Hospital Management, Security, and Performance in Afghanistan
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Problem Statement: The vulnerability of hospitals in settings of armed conflict is a critical issue of growing public health concern. There remain gaps in the literature regarding the evidence-base for preparedness and management infrastructure on actual hospital performance in such settings. Methods: This study uses cross sectional survey data collected from 97 hospitals (49 district, 28 provincial, 5 regional, and 15 national) across Afghanistan in 2012, which encompassed interviews of 1,828 health workers, 1,544 inpatients, and 1,191 outpatients over five years of age. Multiple linear regression was used to study hospital performance - measured using the Balanced Scorecard, physicians per bed, nurses per bed, outpatients per month, and bed turnover rate - across levels of key indicators of management, security, and community linkage, for Chapters 3 and 4. For Chapter 5, multilevel logistic regression was used to examine the association between staff and patient perception of insecurity and key indicators of hospital security and community linkage. Results: The management indicators that were statistically significant varied across each outcome measure of hospital performance but tended to relate to the broad categories of training and having written/documented organization plans or supervisory reports. The statistically significant security indicators were those that related to infrastructure or training interventions, such as the hospital having a safe for storage of cash and important documents or the staff having been trained in disaster management, and the significant community linkage indicators included those pertaining to governance and involving key stakeholders, like having an annual hospital-community action plan or involving a member of a local NGO on the Hospital-Community Board. Overall, the factors that were statistically significantly associated with perception of security across health workers, inpatients, and outpatients referred more to relationships, such as the level of trust, rather than policy or structural features. Conclusions: This study highlights some specific management, security, and community linkage interventions on which hospitals could focus in order to improve different aspects of performance, in situations of limited resources, as well as perceptions of security among health workers, inpatients, and outpatients in Afghanistan.