1. NATIONAL HOSPITALS ASSESSMENT PRELIMINARY RESULTS Dr. Denis Broun April 4, 2004 Kabul TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

2. 2 Organization of the Assessment A survey of 117 hospitals was conducted in October – November 2003 The survey was undertaken by surveyors and supervisers of the Ministry of Health The surveyed hospitals were identified from the national facilities database Excellent cooperation was received from hospital managers and staff. TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

3. 3 Acknowledgement This assessment has been made possible thanks to the financial support of: –The European Commission –The French Government and –USAID –UNFPA –JICA TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

4. 4 GENERAL FINDINGS

5. 5 Location of Hospitals & Clinics included in survey (with main roads) TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

6. 6 Some facilities are called « hospitals » but have no beds:  Khan Abad Hospital (Kunduz Province)  Imam Sahib Hospital (Kunduz Province)  Shahjoi Hospital (Zabul Province) Others have less than 10 beds and can hardly operate as hospitals :  Said Karam Hospita (Paktya Province) – 1 bed  Tamir Hospital (Paktya Province) – 2 beds  Tafahosat Hospital (Balkh Province) - 3 beds  Hairatan Hospital (Balkh Province) – 4 beds  Qaisar Hospital (Faryab Province) – 6 beds  Bilchiragh Hospital (Faryab Province) - 6 beds  Panjwayi District Hospital (Kandahar Province) – 6 beds  Arghistan District Hospital (Kandahar Province) _ 8 beds  Rustaq Hospital (Takhar Province) – 9 beds  Dehrawood Hospital (Uruzgan Province) – 9 beds 3 health clinics without beds were also surveyed

7. 7 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Type of facilities covered by the survey Facilities without beds, health centers and clinics with beds10 (8.5%) Specialized hospitals10 (8;5%) 7 in Kabul District hospitals76 (65%) Provincial hospitals (or equivalent)21 (18%)

8. 8 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Number of beds per hospital: Less than 10 beds 1714.5% 10 to 20 beds1714.5% 29 to 30 beds1714.5% 30 to 40 beds11 9.4% 40 to 50 beds 6 5.1% Total hospitals of less than 50 beds: 68 (58%) 50 to 100 beds2823.9% 100 to 200 beds 8 6.8% 200 to 300 beds 7 6.0% More than 300 beds 6 5.1%

9. 9 Number of beds by hospital TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

10. 10 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Distribution of hospital beds per province Hospitals are unevenly distributed among the various parts of the country. The figures of population per hospital bed show these discrepancies rather well, although they to not give a full picture of the situation. Kabul province has the largest concentration of hospital beds (although they are unevenly distributed among districts within the province). The provinces of Utuzgan, Nuristan, Ghor and Sari Pul have the lowest quantity of hospital beds per population in the country.

11. 11 Bed ratio per province : population per hospital bed TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

12. 12 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Variations in the number of beds Some facilities have an important discrepancy between the official and the actual number of beds. Discrepancies have been found in both directions Hospital with less beds than anticipated Qal-i-Naw hospital (Badghis): 60 beds instead of 96 expected Karte 3 Surgical hospital (Kabul): 416 beds instead of 454 expected Qalat hospital (Zabul): 82 beds instead of 102 expected Hospital with more beds than anticipated Faryab Central hospital (Faryab): 100 beds instead of 43 expected Emergency Surgical Centre for War Victims (Kabul): 102 beds instead of 81 expected Panjshir Emergency Surgical hospital (Parwan): 85 beds instead of 49 expected.

13. 13 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Types of hospital beds available According to the Basic Package, district hospitals (and provincial hospitals) should be able to provide at least medicine, surgery and maternity services. However, the assessment showed that this was seldom the case, and many districts do not have access to a facility able to provide such services. Thre provinces do not have a single such facility in any district (Uruzgan, Zabul, Nuristan).

