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
Jolaikha’s 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 O’clock 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 cleaner’s house claiming he/she had long experience as a birth attendant.
All attempts for next 2-3 hours at the cleaner’s house ended up in vain with the patient’s
condition persistently deteriorating.
Finally at that point, the patient’s 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 and
tired 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
Julekha’s 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?