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Pakistan/North Western Frontier Province Health Cluster Bulletin no 20 - 8 January 2010

ASSESSMENT

Tank District health facilities assessment

The Department of Health NWFP (DoH) requested WHO to provide technical and financial support to conduct an assessment of public health facilities in district Tank. WHO organized a two-days training on the assessment tools for the health department / EDO (H) staff, three teams were formulated and finalized for the assessment in Tank district. The health assessment was carried out from 16th to 18th of November’09. After the assessment, the data entry, analysis and report writing was done by WHO.

• The assessment carried out covered a total of 23 public health facilities out of a total of 34 in the district. These included the Tehsil headquarter hospital, 3 Rural Health centres, 18 Basic health units and 1 Maternal and Child health centre. In addition, 2 warehouses and 4 laboratories were also assessed.
• All the assessed first level health care facilities are functional and provide outpatient services. Routine Expanded Programe of Immunization (EPI) services are provided in 11(52%) health facilities. A total of 8(38%) health facilities at the first level health care facilities in the district provide Maternal and Child health services. All the three RHCs are providing laboratory services. Essential newborn care, post abortion care, growth monitoring, integrated management of childhood illness (IMNC), nutrition counseling/ breast feeding promotion, health education, minor surgical procedures, detection and management of STIs, dental services, access to ambulance services and services for gender and sexual based violence were not available in any of the assessed primary health care facilities. As per the assessment results, there is a deficiency in the supply and availability of essential medicines in the district. This may be attributed to problems in planning and funding lines for medicines, high utilization and irrational use as well as poor distribution mechanisms.
• The services provided at the Secondary Level Care Facilities (SLCF’s) include Outpatient services, inpatient, routine EPI, antenatal/postnatal care services, basic delivery services, essential newborn care, TB DOTS, ambulance services, laboratory services, X-ray services, minor surgical and dental services.
• The only hospital in Tank does not provide life saving surgeries including C sections and laparatomies and does not have blood transfusion services. Key services under maternal and reproductive health such as Vacuum extraction/ forceps delivery, uterine evacuation, Ultrasonography, Health Education, Detections and management of STIs, Voluntary sterilisation, management of victims of rape are also not provided.
• At the Tehsil Headquarters hospital (THQ) some of the common medicines used to treat common available such as analgesics, anti-allergies, intravenous infusions, anti-malarials and antibiotics metronidazole and ciprofloxacin. Antihypertensive and anti-snake venom was also available.
• All health facilities suffered from an insufficient number of qualified and skilled health workers, in particular skilled female health workers. There are only 3 female medical officers posted in 1st level care health facilities, and none in secondary level health facilities. An additional problem is the unequal distribution of medical staff, for example in total there are 29 male medical doctors in the district and of these, 16 are working in the THQ hospital, while 13 are serving in the primary health care facilities.

Details of the assessment results will be shared separately.

South Waziristan Crisis

The UN multi cluster assessment team visited district DI Khan and Tank. The issue of duplication of services was resolved with partners and EDO. The visit helped to identify and address gaps in service coverage and delivery through a rapid assessment done during the visit in order to improve coordination and collaboration between humanitarian agencies and local stakeholders in the ongoing multi cluster humanitarian response to the IDPs in the host districts of DI Khan and Tank.

Disease Surveillance

Diseases early warning system network has been established in the 10 districts hosting IDPs affected by conflict NWFP. Dews in Kohat and Hangu districts which are hosting IDPs from Orakzai and kurram agency could started due to tough security conditions. As soon as the situation eases, the DEWS activities will be started.

