VZCZCXRO1471
OO RUEHDBU RUEHIK RUEHYG
DE RUEHBUL #5926/01 3551339
ZNR UUUUU ZZH
O 211339Z DEC 06
FM AMEMBASSY KABUL
TO RUEHC/SECSTATE WASHDC IMMEDIATE 5027
INFO RUCNAFG/AFGHANISTAN COLLECTIVE PRIORITY
RUEHZG/NATO EU COLLECTIVE PRIORITY
RHEHAAA/NATIONAL SECURITY COUNCIL WASHINGTON DC PRIORITY
RUEAIIA/CIA WASHINGTON DC PRIORITY
RHEFDIA/DIA WASHINGTON DC PRIORITY
RUEKJCS/OSD WASHINGTON DC PRIORITY
RUEKJCS/SECDEF WASHINGTON DC PRIORITY
RUEKJCS/JOINT STAFF WASHINGTON DC PRIORITY
RHMFIUU/HQ USCENTCOM MACDILL AFB FL PRIORITY
RHMFIUU/COMSOCCENT MACDILL AFB FL PRIORITY
RUCNDT/USMISSION USUN NEW YORK PRIORITY 3450

UNCLAS SECTION 01 OF 04 KABUL 005926 
 
SIPDIS 
 
SIPDIS 
 
STATE FOR SCA/FO DAS GASTRIGHT, SCA/A, S/CRS, SA/PB, S/CT, 
EUR/RPM 
STATE PASS TO USAID FOR AID/ANE, AID/DCHA/DG 
NSC PASS TO NSA FOR AHARRIMAN 
OSD FOR KIMMITT 
CENTCOM FOR CFC-A, CG CJTF-76, POLAD, JICCENT 
 
E.O. 12958: N/A 
TAGS: PREL PGOV PTER ASEC MARR AF
SUBJECT: PRT/KUNDUZ: HOSPITAL REFORM WORKING IN NORTHEAST 
 
 
------- 
SUMMARY 
------- 
 
¶1. (SBU) The provincial hospitals in Kunduz and Takhar 
Provinces are two of five pilot projects under the World-Bank 
funded Hospital Reform Program.  They receive extensive 
support from the Ministry of Public Health and are relatively 
well-equipped, have capable and well-paid staff, and appear 
to be delivering good care to the population of the two 
provinces.  The recent decision to re-open the Spinzar 
Hospital in Kunduz, rather than focusing expansion efforts on 
the provincial hospital, may, however, have an overall 
negative impact on health care for Kunduz Province and the 
region.  END SUMMARY. 
 
¶2. (U) PRTOff and German Foreign Office colleagues visited 
the Takhar Hospital in Taloqan, the capital of Takhar, on 
December 9 where Hospital Director Dr. S. Ashrafuddin Aini 
provided information about the hospital's current and future 
programs and took PRT Reps on a tour of the facility.  PRT 
Reps had a similar briefing and tour of Kunduz Hospital on 
September 10 hosted by Hospital Director Dr. Zaher Paknehad 
(who left the hospital in early December) and met with the 
hospital's acting director and other officials for an update 
on December 16. 
 
Kunduz and Takhar Showcase Hospital Reform Program 
--------------------------------------------- ----- 
 
¶3. (U) The hospitals in Kunduz and Takhar Provinces are two 
of the five pilot projects in the Ministry of Public Health's 
World Bank-funded Hospital Reform Program (the others are in 
Baghlan, Zabul, and Ghor Provinces).  This program provides 
for a standard package of services in each province -- 
Emergency Provincial Health Services (EPHS) -- to cover all 
life-threatening cases, at least to the extent of getting 
patients stabilized and, if necessary, sending them to Kabul 
or another location for the required specialized care. 
 