14. 14 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Hospitals with functional « maternity, surgery and medicine » departments. In yellow, provinces without such hospitals Presence of medicine, surgery and maternity together in an least one hospital Provinces without one facility with the 3 basic hospital services

15. 15 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH BED OCCUPANCY RATES

16. 16 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Questionnaires included questions about average length of stay and bed occupancy rate. Most hospitals did not have this information available. Only 19 of the 117 facilities surveyed (16%) had both indicators available. The average length of stay varied between 4 and 10 days, with a median at 7 days. The bed occupancy rate varied between 10% and 85% with a median at 50% The bed occupancy rates declared by the hospital directors corresponded to the observations made by the surveyors.

17. 17 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH On the day of the survey  Of the 8,237 beds in the surveyed facilities, 3,843 were occupied. The corresponding bed occupancy rate amounts to 46.4%  46.7% of the beds were occupied by female patients  21 of the hospitals with beds (19%) did not have a single in- patient hospitalized. These empty hospitals wards were seen in facilities with 10 to 30 beds

18. 18 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Only 7 hospitals had an occupancy rate above 80% on the day of the survey : o Bamyan Central Hospital (Bamyan province) o Hirat Regional Hospital (Hirat province) o Ali Abad Hospital (Kabul province) o IbnSina Emergency Hospital (Kabul province) o Indira Gandhi Child Health Hospital (Kabul province) o Mirwais Hospital (Kandahar province) o Parwan Provincial Hospital (Parwan province)

19. 19 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH STAFFING OF HOSPITALS

20. 20 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Levels of staffing in the surveyed hospitals The 117 surveyed facilities declared that they had a total of 13,247 employees, of which 7,635 support staff (57.6%). Th number of staff per facility varied from 5 in Panjwayi District hospital (Kandahar) to 584 in Indira Gandhi Child Health hospital (Kabul). Hospitals in Kabul district employed a total of 5,441 staff, representing 41% of the total hospital staff of the country.

21. 21 Proportion of Staff categories by province (size=total nb staff in province) TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

22. 22 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Staff ratio per bed By all standards, Afghan hospitals have too much staff compared to the required level, especially in the light of the needs of primary care facilities. The average number of staff per bed for the country is 1.57, which corresponds to a level of specialization that Afghan hospitals do not have on the whole. This figure takes in consideration the actual number of beds. Another ratio to consider is that of the total number of personnel present at the time of the survey over the number of occupied beds. This ration is as high as 2.7. There are important variations in the ratio from one province to another.

23. 23 Total staff per bed, by province (all categories) TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

24. 24 « Medical » staff per bed, by province (doctors, nurses/midwives, other health workers) TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

25. 25 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Staff density Some facilities operate well with a reasonable number of staff: Medical Hospital of Nangarhar (Nangarhar), General Hospital of Public Health (Nangarhar), Nasgee hospital (Baghlan), Ata Turk hospital (Kabul), Hirat Regional hospital (Hirat) operate with a density of 1 staff per bed or less. Others have a much larger staff density, still with a low bed occupancy rate: Kabul Mental hospital (Kabul), Police Hospital (Kabul), Indira Gandhi Child Health hospital (Kabul), Kunduz Regional hospital (Kunduz) have more than 2.5 staff per bed. In spite of high densities of staff, 25% of facilities declared that they had to cancel vacations in 2002 because of staff shortages.

26. 26 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Payment of staff In more than 64% of surveyed cases, full salaries had not been received in 4 months or more. Only 7% of facilities had received full civil servant salaries in the last 3 months.

27. 27 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Female staff Female staff represented 24.5% of the total staff of the surveyed hospitals

28. 28 Male/female ratio among hospital staff TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

29. 29 Percentage of female staff (all categories) by province TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Percentage Female Staff 0-15% 15 – 25% 25 – 38%

30. 30 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Preliminary conclusions on the first part of the survey analysis  Afghanistan has a relatively low number of hospitals and hospital beds compared with other developing countries. The ratio of 1 bed for 1,000 people is not reached in any province  The distribution of hospital facilities and services is uneven with large parts of the population unable to access referral facilities  Hospitals are generally over-staffed, particularly in the large urban areas.  Too few facilities have an adequate number of female staff to provide accesptable services to the whole population they are supposed to serve.

