Cost Analysis of Jangalak Drug Addicts Hospital

2013 Islamic Republic of Afghanistan Ministry of Public Health General Directorate Policy, Planning and International Relations Health Economics and Financing Directorate Cost Analysis of Jangalak Drug Addicts Hospital July 2013 i

Cost Analysis of Jangalak Drug Addicts Hospital July 2013

TABLE OF CONTENTS LIST OF TABLES... iii LIST OF FIGURES... iii LIST OF ACRONYMS... iv EXCUTIVE SUMMARY... v 1. BACKGROUND... 1 2. OBJECTIVES... 2 3. METHOD... 2 3.1. Study Site and Period... 3 3.2. Data Collection... 3 3.3. Data Analysis... 4 4. RESULTS... 5 4.1. Overall Statistics... 5 4.2. Utilization... 6 4.3. Human Resources... 6 4.4. Costs... 7 4.4.1. Total Cost... 7 4.4.2. Cost by Cost Centers... 7 4.4.3. Cost by Services... 9 5. DISCUSSION... 9 6. CONCLUSIONS AND RECOMMENDATIONS... 10 ANNEX 1: DEFINITIONS... 12 ANNEX 2: FIGURES... 14 REFERENCES... 16 Cost Analysis of Jangalak Drug Addicts Hospital Page ii

LIST OF TABLES Table 1. Data Requirements Table 2. Overall Statistics Table: 3. Jangalak Drug Addicts Hospital BOR and ALOS Table 4. Number of Staff Table 5. Hospital Staffing Ratios Table 6. Hospital Costs by Cost Centers Table 7. Hospital Total Cost Breakdown by Budget Line Table 8. Recurrent Costs Breakdown Table 9. Hospital Costs by Services Table 10. Average Cost Per Service LIST OF FIGURES Figure 1. Step-down Cost Allocation by Cost Center Annex 2 Figures Figure 1. Number of Staff by Staff Type Figure 2. Hospital Total Cost Breakdown by Budget Line Figure 3. Recurrent Cost Breakdown Cost Analysis of Jangalak Drug Addicts Hospital Page iii

LIST OF ACRONYMS ALOS BOR DDR HEFD HIV/AIDS HOSPICAL IDUs IPD KMHH MoPH MSH NGO OPD STIs UNODC WHO Average Length of Stay Bed Occupancy Rate Drug Demand Reduction Health Economics and Financing Directorate Human Immune Deficiency Virus/ Acquired Immune Deficiency Syndrome Hospital Cost Allocation Tool Injecting Drug Users Inpatient Department Kabul Mental Health Hospital Ministry of Public Health Management Sciences for Health Non-governmental Organization Out Patient Department Sexually Transmitted Infections United Nations Office on Drugs and Crimes World Health Organization Cost Analysis of Jangalak Drug Addicts Hospital Page iv

EXCUTIVE SUMMARY Background: Drug abuse is a global phenomenon, affecting almost every country, but its extent and characteristics differ from region to region. Illicit drug use not only affects the health and lives of individuals, but also undermines the political, social and cultural foundation of all countries. Problems of drug dependence produce dramatic costs to all societies in terms of lost productivity, transmission of infectious diseases, family and a social disorders, crime and excessive utilization of health care. Method: The study uses step-down method to track the costs of inputs used to find out the unit costs of each service at Jangalak Hospital. The hospital is divided into three cost centers (departments): general, ancillary (intermediate) and clinical. The general cost center provides services to ancillary and clinical cost centers. The ancillary cost center provides services to clinical departments and patients. A clinical department provides services directly to patients. Results: Overall results indicate that the total cost of Jangalak Drug Addicts Hospital during the study period was US$513,904. The cost of per bed day and per community outreach/home-based visit was estimated at US$15.9 and US$25.1, respectively. Considering the cost centers, large proportion of costs goes to general cost centers that account for 75 percent of the hospital s total cost. The second largest proportion of costs goes to clinical departments that account for 21 percent of the total costs. Ancillary departments account for the lowest proportion of total costs at 5 percent. Human resources, recurrent expenditures, and capital costs are major components of the hospital costs. Recommendations: The hospital costing results provide a baseline by which hospitals and the MoPH can measure improvements and identify gaps over time. It is needed to focus on the areas of utilization and efficiency, human resources and costs. The hospital only has pharmacy unit and does not have other diagnostic and lab units which is a reason for lower costs of ancillary departments. It is necessary to establish diagnostic center within the hospital or assess outsourcing the diagnostic service provision. Further studies are needed to find out the costs from societal prospective. Finding the real treatment cost of a patient from a wider perspective, e.g., societal, can give comprehensive evidence to policy makers and program implementers. Cost Analysis of Jangalak Drug Addicts Hospital Page v

