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Pakistan/North Western Frontier Province - Health Cluster bulletin no 17 - 11 November 2009

Health facilities need strengthening with additional staff, supplies, equipment, medicines and ambulances. In DI Khan there are currently no female medical officers in the health facilities.

ASSESSMENT

South Waziristan Crisis

As military operations continue in South Waziristan, civilians fleeing the fighting continue to arrive in DI Khan and Tank. As of 11 November, 46 039 families or approximately 336 000 individuals were registered in the above-mentioned districts, including 11 080 families who were displaced before August 2009. Meanwhile, the National Database and Registration Authority (NADRA) continues its verification process of IDPs. So far, NADRA has verified 22 600 families or approximately 165 000 displaced individuals seeking shelter in DI Khan and Tank.

Assessment of public health facilities in Swat District

The DoH of NWFP, with technical support from WHO, conducted an assessment of public health facilities in Swat district. The assessment was carried out by health personnel (medical doctors and paramedics) of the Executive District Office for Health (EDO-H) Swat and Health Cluster (HC) partners such as Merlin, International Medical Corps, Save the Children and ARC.

A total of 47 first-level health care facilities (three rural health centres (RHCs), 38 basic health units (BHUs), two maternal and child health (MCH) centres and four civil dispensaries (CDs)) were assessed. The team found that nine health facilities were not providing any services as they were either damaged beyond repair or occupied by security forces. At the primary health care (PHC) level, all the other facilities offered outpatient department services, 33 (92%) had health management and information system reporting, 28 (78%) offered routine expanded programme on immunization services, 25 (69%) family planning, 16 (44%) ante- and postnatal care, and 25 (47%) family planning. Only 11 facilities (31%) offered growth monitoring, nine (25%) nutrition counselling and breastfeeding promotion, eight (22%) normal delivery services and nutrition supplementation, seven (19%) TB DOTS, six (17%) detection and management of sexually transmitted infections, four (11%) essential newborn care, three (8%) post-abortion care, and only one (3%) offered Integrated Management of Neonatal and Childhood Illnesses (IMNCI), minor surgical procedures and access to an ambulance. None of the health facilities offered services for gender and sexual-based violence or dental services.

At the secondary health care level, the team found that all (100%) hospitals offered normal delivery services and had an outpatient department, laboratory services, TB DOTS, inpatient facility, ante- and postnatal care and monthly health management and information system reporting. Six (86%) offered family planning, access to an ambulance and dental services, five (71%) offered post abortion care, four (57%) offered nutrition counselling and breast feeding promotion, X-ray facilities and essential newborn care, three (43%) offered nutrition supplementation (including vitamin A/ferrous sulphate/folic acid) and voluntary sterilization, two (29%) offered ultrasonography, IMNCI, growth monitoring, anaesthesia and weekly DEWS reporting, and one (14%) offered surgical obstetrics (Caesarean sections and laparatomies). None of the hospitals had blood transfusion services, uterine evacuation or services for gender and sexual-based violence.

Maternal and child health services, which include ante- and postnatal care, growth monitoring, deliveries and family planning, are the most fundamental components of PHC. Growth monitoring is an important component of MCH: the assessment showed that only two hospitals and 31% of first level care facilities offered growth monitoring services.

Current stocks of medical supplies, including drugs provided by the DoH, are not sufficient to cover the needs of the population. Of all facilities assessed, 36 (84%) had vaccine carriers, 31 (72%) had examination gloves, 27 (63%) had refrigerators, 24 (56%) had functional thermometers, stethoscopes and stabilizers, 19 (44%) had functional BP apparatus, 18 (41%) had cold boxes, 15 (35%) had adult and baby weighing scales, 12 (28%) had sterilizers, 10 (23%) had needle cutters, eight (19%) had fetoscopes, six (14%) had mini surgical kits, five (12%) had vaginal examination sets, and only three (7%) had nebulizers, height measuring scales and safe delivery kits. None of the facilities had disposable clean delivery kits or a light source.