Districts in the DEWS network coverage in NWFP crises

Alerts and outbreaks

During the period (19 Dec-25 Dec), 2009, four alerts were received and responded.The details are as follows:

• Suspected measles:
• One suspected case of Measles reported from Jawarh, Tehsil Takhtbai, district Mardan. The patient was a female child less than 5 year. Throat swab was collected for laboratory confirmation and the laboratory result reported negative from National Institute of Health, Islamabad. One suspected case of Measles reported from Civil Dispensary Rang Mohalla, district Swat. The patient was a female child above 5 years age, resident of Rang Mohalla, tehsil Babuzai, district Swat. Blood sample was collected for laboratory confirmation. NIH reported the laboratory test result negative for Measles (IgM).
• Suspected H1N1:
• An alert from Lady reading Hospital, Peshawar received for Eight persons with Flu like symptoms and history of contact with a confirm case suspected for H1N1. Blood samples were collected for laboratory from National Institute of Health, Islamabad. One out of the eight samples was reported positive for H1N1.
• Suspected Acute Flaccid Paralysis (AFP):
• One suspected case of AFP reported from civil hospital Madyan, district Swat, the patient was a male child less than 5 years age. The Polio Eradication Initiative(PEI) team is investigating the case.

Morbidity and mortality (19-25 December 2009)

A total of 437 health facilities reported 152 839 consultations between 19-25 December, 2009. From the thirty seven health facilities1 224 visits for antenatal care, 1 176 consultations for chronic non-communicable diseases and 287 consultations for injuries.

The table below shows the overall distribution of patients by gender in the number of consultations and the percentage for the priority communicable diseases under surveillance, recorded between 19 and 25 December, 2009.

Out of the total number of consultations, 33 343 or 26% were made by children under five years old.

The seven most common communicable diseases reported from the 10 IDP hosting districts and the conflict affected districts in NWFP from 19 -25 December, 2009

*Others Includes body aches, common fever, follow-ups,minor illness, chronic non communicable diseases Etc

Detail data of these diseases are available from Weekly Morbidity and Mortality Bulletin 52 available at

• http://www.whopak.org

The graph below shows pattern of seven most common communicable diseases reported in the 10 IDP hosting districts in NWFP between 19-25 December, 2009

Morbidity and mortality (August 2008-December 2009)

During the period August 08 to December 2009 the there are 3,263,082 patient consultations recorded in the DEWS network in the 10 districts in NWFP.

Out of the total number of consultations, 757,923 (23%) were made for children less than 5 years of age.

Acute respiratory tract infection (ARTI) was the leading cause of consultations with 7 819 28 (22%) consultations preceded by Acute diarrhea with 3 169 48 (9%) during the reporting period between August 2008 to December 2009.

The Graph below shows the distribution of consultations by priority diseases in IDP crises in the reporting period Aug 08-Dec 09.

COORDINATION

Highlights

Islamabad

• The 44th Health Cluster meeting was conducted in Islamabad on 23 December, 2009. The criteria of formulation for Health Cluster working Group on H1N1 was circulated and discussed among the members. It was decided that the list will be updated next week reflecting the selected members in the working group. The first meeting is scheduled on 6 January, 2010. The Gaps and Challenges faced by Heath Cluster members in their coverage area in the conflict affected areas of NWFP were also highlighted in a separate discussion. Partners briefed and shared their views and information in this regard. In another agenda point briefing on the UN Inter Agency mission in DI Khan/Tank was presented and discussed especially what relates to key aspects of response and actions towards filling the gaps.

Peshawar

• The 63rd Provincial health cluster meeting was held on 24-12-09 at DG health office in the Peshawar district. WHO ‘s response to the current security operation in Orakzai agency was updated for the affected IDPs in Hangu and Kohat districts. There are 4000 registered IDPs in Kohat district whereas 59 families or 407 individuals had been registered in Mohammad Khawaja IDP camp in Hangu district.WHO has sent essential medicines for trauma, primary health care and Reproductive health medicines to the department of Health Hangu and Kohat districts.

Lower Dir

• The District Health Coordination Meeting was conducted at EDO Health Office Timargara on 22nd Dec-09, EDO Health, FSMO, WHO and partners participated, WHO Surveillance officer briefed about disease trends and also about the Measles confirmed case in the district, Measles campaign will be conducted in IDPs Camps & in high risk UCs as soon as DoH will received the required logistic & vaccine from the provincial office. UNFPA & Support with Working Solutions (SWWM) will strengthen 2 health facilities (Basic Health Unit Nasafa & BHU Khadagzai) for Mother and Child Health services; they will also establish labour rooms in these health facilities, covering 30,000 numbers of people.