1. BACKGROUND Drug abuse is a global phenomenon, affecting almost every country, but its extent and characteristics differ from region to region. Illicit drug use not only affects the health and lives of individuals, but also undermines the political, social and cultural foundation of all countries. Problems of drug dependence produce dramatic costs to all societies in terms of lost productivity; transmission of infectious diseases; family and social disorders; crime; and excessive utilization of health care (Kulsudjarit, 2010). The drug problem in Southeast and Southwest Asia is serious, particularly the production of opium and heroin in Afghanistan, Myanmar and Laos - the three largest producers of illicit opium in the world. According to World Drug Report 2011, the total number of drug addicts worldwide is estimated between 149 and 272 million individuals ranging 15 to 64 years, injection drug users (IDU) are about 11 to 21 million out of the total drug users. According to the United Nations Office on Drugs and Crimes (UNODC) report published in 2009, 940 thousand drug users exist in Afghanistan, out of which 230 thousand individuals are opium users and 120 thousand individuals are heroin users (18 to 23 thousand individuals using heroin are IDUs). The recent Afghanistan Drug Use Survey (2012) estimates that nearly one million Afghans or almost 8 percent of the population between the ages of 15 and 64 years are regular and/or problem drug users. Illicit drug use has increased across the country dramatically since 2005. In 2005, the estimated number of regular heroin users in the country was 50,000 compared to approximately 120,000 users in 2009, a leap of 140 percent. In four years, the number of regular opium users in Afghanistan grew from 150,000 to approximately 230,000, which shows a 53 percent increase. According to the World Drug Report (2010), Afghanistan has one of the highest rates of opiate consumption, at the same level as Russia and Iran, with prevalence rate of 2.64 percent (or between 290,000 and 360,000 persons). In 2005, the prevalence rate of opiate use in Afghanistan was almost half of this, at 1.4 percent. Approximately 28 percent of the drug users began using drugs in Iran and about 9 percent initiated drug use in Pakistan as refugees (UNODC Survey, 2012). Among opium and heroin users, up to 40 percent initiated opiate use in Iran. While numbers of women drug users are far fewer than that of men, they too are in need of treatment services. Drug treatment services in Afghanistan have varying settings such as Inpatient Department (IPD); residential drug treatment hospital, community-based treatment centers, village-based centers and home-based settings. According to recent information, there are more than 103 centers throughout the country that provide different services to needy clients, and the overall treatment capacity is around 2.8 percent in the current treatment centers. The World Health Organization (WHO) estimates that 20 percent of the total drug addicts are in need of residential treatment; however, only about 10,000 opium and heroin users have access to drug Cost Analysis of Jangalak Drug Addicts Hospital Page 1

treatment services in Afghanistan right now. This constitutes 2.86 percent of 350,000 opium and heroin users all over the country. Therefore, the drug addiction problem and the low capacity of drug treatment services should be considered as a national challenge and requires comprehensive and serious attention from the government of Afghanistan in order to minimize the negative impact of this phenomenon on security, health, and development. Until 2002, there was limited public awareness about the hazards of drug consumption, drug addiction and its negative consequences. The first drug treatment center with the capacity of 20 beds was established by the MoPH in Kabul in 1987. This center provided detoxification services along with psychosocial and toxicology services. In the 1990s, this center was destroyed due to the civil war and later it was merged with the Kabul Mental Health Hospital (KMHH) supported by WHO and UNODC. Before that time, addiction treatment services were provided at Ali Abad Hospital. 2. OBJECTIVES The objective of this report is to provide a baseline overview of Jangalak Drug Addicts Hospital costs, resources and services. Findings will be used by the MoPH to improve the quality of health services at this hospital. In addition, the hospital will use the findings in order to assess its own performance and improve planning processes. 3. METHOD The study uses step-down method to track the costs of inputs used in order to determine the unit costs of each service at Jangalak Hospital. The hospital is divided into three cost centers (departments): general, ancillary (intermediate) and clinical. The general cost centers provide services to ancillary and clinical cost centers. The ancillary cost centers provide services to clinical departments and patients. A clinical department provides services directly to patients. The following chart shows the step-down cost allocation from general to ancillary and clinical cost centers. Cost Analysis of Jangalak Drug Addicts Hospital Page 2

