An assessment of public health facilities in the earthquake affected districts of Pakistan 2006

DRAFT-2

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II An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Acknowledgments

The World Health Organization (WHO) and the Ministry of Health of NWFP acknowledges and appreciates the key contribution by the staff of the Emergency Humanitarian Action Program (EHA) of WHO Pakistan who were involved in planning and conducting this assessment. Gratitude goes to the partner organizations that helped wholeheartedly in collection of data. This includes UNFPA, UNICEF, Mercy Corps, Save the Children-US, MERLIN, ICRC, Malteaserwhole and the Pakistan Army. Our appreciation also goes to Dr. Mumtaz (MO-Kaladhaka), Dr. Syed Nasir and Mr. Sarbuland (EPI Corodinator, Pattan, Kohistan) for their help. We are grateful to our Operations Manager Dr. Rayana Bou-hakah for her initiative, technical input and continuous support as well as Dr. Khalif Bile, WHO Representative, Pakistan for his encouragement and leadership. We also appreciate the constant partnership and support from EDOs of all Districts as well as their staff; District Health Officers, and the staff from the WHO field offices including our drivers and logisticians. Last but not least, we are indebted to the staff of all the health facilities we visited for welcoming us to their facilities and being cooperative, open and forthcoming in every way.

III An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Table of contents Chapter 1: Introduction ...... 1 Chapter 2: Methodology...... 3 2.1 Limitations ...... 4 Chapter 3: Results and Discussion...... 6 3.1 Accessibility ...... 7 3.2 Physical Infrastructure ...... 9 3.3 Service Utlization...... 11 3.4 Service utilities at health facilities ...... 12 3.5 Human Resources...... 13 3.6 Service Provision ...... 15 3.7 Status of equipment and medical supplies ...... 17 3.8 DEWS: Disease Early Warning System...... 18 3.9 Gender Issues...... 21 3.10 Perceived needs ...... 22 3.11 Management of health facilities...... 23 CHAPTER 4: CONCLUSION AND RECCOMENDATIONS ...... 25 Annexes ...... 27 1. District Bagh...... 28 2. District Muzaffarabad ...... 39 3. District Poonch ...... 50 4. District Battagram ...... 56 5. District Mansehra...... 62 6. District Neelum ...... 78 7. District Shangla...... 84 8. District Kohistan...... 90 Maps...... 100

IV An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

EXECUTIVE SUMMARY An assessment of public health facilities was conducted in all eight earthquake affected districts (Mansehra, Kohistan, Shangla and Battagram in NWFP and Muzaffarabad, Bagh, Poonch and Neelum in AJK) to assess the functionality of public health facilities in the district (staffing, services, supplies, utilization etc.), to perform a comprehensive mapping of all facilities, to identify issues relating to quality health service delivery and to establish baseline data on health facility status for future assessments and evaluation of interventions. This report presents information collected in the field as well as secondary data compiled from many sources including regular monitoring reports of partner organizations and brings forward recommendations for further interventions relating to recovery and reconstruction. A pre-tested questionnaire was used for this cross-sectional survey and consisted of closed- ended questions regarding facility information, access indicators, physical infrastructure, staffing position, equipment and supplies, and reporting. The selection criteria were ‘functioning first level health care facilities including Basic Health Units (BHUs) and Rural Health Centers (RHCs)’. GPS coordinates were also taken as was visual documentation. The assessment was carried out in 303 facilities and analysis was carried out in 297(143 from AJK 154 in NWFP). Of all facilities assessed, 24% are being supported by an external agency (NGOs or the Pakistan Army). Some districts, like Shangla and Kohistan, had none of the facilities being supported by an external agency. Most facilities assessed (65%) were located close to a tarmac or jeep road and were accessible by all types of vehicles. However 47 BHUs (25%) were accessible only by 4X4 jeeps and 19 (10%) were accessible only by foot. The average walking time to the facilities from the closest population pocket was 22 minutes (range: 2 minutes to 60 minutes) while the average time taken to the farthest catchment village was 141 minutes (range 25 minutes to 720 minutes). In three cases, clients in the farthest catchment village would have to walk for up to two days to get to the closest health facility. Average time to the preferred referral facility by vehicle was 108 minutes (range 10 minutes to 960 minutes). The original structures were being used in 60% of all facilities. In many places, the damage is either minimal, or parts of the original structures, such as a single room, are being used. Tents are being exclusively used in 9% of facilities, and pre-fabricated units in 8%, while multiple structures (a combination of tents, buildings, shelters and pre-fabricated) were being used in 23% of all facilities. Over two-thirds (68%) of all facilities had a functional toilet, 49% had a functional water supply within the facility premises and 65% had an electric supply. Half of the facilities (118) burned their waste, 27 (19%) threw it away, and 27 (11%) buried their waste. Forty-six (20%) used multiple methods. In sites where staff claimed to bury their waste, we noted improper waste disposal techniques, with shallow pits overflowing with hazardous waste. On the whole the most available category of staff present in all districts is the medical technician or dispenser (88%), followed by a vaccinator (67%), an LHV (63%) and male Medical Officer (47%). A female Medical Officer was available at only 13% of all facilities. The most common service provided was out-patient consultation (96%), followed by ORS provision (89%), EPI (80%), minor surgical procedures like stitches (69%) and family planning (68%). The least available services were laboratory services (18% of all RHCs), access to an ambulance (27%) and in-patient treatment (29%). Only 23 (10%) facilities were classified as well equipped, 108 (46%) were average and 105 (45%) were classified as poorly equipped. The situation was similar in the two provinces but with considerable variation between districts. Kohistan had the highest percentage of poorly equipped facilities (72%), followed by Neelum (55%) and Poonch (48%). The district with the highest percentage of well-equipped facilities is Muzaffarabad (21%), followed by Battagram (14%) and Bagh (13%). Most facilities (46%) were classified as average. When asked about their needs, staff in many districts mentioned several common issues: construction of staff quarters, improving the water supply, appointing appropriate staff, strengthening reproductive health services, supply of furniture and essential equipment and office supplies, provision of a regular and sufficient drug supply, laboratory services and staff training.

V An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 A complete services package needs to be introduced, and the minimum standard must include maternal and child health services like ante / post-natal care and regular EPI services. The quality of existing services needs to be improved. The water and sanitation issues at health facilities need action. Referral sites need to be strengthened in case of emergency and to provide effective delivery of health services. The government may consider better incentives to retain doctors at peripheral health care facilities. Where the 8th October earthquake has caused disruption and devastation, it has also provided a unique opportunity to reassess and improve the situation and, ultimately, improve the quality of people’s lives.

VI An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

List of abbreviations

AJK Azad Jammu and Kashmir ANC Ante-natal care BHU Basic health Unit CH Civil Hospital DEWS Disease Early Warning System DHO District Health Officer DHQ District Headquarters Hospital EDO Executive District Officer EmOC Emergency Obstetrical Care EPI Expanded Immunization Program FAP First Aid Post FMT Female Medical Technician GPS Geographical Positioning system HMIS Health Management Information System ICRC International Committee of the Red Cross IDP Internally Displaced Persons IPD In-patients Department LHV Lady Health Visitor MCH Maternal and Child Health MMT Male Medical Technician MO Medical Officer MoH Ministry of Health NGO Non-governmental Organization NWFP North West Frontier Province OPD Out-patient Department PNC Post-natal Care RHC Rural Health Center THQ Tehsil Headquarters Hospital UNFPA United Nations Population Fund UNHCR United Nations High Commission for Refugees WHO World Health Organization

VII An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Chapter 1: Introduction

The October 8th earthquake affected a huge area across three countries with maximum damage reported in NWFP and AJK. According to figures reported by OCHA’s Integrated Monitoring Matrix, out of 5,548,181 people, 61,222 were reported dead and 58,642 were injured. Over 3 million people were affected by the disaster of which an estimated 468,024 are still “at risk”1. Vulnerable groups like women and children made a large share of victims. Widows, orphans and the disabled are particularly vulnerable and have required special care and support. In the aftermath of the earthquake, a Destroyed BHU in Shungli Bandi, Oghi massive response by various agencies saw the distribution of 539,916 tents, approximately 3,612,438 blankets, and the construction of 462,561 shelters. In addition, over 56,000 metric tones of food have also been distributed1. With the transition from the relief phase to the to the recovery phase underway, it is imperative to collect, compile and analyze as much information as possible to identify gaps in services and needs in respect to the provision of quality primary health care services. An assessment of facilities was therefore necessary, the objectives of which were as follows: 1. To assess the functionality of public health facilities in the district (staffing, services, supplies, utilization etc.) 2. To perform a comprehensive mapping of all facilities 3. To establish baseline data on health facility status for future assessments, directing interventions and evaluation of interventions. Data collection was carried out in two phases; the first phase from May to June 2006 had a further sub-objective to identify areas of return of Internally Displaced People (IDPs) and issues relating to subsequent quality of health service delivery. The second phase conducted in September 2006 had the sub-objective of identifying pertinent issues related to contingency planning for the forthcoming winter. The report is especially significant because it has covered remote facilities that have never been assessed before, like those in Kohistan District and Kaladhaka Tehsil in Mansehra. The following report presents the findings from the assessment of public health facilities in all earthquake affected districts2; Mansehra, Kohistan, Shangla and Battagram in NWFP and Bagh, Muzaffarabad, Poonch and Neelum in AJK. The report presents information collected in the field as well as secondary data compiled from several sources including regular monitoring reports by the WHO hub offices, progress reports of partner organizations, the internet, and other unpublished sources. The report briefly discusses the current situation of public health facilities of BHU level and above, the situation of human resources, morbidity and mortality patterns and recommendations for further interventions relating to recovery and reconstruction. In fact, even though issues highlighted in this report are specific to the affected districts, they are generally cross cutting and may be relevant to the public health sector in Pakistan.

1 Integrated Monitoring Matrix (IMM), HIC, Pakistan 2 It must be noted, however, that due to the dynamic nature of events, the information presented in this paper is amenable to change, often on a daily or weekly basis. We hope that it will be updated regularly through future surveys and feedback from other partners

1 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

CHAPTER 2: METHODOLOGY

2 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Chapter 2: Methodology

The study was designed as a cross sectional survey with the aim of covering a maximum number of facilities in all districts within the time limitations. The survey was completed in two phases. The first phase of data collection was carried out in May and June 2006 in which almost 60% of facilities were physically visited and assessed. The second round of the survey took place in September 2006 with the aim of covering 100% of facilities. The selection criteria was ‘functioning public health facilities’3 including and above the BHU level i.e. Basic Health Units (BHUs), Rural Health Centers Interviewing health staff at BHU Kawai (RHCs), and secondary care hospitals (THQ, DHQ and CH). In addition, we also visited Civil Dispensaries that have been earmarked for upgrading to BHU level or are presently functioning as BHUs. Current databases (WHO, MoH, UNICEF, UNHCR, GTZ and others) were collected and analyzed to compile data already present and to avoid any duplication. These data were also validated during field work wherever possible. A tool was subsequently developed and circulated to the field offices as well as to relevant technical experts for feedback (see attached at the end of the report). The tool consisted essentially of closed-ended questions regarding facility information, access indicators, physical infrastructure, staffing positions, equipment and supplies, reporting, and the effect of population movements on health facility functions. A few open-ended questions were included to facilitate recording of qualitative data. The tool was pilot tested in the field in nine sites and minor modifications made accordingly. Several teams were formed consisting of WHO staff and staff from participating organizations (UNFPA Mercy Corps, UNICEF, Malteser International, MERLIN and ICRC) and data collectors were trained to use the questionnaire as well as record the GPS coordinates using GPS units. The teams decided collectively the facilities they were going to cover and a matrix was developed which included sites to be visited by each team as well as the dates on which they would be visited. The in-charge of the facility, or any other staff appointed in his/her place, was told the objectives of the study and interviewed in Urdu. Any other comments by staff, clients and villagers were recorded in a section provided specifically in the questionnaire. This included perceived needs of staff and attitudes to international organizations in the area. GPS coordinates were also collected at every site and recorded. The list of coordinates compiled was validated with existing lists. Visual documentation was also undertaken using digital stills and movie recordings. There was some difficulty in listing all facilities due to discrepancies in lists being used by different actors. The discrepancies are essentially are due to the changing status of some facilities as well as closing down of others. For the purpose of this research, several list were compiled and included the official MoH list of facilities (HMIS and EDO office lists) and lists developed by UNICEF, WHO and other partners. In all, 309 facilities were visited (see also table 1). Please note that we did not include tertiary hospitals and hence the exclusion of DHQs and other hospitals above the RHC and THQ level). Forms from six facilities were not entered due to data quality issues and six facilities were closed during the teams visit and could not be completed. Final analysis was performed on 297 facilities. All forms were edited as soon as they were returned by the relevant field team. For the purpose of this report, selected variables were

3 A “functioning health facility” has been defined as any public health facility (BHUs and above), regardless of structure and that was providing any form of health service to the population regardless of quality, quantity or regularity of services

3 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 double-entered on an EXCEL sheet and imported into SPSS version 12 for analysis. A complete data set is being compiled by the data management team in Islamabad and will be constantly reviewed and updated. Any verbatim quotes in this report appear in italics and inverted commas.

2.1 Limitations

Some limitations of this study include:

• Validity of data collected from secondary sources. • Since most of the information collected is reported by the health staff, the chances of interviewees’ bias (the need to answer questions in a way that the interviewee considers acceptable to the interviewer) and recall bias (error due to remembering facts incorrectly) are possible. However, we validated as much information provided by staff by using observational checklists as far as possible. Furthermore, information was validated by secondary data, observations and anecdotal evidence

• The subjective nature of some aspects of the questionnaire (e.g. maintenance of recording and reporting tools) • The assessment of quality of care was beyond the scope of this study. Therefore, for example, the provision of “delivery services” does not imply ‘safe delivery’ or “provision of regular EPI services” does not take in account maintenance of cold chain etc.

• The checklists developed to assess the quality of equipment and reporting were based on WHO and MoH guidelines. The situation in the field is, more often than not, far from the ideal due to which some of the overall reported results like “status of equipment” may be skewed towards “poorly equipped”

• A constantly changing scenario with regards to staffing, equipment, drug stocks and upgrading or downgrading of health facilities may result in the findings being out of date very quickly.

• Despite the limitations discussed above, we believe the study gives a broad overview of the situation in the public health sector in the affected districts, and enough information to plan at a macro level. Planning at the micro level would, however, require updating with the most current situation in the field. Furthermore the qualitative component of the study may offset any statistical weaknesses. Even though we have made some logical assumptions in the interpretation of results, the provision of data in the various tables and health facility profiles as appendices to this report will enable users within the health and development sectors to reinterpret based on contextual realities or undertake further analysis.

All figures and percentages presented in this report have been rounded to the next whole integer

4 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

CHAPTER 3: RESULTS AND DISCUSSION

5 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Chapter 3: Results and Discussion

The assessment was carried out in 309 facilities in all the earthquake affected districts in NWFP and AJK (See also Map: Type of Facilities assessed- WHO-EQ-133). The results presented in the sections below are from 297 facilities including 143 from AJK and 154 in NWFP. In addition to these, forms from six facilities were not entered due to data quality issues and six facilities were closed at the time of visit by the assessment team. One informant in Battagram refused to answer the questionnaire on the first instance, but subsequently agreed on a second. The table below shows a breakdown of the A WHO prefab structure amongst ruins number of facilities assessed district-wise and by level of facility. Despite tremendous difficulties in accessing many sites, the survey teams managed to physically visit and assess well over 93% of facilities in all districts.

Table 1: District wise facilities assessed Province District Total* Damaged Facilities assessed facilities (total/ BHUs** Hospitals*** RHCs Total assessed partial) N (%) AJK Bagh 39 30 31 2 6 39 (100) Muzaffarabad 61 45 2 7 54 (88) Neelum 21 13 18 2 1 21 (100) Poonch 29 21 24 0 5 29 (100) NWFP Mansehra 81 56 9 6 71 (88) Battagram 33 26 26 0 2 28 (85) Shangla 19 14 15 4 0 19 (100) Kohistan 37 16 33 0 3 36 (95) TOTAL 320 248 19 30 297 (93) * These numbers have been compiled from different lists including MoH HMIS data and are amenable to change due to current upgrading and closure of facilities ** BHU: These include CDs that have been or are planned to be upgraded to BHUs in the near future *** Hospitals: These contain THQs and Civil Hospitals

6 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Of all facilities assessed in this survey, seventy-two (24%) are being supported by an external agency (UN agencies, INGOs or the Pakistan Army). Some districts, such as Shangla and Kohistan have no facilities supported by an external agency. In these districts, there are no externally supported facilities due to difficult access, security concerns and restrictions of movement of INGO staff in the area. The highest percentage of supported facilities is in Districts Muzaffarabad and Battagram, both of which have the greatest reported damage as well.