Buner

• The 7th Health coordination meeting held at DHQ Daggar on 23rd of December. The topics discussed included Progress of Health Partners, updates on disease situation in the district by WHO. Partners proposed to develop an Action plan for year 2010 that would include all Health partners in Buner to avoid duplication of services. Expanded programme of immunization & staff capacity building trainings are scheduled for the first week of January and they will be organized by International Medical Corps. CERD will shift its services from Leprosy clinic Pirbaba to Basic Health Unit Dokada. This will include upgrading of the facilities and purchase of equipment

Swabi

• Coordination meetings were held with MS DHQ hospital, District Swabi regarding progress of WASH renovation work.
• District Swabi is considering how to adapt DEWS and will suggest ways of strengthening Diseases early warning system reporting.

Swat

• Executive District Officer (Health) has issued a letter to all Department of Health staff trained on DEWS in Swat, giving direction to submit the DEWS report on Every Saturday till 12:00 Noon, failing which disciplinary action will be taken against the staff member not observing timeliness in submission of reports.

Tank

• WHO defined its role in terms of its technical support e.g. Assessments, Coordination, Gap filling, Capacity building as well as logistic support (provision of medicine).The services to be provided by different NGOs should be streamlined.
• It was decided that all the partners will adopt the Government Policy to start their activities. The policy mentions the need to obtain a No Objection Certificate (NOC) from Provincial Disaster Management Authority, after submitting the Organization’s profile and clearly stating the areas of services they want to offer to the IDPs & host communities, in addition to a formal permission from the Disaster Relief Unit.
• Primary Health Care services should be strengthened as well strong referral system. The decision to establish networking among the partners was taken. WHO will assist in this regard. Maternal and neonatal child health services should be strengthened.
• 1st coordination meeting with Tehsil Municipal Office – Tank was held on 22nd December 2009.

FILLING GAPS

Care International continued providing health services through two mobile and three static clinics in Ellai, Koga, Makhrani, Nawagai, Karapa union councils of Buner district. Total of 2144 patients were provided Primary Health Care facilities (including MCH & referral services) and in static clinics 642 (including 258 females and 292 children) by Care teams during the last two weeks of December 09. Additional 8 mobile camps in the same union councils of Buner district were also arranged where 1502 patients were given treatment. The organization has started providing Primary Health Care services through 2 mobile medical teams and 2 static clinics in sub-districts Mingora & Matta of Swat district where 14 mobile camps were arranged. In this regard 2296 patients were provided health care services where 865 women 1015 children were treated out of these consultations. There were 1670 patients consulted through two static clinics of Matta sub-district. A total of 14 Health and Hygiene promotional sessions were also conducted benefiting 776 persons.

Cordaid medical teams are offering their services in 3 rural Union Councils of Shangla, supporting 3 remote Basic Health Units with a catchment of more than 60,000 conflict-affected populations -still leaving under curfew- and having no other access to basic health care. Cordaid also supports the District’s Head Quarters hospital (DHQ) Alpuri, the central health facility of Shangla district. Mobile Medical Units are continuing their consultations. They had 2314 consultations with 935 males, 623 females and756 children . Most of the cases are of Acute Respiratory Infections, Diarrhoea and scabies. Cordaid team has been up-scaled to support the Maternal Newborn Child Health activities with new male doctors, Lady Health Visitors and a Lady Health Educator. It will enhance the quality of antenatal/ postnatal checkups and growth monitoring of under five children.

Church World Service-Pakistan/Afghanistan (CWS) continued providing mobile health services for IDPs in Swabi, Mansehra and Abbottabad districts. During the last week of December, 1 490 consultations were conducted where reported consultations for female were 1105 and male breakup was 385. CWS is also focusing on mother and child health services through its mobile health units and 21 antenatal clients have been provided with needed healthcare while 266 under 5 children have been treated and provided medicine through CWS mobile health services in Swabi, Mansehra and Abbottabad. CWS conducted 127 health education sessions with 606 participants in Mansehra and Abbottabad. Topics discussed were importance of vaccination, personal hygiene, diarrhoea, dangerous signs of pregnancy and antenatal care besides others.