Figure 1. Step-down Cost Allocation by Cost Center Administration Ancillary and Support Services Inpatient Services (IP) Out Patient Services (OP) This study is performed form provider or MoPH perspective. In this study we have only included the costs related to the provision of treatment services by the hospital and MoPH and does not include other costs related to patients and society. 3.1. Study Site and Period The hospital is located in the seventh district of Kabul city. It is supported by the DDR Project of MoPH through the development budget. The study examines the costs and other indicators of Jangalak Drug Addicts Hospital for one year [Hoot 10, 1390 (February 29, 2012) Hoot 9 1391 (February 27, 2013)]. This time period was selected because the hospital resumed its activity under the DDR Project from the beginning of this period. 3.2. Data Collection The assigned HEFD data collection team collected data from the hospital and the project office in the MoPH from February to April 2013. After meeting with the project leadership and the hospital director, the HEFD team was directed to the Jangalak Drug Addicts Hospital to get the required data. A number of tables were developed to collect the data related to the hospital costs and statistics. The following table shows data type and sources with detailed explanations. Table 1. Data Requirements Area Data Requirements General Hospital Data Hospital organization and cost centers Structure of administrative, ancillary and clinical departments Total number of beds and breakdown by department Cost Analysis of Jangalak Drug Addicts Hospital Page 3

Area Data Requirements Utilization Utilization statistics broken down by department o Total number of visits for all outpatient departments o Total number of admissions, hospitalization days, discharges and deaths for inpatient departments Staffing Complete staff list for facility, including name, function, level, payment source Determination of cost center associated with each staff Detailed salary breakdown for each staff, including base salary, allowances, insurance, etc. Expenditure Total hospital expenditure, broken down by detailed line item o Expenditures on drugs, salaries, capital costs, other recurrent expenditures Drug expenditure broken down by ancillary or clinical department Ancillary Department For each ancillary department, the cost or quantity of ancillary department services broken down by clinical department 3.3. Data Analysis Data were classified into groups related to human resources, drugs and other recurrent medical supplies, food, laundry and cleaning, utilities and other recurrent costs, and capital costs. Human Resources: Human resources costs were allocated to general, ancillary and clinical departments based on the proportion of staff time given to each department. The data related to the distribution of staff time were collected from the hospital through interviews and observation of work schedule. Drugs and other recurrent medical supplies: The costs of drugs and other medical supplies were allocated to the pharmacy unit of ancillary departments. Then, the costs were allocated to clinical departments based on the percent usage. The data on usage of drugs by clinical departments were collected from the records of the medical unit. Laundry, cleaning, utilities and other recurrent expenditures: These costs were allocated to general departments. Then, the costs of general departments were allocated to ancillary and clinical departments. Cost Analysis of Jangalak Drug Addicts Hospital Page 4

Capital: Depreciation costs of medical and nonmedical equipment were not included in the study. The monthly rent of the building was used as the capital cost for the building due to the unavailability of data on the initial price of building, inflation, and interest rates for the past two decades. The Hospital Cost Allocation Tool (HOSPICAL) was used to analyze the information. HOSPICAL is an Excel based tool developed by the Management Science for Health (MSH). The tool adopts the step-down costing approach and provides the total costs and unit costs of each department including the inpatient and outpatient units. 4. RESULTS The results of the analysis are grouped into four categories: overall statistics, utilization, human resources and expenditures. 4.1. Overall Statistics Jangalak Drug Addicts Hospital includes one main clinical section which is divided into two parts: detoxification and rehabilitation. In addition, the hospital has a community outreach program which includes visiting drug addicts in community; providing them awareness and encouraging them to enroll in the rehabilitation program. The patients are admitted to the hospital in groups and in some cases as individuals. After being admitted, a patient will spend the first 15 days in the detoxification ward. Then, they will be transferred to the rehabilitation ward where they will spend up to 30 days. In the first few rounds of admission since hospital resumed its activity, the average number of hospitalization days per patient in both detoxification and rehabilitation wards were around 30 days. The following table shows the overall statistics of Jangalak Drug Addicts Hospital during the study period. Table 2. Overall Statistics Total Number of Hospital Beds 120 Total Outreach/Community Visits 1,127 Total Inpatient Admissions 980 Total Inpatient Discharges 898 Total Inpatient Deaths 1 Total Hospitalization Days 30,463 Cost Analysis of Jangalak Drug Addicts Hospital Page 5