Only three (9%) health facilities had adequate supplies of essential drugs for three months given the current caseload, while six (17%) had only one month's supply and 25 (77%) had less than one month's worth of supplies.

There are not enough qualified and skilled health workers, especially female health workers. There are no female medical officers in first-level care health facilities, and only seven in secondary level health facilities. Moreover, medical staff are unequally distributed: of the 57 male medical doctors in the district, 29 are working in the six civil hospitals and the THQ hospital, and the remaining 28 are posted in the four CDs, 38 BHUs and 3 RHCs.

Health care providers should be trained in case management, rational use of drugs and essential health delivery managerial skills. Most deliveries are carried out at home by an unskilled attendant.

Sanitation and hygiene in the assessed health facilities are very poor. A regular water supply is available only in 15 (42%) of PHC facilities. Hygiene and safe drinking water are a major concern. Health education awareness campaigns should be increased in the entire district in order to educate the community on hygiene, safe drinking water and sanitation.

Disease Surveillance

Alert and outbreak investigations and response

On 4 November 2009, EDO-Health Peshawar received an alert for a suspected case of pandemic (H1N1) 2009 from a private hospital (North West hospital) in Peshawar. A joint WHO/DoH team collected samples that were laboratorytested and confirmed positive. The patient - a 40 year old female from Herat city, Afghanistan who was 35 weeks pregnant - was originally treated in Afghanistan and transferred to Peshawar after her symptoms became progressively worse. She was isolated and hospital staff adopted precautionary measures, including vigilant monitoring. The patient died on 7 November 2009 after giving birth. WHO donated 50 PPE kits to the DoH.

Morbidity and mortality (24-30 October 2009)

A total of 316 sentinel sites reported this week and registered 88 277 consultations. The increase in the number of reporting sites is due to the expansion of the surveillance system in Swat, Buner and Lower Dir Districts. The consultations included 644 visits for antenatal care, 576 consultations for chronic noncommunicable diseases and 181 consultations for injuries.

The table below shows the type of patient, number of consultations and percentages recorded between 3 and 9 October.

Almost a quarter of consultations (21 563 or 24%) were for children under five years old.

The table below shows the seven most common communicable diseases reported from the seven IDP-hosting districts and conflict-affected districts (Buner and Swat).

The leading cause of consultations throughout the reporting period was upper respiratory tract infections (URTI) based on the reports received from health facilities in all IDP camps and in host communities in eight districts. In Swat District, acute diarrhoea was reported as the most common disease among IDPs.

Most of the priority communicable diseases under surveillance have remained stable during recent weeks. However, acute URTIs have shown a consistent upward trend over the last six weeks due to the change of season. Meanwhile, Swat and Nowshera districts reported scabies as the leading cause of consultation. Intensive hygiene promotion and water and sanitation interventions are strongly recommended in these camps for the prevention of scabies.

The graph below shows the weekly morbidity pattern of the seven most common communicable diseases reported in eight IDP-hosting and conflict-affected districts in NWFP between 24 and 30 October.

COORDINATION

Health Cluster, Islamabad

The 39th Pakistan Health Cluster meeting was held in Islamabad on 4 November 2009. Discussions focused on strengthening health care services in DI Khan and Tank:

• Merlin was issued a ‘no-objection certificate’ (NOC) for DI Khan and Tank from EDO-H. The NOC allows Merlin to work in both districts.
• Training of trainers on disease surveillance has been scheduled for health staff from DI Khan, Tank, Bannu and Lakki Marwat districts. The Disease Early Warning System (DEWS) will be established in DI Khan and Tank soon after completion of training.
• Local nongovernmental organizations (NGOs) working in DI Khan and Tank presented each agency’s profile including objectives, activities, geographical and sectoral coverage, and human resource capacity. This will help HC partners to identify the local NGOs that can support international agencies in carrying out activities in DI Khan and Tank. The following NGOs presented: Sahara, Hamdam, Serve, Community Motivation and Development Organization, The Way Welfare Organization, Global Youth Organization and HOME.

