Report | March 13, 2013

Oversight of U.S. Military and Coalition Efforts to Improve Healthcare Conditions and to Develop Sustainable Afghanistan National Security Forces (ANSF) Medical Logistics at the Dawood National Military Hospital

DODIG-2013-053

Who Should Read This Report

Personnel within the Office of the Secretary of Defense, the Joint Staff, the U.S. Central Command and its subordinate commands in Afghanistan, the Military Departments, and Agencies that are responsible for and engaged in efforts to develop the capability of the Dawood National Military Hospital (NMH) and an effective medical logistics system in support of the Afghan National Security Forces (ANSF) should read this report.

Background

This report is the fourth in a series of reports published by the Office of Inspector General’s Special Plans and Operations (SPO) Directorate focusing on the development of a sustainable medical logistics and healthcare capability in support of the ANSF.This report is self-initiated and is particularly focused on the NMH.

During the fall of 2010, Department of Defense Office of Inspector General (DoD OIG) became aware of potential problems with the accountability and distribution of pharmaceuticals at the NMH and within the Afghan National Army (ANA), and management issues specifically at the NMH.Accordingly, the DoD OIG conducted several reviews[1] of the ANSF healthcare system, which included visits to NMH in 2010 and 2011.

In our continued oversight, a DoD IG team which included U.S. civilians and former and retired military medical personnel, visited the NMH in February and June - July 2012 to review the status of U.S. and Coalition efforts to improve the healthcare management and treatment of patients in the NMH, assess related sanitation conditions, and evaluate the medical logistics processes supporting operations at the NMH.

Results

This report is divided into two parts: (1) Notable Progress, and (2) Challenges.The report makes 7 observations and 16 recommendations.The results are discussed therein.

Part 1:Notable Progress

The report notes 11 examples where progress had been made in the areas of planning; development of ANSF healthcare standards, including development of a tool to evaluate the hospital’s achievement and compliance with these standards; focused pre-deployment training for U.S. medical advisors; and initiatives to improve the treatment of patients and the healthcare management at NMH, including hospital sanitation, accountability of staff, and medical logistics support.

Part II:Challenges

Although progress had been made since our previous visits in 2010 and 2011, and February 2012, International Security Assistance Force (ISAF), North Atlantic Treaty Organization Training Mission-Afghanistan (NTM-A), and ANA Medical Command (MEDCOM) continued to face challenges in sustaining effective healthcare operations and medical logistics for the NMH, as well as at other medical facilities within the ANA.Specifically, ISAF and NTM-A needed revised policies and procedures that ensured timely and informed decision-making regarding the transfer of ANSF patients from Coalition medical facilities to the NMH.Additionally, although improved, the control and security of medications in the NMH pharmacy required additional work to prevent theft and mismanagement of these medications.Furthermore, current practices at the NMH relating to the availability and utilization of essential medical equipment, including patient monitoring units, required improvement to ensure that this medical equipment was available for all patients that could benefit.

Additionally, although the overall numbers of ANA medical personnel increased over the past year, personnel shortages continued to affect the NMH, specifically in nursing and in the pharmacy.

ANA hospitals also lacked qualified medical equipment repair technicians to sustain effective medical equipment maintenance and repair programs.Although there were some improvements noted in this program effort at NMH, the company contracted to conduct an inventory of all medical equipment throughout the ANA was unable to do so because they did not have qualified technicians coupled with other deficiencies; therefore the contract was terminated.Students currently enrolled in the Bio-Medical Equipment Technician training program at the Armed Forces Academy of Medical Sciences were expected to provide some technical relief once they completed phase 2 of their on-the-job training and graduate from the program in the 2nd quarter of FY 2013.

Finally, improvements were needed in the logistics system to ensure the reliable availability of disinfectants and other cleaning supplies necessary to properly sanitize the hospital and prevent the spread of infectious disease.

Subsequent Measures Taken by NTM-A/CSTC-A

Following our February and July 2012 fieldwork in Afghanistan, NTM-A/CSTC-A continued to develop healthcare management and improve operations at NMH and across the ANA healthcare system.

Specific actions and ongoing efforts that we observed or were informed of by NTM-A/CSTC-A included:

  • NMH improved physical security of controlled medications in their pharmacy bulk storage room and implemented adequate inventory control measures in the pharmacy dispensary, which will deter mismanagement, theft and waste of pharmaceuticals.
  • Continued cooperation and commitment by Coalition, ANSF and Government of the Islamic Republic of Afghanistan (GIRoA) officials to ensure that the ANA medical equipment Tashkil[2] includes only those items that are necessary, practical, and cost-effective to use, maintain, and replace.
  • ANA and MEDCOM established a process to procure and distribute disinfectants and cleaning supplies rather than rely on donations.Additionally, disinfectants and other cleaning supplies, such as bleach, hand sanitizer, and hand soap were added to the Class VIII Authorized Stockage List for medical supplies, which would allow ANA MEDCOM to have better control over the availability and distribution of these supplies.
  • NTM-A continued use of its Validation Tool to assess NMH progress and compliance with ANSF Healthcare Standards.The Command also focused mentoring efforts on those areas that had yet to achieve the appropriate readiness rating.

[1] DoD IG reports SPO-2011-007, “Assessment of U.S. and Coalition Efforts to Develop the Medical Sustainment Capability of the Afghan National Security Forces,” released June 14, 2011 and 2012-083 and “Additional Guidance and Training Needed to Improve Afghan National Army Pharmaceutical Distribution” released May 7, 2012.

[2] The Tashkil describes the authorized strength and structure of an ANSF organization.