4.2. Utilization The hospital utilization indices, such as bed occupancy rate (BOR) and average length of stay (ALOS), illustrate patterns of utilization. Not all factors affecting hospital utilization are necessarily linked to efficiency or service quality, utilization data is nevertheless an important starting point for identifying inefficiencies; best practices and opportunities for improving service delivery. This section highlights two key utilization indices, as indicated above. BOR and ALOS are important efficiency indictors for hospitals, but there is no standard rate which can be applicable to all hospitals due to differences in the treatment nature and context of hospitals. The following table shows hospital BOR and ALOS during the study period. Table: 3. Jangalak Drug Addicts Hospital BOR and ALOS BOR 70% ALOS (days) 33.9 The 33.9 days of ALOS per admission in Jangalak Drug Addicts Hospital appears high at the first glance, but given the standard treatment period of patients varies between 30 to 45 days, it may be considered reasonable. On the other hand, the 70 percent BOR is relatively high, but there is still room for improvement as the optimal BOR accepted by the MoPH is 80 to 85 percent. As this is a specialty hospital, standard rates from tertiary hospitals may not necessarily apply. 4.3. Human Resources Human resources consume a major proportion of the budget in a hospital. Efficient management of human resources can improve the overall efficiency of a hospital. The doctor to bed, nurse to bed and doctor to nurse ratios are examples of hospital human resources efficiency indicators. The following table indicates the breakdown of Jangalak Hospital staff by their profession. Table 4. Number of Staff Staff Type Total # of Staff Total Doctors 7 Total Psychologists 4 Total Nurses 6 Total Social Workers 16 Total Pharmacists 3 Total Admin Staff 12 Total Others 17 Grand Total 65 Cost Analysis of Jangalak Drug Addicts Hospital Page 6

The number of social workers is higher than the number of doctors and nurses because the Jangalak Drug Addicts Hospital has outreach and home visit programs. The social workers follow up patients in the community and in their homes. The table below shows staffing ratios at Jangalak Drug Addicts Hospital. Table 5. Hospital Staffing Ratios Category Jangalak Hospital Ratio Doctor to Nurse 2.3 : 2 Doctor to Bed 0.2 : 4 Nurse to Bed 0.1 : 2 As it is indicated in the above table the ratios of doctor to nurse, doctor to bed and nurse to bed are 2.3:2, 0.2:4 and 0.1:2 respectively. Since there is no standard staffing ratio for drug addicts hospital, the above figures can provide baseline ratios for comparison of these indictors in the future. 4.4. Costs This section presents some key hospital cost indicators. Understanding the costs of various activities can help the MoPH leadership, DDR project manager and Jangalak Drug Addicts Hospital manager to improve the overall hospital efficiency. 4.4.1. Total Cost The total cost of the hospital was US$513,904 during the study period. This figure includes staff salary, pharmaceutical items, food, cleaning materials and capital depreciation costs. An estimation for building rental cost has been included as part of capital costs. 4.4.2. Cost by Cost Centers Costs were allocated to three main cost centers: general, ancillary and clinical costs. Table 6. Hospital Costs by Cost Centers Category Cost (USD) % of Total General Departments $383,735 75% Ancillary Departments $24,352 5% Clinical Departments $105,818 21% Total Hospital Costs $ 513,904 100% Cost Analysis of Jangalak Drug Addicts Hospital Page 7

As it is shown in the above table, the largest proportion of costs goes to the general departments that account for 75 percent of the hospital s total costs. This could be due to the inclusion of all direct and indirect costs of administration, support staff, maintenance, cleaning and kitchen. The second biggest proportion goes to the clinical departments that account for 21 percent of the total costs. Ancillary departments account for only 5 percent of the total costs. The ancillary cost is the lowest because this hospital has only one pharmacy unit under the ancillary departments while other hospitals have diagnostics and imagery units as well. Human resources, recurrent expenditures, and capital costs are major components of the hospital costs. The following table shows proportion of each component. Table 7. Hospital Total Cost Breakdown by Budget Line Category Cost (USD) % of Total Costs Staff $212,943 41% Recurrent $130,419 25% Capital $170,543 33% Total Hospital Costs $513,904 100% Recurrent Costs: The recurrent costs include expenditures for kitchen, laundry, pharmaceuticals, transportation and other recurrent utilities. Table 7 indicates the breakdown of recurrent costs. Table 8. Recurrent Costs Breakdown Expenditure Item Amount (USD) % of Total Kitchen $66,888 51% Laundry $1,485 1% Pharmaceuticals $19,269 15% Transportation $ 4,444 3% Other Recurrent Expenditures $ 38,332 29% Total $130,419 100% The cost breakdown shows that more than half of the recurrent costs go to kitchen. This is reasonable as the ALOS per admission at this hospital is 33.9 days. The second largest proportion of recurrent costs goes to other recurrent expenditures that include a wide range of procured items, such as stationary, printing, cloths and refreshments, which were not clearly broken-down. Cost Analysis of Jangalak Drug Addicts Hospital Page 8