31. 31 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH PHYSICAL CONDITION OF HOSPITALS

32. 32 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Age and Rehabilitation Afghan hospitals are not very old. Dates of construction stated by interviewees during the survey ranged between 1312 (Maiwand Hospital) and 1382 (Sharan district hospital in Paktika). The physical condition of buildings is often acceptable. It was assessed in detail service by service. 43 hospitals (37%) are currently undergoing a rehabilitation project. This imposes heavy management and coordination constraints. 53 hospitals (45.3%) are currently undergoing an expansion project (which may be part of the rehabilitation project).

33. 33 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Damages 47 of the 117 surveyed hospitals (40%) suffered some degree of damage because of actions of war. War damages to hospitals started as early as 1358, and the most recent war damaged dated back to 1380. The peak of destructions happened in 1371. In addition, two hospitals of Wardak province were damaged by an earthquake in 1379.

34. 34 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Access to power  19 hospitals had no access to power at all (16%).  34 hospitals had a haphazard supply of electricity with power available less than 12 hours per day.  85 hospitals (73%) had a functional generator to supply electricity  4 hospitals used solar energy as a complement: Rukha hospital (Parwan), Mehtar Laam Baba Regional hospital (Laghman), Noor hospital (Kabul) and Dasht-i-Qala hospital (Takhar) and one used wind energy: Mehtar Laam Baba Regional hospital (Laghman)

35. 35 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Access to electrical power in surveyed hospitals

36. 36 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Access to water 20 hospitals had no access to water at all (18%) 12 additional facilities had access less than 12 hours per day. 14 of hospitals connected to a water distribution network also have a water tower in case of failure Number of hospitals with access to water.

37. 37 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Access to drinking water in surveyed hospitals

38. 38 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH In green: good access to water and power In red: access to water and power less than 12 hours/day. Water & Power Supply Water & Power > 12h (53) Water & Power < 12h (22)

39. 39 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Sanitation 96 out of 117 hospitals indicated the sanitation system in use. Waste water was generally managed by a combination 2 or more systems: 7 of the 10 hospitals connected to a city sewage system had a septic tank or a pit before spreading 67 of the 69 hospitals with a septic tank but no connection to a city sewage system used in addition a pit before spreading and or had pits below latrines. 17 hospitals have neither a connection to a city sewage system nor a septic tank but have pits before spreading and or below latrines. On the whole, appropriate attention was paid to sanitation in surveyed hospitals

40. 40 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Solid waste management 47 hospitals, accounting for 35% of the beds in the country, had no functional waste management system: 74 hospitals had an incinerator, of which 53 in perfect condition; 24 hospitals have an additional system for medical waste or other solid waste to compensate for the relatively poor condition of their incinerators. Specific management of medical waste remained exceptional and deserves more attention.

41. 41 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Access to communication Nb of facilities with:No radio, no telephoneRadio or telephone ≥ 151 beds311 51-150 beds1318 11-50 beds3116 ≤ 10 beds214 Total6849 16 facilities ( 13.5%) had no communication capability whatsoever, but more reported that their communication was not permanently functional.

42. 42 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Surveyed hospitals with access to communication (functional phone or radio) Provinces with worst access to communication

43. 43 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Transportation A lot of cars and ambulances have been supplied to Afghan hospitals over the past 2 years. There are major discrepancies between regions and facilities regarding the availability of transportation. It is often facilities located in difficult to access areas which are less well equiped.

44. 44 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Surveyed hospital with vehicle (ambulance, car or van) Provinces with worst access to transportation

45. 45 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Diagrams to determe investment priorities

46. 46 In Garziwal hospital (Faryab), the good infrastructure is not supported by any other element that would make the hospital functional Hirat Regional Hospital (Hirat) has a better than average infrastructure, but still access the power network irregularly.