¶4. (U) One major component of the program is a plan to 
address Afghanistan's very high maternal and infant mortality 
rates.  In addition to the range of medical care provided by 
general practitioners, the EPHS package includes specialists 
in maternity and pediatric care, as well as internal medicine 
and basic surgery.  Specialties that are not included in this 
package include ENT (Ear, Nose and Throat), Ophthalmology, 
and Orthopedics.  These are supposed to be covered in a 
regional hospital, but this program is not yet functioning in 
Kunduz, the designated location for the region, due primarily 
to the lack of space. 
 
¶5. (U) In the absence of the regional ENT and eye care 
capability, the Takhar Hospital has managed to cover most of 
these requirements with resources in Taloqan.  The hospital 
can call on a private eye care clinic when necessary, and 
they are currently looking into working with Kinderberg, a 
German NGO, to set up ENT and Ophthalmologic care in the 
hospital.  In Kunduz, these capabilities currently are 
provided by private practioners or are covered with 
assistance from the German PRT Hospital.  Kunduz Hospital has 
requested an additional building to house the planned 
regional capability, but it appears that a Ministry of Public 
Health plan to re-open Spinzar Hospital in Kunduz may derail 
that plan. 
 
¶6. (U) Other aspects of the Hospital Reform Project include 
measures for infection control -- including banning re-use of 
needles -- and careful waste management.  For example, an 
incinerator is available on site in Kunduz to burn medical 
waste daily. 
 
Program Provides Realistic Salaries and Substantial Support 
--------------------------------------------- ------- 
 
 
KABUL 00005926  002 OF 004 
 
 
¶7. (U) Key aspects of the Hospital Reform Program include 
realistic salaries for the medical staff and provision of 
necessary equipment and medicines, as well as assistance in 
building facilities needed for patient care, that is, 
hospital rooms.  The equipment includes EKG, X-ray, and 
ultrasound equipment, as well as laboratory equipment and 
supplies.  The Takhar hospital had just received new 
incubators and F-100 formula to combat child malnutrition, as 
well as additional examination equipment; Kunduz has received 
similar equipment. 
 
¶8. (U) The capacity of the Kunduz Hospital is 110 beds, while 
the Takhar Hospital currently has only 65.  To reach the 
target for a provincial hospital of 100 beds, the Ministry of 
Public Health funded an expansion project in Taloqan for an 
annex -- due to be completed within a few weeks -- that will 
accommodate 35 beds.  (Note: All rooms in both hospitals are 
multi-bed rooms, usually four beds but sometimes more; 
private rooms are unknown.  End Note.)  The Ministry did not, 
however, fund the actual beds, and the only beds that are 
locally available are plain wooden beds, some of which 
already are in use in the hospital.  The Hospital Director 
welcomed a German Foreign Office offer to consider funding 
35-40 additional hospital beds, and the PRT Civilian Leader 
was surprised to receive the written proposal two days later 
during another visit to Taloqan. 
 
Medical Staff and Salaries 
-------------------------- 
 
¶9. (U) Both hospitals have specialists covering the same four 
specialties: general surgery (3), internal medicine (2), 
gynecology/obstetrics (3), and pediatrics (2).  Kunduz has 14 
and Takhar 13 general practitioners.  Takhar also has one 
trained mental health professional and one GP trained in 
medical sonography.  In addition to its 25 doctors, Takhar 
has 30 nurses and 6 midwives (plus two vacant midwife 
positions).  Kunduz has 120 total staff, including 24 
doctors, 30 nurses, and 8 midwives.  Both hospitals have 
several staff members, both doctors and administrators, who 
have been trained overseas and speak excellent English. 
 
¶10. (U) The reported monthly pay scales for hospital staff 
varied somewhat between the two hospitals, and appear to 
depend on training and experience, but are approximately as 
follows: MD Specialists $400-500; GPs $300-400; Nurses 
$150-240; Midwives about $180, and Orderlies about $100. 
These wages are quite good in the Afghan context (where 
judges, for example, still earn less the $100 a month), and 
the working conditions are also quite good.  At Kunduz, for 
example, the staff normally work from 8 am to 2 pm, though 
they can be called in other times.  Because of this 
attractive pay scale and good working conditions, both 
hospitals have been able to attract and retain good staff. 
The transparency of the financial arrangements -- both 
hospital directors noted that their staff actually do get 
paid what is due them -- also helps. 
 