Table 2: Health facilities supported by agencies other than MoH Province Districts Number assessed Number supported N (%) AJK Bagh 39 13 (33) Muzaffarabad 54 26 (48) Neelum 21 2 (10) Poonch 29 6 (21) NWFP Mansehra 71 15 (21) Battagram 28 10 (36) Shangla 19 0 (0) Kohistan 36 0 (0) TOTAL 8 297 72 (24)

Supported facilities are generally better staffed and better equipped. For example, facilities that are supported by an external agency other than the MoH are three and a half times more likely to have a Medical Officer present (OR=3.5/CI: 2-6) and higher OPD figures (p=0.00) than unsupported facilities. Similarly 20% of supported facilities were graded as ‘well equipped’ as compared to 4% in unsupported facilities. As a result, the community prefers facilities that are supported due to actual and perceived quality of care. A “bahar ka doctor” or foreign doctor was a major incentive to visit a health center. However, over the last year, several agencies have left with little or no arrangements for continuation of services and support causing anxiety in local staff and lowering the quality of service provision. In such cases, proper handover with contingencies to maintain quality is necessary and highly recommended.

3.1 Accessibility

Most facilities assessed (63%) were located close to a tarmac or jeep road and accessible by all types of vehicles. However, 70 BHUs (25%) were accessible only by 4X4 jeeps and 38 (10%) were accessible only by foot. Regardless of access by a road or track, the topography of the area makes most roads and tracks prone to landslides and frequent unpredictable closures based mostly on weather conditions.

Suspension bridge being repaired, Neelum

7 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Table 3: Accessibility of health facilities by road in all districts

Facility level Accessible by all vehicles Accessible by 4X4 Accessible by Total facilities including trucks vehicle only foot only assessed N (%) BHU 104 (65) 70 (25) 38 (10) 248 RHC 29 (100) 0 (0) 1 (0) 30 Hospitals 19 (100) 0 (0) 0 (0) 19 TOTAL 188 (63) 70 (24) 39 (13) 297 If broken down by district, access is most difficult in Kohistan and Shangla with 42% of facilities accessible by foot only. In fact, this was a great constraint in data collection as the data collectors had to walk six to eight hours in almost half the facilities assessed. One can imagine the distances that need to be covered by the community to travel to a facility. The absence of roads makes not only service delivery, but also monitoring and follow-up extremely difficult and in many cases not feasible at all. Table 4: Accessibility of health facilities by roads (breakdown by districts)

Province District Accessible by all Accessible by Accessible by Total facilities vehicles 4X4 vehicle only foot only assessed n (%) n (%) n (%) AJK Bagh 30 (77) 9 (23) 0 (0) 39 Muzaffarabad 48 (88) 4 (7) 2 (4) 54 Neelum 15 (70) 5 (24) 1 (5) 21 Poonch 19 (66) 4 (14) 6 (21) 29 NWFP Mansehra 44 (62) 20(28) 7 (10) 71 Battagram 13 (46) 10 (36) 5 (20) 28 Shangla 13 (68) 3 (16) 3 (42) 19 Kohistan 6 (17) 15 (42) 15 (42) 36 TOTAL 8 188 (63) 70 (24) 39 (13) 297

The mean walking time taken to the facilities from the closest population pocket was 15 minutes (range: 2 minutes to 60 minutes) while the average walking time to the farthest catchment village was 120 minutes or two hours (range 60 minutes to 720 minutes). In two cases in Kohistan, clients in the farthest catchment village reportedly have to walk for up to two days to get to the closest health facility. Often clients have to be carried on the back of animals (usually donkeys) or relatives several hours to a track road, only to wait for some passing vehicle with transport prices rising nearly 200% in the last year. The negative association of health care utilization with geographical factors like A patient carried on a hand-made stature distance to facility and availability of transport has entering in BHU Kathora, District Battagram been well documented4/5. The median time to the

4 Arcury TA, Geslet WM, Preisser JS et al. The effects of geography and spatial behavior on health care utilization among residents of a rural region. Health Serv Res. 2005 Feb;40(1):135-55

8 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 preferred referral facility by vehicle was 60 minutes (range 40 minutes to over two and a half days). Travel at the best of times may be hazardous and unpredictable. Once again, the situation is worst in Kohistan and Shangla. In some areas, on arrival at a facility there is little or no staff or support of any kind available.

3.2 Physical Infrastructure

The devastation of health facilities has been quite overwhelming, with an estimated 60 to 80% of health facilities either partially or totally damaged (See also Maps: Status of health infrastructure in assessed earthquake areas- WHO-EQ-138 and Type of structure of assessed health facilities- WHO-EQ-164)). These health facilities include BHUs, RHCs, hospitals, MCH posts, TB centers, and dispensaries. At the time of assessment, there were several different types of structures being used, including portions of the original buildings, tents, shelters and pre-fabricated units set up by WHO and other agencies. On Ex-office of the LHV at BHU Jozz, District Battagram the whole, the original structures were being used to varying extents in 62% of all facilities. In many places, the damage was either minimal, or parts of the original structures, such as a single room, were being used. Tents were being used in 11% of facilities, pre-fabricated units in 8% while multiple structures (a combination of tents, buildings, shelters and pre-fabricated units) were being used in 18% of all facilities. The type of structure being used is associated with utilization. For example prefabs are significantly associated with higher OPD figures (p=0.00). This may be due to the fact that the pre-fabs are well equipped and staffed and, as previously mentioned, are perceived by the community as providing better services. The following table shows a break-down of physical structures being utilized at health facilities by district. Table 5: Physical infrastructure and utilities available at health facilities assessed in all districts

Province District Current Structure Total assessed Pre-fabricated Multiple (100%) Building Tent units structures AJK Bagh 16 (41) 5 (13) 8 (20) 10 (25) 39 Muzaffarabad 14 (26) 18 (32) 9 (17) 13 (26) 54 Neelum 20 (95) 0 (0) 0 (0) 1 (5) 21 Poonch 18 (62) 1 (3) 1 (3) 9 (31) 29 NWFP Mansehra 53 (75) 0 (0) 3 (4) 15 (21) 71 Battagram 12 (43) 9 (32) 3 (11) 4 (14) 28 Shangla 17 (90) 0 (0) 0 (0) 2 (10) 19 Kohistan 35 (97) 1 (3) 0 (0) 0 (0) 36 TOTAL (%) 185 (62) 34 (11) 24 (8) 54 (18) 297

5 Arcury TA, Preisser JS, Gesler WM, Powers JM. Access to transportation and health care utilization in a rural region

9 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Despite the tremendous support and efforts of all agencies, post-earthquake repairs or construction have been carried out in only 55 (23%) of facilities in all districts. Repairs have been carried out in a systematic manner based on earlier prioritization exercises, and facilities which were not prioritized in the first instance have yet to receive attention. The staff of these facilities feels that “no one cares”. All these sites require in-depth damage assessments and retro-fitting. In eight sites, a rented building is being used as a health facility. These Temporary shelter of RHC Ghori, Muzaffarabad houses are not appropriate for service delivery. For example, in BHU Lawat Bore in Neelum District, the rented house consists of four rooms, the fourth of which houses the landlord’s animals! The landlord complained that he had not been paid rent for the last four months, putting the facility in jeopardy of losing even this inadequate housing.

Although not specifically assessed except for in District Battagram (on a special request by the EDO Health), it was noted that staff quarters in most places have also been damaged. At several sites, staff quarters are being used for service delivery. This has caused tremendous difficulties for staff, and especially female staff like LHVs who do not belong to the same village. Building of staff quarters was one of the more common ‘perceived needs’. In areas which are blocked due to snowfall, staff often leave the site because of lack of appropriate accommodation. In these areas, the provision of winterized tents, and ample drug stocks may ensure continuation of services during the forthcoming winter. Ideally, a BHU aims to cater to a population of 10 to 15,000. In our assessment we found that 86 (38%) BHUs are catering to populations of over 10,000 and 73 (32%) are serving populations of well over the standard6. BHU Komikot in Muzaffarabad, for example, is serving a population of 42,000.

Table 6: catchments population versus level of facility in all districts Type of facility Total Catchment population BHU Hospitals RHC N= 229 N= 19 N=27 N= 275 n (%) n (%) n (%) n (%) < 10000 86 (38) 3 (16) 1 (4) 90 (33) > 10000 143 (62) 16 (84) 26 (96) 185 (67)

6 Catchment populations are reported by health staff at the facility and may differ significantly with ‘official’ estimates. The figures presented have been triangalated with national HMIS data and partners in the field.

10 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 3.3 Service Utlization

There is great variation in the average number of patients per month at different facilities as seen in the table below. The mean consultations per month is 583, the mode is 230 (range 4 to over 16,000). Some facilities cater to a large clientele, while others are apparently under-utilized.

Table 7: Average clients per month versus level of facility in all districts Type of facility Total Average clients per month BHU Hospitals RHC N= 226 N= 11 N=28 N= 265 n (%) n (%) n (%) n (%) < 100 58 (26) 3 (27) 4 (14) 65 (25) 100 to 500 111 (49) 2 (18) 8 (27) 121 (46) > 500 57 (25) 6 (55) 16 (57) 79 (30)

Though OPD figures can be used as proxy indicators for assessing utilization, some caution is needed in interpretation because of the prevalent conditions. For example, one RHC currently has a caseload of less than 50 per month (Chakothi), while their pre-earthquake caseload was considerably higher. However, the local population prefers to visit the Red Cross health facility situated there due to a guaranteed presence of staff and drugs and perceived quality of care. On the other hand, of the six BHUs in Muzaffarabad that have the highest OPD figures, three (Panjgram, Patikka and Khun Bandi) are being managed by external agencies, are better equipped, staffed and supplied and hence the preferred facility for people. There was no significant statistical association between caseload and catchment population. This implies that a larger population does not necessarily lead to a greater number of patient consultations, or a smaller Child receiving immunization, population to less utilization. The factors most likely to determine the Kundal Shahi, Neelum utilization rate are the services available at the health facility falling in the catchment area; if the health facility doesn’t offer a complete package of services, most of the patient load will go to a health facility with a broader range of services. In the background of generally poor utilization of public health facilities in Pakistan, our study shows that utilization is affected by a more comprehensive service package rather than catchment population size. Having said that, prior research shows that the perceived quality of care is equally important to better utilization as service provision7 Coverage of the population in terms of services and supplies varies with regional as well as local disparities. For example, for all districts the average population covered by total number of of primary health care facilities is 16,294 persons per facility. The range however is broad, with the lowest average of 6,242 for Battgram to over 29,000 persons per facility in Mansehra. Caution is advised in interpretation due to multiple factors affecting health service coverage and utilization. For example, the scattered population patterns in some areas would negate the affect of fewer people per facility. Similarly, within Districts, more remote areas may be less covered. An example being Bhoonja Valeey in Balakot, where there is a population of over 14,000 and yet no

7 The effectiveness of patient referral in Pakistan. Siddiqi S, Kielmann A, Khan M, Ali N, Ghaffar A, Sheikh U, Mumtaz Z. Health Policy Plan 2001 Jun; 16 (2): 193-8

11 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 health facility. Furthermore, some areas have a regularly migratory population. The building of further facilities may not be the best answer, and if considered, needs to be planned very carefully. What is perhaps more important is to ensure more comprehensive and tailored services in the present facilities, augmented by mobile services for areas that have no coverage. Currently, for example, Bhoonja valley, with a population of approximately 13,000 in 17 villages and no public or private health facility is being served by mobile clinic services provided by MDM. The shortcomings of currently existing facilities must be overcome by assuring the presence of staff, drugs and essential supplies perhaps augmented by out-reach activities, before the building of further facilities is undertaken.

3.4 Service utilities at health facilities

With regards to utilities available, 65% of all facilities had a functional toilet, only 46% had a functional water supply within the facility premises and 59% had an electric supply.

Presence of a water supply, however, does not imply that the water source is clean or safe. Furthermore, in several facilities, the electric supply was ‘illegal’ whereby the staff has obtained a connection from the main lines without authorization from the relevant departments.

An electric supply is essential for maintenance of the cold chain. In several places like BHU Changa, Neelum District, a recently donated fridge cannot be used because of lack of power. Provision of generators may help only if allowance is made to cover fuel costs. Disposal pit with exposed used syringes at BHU, Mansehra

Table 8: Major utilities available at health facilities in all districts Province District Utilities available Toilet Electricity functional Water supply present Total AJK Bagh 33 (85) 24 (62) 32 (82) 39 Muzaffarabad 33 (61) 20 (37) 37 (69) 54 Neelum 15 (71) 12 (57) 11 (52) 21 Poonch 26 90) 12 (41) 22 (71) 29 NWFP Mansehra 46 (65) 38 (54) 50 (70) 71 Battagram 17 (63) 16 (59) 15 (56) 28 Shangla 5 (26) 10 (53) 6 (32) 19 Kohistan 17 (47) 5 (14) 3 (8) 36 TOTAL (%) 192 (65) 137 (46) 175 (59) 290 (100)

12 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Medical waste is a public health issue and certain categories of medical waste are among the most hazardous and potentially dangerous of all the waste arising in the community8 . In the facilities assessed, 118 facilities (50%) burned their waste, 27 (19%) threw it away, and 27 (11%) buried their waste. Forty-six (20%) used multiple methods. In sites close to a river, we commonly observed waste strewn close by, suggesting disposal into the river regardless of what staff reported. In sites where staff claimed to bury their waste, we noted improper techniques, with shallow pits overflowing with hazardous waste like used syringes and soiled bandages. Even though incinerators have been distributed by several agencies to many sites, our team did not come across any incinerator that was being used on a regular basis, and they are often not maintained. Improper management of medical waste may pose health hazards through transmission of diseases, not only to health workers and their families, but to patients and their relatives, especially children whose play activity and mouthing behaviour increases their contact with medical waste, thus exposing them to injuries and infections9. Discarded drugs may be collected from clinic rubbish and may be sold or consumed without professional advice10 . In addition to health hazards, environmental hazards have to be considered, such as the contamination of soil and groundwater and poisonous emissions from improper burning of medical waste8. Health staff has to be convinced of the benefits of proper waste management and trained to maintain their systems. Arrangements to collect waste and dispose of it in selected central locations may be debated by some as improbable in the current scenario due to resource constraints, but is an intervention that will have a positive affect on the overall health of the communities.

3.5 Human Resources

A dearth of trained human resources within the health sector in Pakistan has been documented previously by researchers and has been a major barrier in the provision of quality services11. The rural urban divide is very prominent, with doctors preferring to settle and work in the larger towns. On the whole the most available staff present in all districts is the medical technician or dispenser (88%), followed by a vaccinator (66%), and LHV (42%) and male medical officer (41). A female medical officer was available at only 13% of all facilities.

Sign on BHU, Neelum

8 Medical waste committee, air and waste management association. Medical waste disposal: report of the medical waste committee (Wt-3), technical council. Air waste, 1994, 44:1176–9. http://www.emro.who.int/publications/emhj/0706/waste.htm. Accessed on October 16th 2006 9 Johnson B. Impact of hazardous waste on human health. Washington DC, Lewis Publishers, 1999 10 Halbwachs H. Solid waste disposal in district health facilities. World health forum, 1994, 85:583–9

11 The district health system: a challenge that remains. B.T. Shaikh and F. Rabbani. http://www.emro.who.int/publications. Accessed October 16, 2006

13 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Table 9: Cadres of staff available at all facilities

Staff Cadre Facilities with staff available (N=297) n (%) Medical Officer (male) 123 (41) Medical Officer (female) 38 (13) Dispenser/ male technician 262(88) LHV 171 (42) Vaccinator 195 (66)

The presence of a medical doctor is significantly associated with higher OPD figures (p=0.001). However the percentages quoted in the table above represent staff that is ‘posted’ (actual posts and not sanctioned posts) and does not imply the presence of staff at their work stations. In reality, staff may be absent or in the process of being transferred. Staff absenteeism has also been well documented as a chronic issue facing the public health sector in Pakistan and authors believe that any health service depending on medical doctors to provide services in rural areas is bound to face difficulties12. A better alternative recommended by the above quoted author is the use of multi-purpose auxiliaries who are more trained than the existing paramedics but less then doctors. Many of the current cadre of dispensers and medical technicians have been serving for a long time now and are often referred to as ‘doctor sahib’ by the local community and are looked upon as respected members of the community and often looked upon to help people. This cadre of staff would tremendously benefit from ‘need-based’ and ‘context-specific’ refreshers in areas such as PHC and IMCI management protocols. There is also variation in different districts with regards to different staff cadres. One example is a very low percentage (24%) of facilities in Neelum with a vaccinator posted. However, in Neelum, the vaccination teams are centrally managed and teams visit facilities periodically. Though such a mechanism sorts out issues like maintainance of cold chain at the facility level and a lack of human resources, it was reported by locals and staff as irregular and insuffient to cover all the population. Table 10: Cadres of staff available at all facilities district wise

Province Districts Medical Medical Dispenser/ male LHV Vaccinator Officer Officer technician (male) (female) N (%) N (%) N (%) N (%) N (%) AJK Bagh 16 (41) 3 (8) 37 (95) 28 (72) 33 (85) Muzaffarabad 25 (46) 8 (15) 51 (95) 42 (78) 38 (70) Neelum 7 (33) 0 (0) 20 (95) 8 (38) 5 (24) Poonch 11 (38) 6 (21) 29 (100) 22 (76) 24 (83) NWFP Mansehra 36 (50) 13 (18) 49 (69) 41 (58) 36 (51) Battagram 10 (36) 2 (25) 28 (100) 13 (46) 16 (57) Shangla 12 (63) 1 (5) 18 (95) 14 (73) 15 (79) Kohistan 6 (16) 0 (0) 30 (83) 3 (8) 28 (78) TOTAL N=297 (%) 123 (41) 38 (13) 262 (88) 171 (58) 195 (66)

12 Bjorkman JW. Health policies and human capital: the case of Pakistan. Pak Dev Rev. 1986 Autumn;25(3):281-330

14 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Once again, Kohistan and Shangla were worse off than other districts. The presence of female staff was far from satisfactory in all districts and will be discussed in the section dealing with gender considerations.

