding prescription patterns.
  4. Reporting: Types and content of regular monitoring including feedback and use for planning

Part 1: SWOT ANALYSIS

STRENGTHS / WEAKNESSES
  • Good equipment
  • Well supplied
  • Provision of multiple facilities for people
  • Provision of high quality medicine
  • Qualified and experienced staff
  • Sufficient funds
  • Future funding prospects good
  • Foreign interest in interventions
  • Hard working
  • Presence of Zakat fund and other social nets
  • Committed staff
/
  • Senior management not serious
  • Management staff does not care (does not even wear uniform)
  • Not enough management meetings with staff
  • Planning not needs based
  • No staff feedback
  • Lack of communication
  • No accountability or transparency
  • Too much reporting (not used
  • Unclear reporting structure
  • No documentation
  • Poor work ethics
  • Staff shortage
  • Alleged corruption (drug procurement)
  • Cannot deal with emergencies
  • Labs not reliable (I don’t believe)
  • Unnecessary referrals
  • Drug stock outs common
  • Irrational prescription practices
No drug protocols/treatment guidelines
  • No community participation
  • Political nepotism
  • No political commitment
  • Shortage of staff residences
  • Staff capacity low

OPPURTUNITIES / THREATS
  • Political will for improving quality
  • Outside funding opportunities
  • New building structures
  • Client satisfied
  • Community support
  • Computer technology
/
  • Local staff de-motivated (not rewarded, discomfort, no place to stay, frustration)
  • Private practice of doctors
  • Lack of maintenance
  • Thankless community
  • Lack of critical staff (orthopedics)
  • Staff conflicts (local versus outside/ senior management and staff)
  • Discrepancy in wages (MoH versus NGOs)
  • secretarial level do not want lower staff to benefit in any way
  • Centralized planning
  • Short term vision (false sense of security)
  • Functioning beyond capacity
  • Community participation difficult

Part 2: General Observations

Despite the peculiar differences between each of the four hospitals, the issues are more or less of similar nature and have been presented here as such.

Service provision:

The greatest strength as perceived by the staff is the level and types of services being provided by the hospitals. In fact all institutions visited are providing the essential services like OPD, emergency, gynecology and obstetrics, pediatrics, surgery and laboratory services. Having said that, we cannot comment on quality of services at this point though some observations point towards areas where improvement is warranted (for example OPD practices including client examination, privacy, communication etc.). Some services, however, are generally less available despite the demand for example orthopedics. It also seems that most hospitals are functioning well beyond their capacity with regards to staff and space available and the population seeking access for care. In one hospital which is being supported by an external agency, serious deficiencies in staffing and subsequently quantity and quality of service provision are expected once the agency withdraws its support. In this particular case, the local staff seems to be little concerned and is confident that a “third party” will come and support them when the current supporting agency leaves.

All facilities though seemed to be well equipped though equipment may not be used (for want of technical expertise, electricity or maintenance). The assessor came across high tech, expensive machinery unused that included an x-ray machine, dental chairs, a huge donated generator, ventilators and incubators to name a few. At DHQ Bagh, a huge pile of relatively sturdy hospital beds lying in open under a parachute cover and rusting.

While laboratories were functioning at each facility, several doctors commented that they do not take the results too seriously due to the poor quality of labs, low capacity of staff and a general dissatisfaction of clinicians with the service.

Barriers to effective service provision as quoted by staff included conflict of interest vis-à-vis the private practice of most physicians, lack of maintenance of equipment and supplies, burn out of health workers due to high case loads and a waning interest by the funding community.

Management structure/processes:

In all facilities visited, management is at best ad-hoc and unscientific. There is little input from staff and manager meetings are rare. While policy issues are centralized at the DG level, micro-management of individual facilities is centered on one individual i.e. the Medical Superintendent. Mostly these are political appointments and not supported by the necessary skills, competencies or aptitudes. For example, in one facility, the previous MS who was one of the few personnel with some management training was replaced by the pathologist. Consequently bothareas; management and pathology, have suffered.

As such there is no functioning management structure. Any “management teams” are on paper only and all decisions of any importance are made by the MS, or another senior clinician appointed by him. It is worth noting that the MS was absent in three out of four facilities visited. While talking to staff, there was a lot due to the “high-handedness” of management. At one facility, the nurses complained that they “did not have a voice” and are “treated so badly”. Infact, after the conclusion of the interview, the assessor overhead the ward doctor on duty reprimanding the nurses in a very insulting way in front of the patients in the ward and saying “you are supposed to work here not give interviews like movie stars… “. The head nurse reported that she had “been begging for phenol for the wards, but the MS just laughs at us”.

Transparency is also an issue and rumors rife regarding embezzlement of funds.

While management skills are obviously wanting, staff reported that they “don’t need training. We just do what we are told”

Staff Morale:

Staff morale was generally poor with visible differences between the clinical staff (particularly doctors) and the lower staff. While senior clinicians seemed mostly satisfied, other cadres, including lower staff, were unmotivated and resentful. According to one worker, “we also workedendlessly in the earthquake despite our personal losses but no one has given us any reward or shown appreciation”.

Conflicts are common and commonly revolve around local staff versus staff from outside (“the local people do not work and just come in to pick their pay… why am I the one shouted at.. I am here all the time”). Conflicts were reported at every level and revolve around “nepotism”, “overwork” and “unequaltreatment” and “no reward”.

