HEALTH POLICY AND DEVELOPMENT; 2 (2) 90-95 UMU Press 2004

DELIVERING HEALTH CARE TO IDPS: EXPERIENCES AND CHALLENGES IN DISTRICT

Onyige T. A.

Abstract There are two broad categories of IDPs in Katakwi district by cause; those displaced by the Karamojong rustlers and those displaced by the Lords Resistance Army (LRA) incursion. Sporadic Karamajong raids started over 50 yrs ago and they are still ongoing to date. By 2001 there were an estimated 75,846 persons from 17,660 households living in 48 IDP camps, mainly in areas bordering Karamoja. Incursions by the LRA started around the 16th June 2003 and lasted till April/May 2004. Rebels of the Lord's Resistance Army invaded the district from Obalanga Sub County and within two weeks, the pillage had spread to 9 other sub counties, mainly in the Counties of Kapelebyong and Amuria. This paper gives a bird's eye view on the extent of displacement in Katakwi, the health status of the IDPs and proposals for improved service delivery.

Introduction Table 1: IDPs due to armed Karamojong rustlers, peak 2000/01 Katakwi district was established in 1997 and is located in the northeastern part of . It shares borders Sub County Number Number of Total with the districts of , Kumi, Moroto, Kotido, Lira, of camps households population and Kaberamaido. It is composed of 3 counties of Amuria, Usuk and Kapelebyong. It has 18 sub- Ngariam 12 2,739 13,907 counties plus a Town Council, 93 parishes and 664 Magoro 7 2,029 8,501 Local Council ones (LC1s). The district has got three Katakwi S/C 3 1,734 8,034 Health Sub Districts, namely Usuk HSD, Amuria HSD Katakwi T/C 1 660 4,738 and Kapelebyong HSD. Usuk 5 3,040 17,636 In the 2002 population census, the total District Ongongoja 3 1,823 9,342 population was 307,302, distributed as follows; Toroma 1 210 1,162 123,215 in Usuk HSD, 122,086 in Amuria HSD and Omodoi 5 1,586 9,324 61,731 in Kapelebyong HSD. (UBOS, 2003.) Kapuian 2 234 2,147 There are two broad categories of IDPs in Katakwi Total 39 14,055 74,305 district by cause; those displaced by the Karimojong Source: Katakwi District Health Directorate rustlers and those displaced by the Lords Resistance Army (LRA) incursion. (Katakwi Local Government, The proportions of those displaced by the Karamojong 2004). raids by sub-county are further presented in figure 1 below: Karimojong rustlers Figure 1: Distribution of IDPs due to armed Sporadic Karamojong raids started over 50 years ago Karamojong raids by sub-county as at 31st/03/2004 and they are still ongoing to date. By 2001 there were an estimated 75,846 persons from 17,660 households (1/3 of the district population then) living in 48 IDP camps, mainly in areas bordering Karamoja in the Health Sub-District catchment areas of Kapelebyong and Usuk. The displacements as a result of the Karamojong raids by Sub-county are shown in table 1 below:

Source: Katakwi District Health Directorate health policy and development 90 volume 2 number 2 August 2004 DELIVERING HEALTH CARE TO IDPS: EXPERIENCES AND CHALLENGES IN KATAKWI DISTRICT

The sub-counties of Usuk and Ngariam were the worst The sub-county of Kuju was the worst affected affected by the Karamojong cattle rustlers. followed by Acowa. The displacements were in equal proportions, males and females as is shown in figures Below is a further illustration of the extent of the 3 and 4 below: displacement again showing that Usuk and Ngariam were the worst affected. Figure 3: LRA IDPs by sex as at 31/03/2004

Figure2. Distribution of IDPs due to armed Karamojong raids by household and total population as at 31.03/2004

Figure 4: Sex distribution of IDPs due to LRA incursions Source: Katakwi District Health Directorate