3.6 Service Provision

The most common service available at health facilities as reported by staff is out-patient consultation (95%), followed by ORS provision (88%), EPI and Tuberculosis Management (80%), minor surgical procedures like stitches (69%) and Family Planning (62%). The least available services were laboratory services (18%), access to ambulance (22%) and in-patient treatment (26%). See also maps; Provision of routine EPI in assessed health facilities- WHO-EQ-134 and Maternal Health Services in assessed areas- WHO-EQ-148 Table 11: Service provision as per level of facility in all districts Type of facility Total Service BHU Hospitals RHC N= 248 N= 19 N=30 N= 297 n (%) n (%) n (%) n (%) Out-patient services 233(94) 19 (100) 30 (100) 282 (95) In-patient services 44(18) 16 (84) 16 (53) 76 (26) Peri-natal care 117 (47) 13 (68) 29 (97) 159 (54) Delivery 76 (31) 14 (74) 24 (80) 114 (39) Family Planning 138 (56) 16 (84) 30 (100) 184 (62) Growth Monitoring 80 (32) 12 (63) 19 (63) 111 (37) TB management 68 (27) 15 (79) 30 (100) 229 (77) EPI 182 (73) 17 (90) 30 (100) 229 (77) ORS provision 215 (87) 19 (100) 29 (96) 263 (88) Laboratory services 22 (9) 14 (73) 18 (60) 54 (18) Minor surgery* 163 (66) 16 (84) 25 (89) 204 (69) Access to ambulance 34 (14) 13 (68) 19 (68) 66 (22) * includes minor procedures like stitching, draining abscess and dressing

Please note that assessment of quality of services is beyond the scope of this study. Therefore, for example, provision of delivery does not imply safe delivery practices, or provision of EPI does not entail proper maintenance of cold chain. Considering our selection criteria was functionaing faciliries, one would expect OPD to be provided in all facilities. However, the team came across 15 facilities in all districts that had no staff or services, but stocks of drugs that were irregularly dispensed. For example at one BHU, Sanikot, there was a tent with several cartons of donated drugs next to a completely demolished building. The staff informed us that a dispensar would visit the tented facility once in two weeks and dispense drugs. In any case, OPDs are mostly run by a dispensers or medical technicians. Although not specifically assessed, it seems that some of these technicians are well trained and

15 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 experienced. At sites where the technician is not a local, OPDs are conducted irregularly. Where local staff is appointed, they are available 24 hours and may be asked to make house calls as well. One dispenser in BHU Surgan, Neelum Valley, reported how he was faced with a case of “intestinal obstruction” and made a “NG tube out of a drip set”. The same dispenser has also assisted in a difficult delivery where “the dai had used her hands with no mercy and the child was dead” but had managed to “save the woman’s life by cleaning her and giving her antibiotics”. On the other hand however, going through the OPD registers one realizes that diagnosis are often absent and treatments provided are also not rational, and in some cases, incorrect.

Perinatal care is provided by the LHV. Traditional birth attendants (Dais) are also providing delivery and related services. More often than not, these women are illiterate and not trained in safe delivery Man being treated for practices. As for EPI services, one would expect 100% facilities to be “weakness” at BHU, Oghi providing immunizations. Most BHUs do not have the appropriate equipment for maintenance of cold chain and are visited by the district EPI teams once a month. It is worth noting that TB management through DOTS was being provided at 77% of all facilities. The concept of mobile teams visiting facilities with these services seems to be effective and should be supported providing monitoring of services and quality can be assured.

Family planning was more readily available (62%) and staff reported that although it was still considered taboo to talk about it publicly, a lot of women came in for FP services. The most popular method requested was reported as “injections”. In some facilities (Neelum Valley and Kohistan) there were still reported misgivings about FP services.

Considering that about six percent of all cases reported pertain to injuries, it is imperative to make sure that staff is skilled and equipped to deal with such clients. In our survey only 66% of BHUs were providing minor surgical procedures. The main reason for non-provision was reported as a lack of the appropriate equipment. At a BHU in Mansehra the technician was upset that “often I get a case that I can easily handle if I had the equipment and feel so bad when I have to refer them for such things”

Growth Monitoring is also an essential PHC service that was not being provided by a majority of facilities despite that fact that a reported 37% of under-five children are underweight in Pakistan. The reason for non-provision was again attributed to lack of the proper equipment. However, we believe that there is little understanding and appreciation of the significance of this simple intervention to identify and deal with malnutrition in children.

In the current scenario, appropriate and timely referral becomes an important intervention. However, access to an ambulance was as low as 14% for BHUs, 68% for hospitals and RHCs and only 22% overall. Often members of the community have to carry their relatives over long distances and pay exorbitant amounts to transporters to transport patients to referral facilities. The ambulances that are available are not accessible due to poor roads and no communication systems. In one village Leswa in Neelum Valley, a community elder commented “Don’t spend so much money on helicopters buy us a small vehicle that we can use as an ambulance!” The request for an ambulance was made by almost every facility that the teams visited. Recommendations by villagers included the provision of a small vehicle (Suzuki cabin pick-up), provision of motorbikes and provision of a loan to buy a small vehicle.

16 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 3.7 Status of equipment and medical supplies

A checklist based on WHO and MoH guidelines was prepared to assess the status of equipment. Facilities were then scored using the checklist as “well equipped”, “average” and “poorly equipped”. On the whole, only 23 (10%) facilities were classified as well equipped, 108 (46%) were average and 105 (45%) were classified as poorly equipped (See also map- Status of equipment in assessed EQ areas- WHO-EQ-148). The situation was similar in both provinces. However there was great variation between districts. Kohistan had the highest percentage of poorly equipped facilities (72%) followed by Neelum (55%) and Poonch (48%). The district with the highest percentage of well-equipped facilities was Muzaffarabad (21%), followed by Battagram (14%) and Bagh (13%). Most facilities (46%) were classified as average. The table below shows the status of equipment by district. Chair repaired with drip sets at BHU, Oghi

Table 12: Status of equipment at health facilities in all districts equipment Total Well Poorly Province District equipped average equipped (100%) Bagh 5 (13) 18 (46) 16 (41) 39 AJK Muzaffarabad 11 (20) 22 (41) 21(39) 71 Neelum 1 (5) 9 (43) 11 (53) 21 Poonch 1 (3) 14 (48) 14 (48) 29 Battagram 3 (11) 11 (39) 14 (50) 28 NWFP Kohistan 0 (0) 5 (28) 31(86) 36 Mansehra 5 (7) 32 (45) 34 (48) 71 Shangla 0 (0) 12 (63) 7 (37) 19 Total 26 (9) 123 (41) 148 (50) 236

Though our checklist did not include furniture, the shortage of furniture was widely reported with many facilities lacking even the basic essentials like chairs and benches. With regards to drug stock situation, interviewees were asked how long their current drug stocks would last. Stocks sufficient for three months were classified as ‘good’, stock sufficient for up to two months were ‘average’ and stocks sufficient for less than a month were classified as ‘poor’. Even though the information was validated as far as possible, this indicator must be read as strictly ‘reported’ and therefore subject to interviewee’s bias. Furthermore, this is one aspect of the assessment that is particularly variable and prone to change based on drug delivery not only by the MoH but private contributions as well. On the whole only 32 facilities (14%) reported a good stock situation while 127 (54%) reported average and 77 (33%) reported poor stocks. A breakdown by district is given in table 8 below

17 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Table 13: Situation of essential drug stocks in all districts Essential drugs stock situation Total facilities Province District Good Average Poor assessed n(%) n(%) n(%) (100%) Bagh 3 (8) 20 (51) 16 (41) 39 AJK Muzaffarabad 8 (15) 17 (32) 28 (52) 54 Neelum 3 (14) 4 (19) 14 (67) 20 Poonch 11 (38) 12 (41) 6(20) 29 Battagram 8 (29) 11 (39) 9 (32) 28 NWFP Kohistan 4 (11) 16 (44) 16 (44) 36 Mansehra 4 (6) 62 (87) 5 (7) 71 Shangla 3 (16) 8 (42) 8 (42) 19 TOTAL 44 (15) 150 (51) 102 (34) 297

From a quality of services aspect, one will obviously argue for the rational use of drugs versus quantity of drugs supplied. At the community level, however, the presence of ample amounts of drugs is perceived as a sign of quality. This factor seems most persistent in decisions of ill people to stay with home-based care and/or traditional medicine, or go to consult modern health services. This phenomenon has been reported elsewhere13. Utilization of facilities was reported as being affected by the availability of drugs. Staff reported that “if there are drugs available we get a lot of clients… when there are no drugs people will not visit”

3.8 DEWS: Disease Early Warning System

The Disease Early Warning System (DEWS) was initiated in the weeks following the earthquake and is maintained by WHO in partnership with the district health offices. This Outpatient Mortality and Morbidity Weekly Surveillance system collects information on priority communicable diseases from all actors (MOH, local and international NGOs and other agencies) involved in health care activities in the earthquake-affected districts. It monitors the epidemiologic situation in order to rapidly detect, verify, investigate, and control outbreaks of communicable diseases requiring public health interventions. On writing of this report, 159 out of the 297 facilities assessed (55%) were regularly reporting to DEWS with the highest number reporting in Poonch (90%) and Battagram (85%) and the lowest number reporting in Shangla (21%) and Kohistan (3%). Though these numbers are amenable to fluctuations, the general trend has been of a steady increase in reporting sites. See also map; Assessed health facilities reporting to DEWS- WHO-EQ-135)

13 Rob Baltussen and Yazoume Ye. Quality of care of modern health services as perceived by users and non-users in Burkina Faso International Journal for Quality in Health Care 2006 18(1):30-34

18 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Table 14: Sites reporting to DEWS

Province District Number reporting to Total facilities DEWS assessed n (%) AJK Bagh 24 (62) 39 Muzaffarabad 33 (61) 54 Neelum 14 (67) 21 Poonch 26 (90) 29 NWFP Mansehra 40 (56) 71 Battagram 17 (85) 28 Shangla 4 (21) 19 Kohistan 1 (3) 36 TOTAL 159 (55) 297

Over the last year, the most frequent disease reported was acute respiratory tract infections (ARI) (n=829,947), followed by acute watery diarrhea (AWD) (n=355,706) unexplained fever (n=207,712) and injuries (n=203,103). In addition, scabies is prevalent in almost every area visited, though not tracked through the surveillance system. One facility reported that a large number of trauma cases were due to falling corrugated sheets handed out by agencies for reconstruction. It is interesting to note that when asked about common health problems, villagers as well as staff came up with a very similar list.

Reported causes of illness in NWFP and AJK 900000 829742 800000 700000 600000 500000 400000 3 5568 1 300000 20 7712 203103 200000 Number of Cases of Number 100000 26003 63 150 76 886 198 2948 24 24 0

With regards to specific morbidity trends, the graphs below show a predictable increase in ARI cases in all districts during the winter months (November to April), and diarrhea during the summer rainy season June to September). Measles cases have been reported quite consistently from the field and have been responded to with an aggressive measles campaign. To date, over one million children have been vaccinated against measles in all districts.

19 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 ARI and AWD trends in affected districts

AWD and ARI Trend In AJK 30.00

25.00 20.00 15.00 AWD ARI 10.00 5.00

0.00 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Months

AWD and ARI trend in NWFP 35 30 25

20 AWD 15 ARI 10 consultations Percent ofAll 5 0 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Months

The DEWS system was initiated immediately after the earthquake and started off with 20 reporting sites. These have increased to 290 sites which include BHUs, RHCs and hospitals as well as refugee camps and other health facilities (field clinics and field hospitals). In the facilities assessed, 159 (53%) are currently reporting weekly to DEWS. This is a great achievement and a good case study for inter-agency collaboration. However, the difficulties reportedly faced by facilities include difficulty in sending forms to WHO. In several places, staff may have to travel a whole day to get to the hub office and back. Staff in different hubs have come up with different innovative ways to overcome the communication problems from paying messengers or sending drivers to salary support to provision of mobile phones to transfer information. In Neelum Valley, bus drivers passing by and requested to deliver the forms to the DHO office in Athmuqam who then sends reports from all facilities to Muzaffarabad, a system which seems to be working well. When the UN compound was still functional, staff attitude was also mentioned as a barrier. Security measures for visitors at the main gate of the old UN Compound in Muzaffarabad, for example, took time and according to one informant, “they treat us with so much disrespect… It’s so insulting and we have to stand in the sun for such a long time”.

20 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

No. Unit Reporting Units and Consultations No. Consult. 200000 300 Reporting Unit Consultation 250 150000

200

150 100000

100 50000

50

0 0 W42 W46 W50 W2 W6 W10 W14 W18 W22 W26 W30 W34 W38

Week

No major epidemic was reported in the affected areas after the earthquake, no doubt partly due to a sensitive and timely warning system. The DEWS also provides documentation of morbidity trends, allowing facilities to be better prepared with appropriate contingency plans, an important advantage of the DEWS system.

Despite the difficulties, the system is very important for epidemic control and has shown to be effective in other districts as well. DEWS needs to be strengthened and in the end, merged with national HMIS system. Along with that, information needs to be fed back into the facilities for involvement of staff, and, subject to appropriate skills, better planning at the local level. Ultimately, the capacity of the district teams needs to be developed so that the system may be handed over and managed by the district staff.

3.9 Gender Issues

Some 30,000 women die each year in Pakistan due to complications of pregnancy, and 10 times more women develop life-long, pregnancy- related disability. Rural women's health is generally poorest due to the lack of health facilities and skilled health providers. For example, the maternal mortality ratio in predominantly rural Balochistan is 800 maternal deaths to 100,000 live births, compared to the national average of 340 per 100,000. Perhaps the biggest issue for women with regards to health service delivery in the earthquake affected areas is the availability of female Women with child leaving staff. Socio-cultural constraints like gender segregation play an RHC Patika, Muzaffarabad

21 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 important part in utilization of services14. As reported earlier only 38 sites (12%) had a female medical officer posted. While an LHV was posted at 171 facilities (58%), they were often not present, especially if she was did not belong to the village, the most common cause of reported absence and the impetus for frequent postings as it is culturally inappropriate for women to travel long distances for work. Peri-natal care depended essentially on the availability of LHVs and was being provided at only 159 sites (53%). Family planning services were more available (62%). Despite the notion that most women prefer to deliver at home, female staff interviewed reported that provision of equipment and supplies would be very well received by the women, encourage them to visit and deliver at the facilities and increase the overall coverage of perinatal care and safe delivery. Poor women's health in Pakistan is as much a social as medical problem. Underlying factors here are the lack of awareness of, and attention to, women's health needs; women's lower education and social status; and social constraints on women and girls, including the practice of seclusion. With all evidence suggesting high maternal and infant mortality, every facility must have a female staff member appointed. The minimum requirement should be of an LHV present at every facility. Effort should be made to post LHVs in their home village, or the closest possible facility. Hiring and admission into public health schools could take this factor into account and recruitment may be based on recommendations by the EDO office taking this factor into account. A village health committee may be best placed to recommend potential trainees.