Health Cluster, NWFP

Health partners working in NWFP discussed manpower capacity and intervention plans for South Waziristan and the challenges foreseen in providing health services to IDPs displaced by the crisis. HC partners agreed to prioritize the following interventions in DI Khan and Tank districts:

• Providing life-saving essential medicines to health departments
• Strengthening 30 health facilities (20 in DI Khan and 10 in Tank) supporting IDPs in host communities. This includes medical supplies, equipment and human resources and the establishment of a trauma centre in DI Khan
• Strengthening the capacity of health care providers on disease surveillance and case management
• Strengthening the referral system by providing ambulances and making PHC and MCH services available
• Expanding disease surveillance
• Identifying local NGOs that are able to provide comprehensive PHC services
• Coordinating with partners for the celebration of mother and child week in all IDP camps in NWFP

Health Cluster, Lower Dir

The District HC meeting was held at the EDO-H office on 4 November. Participants shared information on current activities. The Director of Public Health, Dr Fazal Qayyum, asked HC partners to prioritize the strengthening of health facilities, especially in areas where the health infrastructure has been damaged due to the conflict.

Health Cluster, DI Khan

The first coordination meeting of health partners working in DI Khan was held on 9 November (co-chaired by the DoH and WHO). The first meeting was attended by: IRC, Helping Hands, Sahara Welfare Organization, Hamdam Developing Organization, HRDS, Global Youth Organization, VEER Development Organization and PIMA. The Director of Public Health asked partners to help strengthen the BHUs and RHCs of the respective Union Councils in terms of gap filling, equipment and ambulances.

FILLING GAPS

The American Refuge Committee (ARC) is continuing operations in three health facilities of district Swabi. The total number of consultations recorded to date is 1356. In Swat district, four health facilities (the MCH centre in Barikot, the CD in Ghaligay and the BHUs in Taghma and Bara Samai) will start evening shifts with the help of ARC. Additional staff have been hired.

Care International continues to support IDPs through two mobile health teams in Buner serving five Union Councils (Ellai, Koga, Makhrani, Nawagai and Karapa) and three static units. Last week, a total of 798 patients were treated including 295 females and 373 children. In addition, 11 mobile medical camps treated a total of 1713 patients (416 females and 897 children).

Cordaid has taken a comprehensive approach towards the refurbishment/reactivation of the health system in Shangla through:

• supporting physical infrastructures, (i.e. the central health facility of Alpuri District Headquarters Hospital and three BHUs)
• enhancing the mobility component
• building capacity of local medical personnel and health authorities.

Cordaid has also provided comprehensive PHC services through two mobile medical units (MMUs) in district Shangla in Union Councils Kuzkana and Lilowni (BHUs of Kuzkana and Shalizara). These MMUs held 12 medical clinics last week; a total of 1202 patients were treated, including 656 females and 546 males. Most consultations were for acute URTIs, anaemia, skin infections, gastritis and urinary tract infections.

International Medical Corps (IMC) continues to provide 24/7 comprehensive PHC services in Palosa camp Charsadda including MCH, health education and referral services. The team's daytime shift includes a male and a female doctor, LHV, health educator and a dispenser, while the night shift consists of a male doctor and a male paramedic. A total of 391 consultations were conducted last week. IMC is also providing healthcare services to IDPs living with host families in Charsadda District through two MMUs operating out of government health facilities. The MMUs held a total of 177 consultations last week. In Buner District, IMC provided comprehensive PHC services including health education, MCH and referral services in the Tor Warask BHU, the RHC in Deewana Baba, Bagh (in two shifts) and the District Headquarters Hospital in Daggar. A total of 1289 consultations were conducted last week. In Swat, IMC provided services in Saidu Sharif Central Hospital through a female medical officer and two LHVs. Meanwhile, the RHC in Khazana, the Civil Hospital in Khawazakhela, and one shift in the BHU in Manyar recorded a total of 2424 consultations.