LRA incursions

Incursions by the LRA started around the 16th June 2003 and lasted till April/May 2004. Rebels of the Lord’s Resistance Army invaded the district from Obalanga Sub country and within two weeks, the pillage had spread to 9 other sub-counties, mainly in Source: Katakwi District Health Directorate the counties of Kapelebyong and Amuria. These incursions led to massive displacements as is shown below: An analysis of the ages of the displaced was further carried out and the results are presented in figure 5 Sub-county Name of Number of Total and figure 6 below: camps household population Kapelebyong Kapelebyong 1,675 7,954 Figure 5: Number of IDPs due to the LRA by age Oditel 1,302 5,779 group as at 31/08/2004 Acowa Acowa 3,985 20,966 Obalanga Obalanga 3,624 14,602 Orungo Orungo 3,781 17,822 Asamuk Asamuk 2,039 10,492 Kuju Amuria 6,167 32,407 Morungatuny Morungatuny 1,787 8,381 Wera Komolo 1,018 5,387 Wera Hq 459 2,611 Angole Wera 523 3,003 Habibu 735 4,222 Oimai 666 2,943 Abarilela Abarilela 1,825 8,858 Okudok 619 3,251 Total 30,205 148,678 Source: Katakwi District Health Directorate Source: District Health Directorate

health policy and development 91 volume 2 number 2 August 2004 Onyige T. A

Figure 6: Distribution of IDPs due to the LRA raids by age group as at 31/08/04 As is shown, the effect of the LRA incursion into Katakwi has been the most disastrous, far overshadowing the chronic armed Karamojong raids.

The health of IDPs

Morbidity profile 2003/04 The reported number of cases of the leading causes of morbidity in the IDP based facilities from July 2003 to April 2004 are presented below:

Figure 8: IDP morbidity trends in IDP based facilities July 2003 to April 2004

Source: Katakwi District Health Directorate

Overall, the elderly (60 + yrs) were the least and teenagers and middle ages the most. This definitely has implications on the type of health services that have to be planned for.

Lastly, figure 7 below shows the distribution of the district population by displacement or not as at 31/3/ As figure 8 clearly shows, the reported number o cases 04. of malaria increased greatly during the months of December 2003 to March 2004 and so did the reported numbers of the other diseases. Figure 7: Distribution of the district population by displacement or not as at 31/03/2004 Again figure 9 below shows that malaria was the leading health problem in the IDP camps from July 2003 to April 2004 followed by acute respiratory infections that are not pneumonia.

Figure 9: Morbidity Profile from

Source: Source: Katakwi District Health Directorate

health policy and development 92 volume 2 number 2 August 2004 DELIVERING HEALTH CARE TO IDPS: EXPERIENCES AND CHALLENGES IN KATAKWI DISTRICT

Other selected health indicators

Table 3 below further shows some selected indicators, HIV/AIDS and maternal health indicators.

Table 3: Voluntary Counselling and testing

Indicators 2000/01 2001/02 2002/03 2003/04 HIV seropositivity rate 27% (female: male (VCT outreaches) 67.5%: 32.5%) ANC attendances 77% 85% 74% 38% Deliveries in health units 13% 20% 15% 9% Contraceptive prevalence 6% 10% 12% 10% Rate (CPR)

Source: Katakwi District Health Directorate

In 2003/04 during the LRA incursion, the HIV Table 5: OPD attendance seropositivity rate greatly increased and the number of ANC attendances decreased together with the Category 2003/04 0 – 4 years 5 years number of deliveries in health units and CPR. and over New 118,690 164,845 Table 4 shows some recent statistics on home-based Re-attendances 92,642 99,108 management of fever (HBMF). Referrals to units 1,062 1,642 Referrals from units 1,051 1,342 Table 4: Home Based Management of fever (HBMF)

February March April May Source: 2004 2004 2004 2004 Challenges about IDPs % of <5 receiving 55 51 59 65 effective treatment Health services delivery amongst IDPs is very within 24 hrs challenging. In Katakwi, provision of basic curative Community births 25 54 185 155 services particularly maternal and child health care is in the catchment very challenging especially to populations that are area distant from health facilities. The district health services have however continued to provide Community deaths 11 1 22 33 emergency referral services in the identified health in the catchment facilities security allowing and the presence of area landmines and sniper fire. Health workers have also Source: Katakwi District Health Directorate endeavoured to provide routine immunization and other health preventive services in those health The percentage number of children under 5 years facilities within IDPs camps, emphasising hygiene and receiving effective treatment within 24 hours has sanitation. steadily been increasing however community deaths in the catchment areas have also been increasing. With all these efforts, challenges still exist. First and foremost, getting and convincing the few accessible Lastly, table 5 shows OPD attendance figures during medical staff to go to the camp units to provide the the period of insurgency. above services is difficult.