Storage and Space Problems Key 
------------------------------ 
 
¶11. (U) Although overall conditions are relatively good, both 
hospitals continue to experience problems, the most obvious 
of which is lack of space.  The Takhar Hospital was built 40 
years ago as a 35-bed facility, but now has 65 beds.  The new 
annex, which is being built as a second story on the original 
one-story building, will provide more space for patients, but 
neither hospital has adequate storage areas for drugs or 
other hospital stores and equipment.  In Takhar, various old 
buildings, including the old kitchen, are used as storage 
areas.  Staff were in the process of building and installing 
wooden shelving to better organize the drug storage area, but 
this is only a stop-gap, as the building itself clearly was 
inadequate.  The hospital in Kunduz, which is a recently 
built three-story building outside of the city (funded by 
 
KABUL 00005926  003 OF 004 
 
 
USAID and the original U.S. PRT in Kunduz, and initially 
managed by the Swedish Committee), has no such extra 
outbuildings and has been forced to use the balconies of 
hospital rooms on the second floor as storage areas. 
 
¶12. (U) In addition to storage issues, both hospitals lack a 
place where relatives can wait while their family member is 
in the hospital.  As in many other places, it is normal in 
Afghanistan for families to accompany, and neither hospital 
has waiting rooms or other space for these non-patients to 
stay.  The problem is more acute in winter, of course, and 
also more difficult in Kunduz, where the hospital is outside 
of town and there are no other buildings around where family 
members can wait. 
 
¶13. (U) Electricity is another problem.  Kunduz has a fairly 
reliable grid that is part of a transmission system coming in 
from Tajikistan, but Takhar continues to rely on a 100KW 
generator, with no effective backup capability.  However, the 
Ministry reliably pays for fuel for the generator, so as long 
it works, needed electricity is available. 
 
Reform Program Includes Cost-Sharing Plan 
----------------------------------------- 
 
¶14. (U) Both hospitals have instituted a cost-sharing plan 
that is part of the Reform Program arrangements, which also 
include a hospital board with community participation. 
Although public health care is supposed to be free in 
Afghanistan, the hospitals have begun charging a flat fee of 
10 (Takhar) or 20 (Kunduz) afghanis (about 20 or 40 cents) 
per patient for hospital care or drugs, and 50 afghanis (one 
dollar) for more elaborate procedures such as X-rays.  Kunduz 
also charges 100 afghanis (two dollars) for surgery.  This 
all goes into the Hospital Support Fund, which usually 
amounts to about $800 to $1000 a month.  Upon approval by the 
hospital board, this fund can be used to purchase any missing 
drugs, expendable supplies, or other needed items.  The 
Takhar Director told us this cost-sharing plan was difficult 
to start up due to both official and community resistance, 
but with the assistance of the board, it seemed to be working 
well. 
 
Re-opening Spinzar May Obstruct Kunduz Hospital Development 
--------------------------------------------- --- 
 
¶14. (U) The PRT has recently learned about plans by the 
Ministry of Public Health and Kunduz Province officials to 
re-open the Spinzar Hospital, which was built in the 1940s by 
the Spinzar Cotton Company and, prior to the construction of 
the Kunduz Provincial Hospital in 2003, was the only hospital 
in Kunduz.  The Spinzar Hospital is a lovely old building 
with high ceilings, verandas, and skylights, but the 
electrical wiring and plumbing have not been updated, there 
are virtually no furnishings, and the entire building -- 
although well built -- is in serious need of repair and 
renovation.  The operating room, for example, is completely 
empty except for an ancient light fixture that hangs 
crookedly from the ceiling -- and clearly would not work, 
even if the electricity were to be turned on. 
 