4.4.3. Cost by Services As Jangalak Hospital mainly aims to provide rehabilitation services to drug addicts, the majority of costs should be devoted to inpatient care. The services are divided into detoxification and rehabilitation, and public outreach. The following table shows the proportion of costs driven by these two units. Table 9. Hospital Costs by Services Category Cost (USD) % of Total Detoxification and Rehabilitation $485,170 94% Community Outreach/Home-Based Visits $28,735 6% Total Hospital Costs $513,904 100% As Table 9 shows that the majority of costs, 94 percent, are driven by inpatient care services. The cost of detoxification and rehabilitation services is high, due to long periods of stay by patients and high resource consumption. The cost per inpatient bed day was calculated by dividing the total costs of detoxification and rehabilitation department by the total number of hospitalization days. The cost per community outreach/home-based visit was calculated by dividing the total costs of outreach department by the total number of patients visited. Although the total cost of detoxification and rehabilitation section is higher than the total cost of community outreach/home-based visits section, the unit cost of community outreach/home based visit is much higher than the unit cost of inpatient. This is due to the high number of hospitalization days in inpatient section and a low number of community outreach/home-based visits. Table 10. Average Cost Per Service Category Cost (USD) Cost per bed per year $ 5,818 Cost per admitted patient $ 541 Cost per inpatient per day $ 15.9 Cost per community outreach/home-based visit $ 25.1 5. DISCUSSION Based on the findings, the largest proportion of costs goes to the general departments that account for 75 percent of the hospital s total costs. This could be due to the inclusion of all direct and indirect Cost Analysis of Jangalak Drug Addicts Hospital Page 9

costs of administration, support staff, maintenance, cleaning and kitchen. Indeed, the high patient length of stay incurs higher kitchen and food costs. It is found that the condition of this hospital is quite different from other hospitals because it serves as a shelter as well as a treatment and rehabilitation center. Ancillary departments account for only 5 percent of the total costs. The ancillary cost is the lowest because this hospital has only one pharmacy unit under the ancillary department while other hospitals have diagnostic and imagery units as well. One reason for the low costs of ancillary department could be from the concentration on behavioral therapy rather than drug-based therapy. Considering the services, 94 percent of the total costs go to the detoxification and rehabilitation departments and the remaining 6 percent of costs go to the community outreach/ home based visit activities. Although the total cost of detoxification and rehabilitation section is higher than the total cost of community outreach/home based visits section, the unit cost of community outreach/home based visit is much higher than the unit cost of inpatient. This is due to the high number of hospitalization days in inpatient section and a low number of community outreach/home based visits. It is worth to mention that the community outreach/home-based visit is quite different from the regular outpatient visits in other hospitals. These services are more time consuming and incur transportation costs as well. Based on information provided by the DDR Project, the cost per bed per year in one of the implementing NGOs is estimated to be US$11,000. The cost per bed per year at Jangalak Hospital is almost half of the implementing NGO s cost per bed per year. Projected budget for an Out Patient Department (OPD) of the same NGO is $ 75,000 per year. 6. CONCLUSIONS AND RECOMMENDATIONS Findings of this study provide a baseline which could be used by the hospital and the MoPH to measure improvements and identify gaps over time. The recommendations below highlight the areas where attention is most needed. Special attention should be paid to utilization and efficiency; human resources and costs. This hospital has only one pharmacy unit under the ancillary departments and no diagnostic or imagery units which could contribute to the lower costs of the ancillary department. Since the drug addicts are more prone to the infectious diseases for instance HIV/AIDS, Hepatitis B and C, Sexually Transmitted Infections (STIs) and Tuberculosis, there is need for different diagnostic departments. Currently this hospital does not have specific diagnostic departments so it is necessary to establish diagnostic departments within the hospital or assess outsourcing the diagnostic service provision. Cost Analysis of Jangalak Drug Addicts Hospital Page 10