There is no sense of organizational or institutional identity.Perhaps the frequent transfers and high staff turnover may be one reason for this. Most people view their jobs as essentially “to put bread on the table”. They did not seem to see the prospect of career development as realistic. On the other hand, the assessor did come across some remarkably motivated individuals but these were rare individuals, and, we suspect, not supported by the institution.

Other issues reported included staff absenteeism (especially local staff), “attached staff” (staff being paid from the hospital budget but serving elsewhere), lack of incentives and no accountability.

Drug procurement and supply:

Currently, the drug stock situation in all facilities was up to par. In fact, in one facility, they had an over supply of drugs. These stocks included both governmental supplies as well as private donations. On the other hand, clients at two facilities complained that they were prescribed drugs that were not available in the stores and very expensive. This was corroborated by store keepers at three facilities who reported that doctors often prescribed medicines not as per any guidelines (none exist) promoted by drug representatives without considering the cost, cheaper alternatives or availability of stocks in the market.

While drug procurement was local, as per lists and guidelines provided by the authorities, all decisions regarding specific generics and quantity was centralized. Procurement quantification was done based on the previous years records of drugs dispensed by the hospital pharmacy and supported by rough estimates by senior clinicians.

Further there is little storage space, poor or non-existent warehousing protocols and frequent stock outs.

A huge amount of drugs expired before usage and are supposedly disposed off by “throwing away”.

It seems that the communities’ perspective to quality care linked to the provision of drugs is shared by clinicians also. One clinician reported “How do you expect us to do anything when we don’t have any drugs”.

Reporting:

Reporting is perhaps considered the least important of all functions by hospital staff. To start with there is little culture of documentation and staff has been resistant to initiating proper documentation in the one facility supported by MSF. Secondly, the hospitals produce a myriad of cumbersome reports on a monthly, quarterly and annual basis that “nobody even looks at”. Despite the feeling that reporting is unnecessary, many decisions like procurement of drugs and supplies, staff transfers and such decisions are made based on these reports. However, little of the information collected is utilized for day to day management of the facility or for planning purposes.

Client satisfaction

All seven clients spoken to seem to be satisfied with the services provided. The absolute determinant of satisfaction is the availability of drugs at the facility. This is followed by the presence of a doctor. Long waiting times, inappropriate waiting facilities and perceived quality of care were considered secondary. Ultimately, it seems that for clients, health care is a priority and they can spend a lot of money towards this. One man had spent over PRK 10,000 on hospital bills in two weeks for a prostrate operation. He claimed that except for drips, he had to get all other medicine from the market. Costs related to his attendant’s lodging and meals were around PKR 400 per day. Though it was a lot of money for him, he was satisfied with the results of his surgery.

Clients did complain about staff attitude (especially local ward staff), lack of water in the toilets and frequent power breakdowns.

Part 3: Recommendations

The situation reported here cannot be generalized to other facilities, but does point towards some cross cutting issues across the secondary and tertiary health care system, and generally the “institution” in Pakistan.While most of the issues are structural in nature, the negative affects are magnified due to the softer issues of human relationships, work place environment and individual aspirations of the work force.

Any intervention designed must be needs based and developed in close coordination and involvement of staff. Objectives need to be realistic and achievable. One methodology that may be used in conducting interactive and facilitated SWOT sessions with prior formed health management teams to include a cross section of all staff cadres (and including nurses). These sessions may be used to develop three to five year strategic plans for the hospital in line with departmental goals and objectives. Further, key individuals must be identified and supported and groomed as the “agents of change”. The whole process and subsequent improvement needs to documented and disseminated.

Ultimately, the process can be used for advocating further devolution of power to the hospital, but not until the necessary capacity, transparency and accountability are in place. The following are some areas where intervention is warranted.

Management

Establishing management committees (HMT) with clearly defined TORs and a system of accountability

Revision and/or development of TORs for managerial staff

Restructuring of MIS system

Capacity building with regards to management skills for selected individuals

Initiating improved financial management practices and financial audits

Service provision

Establishing standard treatment protocols and minimum standards of quality of care

Review of health personnel and transfers to be based on needs

Regular clinical audits

Drug procurement

Needs-based drug procurement

Capacity building for warehousing skills

Provision of appropriate space for drug storage

Establishing specific prescription guidelines and protocols

Procurement to be based on multiple client load and specific morbidity patterns.

Others

Interventions for proper hospital waste management

Community involvement

Hospital based community outreach and active public health information campaign

Income generation for hospitalAnnex: Breakdown of interviewees

Facility / # of interviewees / Interviewee breakdown
DHQ Bagh / 12 / MoH administrator
Hospital Administrator (MSF)
Logistics (MSF)
Store keeper X2 (MoH)
Female doctor (MoH)
Nurses X2 (MoH and MSF)
Technician Emergency department (MSF)
OT technician (MoH)
Clients X2
DHQ Forward Kahuta / 4 / MS and doctor (MoH)
TB officer (MoH)
LHV (MoH)
Client
DHQ Battagram / 5 / Doctor OPD male
Nurse
Medical Technician (ward)
Clients X2
RHC Thakot / 6 / Medical Technician
LHV
Sweeper
Watchman
Clients X2