Save the children supported health care facilities saw 5,055 patients who were treated through mobile medical teams and 4,099 patients were treated by medical staff deployed at 18 supported health facilities in Mardan, Swat, Buner and Swabi districts. The total number of patients provided with medical care by Save the Children medical staff has reached 140706 individuals since May 2009. In addition, 88 safe delivery kits were distribution to expectant mothers in third trimester in district Swat. Two Health Awareness sessions were conducted in district Swat on General Health & Hygiene, in which 36 beneficiaries participated. The renovation of the Swat nutrition stabilization centre at central hospital Saidu Shareef has been completed. Screening and enrolment of acutely malnourished children and pregnant and lactating women is ongoing in four districts Buner, Swabi, Mardan and Swat. In total 25962 beneficiaries were screened, out of which 362 were enrolled in Supplementary Feeding Program and 74 in Outpatient Therapeutic Program in which the total individuals screened so far are 47656. In DI Khan, hiring of health staff was partially completed, in which 4 medical officers, 4 dispensers and 4 Lady Health Visitors were hired. The staff will be onboard within this week and health intervention in the 5 Save the Children allotted health facilities will commence. Medicines, 5 ambulances, medical equipment and furniture for the health facilities will be delivered there in a weeks’ time.

International Medical Corps continued providing 24/7 comprehensive primary healthcare services in Palosa camp in Charsadda including Mother and Child Health, health education and referral services. There were 522 consultations conducted in Palosa camp in the last week of December, 09. Healthcare services were also made available to IDPs living with host families in Charsadda District through two mobile medical units operating out of the government health facilities. A total of 255 consultations were conducted through the mobile medical units. In Buner District, IMC is providing comprehensive primary healthcare services including health education, MCH and referral services in BHU Tor Warask, RHC Deewana Baba, DHQ Daggar and RHC Bagh. A total of 1 779 consultations were conducted last week. IMC is providing health services in the Saidu Sharif Teaching Hospital through 1 female medical officer and 2 lady health volunteers. In the rural health centre of Khazana and the civil hospital in Khawazakhela, a total of 3 067 consultations were conducted in last week of December.

MEDECINS DU MONDE-FRANCE (MDM-F) provided Health care services through a medical mobile team in Swabi district working continued working in 6 different locations (Naranji, Amankot, Qamar Dand, Palodand, Goati & Kotai) another team is running Out Patient Department for IDPs in Swabi in District Head Quarters Hospital. In Buner district a medical mobile team in Buner district working in Sarwai Union Council in 3 different villages Dargalai, Mangaltana and Dakara. Another team is working in medical mobile team working in Kawga and Amnawar Union Councils of Buner district. A total of 1719 curative consultations have been performed in the last two weeks in the above mentioned health facilities. 57% of the total consultations were female consultations, 29.7% of the total consultations are reported in children less than 5 years age, Acute upper respiratory infection with 6.9% is the most common disease, Skin diseases represent 13.9% in all age groups and acute diarrhoea represent 5.2% in all age groups.126 children between 6&59months are currently in the active file of weekly nutritional program.

CAMP continued providing primary health care services including referrals, for the IDPs residing in phase six of Jalozai camp, Nowsehra district. Total consultations were 683 in the last week of December. Other activities include clinic based Health Hygiene Awareness session (two sessions) for female patients on daily basis. Each session comprises an average of 15-20 participants. The Medical Officers regularly attended the weekly coordination meeting carried out at camp level and share the health related and other issues with the Implementing partners.