health policy and development 93 volume 2 number 2 August 2004 Onyige T. A

Secondly close linking up with other active partners n involvement in voluntary community based service health service delivery in order to optimise the delivery e.g. the Community Own Resource Persons available resources for service delivery so as to provide (CORPs). Sensitisation meetings and the comprehensive services amongst IDPs has been commemoration of National Health Days will be difficult. Attempts have been made to hold encouraged. coordination meetings and also to share information but in vain. There will be improvement in HMIS and in the utilization of service data generated timely with special Further, currently in the camps in Katakwi, there is focus on IDPs in order to facilitate lobbying, planning, wide spread unhealthy social behaviour i.e. alcoholism, supervision and monitoring. promiscuity and apathy. These have posed a serious challenge and will further be problematic during the The district will engage in capacity building, transition period and there after. The question of how recruitment and training of staff and the communities to organize and offer services in the transition period in liaison with partners. Emphasis will also be put in between camp life and resettlement has not yet been strengthening support supervision at all district levels seriously addressed. In Katakwi, some IDPs re through supervisory teams. returning to their homes and these also have to be catered for. Lastly continued wide lobbying for funds and other support essential for health service delivery and Lastly there is the issue of mobility of IDP populations infrastructure development (health unit construction according to the state of security in the district, and procurement of transport) for easing access to the especially as the Karimojong problem has been long remote service areas will actively be pursued. standing and might not be about to end. How do district health services accommodate this in their day- Conclusion to-day work? There are formidable but not insurmountable District Partners constraints and challenges. Staffing problems will cause a major challenge together with sustaining timely The major partners that have been involved in supplies of drugs and sundries. Ensuring sustained organizing and delivering health services for the IDPs community involvement, ownership and concern for in Katakwi include the Ministries of Health; Finance their health is another challenge and this will be very and Defence. Development partners include WHO, vital in order to ensure the sustainability of UNICEF; UNFPA; MSF; OXFAM; ACTIONAID [U]; intervention. RERDCROSS; MEDAIR; MEDICALID [U]; CCF; AIM and UPHOLD. Uncertainties about timely reception of funds for Indigenous NGOs such as HEALTHNEED [U]; activity implementation have always been in existence SOCADIDO; AIC; COU and YWAM have also been but in such a situation of need they pose a real active in Katakwi. There are also 22 CBOs and also challenge. Conditional ties for some donor funds with private individuals. no flexibility at all in the utilization of these funds leaves health workers with their hands tied. Occasional However all these partners have various areas of focus. political interference, especially at times of allocation of resources is also sometimes a hindrance to effective Strategies for improved service delivery service delivery. Bureaucracy especially in tendering processes is a big problem. The district health service team plans to ensure timely procurement of drugs, sundries and medical equipment Uncoordinated supervisory visits by central/donor based on needs. There will be liaison with other active supervisors wastes time and remove health workers partners in the provision of Primary Health Care from their routine duties. Lastly, maintaining staff outreach services to communities in the three Health working in areas of conflict and Internally Displaced Sub Districts. There are however fewer partners Persons camps is not going to be easy. engaged in curative services. A number of recommendations can be made based on Active awareness creation among the community and the experiences. The current staffing gaps should be promoting their participation in health programmes filled with qualified health workers and means of will be encouraged through IEC and their direct giving these health workers incentives to work in

health policy and development 94 volume 2 number 2 August 2004 DELIVERING HEALTH CARE TO IDPS: EXPERIENCES AND CHALLENGES IN KATAKWI DISTRICT hostile environments need to be explored. There References should be an increase in effective partnerships and coordination of government service providers with GO UBOS 2003 “Preliminary results of the National and meetings for information sharing should be Population and Housing Census 2001/2002” Uganda encouraged. Provision user-friendly yet robust means Bureau of Statistics . of telecommunication and transport are now more vital than ever. Its effective services are to deliver and Katakwi Local Government “Health Reports on IDPs coordinate. Devising sustainable and timely funding 2001-004” Katakwi District Health Directorate. mechanisms and also procurement and distribution of drugs and sundries very important. Lastly, there should be an increase of community own resources persons (COR).

health policy and development 95 volume 2 number 2 August 2004