Pakistan Health Cluster bulletin 2 - 3 June 2009
Latest information on health partners and health needs in the current crisis in Pakistan:
- As of 02 June, the Provincial Relief Commissionerate reported 3 023 331 IDPs in 12 NWFP districts compared to 1 716 026 on 15 May (including the previous caseload of 462 528)
- Trend of reported acute watery diarrhoea cases is rising. Scarce drinking water and inadequate hygiene and sanitation facilities remain a problem
- Current stock of drugs and medical supplies in affected districts is running out (one to three months depending on district)
- Malaria cases are expected to increase as the monsoon season starts in July
- Insufficient number of qualified and skilled health staff in place, especially female medical doctors
- Mental health and psychological support need urgent attention
- Between 28-30 May, more than 1 762 629 children under five were vaccinated against polio in IDP hosting districts of NWFP.
Large numbers of internally displaced people, the threat of disease outbreaks, and huge strains on health systems inside temporary accommodation camps and hosting communities are major hallmarks of the current health situation in Pakistan's North West Frontier Province, where an upsurge in violence fanned a new wave of displacement starting 2 May.
More than 82 communicable diseases alerts and 25 outbreaks have occurred during recent months, with most being controlled before evolving into larger outbreaks. Communicable diseases are monitored and controlled via the Disease Early Warning System (DEWS) that WHO implemented in August 2008 in collaboration with the Federal Ministry of Health (MoH) and health partners in Peshawar, Charsadda, Mardan, Nowshera and Lower Dir districts. Lower Dir is not reporting due to the insecurity. WHO and Health Cluster partners are planning to expand the DEWS to Swabi district.
From 16-22 May, 50 148 consultations were recorded in 164 sites reporting to the DEWS. Of these, 13 are health facilities in IDP camps, four are mobile clinics and 147 public health facilities in the four districts hosting IDPs.
Acute diarrhoea and malaria will be the main diseases of concern for the coming weeks. The trend for acute diarrhoea is gradually increasing in all IDP-hosting districts but in higher proportions in some IDP camps such as Palosa, Jalozai (1, 2, 3, and 4), the Benazir complex, Sheikh Shahzad and Sheikh Yaseen and Jalala. Hygiene promotion activities have been intensified in the camps.
The following graph shows weekly proportion of consultations for the common priority communicable diseases in IDP hosting districts of NWFP from 25 April to 22 May 2009.
Some 955 children were vaccinated against measles in the Labour colony, Mardan where a measles alert was reported. Malaria cases are expected to increase as the monsoon season starts.
Assessments of 94% of Swabi district's health facilities were conducted by WHO in May 2009. The assessments were facilitated by the NWFP Health Department/PPHI (People's Primary Health Initiative) and identified the following needs:
- Qualified and skilled health workers, especially female medical officers and female medical technicians
- Essential drugs and medical supplies
- Improved services for maternal, neonatal and child health, including obstetric heath care and safe delivery kits, ambulances for referral of patients to secondary health care facilities
- Safe drinking water, promotion of health education to improve hygiene practices, especially through the Lady Health Worker (LHW) Programme
- Water and sanitation facilities especially in the IDP camps
Similar needs have been identified in the other districts.
More than 500 000 child IDPs aged under five need care and support, plus more than 600 000 women of childbearing age. According to UNFPA, there are 69 300 pregnant women among IDPs, 6000 of whom are expected to deliver within the next month. Nine hundred of these women will require emergency obstetric care to handle pregnancy-related complications.
Health Cluster, Peshawar
- • The provincial Health Cluster meeting was held on 29 May in Peshawar. The NWFP director-general of health pointed out existing duplication and parallel services in some camps and requested partners to coordinate activities with the Executive District Officer (EDO) of Health of the respective districts. The Health Sector Reform Unit of the provincial Department of Health shared guidance on what should be included within the basic package of health services for different levels of health care. All partners were requested to regularly share their weekly activity report with the Cluster Coordinator.