3.10 Perceived needs

We asked both staff present as well as villagers what were the major issues they faced with regards to health and health service delivery and what they considered as priority needs15. The following are arranged in order of number of times they are mentioned, starting with the most mentioned: Ambulance stationed at THQ, Balakot Water supply: This particular problem was mentioned at almost every facility visited. The earthquake has destroyed most pipelines and springs have dried up. In most places it is simply an issue of a few hundred feet of pipe. Contaminated water supplies were quoted as the cause of rising diarrhea and skin infections. Health Staff: Availability of staff, and especially female staff was a common demand. Also mentioned frequently were the problems caused by frequent and ad-hoc transfers. Though most of these transfers were justified in order to provide services at the many IDP camps all over the district, a review of staff positions is essential with preference of posting given to personnel belonging to the particular village (see Map 9). One villager suggested to “tell the doctor not to sit in the hospital but go visit villages...” An old man reported that the “LHV only comes in to take her salary… why waste OUR money on that” Reproductive health Services: RH Services were mentioned by staff and villagers as essential. One villager informed us, “Our women die in childbirth all the time… The dai knows nothing”. Another distraught villager who had recently lost his wife in childbirth commented, “We have to carry our women on our backs for five to six hours…. How can they survive?” A well equipped delivery room was also demanded in many places, challenging the accepted view that people in the area prefer to deliver at home.

14 Babar T. Shaikh 1* and Juanita Hatcher Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers http://jpubhealth.oxfordjournals.org/cgi/content/abstract/fdh207v1. Accessed on October 16 2006

15 It is worth mentioning that the list created by villagers makes logical sense if one was to do an official prioritization matrix of health problems. Also, note that the need for buildings is the last item on the list!

22 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Supplies and furniture: Most facilities were poorly equipped and furnished. A fridge was needed at most places, and beds and chairs were the next most common items requested. Similarly, over 80% or facilities visited had a shortage of stationery including all recording and reporting tools. At RHC Kahori, the staff showed us piles of donated medicines that were stored under leaky tents and exposed to sun. The health staff asked us “What is the use of all this medicine if it is to be wasted… either give us a fridge or make us a store or take all this back” Referral: Transporting sick patients to referral hospitals in Muzaffarabad was a major problem with difficult roads, lack of transport and post-quake inflated prices. At one village, a village elder asked us to help them with an ambulance. “We don’t need a big ambulance… give us a small Suzuki like the EDHI ambulances and we will use it” Vaccination: EPI was also a regularly demanded service. Problems identified included absence of staff or vacant posts, and appropriate equipment. It seemed that there was great demand in the community for vaccinations. Road access: Despite explaining that this was a health survey, most staff and villagers we spoke to insisted that we advocate for the building of proper roads. One elder explained, “If there are good roads then the doctors will come, medicine will also come and people can easily visit the big hospitals” Buildings: Since most of the facilities totally damaged are still functioning in tents, and news of recently erected pre-fabricated structures has spread, staff insisted that their buildings be built on a priority basis. They did not want tents, as these are too hot during the day and “impossible to sit in”. Only in one village, Sanikot, staff asked us to provide them with a tent as they currently had only one tent. Apart from buildings, quarters for staff were also demanded, as was electric supply.

3.11 Management of health facilities

The devolution of responsibility for health has put many responsibilities at the district level with little capacity in planning, budgeting, and management. Major issues, as reported in the National Maternal and Child Health Policy and Strategic framework (2005-2015) mention weak leadership, fragmentation of health programmes, inadequate financing, lack of human resources, confusion about roles and responsibilities as some of the major issues being faced. Also mentioned is a lack of career structures and guidelines for personnel, low salaries and poor working conditions as well as a lack of community involvement in planning, implementation and accountability. Even though we did not assess management capacity of staff, it is evident that this area needs a lot of input. While interviewing the ICRC team at Patika, the fear expressed was that after external agencies leave in the selected facilities, the “organization and management” would suffer. It was thought that imparting critical OPD register management skills should be part and parcel of the strategy of any external agency supporting a facility. Another international staff observed that her Pakistani counterparts were “naturally good in book-keeping and accounting”, a skill that can be further developed. Supervision and monitoring is also an essential component of ensuring quality health care. Two separate health staff while commenting about the district health system reported, “since the DHO has moved into the Neelum Hospital premises, every staff is present and all activities are being done”. Though ideally, the presence of a senior official should not be the criteria for effective performance, the statement makes a strong point for regular monitoring and guidance.

23 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

CHAPTER 4: CONCLUSION AND RECCOMENDATIONS

24 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

CHAPTER 4: CONCLUSION AND RECCOMENDATIONS

Based on our findings, we make the following recommendations:

Coverage of population in terms of service provision as per international and MoH standards may be insufficient based on our findings with distances to the closest facility of up to several hours (and in some cases days). The migratory patterns of some populations, like in the upper Neelum area further compounds the issue. The building of further facilities may not be the answer considering the scattered population patterns but rather a rational and evidence based reorganization and appropriate planning with a focus on remote areas is much needed. The shortcomings must be overcome by assuring the presence of staff, equipment, and supplies in the facilities that do exist, augmented perhaps by outreach activities. Distribution of supplies and equipment needs to be more equitable to minimize the communities’ feeling of being ignored by the authorities and agencies.

Utilization of facilities depends more on status of equipment, supplies and staff availability than on catchment population. Caution is advised while reviewing upgrading and/or closing down facilities and must take many variables in account including road access and condition, referral patterns, population demographics and utilization rates. All information available needs to be reviewed and a master plan developed to rationalize the distribution of health facilities prior to permanent reconstruction.

One major issue that needs to be dealt with in addition to the above is whether the service package is comprehensive and of good quality. The minimum standard must include maternal and child health services like ante/post-natal care and regular EPI services. The establishment of delivery services would involve more than refresher training and include proper equipment, monitoring and developing referral networks.

Staffing is a chronic problem and must be dealt with urgently. The nature of the emergency necessitated widespread transfers. The problems in the past, however, include in-appropriate and frequent transfers, political deployments, absenteeism, low staff morale, and an inappropriate staff mix. Perhaps recruitment should be “assigned to the facility” and local staff should be given priority for posts closest to their homes. Appropriate female staff is a priority in order for quality MCH services at the BHU level.

Building the capacity of dispensers/technicians not only in case management and rational use of drugs but also basic management skills is prudent.

Reproductive health services are not only a need but a demand. The possibility of identifying selected facilities to establish EmOC centers is a valid recommendation. Having said that, however, the linkages between community based services like the dais and TBAs and facility based services is an area of research that needs to be undertaken and questions like the cultural acceptability of delivery services at the BHU level be studied.

25 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Supply of drugs and equipment is an ongoing process and proper mechanisms must be put into place to ensure timely delivery. Furthermore, rational use of drugs needs to be established and protocols made available at each facility and promoted.

The government should explore all options to develop a referral system that is community based, possibly using local phone lines or strategically placed radio sets to order an ambulance. Options to recover costs need to be devised for example initiating a cost sharing mechanism that subsidizes the use of ambulances or providing ambulance services for clients with a referral note from the facility.

Laboratory services are also lacking in most places. Redundant members of the BHU staff like malaria supervisors may be effectively utilized by further training and setting up small labs in selected facilities.

Specific guidelines for management and case definition need to be developed and workers trained. Monitoring and evaluation should judge quality of care by assessing how far guidelines are adhered to.

Planned intervention in water and sanitation (possibly include developing safe water storage and piped water supply to facilities) and solid waste disposal are critical areas that need to be addressed.

The establishment of ‘Village Health Committees’ is a valid methodology that has been tried and tested in many countries and may be considered as a method of ensuring community involvement, improving management and accountability as well as empowering the communities to take control and responsibility for their health. A second phase of assessment must also include more in-depth analysis of referral mechanisms and assess changes in pertinent variables like staff position and status of equipment and supplies. Further focus groups discussions and qualitative assessments, KAP studies and verbal autopsies can augment our understanding of local realities and needs and help design more affective interventions.

With all the chronic management and system issues facing the public health facilities in the earthquake affected districts, the earthquake of 8th October was a big blow. The local population suffers poor access due to long travel distances, poor road conditions, and high costs of travel. More often than not, they are faced with absent staff, poor supplies, and non-provision of essential services. Vulnerable groups like women and children are perhaps the hardest hit with very little quality MCH services. For the success of recovery and reconstruction efforts, coordination between donors and the government needs to be sustained and strengthened to prevent duplication, lack of sustainability and the current poor documentation of short and long- term results. The Cluster approach seems to have proven an effective method of coordination and needs to be maintained. Political will is essential to improve the quality of health care. Above all the community has to be involved and engaged in all efforts through various channels. Where the 8th October earthquake has caused disruption and devastation, it has also provided a unique opportunity to reassess and improve the situation and, ultimately, improve the quality of peoples’ lives.

26 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

Annexes

27 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

1. District Bagh

28 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 1.1: Public Health Facilities Assessed in District Bagh

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle RHC Arja Arja Maloot Dhir Kot 33.9770000 73.6634722 14280 All vehicles BHU Bhatakot Bhattakot Budhal sharif Haveli 33.9115278 74.0058611 4957 4 X 4 only BHU Birpani Birpani Birpani bagh 34.0489444 73.7577222 20662 All vehicles BHU Chanjal Hotter Chanjal Haveli 33.8925333 74.1452972 10530 All vehicles RHC Chatter Chatter Dharie Bagh 33.9419167 73.8352222 14520 All vehicles RHC Chitra Chetra topi Topi Bagh 33.9228667 73.7721917 40000 All vehicles Topi BHU Dagwar Dagwar Dagwa Haveli 33.8337500 74.0825000 116961 4 X 4 only RHC Dhir Kot Dheer Kot Dheer Kot Dhir Kot 34.0334167 73.5796389 38940 All vehicles Hospitals DHQ Bhajrool Bagh Bagh 33.9759806 73.7903694 485000 All vehicles Bagh BHU Ghal Topi Ghal Topi Topi Bagh 33.8988611 73.7508917 6000 4 X 4 only BHU Ghazia Bad Makhyalla Dhir kot 33.9916944 73.6283000 15348 All vehicles Ghaziabad BHU Gugdar Gugdar Budhal Haveli 33.8766667 74.0306389 23904 All vehicles BHU Hallon Hallon Kalamula Haveli 33.9075806 74.1075056 11601 All vehicles BHU Harighel Harighel Rawvli Bagh 33.9473333 73.7050000 19397 All vehicles BHU Juglari Juglari Juglari Bagh 33.9956944 73.7171389 11942 All vehicles BHU Kafal Kafal Gharah Juglari Bagh 33.9807500 73.7101389 7856 All vehicles Gharah BHU Kharal Kharal Abasian Bot Mayan Bagh 33.9900000 73.8492222 8569 All vehicles Abassian BHU Kharial Kharial Maldiyla Islam Magar Bagh 33.9770556 73.8613333 12676 4 X 4 only Maldiylan Hospitals Khotta Kalali Haveli 33.8841667 74.1089444 145000 All vehicles Khotta RHC Khurshid Abad Khurshid Abad Haveli 33.9218194 74.1722389 16257 All vehicles Khurshidabad BHU Kothian kothian topi Bagh 33.9259167 73.7605278 14698 4 X 4 only BHU Kotli Saira Sair Chamety Dhir kot 34.0630833 73.5900556 17979 All vehicles BHU Mallot Mallot Mallot Dhir kot 34.0270833 73.6916111 30000 All vehicles BHU Mofawali Mofa Wali Bedhi Haveli 33.9991111 74.0744722 4 X 4 only BHU Naryola Naryola Rawali Bagh 33.9512361 73.7805556 All vehicles

29 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle BHU Nelabut Nelabut Dheer Kot Dhir Kot 34.0048889 73.5932500 16332 All vehicles BHU Panyali Panali Bagh Bagh 33.9667778 73.8460556 9696 All vehicles Narshar ali BHU Raikot Lohar Bella Bagh 33.9394167 73.9424722 15000 All vehicles Khan BHU Rera Rera Swang Bagh 33.9323861 73.8678750 11324 All vehicles BHU Rongla Rongla Rongla Dhir kot 34.0574444 73.6469167 46556 All vehicles Hospitals Salian Dhouda Salian Dhir kot 34.0281111 73.5391944 18775 All vehicles Salian Dhouda Hospitals Sanghar Sanhar Ptharan Chameti Dhir kot 34.0898611 73.5575833 11255 All vehicles Ptharan BHU Saripiran Saripiran Rerben bagh 34.0581389 73.7363056 17360 4 X 4 only RHC Saser Saser Dirkot Dhir kot 34.0008611 73.5653889 18179 All vehicles BHU Sirsydian Sirsydian Rawvli Bagh 33.9775833 73.7731944 13590 4 X 4 only BHU Sohawa Sohawa Sharif Charala Dhir kot 33.9531944 73.5648333 11417 4 X 4 only Sharif BHU Soli Soli Kalamula Haveli 33.9058583 74.1387333 14670 All vehicles BHU Thub Thub Thub bagh 34.0325000 73.7156389 19820 All vehicles BHU Tuangari Tangari Kalali Haveli 33.8546111 74.0748611 6673 All vehicles

30 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 1.2: Provision of utilities at public health facilities in District Bagh

Water Supply Electricity Waste Disposal Post EQ Access to Facility Name Toilet functional present present method construction Ambulance RHC Arja Yes Yes Yes Burn Yes Yes BHU Bhatakot Yes Yes No Burn Yes No BHU Birpani Yes Yes Yes Burn Yes Yes BHU Chanjal Yes Yes Yes Burn No Yes RHC Chatter Yes No Yes Burn No No RHC Chitra Topi No No Yes Burn Yes Yes BHU Dagwar Yes No Yes Burn No No RHC Dhir Kot Yes Yes Yes Burn No Yes Hospitals DHQ Yes Yes Yes Burn No Yes Bagh BHU Ghal Topi Yes Yes Yes Multiple methods No No BHU Ghaziabad Yes Yes Yes Burn Yes No BHU Gugdar Yes Yes Yes Burn No No BHU Hallon Yes No Yes Burn No Yes BHU Harighel Yes No Yes Burn No Yes BHU Juglari Yes Yes Yes Burn Yes Yes BHU Kafal Gharah Yes No Yes Burn No Yes BHU Kharal Yes Yes Yes Burn Yes Yes Abassian BHU Kharial Yes No Yes Multiple methods No No Maldiylan Hospitals Khotta Yes Yes Yes Thrown Yes Yes RHC Yes Yes Yes Burn No Yes Khurshidabad BHU Kothian No Yes No Thrown Yes No BHU Kotli Saira Yes No No Burn No No BHU Mallot Yes Yes Yes Burn Yes Yes BHU Mofawali Yes Yes No Thrown Yes No BHU Naryola Yes Yes Yes Burn No No BHU Nelabut Yes Yes Yes Buried No Yes BHU Panyali No No No Thrown No No BHU Raikot No No Yes Thrown No No

31 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Water Supply Electricity Waste Disposal Post EQ Access to Facility Name Toilet functional present present method construction Ambulance BHU Rera Yes Yes Yes Burn No Yes BHU Rongla Yes Yes Yes Burn Yes Yes Hospitals Salian Yes No Yes Thrown No No Dhouda Hospitals Sanghar Yes Yes Yes Burn No No Ptharan BHU Saripiran No No No Buried No No RHC Saser Yes Yes Yes Thrown Yes Yes BHU Sirsydian No No No Burn No No BHU Sohawa Yes No Yes Burn No No Sharif BHU Soli Yes Yes Yes Burn Yes Yes BHU Thub Yes No Yes Buried No Yes BHU Tuangari Yes Yes Yes Burn Yes No

32 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 1.3: Staff posted at health facility in District Bagh

Facility Name Male MO Female MO Dispensar/ MT LHV EPI tech

RHC Arja Yes No Yes Yes Yes BHU Bhatakot No No Yes No Yes BHU Birpani Yes No Yes Yes Yes BHU Chanjal No No Yes Yes Yes RHC Chatter No No Yes No Yes RHC Chitra Topi Yes No Yes Yes Yes BHU Dagwar No No Yes No Yes RHC Dhir Kot Yes Yes Yes Yes Yes Hospitals DHQ Bagh Yes Yes Yes Yes Yes BHU Ghal Topi No No Yes No No BHU Ghaziabad Yes No Yes Yes Yes BHU Gugdar Yes No No Yes Yes BHU Hallon Yes No Yes Yes Yes BHU Harighel Yes No Yes Yes Yes BHU Juglari No No Yes No Yes BHU Kafal Gharah Yes No Yes Yes Yes BHU Kharal Abassian Yes No No Yes Yes BHU Kharial No Yes No Yes Maldiylan No Hospitals Khotta No No Yes Yes Yes RHC Khurshidabad Yes No Yes Yes Yes BHU Kothian No No Yes Yes No BHU Kotli Saira No No Yes No No BHU Mallot Yes No Yes Yes Yes BHU Mofawali No Yes Yes Yes Yes BHU Naryola No No Yes No Yes BHU Nelabut No No Yes No Yes BHU Panyali No No Yes No No BHU Raikot No No Yes Yes Yes BHU Rera No No Yes Yes Yes BHU Rongla No No Yes Yes Yes Hospitals Salian No No Yes Yes Yes