47. 47 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Preliminary conclusions on the second part of the survey analysis  Afghan hospitals are in a relatively good condition in spite of the 20 years of armed conflict. Strong international cooperation is rehabilitating and expanding facilities, but actual needs seem not to have always been thoroughly analyzed.  In spite of recent investment, access to power and water remains a problem for many hospitals, and could be addressed relatively easily.  Waste management, especially for medical waste, requires additional efforts.  The building cluster indicators approach may help target investment priorities.

48. 48 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Analysis of specific hospital functions The survey gathered elements of a complete functional analysis of facilities. However, particular functions were analyzed in priority: - Emergencies - Blood banks - Maternities and emergency obstetric care - Operating theaters and sterilization

49. 49 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH EMERGENCIES Emergencies are the main point of entry of patients with the hospital system. The emergency department (ER) is often used for primary care consultations Many district hospitals that did not have in-patients received patients in the ER.

50. 50 Performance of emergency rooms 30% of all surveyed facilities had no emergency room at all. Some entire provinces have access to only one single ER. Most ER were poorly equipped and not able to handle some of their basic functions: - only 10 hospitals could perform an electrocardiogram in the ER. - only 26 hospitals had oxygen available in the ER. Over 40,000 patients/month are seen in ER of 82 hospitals Actual total is probably much larger, as several hospitals do not keep a registry of emergency cases. 252 hospital beds are labeled “emergency room beds”. TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH

51. 51 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Staffing of emergency rooms Only 14 hospitals (17% of facilities with an ER) did not have a doctor present 24h/24h Of these 9 had a doctor available on call at all time Only 5 ER were without medical staff at night (6%). 59 of the 82 hospitals with an emergency room accepted patients for emergency obstetric care during daytime (72%) and 57 during night time (69.5%).

52. 52 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Equipment of ER Based on their level of equipment and access to emergency drugs, surveyed Ers were broken down into functional Ers (19 hospitals – 23.1%) and potentially functional Ers (63 hospitals). Only Qalat hospital (Zabul) was found to have a fully equiped ER. Two functional operating rooms (Nimroz hospital and Kapisa Provincial hospital) operated in buildings in serous need of repair. Three functional Ers operated without adequate access to electricity and water: Lashkar Gah General hospital (Hilmand), Qalat hospital (Zabul), Kapisa Provincial hospital (Kapisa)

53. 53 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Intensive care units 37 hospitals (31.6%) have an intensive care unit (ICU). Among these, only 20 have oxygen available, 18 have at least one ventilator in operating condition, 26 have succion equipment, 9 had intubation sets at the time of the survey. ICUs are not fully operational The busiest ICU in the country is in Ahmed Shah Baba Minah hospital (Kabul), but other large hospitals have more than 200 patients treated per month in intensive care:Central Hospital of Public Health (Nangarhar), Hirat Regional hospital (Hirat), Indira Gandhi Child Health hospital (Kabul), Medical Hospital of Nangarhar (Nangarhar) and Ghazni Civil Provincial hospital (Ghazni).

54. 54 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Blood banks 25 of the surveyed facilities (21%) declared that they had some transfusion activities. 7 additional facilities had some or all of the equipment needed to perform transfusions. Transfusion happens in the larger than average facilities (average 158 beds) An average 2,000 transfusions were performed per month in the hospitals of the country. This corresponds to a yearly “transfusion incidence rate” less than 0.11%. The transfusion incidence rate in developed countries is usually situated between 3% and 5%.

55. 55

56. 56 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Blood donations 82.5% of all transfusions were made with blood donated by a family member of the patient, 9.1% with blood from a paid donor 8.4% with blood from a volunteer donor. The average in countries with a low human development index is 31% of donations from voluntary non-remunerated donors and 61% from family and relatives. Only 14 hospitals had a registry of donors and 12 had a plan to contact donors in case of need.

57. 57 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH Grouping and cross-matching Test for syphilisTest for HIV Test for Hep. B Test for Hep. C 100%76%72% 60% Quality of blood for transfusion Only 10 operational transfusion services had the capacity to pack cells and thus separate and keep plasma or administer red cells or platelets to patients.