Health Cluster, Islamabad
- The Islamabad Health Cluster meeting was held on 27 May, co-chaired by the MoH and WHO.
- The MoH is creating an advisory group for strategic guidance on health sector response and requested NGOs to nominate one organization to represent them in the group. WHO shared the proposed Health Cluster financial resource mobilization plan and requested partner support to conduct joint resource mobilization activities.
- The “Who is doing What and Where” matrix was shared with partners with a request to avoid duplication in camps and to fill gaps in host communities in Mardan, Charsadda, Peshawar and Nowshera districts.
Coordination with MoH
- • On 26 May, the WHO Representative met with both NWFP's Minister for Health and Secretary for Health. The Minister said the health sector was facing challenges to assist IDPs inside and outside camps. WHO and the Minister decided that health services in IDP camps must be comprehensive and based on standards that ensure the required access and quality of care. Mental health services are a priority.
Who, does what, where?
- During the 28–30 May National Immunization Day (NID) campaign, the MoH, WHO, UNICEF and other health partners immunized 1 762 629 children under five against polio in IDP hosting districts of NWFP. Children aged 6 months to 5 years also received vitamin A capsules. This was the first time these children were accessible because, before their displacement, many lived in areas that polio teams could not access due to security restrictions. WHO is advocating that this opportunity be taken to increase routine childhood immunization coverage against polio and other vaccine-preventable diseases.
- Merlin is conducting a mass hepatitis B vaccination campaign in the Jalozai camps and has already completed similar campaigns in Kacha Gari 1 and 2 camps. More than 30 000 children aged above one and adults have been vaccinated against hepatitis B. This campaign is being conducted in collaboration with the Department of Health and is using vaccines provided by the Frontier Corps.
Medicines and medical supplies
- The amount of medicines and medical supplies available is insufficient to cover the needs of the IDP and host communities and the stocks are expected to be depleted in one to three months, depending on the area.
- To fulfil national requirements, the Mini Emergency Health Kit (MEHK) was standardized with the addition of maternal and child health, reproductive health and mental health modules. All the Inter-Agency Emergency Health Kits (IEHK) now in stock will be converted into MEHK. A further 110 MEHK, able to cover the basic health needs of 660 000 people for one month, are being procured. (Each MEKH covers the needs of 6000 persons for one month).
- WHO is preparing a list of essential medicines and surgical supplies required for 2.7 million IDPs with buffer stock as the figure may double in coming months. The list will be shared soon with Health Cluster partners.
- WHO is hiring a secure facility in Mardan to pre-position medical stocks ahead of the monsoon season. Stock is expected to be transferred by mid-June. A logistics assistant is managing the supplies, including medicines in affected areas. WHO has posted a pharmacist in Peshawar to monitor the medicine and supply needs.
Health infrastructure and medical staff
- Health services for host communities must be improved by strengthening of referral hospitals and mobile clinics. There are currently 617 public health facilities (75 hospitals, 54 rural health centres and 488 basic health units) in districts hosting IDPs. Another 43 health clinics are providing healthcare in camps and at least 27 mobile medical teams are operating in host communities.
- Authorities airlifted a team of 22 doctors and paramedics, one MEHK and surgical supplies to Mingora, Swat.
- There is an acute shortage of ambulances and mobile hospitals which need to be addressed urgently. At Jalozai-3 IDP Camp, Nowshera, and some camps in Malakand there are gaps in ambulance services. More than 35 ambulances (26 belonging to partners and nine to the Department of Health) are serving various IDP camps.
- The Federal MoH is supporting the Pabbi Satellite Hospital and a field hospital at Jalozai IDP Camp, Nowshera to provide 24/7 comprehensive services to the IDPs.
- A medical team from Department of Health, Punjab, is providing medical, surgical and MNCH services at the Mardan Medical Complex and supporting 10 mobile teams for IDPs living in host communities in Mardan.
- The Pakistan Army set up two field hospitals (Sheikh Shahzad IDP Camp, Mardan, and Jalozai IDP Camps, Nowshera.)