Johanniter International (JI) continues to support IDPs in host communities in Charsadda. Around 122 health education sessions have been conducted with 2017 participants. Health education topics discussed included personal, domestic and environmental hygiene, breastfeeding, family planning, food hygiene, water and sanitation. JI's two mobile teams held 1126 consultations, including MCH and PHC services.

Malteser International is strengthening health service delivery in the BHUs in Meragai (Kokarai UC) and Islampur and the CDs in Citar and Chewetar (both in Islampur UC). After ten weeks of field activities, 12 303 patients have been treated. In coordination with and support from WHO and the EDO-H Office in Swat district, an outbreak of watery diarrhoeal diseases in Union Council Islampur has been brought under control.

Medecins Du Monde-France (MDM-F) is providing health care services through a medical mobile team in Swabi district that operates in six different locations (Naranji, Amankot, Qamar Dand, Palodand, Goati and Kotai). Another team is running the outpatient department of the District Headquarters Hospital for IDPs in Swabi.

In Buner district, a medical mobile team is providing health care services in Sarwai Union Council in three different villages (Dargalai, Mangaltana and Dakara). Another medical mobile team is working in Kawga and Amnawar Union Councils of Buner district. A total of 1628 consultations were conducted last week, 55.1% of which were female and 21.9% were for children under five. Acute URTI, with 18.6%, is the most common cause of consultation. Skin diseases represent 13.4% in all age groups and acute diarrhoea represents 5.5% in all age groups. A weekly nutritional programme is currently treating 78 children between six and 59 months old.

Mobile Immunization & Healthcare Organization (MIHO), which recently joined the HC, continues to participate in health training workshops in order to learn about emergency health actions for IDPs, effective emergency operations and rapid response mechanisms. Two MIHO field team leaders attended a training session on disease surveillance, early detection of diseases, case management and control conducted between 28 and 29 October in Timergara, Dir Lower. WHO conducted the training with support from the National Institute of Health and the District Health Office.

Merlin continues its health care services in Swat district in the CDs of Nawakaley, Amankot, Kokarai and Civil Hospital Madayan, where whitewashing and building repairs are in progress along with health promotion sessions. A total of 124 health promotion sessions were conducted during the last week, attended by 557 males and 593 females. Last week, health staff were trained on DEWS. A needs assessment was completed for Tehsil Headquarters Hospital Matta, Civil Hospital Kabal and the BHU in Bandai. Merlin donated a high-voltage stabilizer (1000W) to all health facilities for cold chain maintenance, and will begin sending medicines, equipment and furniture this week.

In Buner district, additional health staff in Union Council Sorrai have been hired for two more mobile teams in Topai and Gulbandi. Health care activities have already started. Merlin has donated furniture to the RHC in Nagrai and has distributed hygiene kits in Katcha Gari Camps (1&2). It has also held training sessions on DEWS, diarrhoeal diseases, and MCH for 88 medical staff including doctors, LHVs, health & nutrition promotion staff, home visitors and EPI technicians.

In Jalala Camp (Mardan district), Merlin's health and nutrition promotion teams have screened 2497 children and 742 PLWs and have conducted 1860 health, hygiene & nutrition sessions attended by 13 282 persons. Merlin has also conducted training sessions in Jalala camp on DEWS and MCH for health and nutrition promotion staff, LHVs and home visitors. A total of 5094 patients were treated in Merlin-supported health facilities.