33 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Facility Name Male MO Female MO Dispensar/ MT LHV EPI tech Dhouda Hospitals Sanghar No Yes Yes Yes Ptharan No BHU Saripiran Yes No Yes Yes Yes RHC Saser Yes No Yes Yes Yes BHU Sirsydian No No Yes Yes Yes BHU Sohawa Sharif No No Yes Yes No BHU Soli No No Yes Yes No BHU Thub Yes No Yes Yes Yes BHU Tuangari No No Yes No Yes

34 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 1.4: Services provided at health facilities in District Bagh

Time to ANC & Deliveries Family Routine Minor TB Facility Name OPD IPD referral PNC conducted Planning EPI surgery management hospital RHC Arja Yes Yes Yes Yes Yes Yes Yes Yes 45 BHU Bhatakot Yes No No No No No Yes No 150 BHU Birpani Yes Yes Yes Yes Yes Yes No No 45 BHU Chanjal Yes Yes Yes No Yes Yes No No 60 RHC Chatter Yes No Yes No Yes Yes Yes Yes 45 RHC Chitra Topi Yes Yes No No Yes Yes Yes Yes 75 BHU Dagwar Yes No No No No Yes Yes No 180 RHC Dhir Kot Yes Yes Yes Yes Yes Yes Yes Yes 90 Hospitals DHQ Bagh Yes Yes Yes Yes Yes Yes Yes Yes 360 BHU Ghal Topi Yes No No No No No Yes Yes 45 BHU Ghaziabad Yes No Yes Yes Yes Yes Yes No 60 BHU Gugdar Yes No Yes Yes Yes Yes Yes Yes 30 BHU Hallon Yes Yes Yes No No Yes Yes No 45 BHU Harighel Yes Yes Yes Yes Yes Yes Yes Yes 30 BHU Juglari Yes No No No Yes Yes Yes Yes 45 BHU Kafal Gharah Yes Yes Yes Yes Yes Yes Yes No 60 BHU Kharal Abassian Yes No Yes No Yes Yes Yes No 90 BHU Kharial Maldiylan Yes No No No No Yes No Yes 120 Hospitals Khotta Yes Yes Yes Yes Yes Yes Yes Yes 960 RHC Khurshidabad Yes Yes Yes Yes Yes Yes Yes No 90 BHU Kothian Yes No Yes Yes No No No Yes 120 BHU Kotli Saira Yes No No No No No Yes No 30 BHU Mallot Yes Yes Yes Yes Yes Yes Yes Yes 60 BHU Mofawali Yes No Yes Yes No Yes No Yes 300 BHU Naryola Yes No No No No Yes Yes No 45 BHU Nelabut Yes No No No Yes Yes No No 20 BHU Panyali Yes No No No No No No No 45

35 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Time to ANC & Deliveries Family Routine Minor TB Facility Name OPD IPD referral PNC conducted Planning EPI surgery management hospital BHU Raikot Yes No Yes No Yes Yes Yes Yes 60 BHU Rera Yes Yes Yes No Yes Yes Yes Yes 45 BHU Rongla Yes No Yes No Yes Yes No Yes 45 Hospitals Salian Dhouda Yes No Yes No Yes Yes Yes No 120 Hospitals Sanghar Ptharan Yes No Yes No Yes Yes Yes No 60 BHU Saripiran Yes No No No Yes Yes No No 180 RHC Saser Yes Yes Yes Yes Yes Yes Yes Yes 180 BHU Sirsydian Yes No Yes No Yes Yes No Yes 60 BHU Sohawa Sharif No Yes Yes No Yes Yes Yes No 150 BHU Soli Yes Yes No No Yes Yes No Yes 120 BHU Thub Yes Yes Yes Yes Yes Yes Yes No 90 BHU Tuangari Yes No No No No Yes Yes No 30

36 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 1.5: Status of equipment and reporting at health facilities in District Bagh

Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS RHC Arja Well equipped Yes Yes Well maintained BHU Bhatakot Poorly equipped Yes Yes Poor BHU Birpani Averagely equipped Yes Yes Poor BHU Chanjal Poorly equipped Yes Yes Poor RHC Chatter Poorly equipped Yes Yes Poor RHC Chitra Topi Averagely equipped Yes Yes Poor BHU Dagwar Averagely equipped Yes No Poor RHC Dhir Kot Averagely equipped Yes Yes Average Hospitals DHQ Bagh Well equipped Yes Yes Well maintained BHU Ghal Topi Poorly equipped Yes No Poor BHU Ghaziabad Averagely equipped Yes Yes Poor BHU Gugdar Averagely equipped Yes Yes Average BHU Hallon Averagely equipped Yes Yes Average BHU Harighel Averagely equipped Yes Yes Average BHU Juglari Well equipped Yes Yes Poor BHU Kafal Gharah Well equipped No Yes Poor BHU Kharal Abassian Averagely equipped Yes Yes Poor BHU Kharial Maldiylan Poorly equipped Yes No Poor Hospitals Khotta Averagely equipped Yes Yes Average RHC Khurshidabad Averagely equipped Yes Yes Well maintained BHU Kothian Poorly equipped Yes No Poor BHU Kotli Saira Poorly equipped Yes No Poor BHU Mallot Averagely equipped No No Average BHU Mofawali Averagely equipped Yes Yes Average BHU Naryola Poorly equipped Yes No Poor BHU Nelabut Poorly equipped Yes No Average BHU Panyali Poorly equipped Yes No Poor BHU Raikot Poorly equipped Yes No Poor BHU Rera Averagely equipped No No Poor BHU Rongla Averagely equipped Yes Yes Average Hospitals Salian Dhouda Poorly equipped Yes Yes Poor

37 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS Hospitals Sanghar Ptharan Poorly equipped Yes Yes Poor BHU Saripiran Poorly equipped Yes No Poor RHC Saser Well equipped Yes Yes Average BHU Sirsydian Poorly equipped No No Poor BHU Sohawa Sharif Poorly equipped Yes Yes Poor BHU Soli Averagely equipped Yes No Poor BHU Thub Averagely equipped Yes No Poor BHU Tuangari Averagely equipped Yes Yes Poor

38 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

2. District Muzaffarabad

39 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 2.1: Public Health Facilities Assessed in District Muzaffarabad

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude population with vehicle BHU Anwar Sharif Anwar Sharif Charak pura Muzaffarabad 34.2975000 73.5241667 13000 All vehicles Hattian BHU Awan Patti Awan Patti duppatta Muzaffarabad 34.2584900 73.6498900 8115 All vehicles BHU Badara Badara Machiara Muzaffarabd 34.4917800 73.5765400 8500 All vehicles BHU Banamula Banamula Hatian 34.2402800 73.8261100 27621 4 X 4 only BHU Bararkot Bararkot Gojra Muzaffarabad 34.3744000 73.4028000 10820 All vehicles BHU Batdara Batdara Muzaffarabad Muzaffarabad 34.4897200 73.5763900 All vehicles BHU Behri Bheri Behri Muzaffarabad 34.5271200 73.5713900 20000 All vehicles BHU Buttle Buttle Khori Muzaffarabad 34.4708300 73.4933300 All vehicles BHU Chakhama Chakhama Chakhama Hatian 34.1722220 73.8750000 All vehicles RHC Chakothi Chakhoti Chinari Hatian 34.1138900 73.8825000 20000 All vehicles BHU Chattar Chattar Heer kotli Muzaffarabad 34.4327800 73.4680600 All vehicles BHU Chattar Kalas Chattar Kalas Chattar Kalas Muzaffarabad 34.2022200 73.5013900 18900 All vehicles BHU Chham Chham Chakhama Hatian 34.4222222 72.8330556 12000 4 X 4 only Hospitals Chikar Chikar Chikar Hatian 34.1528200 73.6780300 250000 All vehicles BHU Chinari Chinari Chinari Hatian 34.1589000 73.8272000 30000 All vehicles RHC Danna Danna Danna Muzaffarabad 34.1388890 73.5472220 60000 All vehicles RHC Dhanni Dhanni Muzaffarabad 34.3264900 73.4666200 32000 All vehicles BHU Dichore miran Dichore miran Kai manja Muzaffarabad 34.2324440 73.6933900 10116 All vehicles BHU Dullai Dullai Chattar kalas Muzaffarabad 34.2472220 73.4758333 10000 All vehicles RHC Gari Dopatta Gari Dopatta gari Dopatta Muzaffarabad 34.2274100 73.6126400 48000 All vehicles RHC Kahori Kahori Kahori Muzaffarabad 34.4455100 73.5014600 55000 All vehicles BHU Khun bandi Khun bandi Langar pura Muzaffarabad 34.2856900 73.5687300 13000 All vehicles BHU Kohala Kohala Chattar kalas Muzaffarabad 34.1166667 73.5033333 12300 All vehicles BHU Komikot Komikot Komikot Muzaffarabad 34.1988889 73.5894444 42000 All vehicles Hospitals Kot Tarhalla Kot Tarhalla Katchli Muzaffarabad 34.0894400 73.6027800 6901 All vehicles BHU Lamian Pattian Lamian Pattian Muzaffarabad 34.3915100 73.4307000 All vehicles

40 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude population with vehicle BHU Lamnian Lamnian Lamnian Hatian 34.2363889 73.7827778 16385 All vehicles RHC Lamnian Lamnian Lamnian Hatian 34.2462778 73.7679750 5666 All vehicles BHU Langar Pura Langar Pura Langar Pura Muzaffarabad 34.3235700 73.5408700 25000 All vehicles RHC Leepa Leepa Leepa Nowkot Hatian 34.3027778 73.8722222 26397 By foot only BHU Machiara Machiara Machiara Muzaffarabad 34.5097222 73.6222222 8686 4 X 4 only BHU Muzaffarabad Muzaffarabad Ward no. 5 Muzaffarabad 34.3689400 73.4759000 30000 All vehicles BHU Naran Sharif Naran Sharif Chanal bung Muzaffarabad 34.2341700 73.5611000 20000 All vehicles BHU Niazpura Naran Sharif Muzaffarabad Muzaffarabad 34.3666700 73.5258300 2000 All vehicles BHU Nowkot Nowkot Nowkot Hatian 34.3013611 73.9075833 8131 4 X 4 only BHU Panjgran Panjgran Panjgran Muzaffarabad 34.4409000 73.6291800 25000 All vehicles BHU Pattika Pattika Ghori Muzaffarabad 34.4502100 73.5449300 7411 All vehicles BHU Phagwan Phagwan Hattian duppatta duppatta duppatta Muzaffarabad 34.2222220 73.6472220 10000 All vehicles BHU Rahimkot Rahimkot Katkair Muzaffarabad 34.0961111 73.6594444 6000 All vehicles BHU Rajpyan Kialy Thulgram Muzaffarabad 34.5180600 73.4791700 15000 All vehicles BHU Reashian Reashian Lamnian Muzaffarabad 34.2575000 73.8197220 9000 All vehicles BHU Saidpur Saidpur Saidpur Muzaffarabad 34.4938889 73.5044444 15000 All vehicles BHU Salmia Salmia Salmia Hatian 34.1147200 73.7041700 10000 All vehicles BHU Sanikot Sanikot Gari duppatta Muzaffarabad 34.2873340 73.6345300 4500 All vehicles BHU Saran Saran Hatian Hatian 33.1881800 73.6744800 22500 All vehicles BHU Sarli Sachha Sarli Sachha Sarli Sachha Muzaffarabad 34.4861110 73.6458330 14000 All vehicles BHU Sawan Sawan Chattar kalas Muzaffarabad 34.2592000 73.4922000 8281 All vehicles BHU Seri Dara Seri Dara Seri Dara Muzaffarabad 34.3891170 73.4947200 5000 By foot only BHU Sharia Sharia Langla Hatian 34.2000000 73.7881389 4666 All vehicles BHU Sharian Sharian Langla Hatian 34.1933333 73.7972222 9000 All vehicles BHU Taitra Taitra Panjkot Muzaffarabad 34.3416700 73.7211100 All vehicles BHU Tandali Tandali Chattar domail Muzaffarabad 34.3050000 73.5430600 1500 All vehicles BHU Temi Bhana Temi Bhana Ghangram Muzaffarabad 34.4069444 73.6116667 25000 All vehicles BHU Upper Muncipal Chattar Upper Chattar corporati Muzaffarabad 34.3441700 73.4663900 10600 All vehicles

41 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 2.2: Provision of utilities at public health facilities in District Muzaffarabad

Water supply Electricity Waste disposal Post EQ Access to Facility Name Toilet functional present present method construction ambulance BHU Anwar Sharif Yes Yes Yes Burn No Yes BHU Awan Patti No No No Thrown No No BHU Badara No No Yes Buried No No BHU Banamula Yes Yes Yes No No BHU Bararkot Yes Yes Yes Burn No No BHU Batdara No No No Thrown No No BHU Behri No No No Burn No No BHU Buttle No No No Multiple methods No No BHU Chakhama No No No Burn No RHC Chakothi No No Yes Multiple methods No No BHU Chattar No No No Multiple methods No No BHU Chattar Kalas Yes No Yes Multiple methods No No BHU Chham Yes Yes Yes Burn No No Hospitals Chikar Yes Yes Yes Burn No Yes BHU Chinari Yes Yes Yes Burn Yes No RHC Danna No No Yes Multiple methods No Yes RHC Dhanni Yes Yes Yes Burn Yes Yes BHU Dichore miran Yes Yes Yes Buried Yes No BHU Dullai Yes Yes Yes Multiple methods Yes No RHC Gari Dopatta Yes No Yes Burn No Yes RHC Kahori No No Yes Burn Yes Yes BHU Khun bandi Yes No Yes Burn Yes Yes BHU Kohala Yes No Yes Burn No No BHU Komikot Yes No Yes Burn Yes No Hospitals Kot Tarhalla No No Yes Multiple methods No No BHU Lamian Pattian Yes Yes Yes Thrown No No BHU Lamnian No No No Burn No Yes RHC Lamnian No No Yes Buried Yes BHU Langar Pura Yes Yes Yes Multiple methods No Yes

42 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Water supply Electricity Waste disposal Post EQ Access to Facility Name Toilet functional present present method construction ambulance RHC Leepa Yes No Yes Burn No BHU Machiara No No No Burn Yes No BHU Muzaffarabad No Yes No Thrown Yes No BHU Naran Sharif Yes No Yes Buried Yes No BHU Niazpura No No No Buried No No BHU Nowkot Yes No Yes Burn No Yes BHU Panjgran Yes Yes Yes Burn Yes No BHU Pattika Yes Yes Yes Burn Yes Yes BHU Phagwan duppatta Yes No Yes Multiple methods No No BHU Rahimkot No No No Burn No No BHU Rajpyan Yes No No Burn No No BHU Reashian Yes No No Burn No No BHU Saidpur Yes Yes Yes Burn No No BHU Salmia Yes Yes Yes Burn No Yes BHU Sanikot No No No Thrown No No BHU Saran Yes Yes Yes Buried Yes No BHU Sarli Sachha Yes No No Multiple methods Yes No BHU Sawan Yes Yes Yes Burn Yes No BHU Seri Dara No No No Thrown No No BHU Sharia No No Yes Burn No No BHU Sharian No No No Burn No No BHU Taitra Yes Yes Yes Burn Yes Yes BHU Tandali Yes No Yes Thrown Yes No BHU Temi Bhana Yes No Yes Burn No No BHU Upper Chattar Yes Yes Yes Burn No No

43 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 2.3: Staff posted at health facility District Muzaffarabad