- A team from Ayub Medical Complex, in Abbottabad, is supporting the Shah Mansoor Hospital, in Swabi.
- The Pakistani NGO Frontier Primary Health Care is providing 24/7 comprehensive services in Sheikh Yaseen IDP Camp, Mardan. Their medical team comprises three male and two female medical officers, four dispensers/medical technicians, two lady health visitors, two midwives, two EPI technicians and five social mobilizers.
- UNFPA is supporting maternal, neonatal and child health services at Pabbi Satellite Hospital, Nowshera.
- Save the Children is supporting two mobile clinics and three health facilities (Civil Hospital Kalu Khan, Rural Health Center Ambar Kunda and Civil Dispensary Col Sher Kaley) that are providing health services to IDPs living outside the camp in Swabi. They treated 3399 patients between 11-27 May.
- Relief International has been providing health care in Palosa-II IDP Camp, Charsadda, since 13 May. Their medical team comprises two male and one female medical officer, two male medical technicians and two lady health visitors. They have conducted 10 health and hygiene sessions attended by 110 pregnant and lactating women.
- International Medical Corps (IMC) is providing 24/7 health services in Palosa IDP Camp, Charsadda and Yar Hussain IDP Camp, Swabi. They are also providing health services to IDPs living with host population in district Charsadda through 2 mobile units and covering two BHUs and one RHC.
- Merlin has been providing comprehensive primary health care and referral services for IDPs and host communities since January. It has provided around 138 000 consultations and referred 1273 cases to hospitals supported by the Department of Health, WHO and UNFPA. Merlin is treating on average 1900 new cases per day. It has also held 6271 health promotion sessions, reaching 45 585 participants.
Merlin is covering the health needs of more than 180 000 IDP accommodated in camps or host communities in coordination with the Health Cluster and health authorities. Seven 24/7 static clinics in Kacha Gari 1 and 2, Jalozai 1/2/3, Jalala and Sheikh Shahzad camps and five mobile clinics in Mardan district are providing health care. Merlin is also supporting existing health facilities in host communities and setting up another clinic in Jalozai 4 camp. It is also establishing three additional medical teams to cover 34 union councils in Mardan district. Medicines are provided by WHO.
In coming weeks Merlin, the provincial TB control programme and the NWFP Department of Health will establish two TB diagnostic centres in Jalozai 2 and Sheikh Shahzad camps to serve all surrounding camps.
Maternal, neonatal and child health
- UNFPA established six service delivery points to support comprehensive reproductive health services in Jalozai, Sadbarkaly, Jalala, Palosa and Yar Hussain camps and in Nowshera’s Pabbi Satellite Hospital. Since November 2008, UNFPA has supported the treatment of 28 466 patients, including 1033 antenatal and 128 postnatal consultations, 15 deliveries, one c-section, 22 cases of sexually transmitted infections (STI), 529 family planning services and other consultations. UNFPA has over 5800 hygiene kits in stock at Peshawar and is procuring an additional 150 000 kits after already distributing 7706. Reproductive health kits for assisted clinical deliveries, containing medical instruments and necessary obstetric and gynaecological medicines, are available at the six UNFPA service delivery points. UNFPA is also training healthcare providers in Peshawar on syndromic case management of sexually transmitted infections (STI) and recruiting female healthcare providers.
- All Merlin facilities (static and mobile) have separate female wards attended by female health staff (doctors and lady health visitors) to enable women to access healthcare. In addition to curative care, health staff are trained on referral protocols and are referring advanced/complicated obstetrical cases. A delivery room for unexpected cases has been established by Merlin in Jalozai 2. Merlin is providing essential laboratory rapid tests for pregnant women and women of childbearing age. These include malaria diagnostic, urine analysis, rapid diagnostic test for pregnancy, glycaemia and haemoglobin levels. This is being done to increase the quality of antenatal and postnatal services, accurate diagnostics, early identification of pregnancy/postpartum complications, and ease the burden posed by increased caseload on referral hospitals. To date, Merlin has provided over 75 000 female consultations.