58. 58 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH MATERNITIES 24 of the 117 surveyed hospitals (20.5%) declared not to provide maternity services. 59 facilities declared receiving out-patients for maternity related services. Some inconsistencies were noticed: Qaisar hospital (Faryab) declared receiving over 250 patients per month on average, but had no gynecologist or midwife on the staff. Conversely, Khair Khana hospital in Kabul declared receiving less than 60 out-patients per month on average in spite of a staff of 18 gynecologists and 14 midwives.

59. 59 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH MATERNITIES / Out-patients The average number of out-patients per month varied from -From 2 in Baglan district hospital (Baghlan) - to 4,792 in the Medical Hospital of Nangarhar (Nangarhar). ProvinceHospital nameOut-patients/r month NANGARHARMedical Hospital of Nangarhar4,792 HIRATHirat Regional Hospital3,929 KABULRabia-i-Balkhi Hospital2,100 NANGARHARSultan Pur Clinic2,008 GHAZNIGhazni Civil Provincial Hospital1,439 KANDAHARAbdul Hakim Hospital1,287 JAWZJANProvincial Hospital Jawzjan1,042 HIRATGuzara District Hospital750 BADAKHSHANFaizabad Hospital621 PARWANRukha Hospital596

60. 60 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH MATERNITIES / In-patients 69 hospitals declared they had at least one maternity bed. 38 (55%) have small maternities of 5 beds or less. Of these 5 declared not having performed a single delivery in the 6 months before the survey. 19 (14.5%) have 20 beds or more..At the time of the survey, there were four provinces without a single maternity bed

61. 61 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH KABUL391FARYAB8 NANGARHAR88HILMAND8 HIRAT50BAMYAN7 BALKH42KUNAR6 BADAKHSHAN28KAPISA5 LOGAR28KUNDUZ5 PARWAN28BADGHIS4 BAGHLAN22GHOR4 WARDAK22JAWZJAN4 PAKTYA21NIMROZ4 GHAZNI16PAKTIKA3 LAGHMAN15SAMANGAN2 KHOST14NURISTAN0 FARAH13SARI PUL0 KANDAHAR10URUZGAN0 TAKHAR10ZABUL0 Maternity beds / 100,000 population

62. 62 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH MATERNITIES / Deliveries 6 hospitals performed more than 200 normal deliveries per month on average. 32 hospitals performed less than 20 normal deliveries per month. ProvinceHospital nameMaternity bedsNormal deliveries KABULMalalay Maternity Hospital2171,333 KABULRabia-i-Balkhi Hospital1131,305 NANGARHARMedical Hospital of Nangarhar55805 HIRATHirat Regional Hospital40488 KHOSTKhost Hospital14319 GHAZNIGhazni Civil Provincial Hospital10244 KANDAHARAbdul Hakim Hospital10208 KABULKarte 3 Surgical Hospital20200

63. 63 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH MATERNITIES / Cost recovery 21 of the 69 (30.5%) hospitals practicing deliveries declared to charge for that service. The amount charged varied between 10 and 1,000 Afs. The median amount of the charge was 58 Afs. Hospitals declaring to charge for deliveries were all locate in the Eastern half of the country, although hospitals in the other half would eventually charge for other services..

64. 64 Hospital charging for deliveries :

65. 65 TRANSITIONAL ISLAMIC STATE OF AFGHANISTAN MINISTRY OF HEALTH MATERNITIES / Staff  The survey identified 373 obstetricians/gynecologists and 341 midwives.  Staff is poorly distributed among facilities. Most hospitals performing deliveries had a small amount of staff not enough to cover night shifts (only 58 of the 69 hospitals had staff in the maternity at night).  Other hospitals have a large number of specialists: Malalay Maternity hospital has 21% of all specialists working in the country’s hospitals.  Kabul province, with about 16% of the total population of Afghanistan, concentrated 46% of obstetricians/gynecologists and 45% of midwives.  Four district hospitals perform deliveries without one single obstetrician or midwife.