Dispensar/ Medical Facility Name Male MO Female MO LHV EPI tech Technician BHU Anwar Sharif No No Yes Yes No BHU Awan Patti No No Yes No No BHU Badara No No Yes Yes Yes BHU Banamula No No Yes No Yes BHU Bararkot No No Yes Yes Yes BHU Batdara Yes No Yes Yes Yes BHU Behri Yes No Yes Yes No BHU Buttle Yes No Yes Yes Yes BHU Chakhama No No Yes Yes No RHC Chakothi No No Yes Yes No BHU Chattar No No Yes No No BHU Chattar Kalas Yes No Yes Yes Yes BHU Chham No No Yes Yes Yes Hospitals Chikar No No Yes No Yes BHU Chinari Yes Yes Yes Yes RHC Danna Yes Yes Yes Yes Yes RHC Dhanni No Yes Yes Yes Yes BHU Dichore miran Yes No No Yes Yes BHU Dullai Yes No Yes Yes Yes RHC Gari Dopatta Yes No Yes Yes Yes RHC Kahori Yes Yes Yes Yes BHU Khun bandi Yes No Yes Yes Yes BHU Kohala Yes No Yes Yes Yes BHU Komikot No No Yes Yes Yes Hospitals Kot Tarhalla No No Yes Yes Yes BHU Lamian Pattian Yes No Yes Yes Yes BHU Lamnian Yes No Yes Yes Yes RHC Lamnian No No Yes Yes Yes BHU Langar Pura Yes No Yes Yes Yes RHC Leepa Yes Yes Yes Yes Yes BHU Machiara Yes No Yes No Yes

44 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Dispensar/ Medical Facility Name Male MO Female MO LHV EPI tech Technician BHU Muzaffarabad No Yes Yes Yes Yes BHU Naran Sharif No No Yes No Yes BHU Niazpura No No Yes No No BHU Nowkot No No Yes Yes Yes BHU Panjgran Yes Yes Yes Yes Yes BHU Pattika Yes No Yes Yes No BHU Phagwan duppatta Yes No Yes Yes Yes BHU Rahimkot Yes No Yes Yes No BHU Rajpyan No No Yes Yes No BHU Reashian No No Yes No No BHU Saidpur Yes No Yes Yes Yes BHU Salmia No Yes Yes Yes Yes BHU Sanikot No No No No No BHU Saran Yes No Yes No Yes BHU Sarli Sachha Yes Yes Yes Yes Yes BHU Sawan No No Yes Yes No BHU Seri Dara No No No Yes No BHU Sharia No No Yes Yes Yes BHU Sharian No No Yes Yes Yes BHU Taitra Yes Yes Yes Yes No BHU Tandali No No Yes No No BHU Temi Bhana No No Yes No Yes BHU Upper Chattar No No Yes Yes Yes

45 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 2.4: Services provided at health facilities in District Muzaffarabad

TB Time to ANC & Deliveries Family Routine Minor Facility Name OPD IPD manageme referral PNC conducted planning EPI surgery nt hospital BHU Anwar Sharif Yes Yes No Yes Yes Yes No No 60 BHU Awan Patti Yes No No No No Yes No No 45 BHU Badara Yes No No No Yes No Yes Yes 80 BHU Banamula Yes No No No No Yes No 30 BHU Bararkot Yes Yes Yes Yes Yes Yes Yes Yes 120 BHU Batdara Yes No Yes No Yes Yes No No 120 BHU Behri Yes No No No No No No No 45 BHU Buttle Yes No Yes No Yes Yes No No 120 BHU Chakhama Yes No No No No No No 60 RHC Chakothi Yes No Yes No Yes Yes Yes No 180 BHU Chattar Yes No No No No No No No 150 BHU Chattar Kalas Yes No Yes Yes Yes Yes Yes Yes 25 BHU Chham Yes No Yes Yes Yes Yes Yes No 90 Hospitals Chikar Yes Yes Yes Yes Yes Yes No Yes 120 BHU Chinari Yes No Yes Yes Yes Yes No Yes 30 RHC Danna Yes Yes Yes Yes Yes Yes Yes Yes 90 RHC Dhanni Yes No Yes Yes Yes Yes No Yes 150 BHU Dichore miran Yes Yes No No Yes Yes No No 120 BHU Dullai Yes Yes No No Yes Yes Yes No 60 RHC Gari Dopatta Yes No Yes Yes Yes Yes Yes No 60 RHC Kahori Yes No Yes No Yes Yes No Yes 45 BHU Khun bandi Yes Yes No No Yes Yes No No 30 BHU Kohala Yes Yes Yes Yes Yes Yes Yes No 60 BHU Komikot Yes No Yes No Yes Yes Yes Yes 60 Hospitals Kot Tarhalla Yes No No No No Yes No No 30 BHU Lamian Pattian Yes No No No Yes Yes No No 60

46 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 TB Time to ANC & Deliveries Family Routine Minor Facility Name OPD IPD manageme referral PNC conducted planning EPI surgery nt hospital BHU Lamnian Yes Yes Yes Yes Yes Yes Yes Yes 180 RHC Lamnian Yes No Yes Yes Yes Yes Yes 120 BHU Langar Pura Yes Yes Yes Yes Yes Yes Yes No 30 RHC Leepa Yes No Yes No Yes Yes No 10 BHU Machiara Yes Yes Yes Yes Yes Yes Yes No 180 BHU Muzaffarabad Yes No Yes No Yes Yes No No 10 BHU Naran Sharif Yes No No No Yes Yes No Yes 240 BHU Niazpura Yes No No No No No No No 45 BHU Nowkot Yes No No No No No No No 15 BHU Panjgran Yes Yes Yes Yes Yes Yes Yes No 90 BHU Pattika Yes No Yes Yes Yes Yes Yes Yes 60 BHU Phagwan duppatta Yes Yes No No Yes Yes No No 120 BHU Rahimkot Yes No No No No Yes Yes No 150 BHU Rajpyan Yes No No No No No No No 180 BHU Reashian Yes No No No No No No No 90 BHU Saidpur Yes No No No Yes Yes No No 120 BHU Salmia Yes No No No No Yes Yes No 180 BHU Sanikot No No No No No No No No 300 BHU Saran Yes Yes No No Yes Yes No No 90 BHU Sarli Sachha Yes Yes Yes Yes Yes Yes Yes No 120 BHU Sawan Yes Yes No No No Yes No No 60 BHU Seri Dara Yes No No No No No No No 60 BHU Sharia Yes No No No Yes Yes No No 30 BHU Sharian Yes No Yes No Yes No Yes No 120 BHU Taitra Yes Yes Yes Yes Yes Yes Yes No 120 BHU Tandali Yes No No No No Yes No No 20 BHU Temi Bhana Yes No No No No Yes No No 120 BHU Upper Chattar Yes No No No No Yes No No 10

47 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 2.5: Status of equipment and reporting at health facilities in District Muzaffarabad

Reporting to Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Anwar Sharif Averagely equipped Yes Yes Poor BHU Awan Patti Poorly equipped Yes Yes Poor BHU Badara Poorly equipped Yes No Poor BHU Banamula Averagely equipped Yes Yes Poor BHU Bararkot Averagely equipped Yes No Well maintained BHU Batdara Poorly equipped Yes No Well maintained BHU Behri Poorly equipped Yes No Poor BHU Buttle Poorly equipped Yes Yes Poor BHU Chakhama Poorly equipped Yes Yes Poor RHC Chakothi Poorly equipped Yes No Poor BHU Chattar Poorly equipped No Yes Poor BHU Chattar Kalas Poorly equipped Yes No Poor BHU Chham Well equipped Yes No Average Hospitals Chikar Poorly equipped Yes No Poor BHU Chinari Well equipped Yes Yes Average RHC Danna Well equipped Yes No Average RHC Dhanni Well equipped Yes Yes Well maintained BHU Dichore miran Averagely equipped Yes Yes Poor BHU Dullai Averagely equipped No Yes Poor RHC Gari Dopatta Averagely equipped Yes No Poor RHC Kahori Averagely equipped Yes Yes Average BHU Khun bandi Averagely equipped Yes Yes Poor BHU Kohala Well equipped Yes No Well maintained BHU Komikot Averagely equipped Yes No Poor Hospitals Kot Tarhalla Poorly equipped Yes No Poor BHU Lamian Pattian Averagely equipped Yes Yes Poor BHU Lamnian Averagely equipped Yes Yes Poor RHC Lamnian Poorly equipped Yes Average BHU Langar Pura Well equipped Yes Yes Well maintained RHC Leepa Well equipped Yes Average BHU Machiara Well equipped Yes Yes Well maintained BHU Muzaffarabad Poorly equipped Yes Yes Average

48 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Reporting to Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Naran Sharif Averagely equipped Yes Yes Poor BHU Niazpura Poorly equipped Yes Yes Poor BHU Nowkot Averagely equipped Yes Yes Poor BHU Panjgran Averagely equipped Yes No Well maintained BHU Pattika Well equipped Yes Yes Well maintained BHU Phagwan duppatta Poorly equipped Yes Yes Poor BHU Rahimkot Averagely equipped Yes Yes Average BHU Rajpyan Poorly equipped No Yes Poor BHU Reashian Poorly equipped No No Poor BHU Saidpur Averagely equipped No No Poor BHU Salmia Averagely equipped Yes No Average BHU Sanikot Poorly equipped No No Poor BHU Saran Well equipped Yes Yes Average BHU Sarli Sachha Well equipped Yes Yes Well maintained BHU Sawan Averagely equipped Yes No Poor BHU Seri Dara Poorly equipped No No Poor BHU Sharia Averagely equipped Yes Yes Average BHU Sharian Averagely equipped Yes Yes Average BHU Taitra Averagely equipped Yes Yes Average BHU Tandali Poorly equipped No Yes Poor BHU Temi Bhana Poorly equipped Yes No Poor BHU Upper Chattar Averagely equipped Yes Yes Average

49 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

3. District Poonch

50 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 3.1: Public Health Facilities Assessed in District Poonch

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle RHC Abbaspur Abbaspur Chatara Abbaspur 33.8123611 73.9786111 74000 All vehicles RHC Ali sojal Ali sojal Ali sojal Rawalakot 33.8696111 73.8787500 13000 All vehicles BHU Bangoin Bangoin Bangoin Rawalakot 33.9363611 73.6629722 20900 All vehicles BHU Bhalgran Bhalgran Thorar Rawalakot 33.8498056 73.6080600 14130 4 X 4 only BHU Bunjosa Bunjosa Banjosa Rawalakot 33.7962222 73.7963611 11932 All vehicles BHU Chaffar Chaffar Chaffar Rawalakot 33.8158300 74.0130600 8246 4 X 4 only BHU Chotagalah Chotagalah Dhootan Rawalakot 33.8150000 73.8051389 8054 All vehicles BHU Datoot Datoot Pachiot Rawalakot 33.9039722 73.6703889 16586 All vehicles BHU Dhamni Dhamni Dhamni Rawalakot 33.8643611 73.7920278 15055 All vehicles RHC Hajira Hajira Hajira Hajira 33.7707778 73.8957500 300000 All vehicles BHU Hussain kot Hussain kot Dhamni Rawalakot 33.8070278 73.7651944 18414 All vehicles BHU Jandala Jandala Bangoin Rawalakot 33.9562778 73.6313333 8098 All vehicles BHU Jandali Jandali Jandali Rawalakot 33.7896389 73.8186111 8900 All vehicles BHU Khaigala Khaigala Dhamni Rawalakot 33.8470556 73.8295000 21000 All vehicles BHU Khali draman Khali draman Khali Draman Abbaspur 33.8581667 73.9653889 26441 By foot only BHU Mandhole Mandhole Mandhole Hajira 33.6774167 73.9602778 25422 4 X 4 only BHU Mohri Furman Mohri Furman Shah Shah Hunamera Rawalakot 33.9141667 73.7194167 19000 By foot only BHU Namnota Namnota Pakhar Rawalakot 33.8594722 73.8490833 11735 All vehicles RHC Paniolla Paniolla Paniolla Rawalakot 33.9196389 73.6871389 21697 All vehicles BHU Pothi Chaprian Pothi Chaprian Pothi Chaprian Hajira 33.8172200 73.8750000 14000 0 Pothi BHU Pothi Makwalan Makwalan Rawalakot Rawalakot 33.8892778 73.7349167 19370 All vehicles BHU Rakkar Rakkar Phagawti Hajira 33.7057222 73.9171111 12500 By foot only Rawalakot BHU Rawalakot town town Rawalakot Town Rawalakot 33.8543056 73.7664444 45106 By foot only BHU Rehara Rehara Riara Rawalakot 33.8305600 73.6827800 25000 By foot only BHU Sarrari Sarrari Sarrari Hajira 33.8178056 73.9133056 17299 All vehicles BHU Singola Singola Singola Rawalakot 33.8938333 73.7940000 23183 All vehicles RHC Tain Tain Tain Rawalakot 33.9012222 73.6117222 21850 All vehicles BHU Tanda Ghamir Tanda Ghamir Ghambir Hajira 33.7839167 73.9465833 16000 All vehicles BHU Thorar Thorar Thoral Rawalakot 33.8491700 73.6411100 12506 By foot only

51 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 3.2: Provision of utilities at public health facilities in District Poonch

Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance RHC Abbaspur Yes Yes Yes Multiple methods No Yes RHC Ali sojal Yes Yes Yes Burn No Yes BHU Bangoin Yes No Yes Multiple methods No No BHU Bhalgran Yes Yes Yes Burn No No BHU Bunjosa Yes No Yes Multiple methods No No BHU Chaffar Yes Yes No Burn Yes No BHU Chotagalah Yes No Yes Multiple methods No No BHU Datoot Yes Yes Yes Multiple methods Yes No BHU Dhamni Yes Yes No Burn No No RHC Hajira Yes No Yes Multiple methods No Yes BHU Hussain kot Yes No Yes Multiple methods No Yes BHU Jandala Yes Yes Yes Multiple methods No No BHU Jandali Yes No Yes Multiple methods No No BHU Khaigala Yes Yes Yes Burn Yes No BHU Khali draman No No No Multiple methods No No BHU Mandhole Yes No Yes Burn No No BHU Mohri Furman Shah Yes No Yes Burn No No BHU Namnota Yes No Yes Burn No No RHC Paniolla Yes Yes Yes Multiple methods No No BHU Pothi Chaprian Yes No No Burn Yes No BHU Pothi Makwalan Yes No Yes Multiple methods No No BHU Rakkar No No No Burn No No BHU Rawalakot town Yes No Yes Burn No Yes BHU Rehara Yes Yes Yes Burn No No BHU Sarrari Yes No No Burn Yes No BHU Singola No No No Multiple methods No No RHC Tain Yes Yes Yes Multiple methods No Yes BHU Tanda Ghamir Yes Yes Yes Multiple methods No No BHU Thorar Yes No No Burn No No

52 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 3.3: Staff available at facility at time of visit in District Poonch

Facility Name Male MO Female MO Dispensar/ MT LHV EPI tech

RHC Abbaspur Yes No Yes Yes Yes RHC Ali sojal No No Yes Yes Yes BHU Bangoin No No Yes No Yes BHU Bhalgran No No Yes No Yes BHU Bunjosa Yes No Yes Yes No BHU Chaffar No No Yes Yes No BHU Chotagalah No No Yes Yes Yes BHU Datoot No No Yes Yes No BHU Dhamni No No Yes No Yes RHC Hajira Yes Yes Yes Yes Yes BHU Hussain kot Yes No Yes Yes Yes BHU Jandala No No Yes No Yes BHU Jandali No No Yes No Yes BHU Khaigala No Yes Yes Yes Yes BHU Khali draman No No Yes Yes Yes BHU Mandhole Yes No Yes Yes Yes BHU Mohri Furman Shah No No Yes Yes Yes BHU Namnota No No Yes Yes Yes RHC Paniolla Yes Yes Yes Yes Yes BHU Pothi Chaprian No No Yes Yes Yes BHU Pothi Makwalan No Yes Yes Yes Yes BHU Rakkar No No Yes No Yes BHU Rawalakot town Yes Yes Yes Yes Yes BHU Rehara No No Yes Yes Yes BHU Sarrari Yes No Yes No No BHU Singola Yes No Yes Yes No RHC Tain Yes Yes Yes Yes Yes BHU Tanda Ghamir No No Yes Yes Yes BHU Thorar Yes No Yes Yes Yes

53 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 3.4: Services provided at health facilities in District Poonch

