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A CASE STUDY

With the present health system structure in Lakhabi district in Afghanistan the following

story is a tip of iceberg of underlying problems of health service delivery. The Lakhabi

district hospital has coverage of 150,000 people. A comprehensive spectrum of

diagnostic and curative services ranging from pathological laboratory, X-Ray,Electrocardiogram, Ultrasonography, emergency, in and out patient department,

emergency obstetric care and immunization for mother and child are available. The

EPHS clearly defines the pattern of care providers and scope of services for this

particular tier of health care outlet. It is supposed to be having uninterrupted services

round-the-clock services as written in the document.

Despite a mandated coordinated mechanism to ensure health care for all, patient like

Jolaikhas experience is unfortunate and unexpected one. This resulted from lack of

coordination, lack of information sharing, not taking a proactive role, not being empathic

to a life and poorly managed logistics.

Around 10 Oclock at night, this 29 years old mother of two along with a woman from

her neighborhood reached Lakhabi district hospital after 12 hours of struggle at home for

normal vaginal delivery. It is not known why she made such a long delay although the

attending woman reportedly was experienced in child birth process and techniques. She

was fortunate to find doctor and nurse to attend her. On examining Julekha, nurse

observed the position of the baby was in breach presentation. This was clearly an

obstretrics emergency requiring specialize service of a qualified obstetrician. The

midwife then called up the Gynecologist on call to attend Julekha. The gynecologist

declined to attend Julekhas delivery on the ground it was quite late at night. Upon hearing

the refusal from expert gyanecologist the midwife could not make out about what to do

and took quite sometime to approach doctor on duty for a decision about what to do with

the case. The nurse did not provide doctor the information that the lady was having a

breech presentation. The doctor then suggested Julekha to do a quick ultrasonogram to

help him making a diagnosis. Julekha then had to wait for a further assessment requiring

time which she was unable to afford. Unfortunate Julekha got to ultrasonogram room

however, was unable to find little gel required for doing her ultrasonogram. The day time

doctor was the last person to use the gel, it was his duty to check and make sure if every

single necessary supplies are in place, if all other stocks are replenished. It was evident

the doctor did not replenish the necessary stocks neither did he inform any body else who

came for duty after him. The team on duty then had no option but to send Julekha to a

provincial hospital. This time attendant of Julekha declined to follow her.

This time a very common scenario came into being. While Julekha was amidst struggle

of life and death, one of the attending cleaners in the hospital showed up to take the

patient to the cleaners house claiming he/she had long experience as a birth attendant.

All attempts for next 2-3 hours at the cleaners house ended up in vain with the patients

condition persistently deteriorating.

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Finally at that point, the patients attendant agreed to take her to provincial hospital and

by the time they reached, it was already quite late at night and gynecologist had left

assuming there might be no emergencies. The attending doctor, having no other

alternatives, opted to keep the patient under observation with Intravenous Fluid

supplement until the gynecologist will come and take over next morning. The doctor

established the intravenous channel and left the patient with her extremely exhausted andtired attendant next to her falling asleep in minutes. The deadliest part of the entire

scenario began when the attendant was awakened by deep, shallow breathing of the

patient accompanied by abnormal noises. The attendant ran to find a doctor to help

Julekha. The doctor too rushed in and tried all he could do to restore vital signs of

Julekhas life. Julekha could not any more bear the burden of life.

The sun rose to announce another morning, the gynecologist began another day at

hospital; the ultrasound gel was replenished but was of no use or hope to Julekha. The

would be new member within Julekha was unable to see a new sun for ever for which she

was grown for last 10 months with flesh and blood taken from Julekha.

Questions for Discussions

1. What are the problems you identify in the above case for hospital management and

also for individual?

2. Which of the problems are resulted due to lack of applying management principle?

How a breach in the logistics chain affects the whole scenario?

3. What are the possible steps you may take to prevent such and similar things happen in

your hospital?

4. Could there have been some empathetic initiative to save the life of Julekha?