This study has been conducted from provider prospective that only includes costs incurred by hospital and MoPH and does not includes costs incurred by patients and society. Further studies are needed to find out the costs from societal perspective. Study from the societal perspective includes costs incurred by patients, society and other government agencies. The drug addiction problem is a social problem so there is need for strong advocacy strategies to involve other sectors. The cost analysis from societal perspective can give strong evidence on the costs of drug addicts including cost of individual, cost of law enforcement, and costs related to loss of productivity which can be important for advocacy to involve wide range of stockholders and raise funds for the problem. Finding the real treatment cost of a patient from societal perspective can give comprehensive evidences to policy makers and implementers of the program. Cost Analysis of Jangalak Drug Addicts Hospital Page 11

ANNEX 1: DEFINITIONS (Adapted from the HOSPICAL User Guide, 2012, MSH) Allocation of Costs: The assignment of costs to different cost centers or departments according to estimated use of resources (in terms of space, number of staff, cost, number of bed days and admission etc.) by those cost centers. Average Length of Stay (ALOS): average length of one inpatient hospitalization stay. It is calculated by dividing the total number of bed days by the total number of discharges (including deaths). Bed Day: a day during which a person is confined to a bed and in which the patient stays overnight in a hospital. Day cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) should be excluded. It should be based on a head count that is performed at the same time each day. Bed Occupancy Rate (BOR): the number of bed days occupied by patients as a percentage of the total available bed days in the hospital. BOR is calculated by dividing the number of occupied bed days for the period by the number of available bed days for the period, and expressing the result as a percentage. An ideal BOR is 85%. Cost-Center: a program or a department within a hospital. 1. General Cost Center: Managerial, administrative, and financial activities that support but do not directly provide patient care services. For example, administration, maintenance and utilities, transport, kitchen, social services, clinical management, etc. 2. Ancillary Cost Center: Medical support activities indirectly required to deliver a clinical service. For example, central store, pharmacy, blood bank, family planning, vaccination, radiology, Operation Theater, laboratory, physical therapy, etc. 3. Clinical Cost Center: Direct medical activities pertaining to the production of clinical services. Step-down Costing: This is a process of allocating general and ancillary costs to clinical cost centers to get a fully loaded unit cost per visit and per bed day. The allocation is based on a proportional distribution of those costs. It is a two-step allocation. In the first step, the costs of general departments are assigned to inpatient, outpatient and ancillary cost centers based on a certain allocation factor. In the second step, the costs of ancillary services are allocated to inpatient and outpatient cost centers according to their service utilization figures. Unit Cost per Bed Day: the total (direct and indirect) cost of producing inpatient services divided by the total number of bed days for a given timeline. Note that it is very difficult to get a unit cost per bed Cost Analysis of Jangalak Drug Addicts Hospital Page 12

day by diagnosis (e.g., peritonitis) because hospitals include many complex diagnoses. For this reason, the final result of the step-down process is the unit cost per bed day by department. Unit Cost per Outpatient Visit: the total cost (direct and indirect) of producing outpatient services divided by the number of outpatient visits for a given timeline. Cost Analysis of Jangalak Drug Addicts Hospital Page 13

ANNEX 2: FIGURES Figure 1. Percentage of Staff by Staff Type Total Doctors 17. 26% 7. 11% 4. 6% 6. 9% Total Psychologists Total Nurses Total Social Workers 12. 18% 16. 25% Total Pharmacists Total Admins 3. 5% Total Others Figure 2. Hospital Total Cost Breakdown by Budget Line $170,543 33% $212,943 42% Total Staff Costs Total Recurrent Costs Total Capital Costs $130,419 25% Cost Analysis of Jangalak Drug Addicts Hospital Page 14

Figure 3. Recurrent Cost Breakdown 4% Kitchen 29% Laundry 51% Pharmaceuticals 15% Recurrent Expenditure 1% Transportation Cost Analysis of Jangalak Drug Addicts Hospital Page 15

REFERENCES Kulsudjarit, K. (2010). Drug Problem in Southeast and Southwest Asia. Bangkok, Thailand: Institute on Narcotics Control, Office of the Narcotics Control Board (ONCB). MSH. (2012). HOSPICAL Overview. Kabul: Management Sciences for Health. UNDOC. (2012). Updated list of drug treatment facilities in Afghanistan. Kabul: INL/MCN. UNODC. (2011). World Drug Report 2011. United Nation Office on Drugs and Crimes. UNODC. (2012). Afghanitsn Urban Drug Survey. United Nation Office on Drugs and Crimes. Cost Analysis of Jangalak Drug Addicts Hospital Page 16