TB Time to ANC & Deliveries Family Routine Minor Facility Name OPD IPD managem referral PNC conducted Planning EPI surgery ent hospital RHC Abbaspur Yes No Yes Yes Yes Yes No Yes 150 RHC Ali sojal Yes No Yes Yes Yes Yes Yes Yes 90 BHU Bangoin Yes No No No No Yes No No 90 BHU Bhalgran Yes No No No No Yes Yes No 40 BHU Bunjosa Yes No Yes No Yes Yes Yes No 45 BHU Chaffar Yes No No No No No No No 60 BHU Chotagalah Yes No Yes No Yes Yes No No 60 BHU Datoot Yes No Yes No Yes No Yes No 110 BHU Dhamni Yes Yes No No No Yes No No 30 RHC Hajira Yes Yes Yes Yes Yes Yes Yes Yes 25 BHU Hussain kot Yes No Yes Yes No Yes No No 75 BHU Jandala Yes No No No No Yes Yes No 100 BHU Jandali Yes No No No No Yes Yes No 60 BHU Khaigala Yes No Yes No Yes Yes Yes No 30 BHU Khali draman Yes No No No Yes Yes Yes No 30 BHU Mandhole No No No No Yes Yes Yes No BHU Mohri Furman Shah Yes No Yes No Yes Yes Yes No 45 BHU Namnota Yes No Yes Yes Yes Yes Yes Yes 30 RHC Paniolla Yes No Yes Yes Yes Yes Yes Yes 50 BHU Pothi Chaprian Yes No Yes No Yes Yes Yes No 60 BHU Pothi Makwalan Yes No Yes No Yes Yes Yes No 20 BHU Rakkar Yes No No No Yes No Yes No 60 BHU Rawalakot town Yes No Yes No Yes Yes Yes Yes 15 BHU Rehara No No Yes Yes Yes Yes Yes No 40 BHU Sarrari Yes No No No No No Yes No 45 BHU Singola Yes No No No Yes No Yes No 60 RHC Tain Yes Yes Yes No Yes Yes Yes Yes 150 BHU Tanda Ghamir Yes No Yes No Yes Yes Yes No 60 BHU Thorar Yes No Yes Yes Yes Yes No No 60

54 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 3.5: Status of equipment and reporting at health facilities in District Poonch

Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMISt RHC Abbaspur Well equipped Yes Yes Well maintained RHC Ali sojal Averagely equipped Yes Yes Average BHU Bangoin Poorly equipped Yes Yes Poor BHU Bhalgran Averagely equipped Yes Yes Poor BHU Bunjosa Averagely equipped Yes Yes Poor BHU Chaffar Poorly equipped Yes Yes Poor BHU Chotagalah Poorly equipped Yes Yes Poor BHU Datoot Poorly equipped Yes No Poor BHU Dhamni Poorly equipped Yes Yes Poor RHC Hajira Averagely equipped Yes Yes Average BHU Hussain kot Averagely equipped Yes Yes Average BHU Jandala Poorly equipped Yes Yes Poor BHU Jandali Poorly equipped Yes Yes Poor BHU Khaigala Averagely equipped Yes Yes Poor BHU Khali draman Averagely equipped Yes Yes Average BHU Mandhole Averagely equipped Yes Yes Poor BHU Mohri Furman Shah Poorly equipped Yes No Poor BHU Namnota Averagely equipped Yes Yes Poor RHC Paniolla Averagely equipped Yes Yes Average BHU Pothi Chaprian Poorly equipped Yes Yes Poor BHU Pothi Makwalan Poorly equipped Yes Yes Poor BHU Rakkar Poorly equipped Yes Yes Poor BHU Rawalakot town Averagely equipped Yes Yes Well maintained BHU Rehara Averagely equipped Yes Yes Average BHU Sarrari Poorly equipped Yes Yes Poor BHU Singola Poorly equipped Yes Yes Poor RHC Tain Poorly equipped Yes Yes Poor BHU Tanda Ghamir Averagely equipped Yes Yes Poor BHU Thorar Averagely equipped Yes No Well maintained

55 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

4. District Battagram

56 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 4.1: Public Health Facilities Assessed in District Battagram

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle BHU Arghashori Battagram Battagram Battagram 34.6875000 73.0375000 17000 All vehicles RHC Banna Banna Banna Allai 34.8375000 73.0625000 130000 All vehicles BHU Barocha Barocha Pashtoo Allai 34.8986100 73.0336100 10000 By foot only BHU Batamori Batamori Batamori Battagram 34.6880600 73.0875000 12960 All vehicles BHU Bateela Bateela Bateela Allai 34.8722200 73.0944400 14000 4 X 4 only BHU Batlay Danda Thakot Battagram 34.7152800 72.9819400 12000 All vehicles BHU Battian Battian Bandigo Battagram 34.5833300 73.0833300 5000 All vehicles BHU Charbagh Charbagh Tarand Battagram 34.7579500 72.9173000 5000 All vehicles BHU Gantar Gantar Rashang Allai 34.8722200 73.1527800 4 X 4 only BHU Garhi Nawab Said Garhi Nawab Said Trand Battagram 34.6138900 72.9375000 15000 4 X 4 only BHU Hutal Batkool Hutal Batkool Batkul Allai 34.8097200 72.9694400 7000 All vehicles BHU Jambera Jambera Jambera Allai 34.8527800 72.9833300 7000 By foot only BHU Joz Jabbo Batamori Battagram 34.7152800 73.0766700 15000 4 X 4 only BHU Kanai Kanai Batkol Allai 34.7994400 72.9930600 7000 All vehicles BHU Kathora Kathora Rajdhari Battagram 34.6611100 73.1236100 12000 4 X 4 only BHU Khairabad Khairabad Kuza banda Battagram 34.6069400 72.9902800 All vehicles BHU Kharari Kharari Banian Battagram 34.6211100 73.0277800 3000 All vehicles BHU Kuz tandol Tandol Sakkar garh Allai 34.8860100 73.0038700 12000 4 X 4 only RHC Kuza Banda Tikri Maira Kuza Banda Battagram 34.6347200 73.0027800 7000 All vehicles BHU Pagora Pagora Raj Dhari Battagram 34.6444400 73.0644400 17500 All vehicles BHU Paimal Sharif Qilla Paimal Sharif Allai 34.7425000 72.9844400 14000 By foot only BHU Pashtoo Pashtoo Pashtoo Allai 34.8897200 73.0430600 12000 4 X 4 only BHU Pomong Pomong Peshora Battagram 34.7152800 72.9819400 4000 4 X 4 only BHU Rashang Rashang Rashang Allai 34.8208300 73.1194400 15000 All vehicles BHU Sakkar Gah Sakkar Gah Sakkar Gah Allai 34.9087200 72.9646800 15000 By foot only BHU Shumlai Shumlai Shumlai Battagram 34.7044400 73.1166700 23000 4 X 4 only BHU Shungli Payeen Shungli Payeen Peshora Allai 34.7025000 72.9107220 20000 4 X 4 only BHU Talous Talous Banna Allai 34.8486100 73.0333300 7000 By foot only

57 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 4.2: Provision of utilities at public health facilities in District Battagram

Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance BHU Arghashori Yes Yes Yes Burn No No RHC Banna Yes Yes Yes Multiple methods No Yes BHU Barocha No No No Thrown No No BHU Batamori Yes Yes Yes Multiple methods No Yes BHU Bateela Yes No No Burn No No BHU Batlay Yes No Yes Multiple methods No No BHU Battian No No Yes Burn No No BHU Charbagh Yes No Yes Multiple methods No No BHU Gantar Burn No BHU Garhi Nawab Said Yes Yes Yes Burn No No BHU Hutal Batkool No Yes No Burn No No BHU Jambera Yes No No Burn No No BHU Joz No Yes Yes Multiple methods No No BHU Kanai Yes Yes No Burn No No BHU Kathora No No Yes Thrown No No BHU Khairabad Yes Yes No Multiple methods No No BHU Kharari No No Yes Burn No No BHU Kuz tandol Yes Yes No Buried No No RHC Kuza Banda Yes Yes Yes Burn No No BHU Pagora No No No Burn No No BHU Paimal Sharif Yes Yes No Burn No No BHU Pashtoo Yes Yes Yes Burn No No BHU Pomong No Yes No Burn No No BHU Rashang Yes Yes No Burn Yes No BHU Sakkar Gah No No Yes Thrown No No BHU Shumlai Yes Yes Yes Multiple methods No Yes BHU Shungli Payeen Yes Yes Yes Burn No No BHU Talous No No No Burn No No

58 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 4.3: Staff posted at health facility in District Battagram

Dispensar/ Male Facility Name Male MO Female MO LHV EPI tech technician BHU Arghashori No No Yes Yes Yes RHC Banna Yes Yes Yes Yes Yes BHU Barocha No No Yes Yes Yes BHU Batamori Yes Yes Yes Yes Yes BHU Bateela No No Yes No Yes BHU Batlay No No Yes Yes Yes BHU Battian Yes Yes Yes Yes Yes BHU Charbagh No No Yes Yes No BHU Gantar No No Yes No No BHU Garhi Nawab Said Yes Yes Yes No No BHU Hutal Batkool Yes No Yes Yes Yes BHU Jambera No No Yes No Yes BHU Joz No No Yes No No BHU Kanai Yes No Yes No Yes BHU Kathora No No Yes No No BHU Khairabad No No Yes No No BHU Kharari Yes Yes Yes Yes Yes BHU Kuz tandol No No Yes No No RHC Kuza Banda Yes No Yes Yes Yes BHU Pagora No No Yes Yes No BHU Paimal Sharif No No Yes No Yes BHU Pashtoo No No Yes No No BHU Pomong No No Yes No No BHU Rashang No No Yes Yes Yes BHU Sakkar Gah No No Yes No No BHU Shumlai Yes Yes Yes No Yes BHU Shungli Payeen Yes Yes Yes Yes Yes BHU Talous No No Yes No No

59 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 4.4: Services provided at health facilities in District Battagram

ANC & Deliveries Family Routine Minor TB Time to referral Facility Name OPD IPD PNC conducted Planning EPI surgery management hospital BHU Arghashori Yes No Yes Yes Yes Yes Yes No 15 RHC Banna Yes Yes Yes Yes Yes Yes Yes Yes 120 BHU Barocha Yes No Yes No Yes Yes No No 120 BHU Batamori Yes No Yes Yes Yes Yes Yes Yes 60 BHU Bateela Yes No No No No Yes Yes No 180 BHU Batlay Yes No Yes Yes Yes Yes Yes Yes 120 BHU Battian Yes No No Yes Yes Yes Yes No 120 BHU Charbagh Yes No No No Yes Yes Yes Yes 30 BHU Gantar No No No No No No Yes No 120 BHU Garhi Nawab Said Yes No Yes Yes Yes Yes Yes Yes 720 BHU Hutal Batkool Yes No Yes Yes Yes Yes Yes No 45 BHU Jambera Yes No No No Yes Yes No No 240 BHU Joz Yes No Yes Yes Yes Yes Yes No 120 BHU Kanai Yes No No No No No Yes No 60 BHU Kathora Yes No No No No Yes Yes No 120 BHU Khairabad Yes Yes No No No Yes Yes Yes 60 BHU Kharari Yes No Yes Yes Yes Yes Yes Yes 60 BHU Kuz tandol Yes No No No No Yes Yes No 60 RHC Kuza Banda Yes Yes Yes Yes Yes Yes Yes Yes 30 BHU Pagora Yes Yes Yes Yes Yes No Yes Yes 15 BHU Paimal Sharif Yes No No No Yes Yes Yes No 60 BHU Pashtoo Yes No No No No Yes Yes Yes 35 BHU Pomong Yes No No No Yes No Yes No 120 BHU Rashang Yes Yes Yes Yes Yes Yes Yes No 15 BHU Sakkar Gah Yes No No No No No Yes No 60 BHU Shumlai Yes Yes Yes No Yes Yes Yes No 200 BHU Shungli Payeen Yes Yes Yes Yes Yes Yes Yes No 30 BHU Talous Yes Yes Yes Yes Yes No Yes Yes 10

60 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 4.5: Status of equipment and reporting at health facilities in District Battagram

Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Arghashori Averagely equipped Yes Yes Average RHC Banna Averagely equipped Yes Yes Average BHU Barocha Poorly equipped Yes No Poor BHU Batamori Well equipped Yes Yes Average BHU Bateela Poorly equipped Yes Yes Poor BHU Batlay Averagely equipped Yes Yes Poor BHU Battian Well equipped Yes Yes Well maintained BHU Charbagh Averagely equipped No Yes Poor BHU Gantar Poorly equipped No No Poor BHU Garhi Nawab Said Poorly equipped Yes Yes Average BHU Hutal Batkool Averagely equipped Yes Yes Poor BHU Jambera Poorly equipped No No Poor BHU Joz Poorly equipped No No Poor BHU Kanai Poorly equipped Yes Yes Poor BHU Kathora Poorly equipped Yes Yes Poor BHU Khairabad Poorly equipped No Yes Poor BHU Kharari Averagely equipped Yes Yes Poor BHU Kuz tandol Poorly equipped No Yes Poor RHC Kuza Banda Averagely equipped Yes Yes Average BHU Pagora Averagely equipped Yes Yes Average BHU Paimal Sharif Averagely equipped Yes Yes Poor BHU Pashtoo Poorly equipped Yes Yes Poor BHU Pomong Poorly equipped Yes Yes Poor BHU Rashang Averagely equipped Yes Yes Poor BHU Sakkar Gah Poorly equipped Yes No Poor BHU Shumlai Averagely equipped Yes Yes Poor BHU Shungli Payeen Well equipped Yes Yes Average BHU Talous Poorly equipped Yes Yes Poor

61 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

5. District Mansehra

62 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 5.1: Public Health Facilities Assessed in District Mansehra

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle

BHU Arbora Arbora Oghi Oghi 34.4625000 73.0583330 11000 All vehicles BHU Attarsheesha Attarsheesha Attarsheesha Mansehra 34.3955700 73.3007300 11000 All vehicles Hospitals Baffa baffa baffa Mansehra 34.4333330 73.2366670 50000 All vehicles Hospitals Balakot balakot Balakot balakot 34.5467000 73.3502300 40000 All vehicles BHU Bandi parao Bandi parao Karori Oghi 34.4327780 72.9191670 All vehicles BHU Baobandi baobandi Jallu Mansehra 34.3227778 73.1002778 15000 All vehicles BHU Bartooni Bartooni Kaladhaka Oghi 34.7028056 72.9410000 5945 4 X 4 only Hospitals Battal Battal Battal Mansehra 34.5830833 73.1448667 30000 All vehicles BHU Behali Behali Behali Behali 34.2568083 73.1699528 14000 All vehicles BHU Belian Belian Belian Oghi 34.5258100 72.9838300 8000 All vehicles BHU Bher Kund Bher Kund Bher Kund Mansehra 34.3918167 73.1459833 33301 All vehicles BHU Chakal Kajla Nika pani Oghi 34.4193889 72.8335667 3000 All vehicles BHU Chandur Chandur Lassan Nawab Mansehra 34.2625000 72.9138889 4000 All vehicles RHC Chattar Plane Chattar Plane Chattar Plane Mnasehra 34.6114167 73.1208500 15000 All vehicles RHC Choki Shoukatabad Shauaktabad 34.4511110 73.1316670 30000 All vehicles BHU Danda Shingaldar Shingaldar Kaladhaka Oghi 34.3800000 72.8900000 10000 By foot only Hospitals Darband New Darband New Darband Oghi 34.3291670 72.8669440 30000 All vehicles BHU Darbani darbani Kaladhaka Oghi 34.5544722 72.8240000 7500 4 X 4 only BHU Datta Datta Mansehra Mansehra 34.2875333 73.2503833 8000 All vehicles BHU Dheryal Dheryal Sumalahimung Mansehra 34.5083420 73.2664600 19000 4 X 4 only BHU Dilbori Dilbori Dilbori Oghi 34.5624333 72.9968667 30000 All vehicles BHU Doga Doga Karnol balakot 34.3754333 73.3390000 15000 4 X 4 only BHU Dure Mera Kablay Kaladhaka Oghi 34.7606944 72.8376389 10000 All vehicles BHU Gali Badral Gali Badral Shergharh Oghi 34.4183500 73.0202000 8000 4 X 4 only BHU Gandhian gandhian hinayatabad Mansehra 34.3922833 73.2118000 20000 All vehicles Hospital Gari habibullah Gari habibullah Gari habibullah Balakot 34.4012000 73.3776200 30000 All vehicles BHU Hangrai Hangrai Hangrai Balakot 34.6348611 73.3684000 15000 4 X 4 only