Malteser International started early recovery health support project in Swat district, focusing initially returnees and resident population of 3 Union Councils: Kokarai, Islampura, Nawakalay and Basic Health Unit Meragai (Kokarai Union council), Basic Health Unit Islampura and Civil Dispensary Citar/ Chewetar ( Islampura Union council). The field project activity, support to the governmental health facilities, continued successfully and in the last quarter of the year more than 21,000 patients has been treated, in all three supported health facilities. Islampura union council is one amongst epidemiologically problematic areas in Swat District, and with support of WHO and Executive District Health Office, Malteser International health support teams put under control outbreak of watery Diarrhoea diseases in Swat. Due to recent outbreak of Measles, Malteser is now supporting WHO/ EDO Health mass-immunization campaign in Islampura UC.

Medical Emergency Relief International (MERLIN) continued its provision of health services to IDPs in the districts of Swat, Buner, Mardan, DI Khan, Tank districts and the IDP camps in Katcha Gari (Peshawar district)and Jalozai (Nowsehra district). In Swat district, a total of 959 health promotion sessions were conducted where 388098 participants attended in the last quarter of 2009 .The total consultations during the last quarter of the year were 67 350. Provision of equipment and human resources of Civil Hospital Kabal, Tehsil Head quarter Matta and basic Health Unit Bandai in Swat district. In Buner district the total number of consultations conducted during the last quarter were 99 000 in 13 health facilities allocated to MERLIN. There were 7000 Health & Hygiene sessions were 75 000 population participated in these sessions. While in Mardan district, 676 hygiene and nutrition sessions were conducted for 5 260 individuals. The total consultation during the last week of December were 2 461. In Katcha Gari camp, a total of 149 hygiene and nutrition sessions were conducted for 906 participants. The total consultation during last week was 1205 with 730 female and 472 male. Last week in Jalozai camp, six static health facilities provided 24/7 Health care services. There were 2202 health and Hygiene sessions conducted with 27 539 participants. The number of consultations during the last week were 1 4522 with 7125 females and 7397 males.

UNFPA continues to provide reproductive health care services in Lower Dir, Swat and Tank districts. A total of 984 patients were consulted during last week of December 09 in district Tank, Swat and Lower Dir. This includes 151 antenatal consultations, 44 postnatal consultations, 41 deliveries, 1 post abortion care, 2 family planning consultations, 31 STIs, 175 ARI, 124 gastroenteritis, 111 fever, 14 scabies and 286 consultations for other minor general outpatient services etc. During last week of December 252 hygiene kits were distributed for improving menstrual and personal hygiene of the affected women at reproductive age group.

The World Health Organization (WHO) has deployed and prepositioned life saving drugs to Dera Ismail Khan and Tank which included 5 interagency emergency health kits (IEHK), 39 mini emergency health kits (MEHK), 3 cholera kits in these areas. Since June 2008 till December 23, 2009; 558 mini emergency health kits (1 MEHK kit is a package of essential medicines sufficient for 6000 population for 2 months) , 1 new emergency health kit, 32 inter-agency emergency health kit (1 IEHK package of essential medicine, sufficient for 10,000 population for 2 months), 76 diarrhoea treatment kits( 1 kit is a package of essential medicines for 500 chronic cases), 6 surgical kits, 193 clean delivery kits, 3 MCH-A kit, 2 reproductive health kits, 2 trauma kit A & 3 trauma kit B, 8,880 washing soaps, 9,880 toilet soaps, 100,070 ORS and 635,333 syringes have been delivered to the hosting and conflict affected districts in NWFP.

During the past 12 months around 1,349 water samples were tested for microbial quality from various sources of the IDP camps and IDPs hosting districts, where 100% of the water samples taken from deep boreholes were found to be fit for drinking, but 29% and 40% of the household and hand-pumps were found to be unfit for human consumption respectively. Also there were 1760 water samples tested for residual chlorine 86% of the samples were found to have the minimum required chlorine residual 0.2 mg/litter as per WHO and Pakistani government standards.

Funding situation

As of 04 January, the Health Cluster has received 48% of funds required as presented in the UN Pakistan Humanitarian Response Plan (Revision) document. (Needs identified: US$42 065 870 . Funds available: US$20,380,286 .) (Source: OCHA Pakistan, 04 January).

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

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

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