Save the Children completed a needs assessment of 20 health facilities assigned to the organization in Swat, Swabi, Buner and Mardan districts. Save the Children donated life-saving medicines to the RHC Chuprial in Swat district. It also conducted a three-day training workshop on nutrition in Mardan with 21 health staff participants from Mardan, Swat, Swabi and Buner, and donated nutritional food supplements to the stabilization centre in DHQ Hospital Mardan. Save the Children continued to provide health care services in health facilities: a total of 5276 patients were treated in Swat, Buner, Mardan and Swabi districts.

UNFPA continues to provide reproductive health care services in Lower Dir. Last week, UNFPA shifted from Sadbarkaly to Wali Kandao camp at the request of the Commissioner Office in Lower Dir. A total of 183 patients were treated last week in Lower Dir. This includes five ante- and three postnatal consultations and two family planning visits. There were 42 consultations for acute respiratory infections, 34 for gastroenteritis, and 95 for other minor general outpatient services. Last week UNFPA distributed 15 hygiene kits and gave psychosocial support to women of reproductive age.

UNICEF provided essential health care services to 192 patients at two MCH centres in Jalozai camps (Nowsehra District). Last week it provided antenatal care to 107 pregnant women, and supported 18 deliveries. To date, a total of 108 591 patients have been treated in UNICEF-supported health facilities. UNICEF has also conducted 119 health education sessions on different MCH topics, attended by 377 participants.

WHO continues to support IDPs in DI Khan and Tank. By 11 November, in DI Khan, WHO had donated and delivered life-saving drugs and medical supplies (enough to cover the health needs of around 193 000 persons for two months), and had pre-positioned medical supplies and treatments for acute watery diarrhoea (AWD) outbreaks. In Tank, WHO donated and delivered life-saving drugs and medical supplies (enough to cover the health needs of around 106 000 persons), anti-rabies vaccine, snake venom antiserum and medical supplies for AWD outbreaks. WHO also continues to support WASH activities. So far, WHO has distributed 680 000 aquatabs, 2000 leaflets with messages on diarrhoeal control, and 200 posters in Swat District.

Needs

• Health facilities in DI Khan and Tank need to be strengthened with additional staff, supplies, equipment, medicines and ambulances. The referral sytem needs to be strengthened in both districts.
• Twenty additional medical officers are needed for DI Khan. Currently, there are no female medical officers in health facilities.

Funding situation

• As of 11 November, the Health Cluster has received 44% of funds required as presented in the UN Pakistan Humanitarian Response Plan (Revision) document. (Needs identified: US$42 065 870. Funds available: US$18 651 913.) (Source: OCHA Pakistan, 11 November)

Communication and advocacy activities

• Efforts are being made to raise the visibility of the health response to the crisis through:
• Production of South Waziristan situation reports
• Pakistan health in photos
• Production and distribution of Health Cluster bulletins
• Packaging of disease surveillance film for distribution
• Updating of health cluster website
• Production of NWFP crisis slide show

Related links

• Health Cluster Pakistan
• Provincial Relief Commissionerate
• Pakistan Ministry of Health
• WHO Regional Office for the Eastern Mediterranean
• Relief Web FTS

• Health Cluster bulletin in PDF format
  pdf, 976kb

For further information please contact:

WHO Pakistan Country Office
Dr Khalif Bile Mohamud
WHO Country Representative to Pakistan
e-mail: wr@pak.emro.who.int

Dr Hendrikus Raaijmakers
Emergency Preparedness and Humanitarian Action Coordinator
E-mail: raaijmakersh@pak.emro.who.int

WHO Regional Office for the Eastern Mediterranean
Dr Irshad Shaikh
EHA Regional Adviser
e-mail: shaikhi@emro.who.int
tel.: + (202) 2276 5525
mobile: + (201) 01733924
http://www.emro.who.int/eha/

WHO Headquarters
Mr Paul Garwood
Communications Officer
Health Action in Crises
e-mail: garwoodp@who.int
tel. +41 22 791 3462
mobile: +41 79 475 5546
http://www.who.int/disasters