¶15. (SBU) The Spinzar Hospital is allegedly to be officially 
re-opened by the Minister of Public Health when he comes to 
Kunduz on January 9 to open the District Hospital in Imam 
Sahib.  When PRT Reps visited Spinzar on December 16, some 25 
or 30 people -- including the Kunduz Deputy Director of 
Public Health, who reportedly will be the new Spinzar 
Hospital Director -- were busily moving in beds (not hospital 
beds), chairs, and cabinets -- apparently the only 
furnishings so far acquired.  The Ministry reportedly is 
paying the owner of the hospital, the Ministry of Mines and 
Industry, $2000/month in rent, but no one seemed concerned 
about where the necessary equipment, staff, and funding to 
run the "new" hospital would come from.  We were first told 
that Spinzar would take on only the regional functions (ENT, 
 
KABUL 00005926  004 OF 004 
 
 
Ophthalmology, and Orthopedics), then that it would also do 
surgery and include an emergency room, and finally that it 
would offer the "same services" as the existing hospital and 
"be better equipped than the other one."  Rows of chairs were 
lined up in a hallway in preparation for the opening 
ceremony, but as far as PRT Reps could see, there was very 
little to open, and would not likely be a great deal more 
before January 9. 
 
Comment 
------- 
 
¶16. (SBU) Both the Kunduz and Takhar Hospitals appear to 
function considerably better than many other public 
facilities in the region, and the standards at both are 
higher than one might expect.  Kunduz has received 
substantial assistance from the German PRT in Kunduz, which 
has a Role 2 hospital on site capable of fulfilling most 
requirements for the ISAF soldiers and others in the PRT, 
including dental care and basic surgery.  In addition to 
permitting access by local Afghans in need of substantial 
care, the German Hospital staff visit Kunduz Hospital 
regularly and provide on-site medical care and consultation. 
 
¶17. (SBU) Although the Takhar Hospital has not benefited from 
such direct PRT assistance, the hospital staff (including a 
medical director who trained for several years in Holland), 
taking advantage of the Reform Program benefits from the 
Ministry and the assistance of several other donors, have 
developed a facility and a capability that appear to be even 
better than that so far attained in Kunduz. 
 
¶18. (SBU) PRT Reps are concerned that the decision to re-open 
the Spinzar Hospital will shift the focus away from the 
Kunduz Provincial Hospital and the expansion necessary before 
it can fulfill its provincial and regional functions.  The 
Spinzar Hospital is located in Kunduz City, so it will be 
easier to reach than Kunduz Hospital and may also take away 
patients, doctors, and other staff.  The only identified 
funding stream, however, is from the Ministry of Public 
Health, which is unlikely to have either the resources or the 
focus to make the Spinzar project succeed.  During 
discussions at Kunduz Hospital, it was intimated that some 
equipment would end up shifting to the "new" hospital, which 
could leave donors reluctant to provide any additional 
assistance to Kunduz.  Yet once the Spinzar Hospital is 
officially open, it almost certainly will start canvassing 
donors for support.  All of this is bound to set back the 
pilot project in Kunduz, and may already have done so.  The 
Hospital Director resigned two weeks ago, and PRT Reps agree 
that the Takhar Hospital seems to be running much better than 
Kunduz; the specter of Spinzar may be part of the reason why. 
 
Biographic Notes 
---------------- 
 
¶19. (U) Takhar Hospital Director Dr. S. Ashrafuddin Aini is a 
trained internal medicine specialist originally from Chah Ab 
District of Takhar, though he attended school in Taloqan. 
Although he has never lived for any length of time outside of 
Afghanistan, he speaks English very well, and he also appears 
to have excellent management skills.  He worked for UNICEF 
for two years in Kunduz, and has also worked for the Ministry 
of Public Health in Kabul.  He ran as a candidate for the 
Wolesi Jirga (lower house of parliament) in Takhar in 2005 
and narrowly missed gaining a seat.  He appears to be in his 
early to mid-forties. 
 
NORLAND