Water, sanitation and hygiene
- More than 90% of water samples taken from available drinking water supplies in IDP hosting districts were contaminated with faecal coliforms, according to surveys conducted by WHO and the Pakistan Water Research Council. This resulted in UNICEF and other WASH partners supplying water to IDP camps and conducting continuous disinfection of water supplies and provision of hygiene kits to most families.
- WHO has brought public health issues to the forefront of the WASH cluster agendas. WHO in collaboration with WASH cluster partners, has been conducting regular water quality control activities and supporting the provision of chlorine, conducting routine training on water treatment, including water treatment at household level, and hygiene promotion and ensuring the availability of water to health facilities and healthcare waste management.
- A WHO environmental health team is training sanitary workers to deliver messages focused on proper use of latrines, hand washing with soap, safe water handling and storage, safe waste water and solid waste disposal, personal hygiene and causative and preventive measures of diarrhoeal diseases.
- • Merlin is monitoring the nutritional status of IDPs living in camps (Kacha Gari 1/2, Jalozai 1/2/3) and in host communities in Mardan district and providing treatment for acute malnutrition cases. Two new nutritional centres are under preparation in Jalozai 3 and 4 camps. Five Merlin mobile teams are providing community-based management of acute malnutrition (CMAM) in Mardan host communities. Merlin’s curative interventions have been strengthened through comprehensive health education with emphasis on infant and young child feeding. To date, over 10 000 children and 6000 pregnant and lactating women have been screened.
The capacity to identify and manage mental health and psychosocial problems must be built up urgently. Primary health care facilities require psychological and pharmacological interventions, as well as psychotropic medicines on a regular basis.
A brief needs assessment was carried out by WHO in Yar Hussain camp, Swabi district (population of 9000), with 40–60% of consultations (particularly women) being primarily because of psychosocial and mental health problems.
No mental health and psychosocial support services are being provided within the PHC services package. Only a few psychosocial sessions have been organized in several IDP camps by some local and international NGOs and tertiary care hospitals from Peshawar, Islamabad and Abbottabad in the IDP camps.
Mardan district hospital psychiatry departments and district outpatient facilities in Swabi, Nowshera and Mardan Medical complex have been identified to assist in the expansion of psychosocial services in camps and hosting communities. Psychiatry departments from NWFP medical colleges are being readied to actively participate in this action. WHO has fielded a mental health expert to evaluate the mental health needs in this field and revise operational guidelines to be shared with health partners.
Funds appealed for by the Health Cluster
The Health Cluster projects included in the third revision of the Pakistan Humanitarian Response Plan had amounted to US$ 42 065 870. But a WHO project to revitalize PHC services for flood-affected areas was shifted to the Early Recovery Cluster. Now, the total amount being requested by the Health Cluster following the latest revision launched 22 May 2009 is US$ 37 186 028.
Funds received & funding gap
At 30 May, the Health Cluster had received 11% of funds needed, according to the OCHA Financial Tracking System. As of 30 May, the USA had pledged US$ 1 million and Italy had pledged Euros 1 million.
Efforts are being made to advocate and raise the visibility of the health response to the crisis. WHO is reinforcing its communication/information team to support Health Cluster advocacy and communications activities.
On 26 May, WHO and the Health Secretary for NWFP conducted from Peshawar a teleconference with 20 journalists based at the UN HQ in Geneva. The feedback from the reporters was very positive, as they had an opportunity to receive first hand information from Peshawar.
The WHO Representative attended a talk show on News 1 TV (Pakistan), highlighting the needs and responses of the Health Cluster.
WHO, UNHCR and WFP attended an inter-cluster press conference on 28 May organized by OCHA. WHO highlighted the concern regarding the poor funding of the Health Cluster and praised the work of the Health Cluster partners in controlling communicable disease outbreaks.
WHO provided input on the Health Cluster activities implementation for a press release issued by OCHA on 28 May.
For more information please contact:
WHO Pakistan Country Office
Dr Khalif Bile Mohamud
WHO Country Representative to Pakistan
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