63 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle

BHU Hillkot Hillkot Hillkot Mansehra 34.6166670 73.1666670 5000 4 X 4 only BHU Jaba Jaba Attarsheesh Mansehra 34.4239800 73.3117800 8500 By foot only BHU Jabori Jabori Jabori Mansehra 34.6083330 73.2750000 18000 All vehicles BHU Jabri Shohal Kalesh Jabri Mazullah Balakot 34.4715222 73.3795972 6000 4 X 4 only BHU Jared Jared Mohandari Balakot 34.6761700 73.5564700 By foot only BHU Jhalgali Jhalgali Battal Battal 34.6001944 73.2676667 10000 4 X 4 only BHU Judbah Judbah Kaladhaka Oghi 34.6001389 72.8063611 2000 4 X 4 only BHU Kabbal Lamma Chakal Khatai Oghi 34.5544444 73.0646944 7000 4 X 4 only Hospitals Kaghan Mori pura kaghan Balakot 34.7799389 73.5219889 7000 All vehicles BHU Kamiser Mangri Kaladhaka Oghi 34.6565000 72.9446667 5366 4 X 4 only BHU Kandar Shagai Shagai Kaladhaka Oghi 34.6770000 72.8110833 1639 4 X 4 only BHU Karori karori karori Oghi 34.3958700 72.9445200 1000 All vehicles BHU Kawai Kawai Kawai Balakot 34.6327000 73.4441700 1800 All vehicles BHU Khathai Khathai Khathai Oghi 34.5236110 73.0847220 18000 All vehicles RHC Khawari Khawari Lassan Thakral Mansehra 34.2633333 73.1275000 15000 All vehicles BHU Kot gali Kot gali Satbani Balakot 34.6076611 73.3558806 14000 By foot only Thanda BHU Kotli Bala Kotli Bala Tehrian Mansehra 34.5166670 73.2166670 32601 All vehicles RHC Lassan Nawab Lassan Nawab Lassan Nawab Mansehra 34.2727778 72.9770000 All vehicles BHU Lassan Thakral Lassan Thakral Lassan Thakral Mansehra 34.2681667 73.0749333 800 All vehicles BHU Mohandri mohandri jared Balakot 34.6964100 73.5769600 4 X 4 only BHU Mohar Mohar Sawan Mera Mansehra 34.3162889 72.9591750 6000 4 X 4 only BHU Nambal Nambal karori Oghi 34.4207400 72.9471600 6000 4 X 4 only BHU Naran Naran kaghan Balakot 34.9080580 73.6541170 5000 All vehicles Hospitals Nawazabad Nawazabad Sucha Kala Mansehra 34.6455500 73.2281500 10000 All vehicles Hospitals Oghi Oghi Oghi Oghi 34.5040000 73.0167500 50000 All vehicles RHC Oghi Oghi Oghi Oghi 34.5001167 73.0265167 40000 All vehicles BHU Pairan Pairan Pairan Mansehra 34.3360333 73.3109500 10800 4 X 4 only

64 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle Khairabad Khairabad Kahirabad BHU Panjool Panjool Panjool Mansehra 34.6572500 73.2512833 5000 4 X 4 only BHU Panuderi Panu Dheri Hamshiria Mansehra 34.3598300 73.1972000 14597 All vehicles BHU Paras Paras Kawai Balakot 34.6610800 73.4545000 2000 By foot only BHU Parehna Parehna Parehna Mansehra 34.3619200 73.0925400 12000 All vehicles BHU Phulra Phulra Phulra Mansehra 34.3333330 73.0500000 20125 All vehicles BHU Plosa Plosa Kaladhaka Oghi 34.5093889 72.8372500 7000 4 X 4 only BHU Rajwal Rajwal kaghan Balakot 34.8212556 73.5182833 7000 By foot only BHU Sachan Kalan Sacha Kalan Sacha Kalan Mansehra 34.6175139 73.2361000 15000 All vehicles BHU Sandesar Sandesar Sandesar Mansehra 34.3694200 73.2663100 16500 All vehicles BHU Sangarh Sangarh Ghanool Balakot 34.5813333 73.3763361 13000 4 X 4 only BHU Shergarh Shergarh Shergarh Oghi 34.4500000 72.9833333 22000 All vehicles RHC Shinkyari shinkyari shinkyari Mansehra 34.4666670 73.2833330 45000 All vehicles BHU Shungli bandi Shungli bandi Shungli bandi Oghi 34.4824500 72.9357800 By foot only BHU Sohal Sohal Balakot Balakot 34.4790833 73.3499667 15000 All vehicles BHU Talhatta Talhatta Talhatta Balakot 34.4500000 73.3666670 16000 All vehicles BHU Tarangari Tarangari Tarangari Mansehra 34.4357800 73.1624100 25000 All vehicles BHU Trappi Trappi Sawan Merah Mansehra 34.2972222 73.0655556 15771 All vehicles

65 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 5.2: Provision of utilities at public health facilities in District Mansehra

Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance BHU Arbora Yes Yes Yes Buried No No BHU Attarsheesha No Yes Yes Burn No Yes Hospitals Baffa Yes Yes Yes Burn Yes Yes Hospitals Balakot Yes Yes Yes Thrown Yes Yes BHU Bandi parao Yes Yes No Thrown No No BHU Baobandi Yes No Yes Burn No No BHU Bartooni Yes No No Thrown No No Hospitals Battal Yes No No Thrown Yes Yes BHU Behali No No Yes Burn Yes No BHU Belian Yes Yes Yes Buried No No BHU Bher Kund Yes No Yes Burn No No BHU Chakal No Yes Yes Burn No No BHU Chandur Yes No No Buried No No RHC Chattar Plane Yes Yes Yes Burn Yes Yes RHC Choki Yes Yes Yes Burn No Yes BHU Danda Shingaldar No No No Burn No No Hospitals Darband Yes Yes Yes Burn Yes No BHU Darbani Yes Yes Yes Burn No No BHU Datta Yes Yes Yes Burn No No BHU Dheryal Yes Yes Yes Burn No No BHU Dilbori Yes No Yes Burn No Yes BHU Doga No No Yes Burn No No BHU Dure Mera No Yes Yes Burn No No BHU Gali Badral Yes Yes Yes Burn No No BHU Gandhian Yes No Yes Burn No No Hospitals Gari habibullah Yes No Yes Burn Yes No BHU Hangrai Yes Yes Yes Thrown Yes No BHU Hillkot Yes Yes Yes Burn Yes No

66 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance BHU Jaba No Yes Yes Buried No No BHU Jabori No No Yes Burn Yes Yes BHU Jabri Kalesh Yes Yes Yes Burn Yes No BHU Jared Yes No No Thrown Yes No BHU Jhalgali No Yes Yes Burn No No BHU Judbah Yes Yes Yes Burn No No BHU Kabbal No No No Burn No No Hospitals Kaghan Yes Yes Yes Burn No Yes BHU Kamiser No No No Burn No No BHU Kandar Shagai No No No Burn No No BHU Karori Yes No No Burn No No BHU Kawai No Yes Yes Burn Yes Yes BHU Khathai No Yes Yes Burn No No RHC Khawari Yes No Yes Burn No No BHU Kot gali No No No Thrown No No BHU Kotli Bala Yes Yes Yes Burn No No RHC Lassan Nawab Yes Yes Yes Burn Yes No BHU Lassan Thakral Yes Yes Yes Burn No No BHU Mohandri No No No Buried No No BHU Mohar Yes No No Buried No No BHU Nambal Yes No No Thrown No No BHU Naran Yes Yes No Thrown No No Hospitals Nawazabad Yes Yes Yes Burn Yes Yes Hospitals Oghi No No Yes Burn No Yes RHC Oghi Yes Yes Yes Burn No Yes BHU Pairan Khairabad No No No Burn No No BHU Panjool No No No Burn Yes Yes BHU Panuderi Yes No Yes Buried No No BHU Paras Yes Yes No Thrown Yes No

67 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance BHU Parehna Yes Yes Yes Buried No No BHU Phulra Yes No Yes Burn No No BHU Plosa No No No Burn No No BHU Rajwal Yes Yes No Thrown No No BHU Sachan Kalan No No No Thrown Yes No BHU Sandesar No No Yes Burn No No BHU Sangarh Yes Yes Yes Burn No No BHU Shergarh Yes No Yes Burn Yes No RHC Shinkyari Yes Yes Yes Burn Yes No BHU Shungli bandi Yes No Yes Buried No No BHU Sohal No Yes Yes Buried No No BHU Talhatta No No Yes Burn No No BHU Tarangari No Yes Yes Burn No No BHU Trappi Yes Yes Yes Burn No No

68 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 5.3: Staff posted at health facility in District Mansehra

Dispensar/ Medical Facility Name Male MO Female MO LHV EPI tech technician BHU Arbora No No Yes Yes Yes BHU Attarsheesha Yes No Yes Yes Yes Hospitals Baffa Yes Yes No No Yes Hospitals Balakot Yes Yes No No Yes BHU Bandi parao No No Yes No No BHU Baobandi Yes No No No No BHU Bartooni No No No No No Hospitals Battal Yes No No Yes Yes BHU Behali No No No Yes No BHU Belian No No Yes Yes No BHU Bher Kund Yes No Yes Yes Yes BHU Chakal No No Yes No No BHU Chandur Yes No No No No RHC Chattar Plane Yes Yes Yes Yes Yes RHC Choki Yes Yes Yes Yes Yes BHU Danda Shingaldar No No Yes No No Hospitals Darband Yes No No No Yes BHU Darbani No No Yes No No BHU Datta Yes No No Yes Yes BHU Dheryal No No Yes Yes No BHU Dilbori Yes No Yes Yes Yes BHU Doga No No Yes Yes Yes BHU Dure Mera No No Yes No No BHU Gali Badral No No Yes Yes No BHU Gandhian Yes No Yes Yes Yes Hospitals Gari habibullah Yes Yes No Yes Yes BHU Hangrai Yes No Yes Yes No BHU Hillkot No No Yes No No BHU Jaba No No No Yes No BHU Jabori No No Yes No Yes

69 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Dispensar/ Medical Facility Name Male MO Female MO LHV EPI tech technician BHU Jabri Kalesh Yes Yes Yes No Yes BHU Jared No No Yes No No BHU Jhalgali No No Yes No No BHU Judbah Yes No Yes Yes Yes BHU Kabbal No No Yes No No Hospitals Kaghan Yes Yes Yes Yes Yes BHU Kamiser No No Yes No No BHU Kandar Shagai No No Yes No No BHU Karori Yes No No Yes No BHU Kawai Yes Yes Yes Yes Yes BHU Khathai Yes No Yes Yes No RHC Khawari No Yes Yes Yes Yes BHU Kot gali No No No No No BHU Kotli Bala No No Yes Yes Yes RHC Lassan Nawab Yes No Yes Yes Yes BHU Lassan Thakral Yes No No Yes Yes BHU Mohandri No No Yes No Yes BHU Mohar No No Yes No No BHU Nambal No No Yes No No BHU Naran Yes No Yes Yes No Hospitals Nawazabad No No No No Yes Hospitals Oghi Yes Yes Yes No No RHC Oghi Yes Yes No Yes Yes BHU Pairan Khairabad No No Yes Yes Yes BHU Panjool No No No Yes No BHU Panuderi No Yes Yes Yes Yes BHU Paras No No No No No BHU Parehna Yes No Yes Yes Yes BHU Phulra Yes No Yes No No BHU Plosa No No Yes No No BHU Rajwal Yes No No Yes No BHU Sachan Kalan No No No Yes No

70 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Dispensar/ Medical Facility Name Male MO Female MO LHV EPI tech technician BHU Sandesar Yes No Yes Yes Yes BHU Sangarh No No Yes No No BHU Shergarh Yes No No Yes Yes RHC Shinkyari Yes Yes Yes Yes Yes BHU Shungli bandi No No Yes Yes No BHU Sohal Yes No Yes Yes Yes BHU Talhatta Yes No No Yes Yes BHU Tarangari Yes No Yes No Yes BHU Trappi Yes No Yes Yes Yes

71 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 5.4: Services provided at health facilities in District Mansehra

Time to ANC & Deliveries Family Routine Minor TB Facility Name OPD IPD referral PNC conducted Planning EPI surgery management hospital BHU Arbora Yes No Yes Yes Yes Yes Yes Yes 45 BHU Attarsheesha Yes No Yes Yes Yes Yes Yes Yes 30 Hospitals Baffa Yes Yes Yes Yes Yes Yes Yes Yes 45 Hospitals Balakot Yes No No No No No No No 60 BHU Bandi parao No No No No No No No No 75 BHU Baobandi Yes No Yes Yes Yes Yes Yes Yes 30 BHU Bartooni No No No No No No No No 240 Hospitals Battal Yes Yes Yes Yes Yes Yes Yes Yes 60 BHU Behali Yes No No No Yes Yes No No 50 BHU Belian Yes No Yes No Yes Yes Yes No 120 BHU Bher Kund Yes No Yes Yes Yes Yes Yes Yes 30 BHU Chakal Yes No No No No No Yes No 120 BHU Chandur Yes No Yes Yes Yes No Yes No 30 RHC Chattar Plane Yes No Yes Yes Yes Yes Yes Yes 45 RHC Choki Yes No Yes Yes Yes Yes Yes Yes 45 BHU Danda Shingaldar Yes No No No No No Yes No 480 Hospitals Darband Yes Yes No No No Yes Yes Yes 180 BHU Darbani Yes No Yes Yes Yes No Yes No 300 BHU Datta Yes No Yes No Yes Yes Yes Yes 45 BHU Dheryal Yes No No No Yes Yes Yes Yes 90 BHU Dilbori Yes Yes Yes No Yes Yes Yes No 90 BHU Doga Yes No Yes No Yes Yes Yes No 30 BHU Dure Mera Yes No No No No No Yes No 150 BHU Gali Badral Yes No Yes Yes No No Yes No 90

72 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Time to ANC & Deliveries Family Routine Minor TB Facility Name OPD IPD referral PNC conducted Planning EPI surgery management hospital BHU Gandhian Yes No Yes Yes Yes Yes Yes Yes 30 Hospitals Gari habibullah Yes Yes Yes Yes Yes Yes Yes No 45 BHU Hangrai Yes No No No No Yes Yes No 30 BHU Hillkot Yes Yes Yes Yes Yes Yes Yes No 30 BHU Jaba Yes No Yes Yes Yes No Yes Yes 30 BHU Jabori Yes Yes Yes Yes Yes Yes Yes No 120 BHU Jabri Kalesh Yes No No No Yes Yes Yes No 90 BHU Jared No No No No No No No No 120 BHU Jhalgali Yes No No No Yes No Yes Yes 150 BHU Judbah Yes No Yes Yes Yes No Yes No 600 BHU Kabbal Yes No No No No No Yes No 240 Hospitals Kaghan Yes Yes Yes Yes Yes Yes Yes Yes 300 BHU Kamiser Yes No No No No No Yes No 210 BHU Kandar Shagai Yes No No No No No Yes No 600 BHU Karori Yes No Yes No Yes No Yes No 90 BHU Kawai Yes Yes Yes Yes No Yes Yes No 60 BHU Khathai Yes No Yes Yes Yes No Yes No 15 RHC Khawari Yes Yes Yes Yes Yes Yes Yes 0.00 60 BHU Kot gali No No No No No No No No 0 BHU Kotli Bala Yes No Yes Yes Yes Yes No Yes 15 RHC Lassan Nawab Yes Yes Yes Yes Yes Yes Yes Yes 120 BHU Lassan Thakral Yes No Yes Yes Yes Yes Yes Yes 60 BHU Mohandri Yes No No No No Yes Yes No 180 BHU Mohar Yes No No No No No No No 180 BHU Nambal Yes No No No No No No No 75 BHU Naran Yes No Yes Yes No No Yes No 30 Hospitals Nawazabad Yes Yes Yes Yes Yes Yes Yes No 120

73 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Time to ANC & Deliveries Family Routine Minor TB Facility Name OPD IPD referral PNC conducted Planning EPI surgery management hospital Hospitals Oghi Yes Yes Yes Yes Yes No Yes Yes 120 RHC Oghi Yes No Yes Yes Yes Yes Yes Yes 60 BHU Pairan Khairabad Yes No Yes 0.00 Yes Yes No Yes 90 BHU Panjool Yes Yes Yes No Yes No Yes No 150 BHU Panuderi Yes No Yes No Yes Yes Yes Yes 15 BHU Paras No No No No No No No No 180 BHU Parehna Yes No Yes Yes Yes Yes Yes Yes 90 BHU Phulra Yes Yes Yes Yes Yes Yes Yes Yes 45 BHU Plosa Yes No No No No No Yes No 240 BHU Rajwal Yes No No No Yes No No No 60 BHU Sachan Kalan No No No No No No No No 70 BHU Sandesar Yes Yes Yes Yes Yes Yes Yes Yes 30 BHU Sangarh Yes No No No Yes Yes Yes No 30 BHU Shergarh Yes No Yes Yes Yes Yes Yes No 90 RHC Shinkyari Yes Yes Yes Yes Yes Yes Yes Yes 45 BHU Shungli bandi Yes No Yes Yes Yes No Yes No 60 BHU Sohal Yes Yes Yes Yes Yes Yes Yes No 45 BHU Talhatta Yes No Yes Yes Yes Yes Yes Yes 20 BHU Tarangari Yes No No No Yes Yes Yes Yes 45 BHU Trappi Yes No Yes Yes Yes Yes Yes Yes 45

74 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 5.5: Status of equipment and reporting at health facilities in District Mansehra

Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Arbora Averagely equipped Yes No Average BHU Attarsheesha Averagely equipped Yes Yes Poor Hospitals Baffa Averagely equipped Yes Yes Well maintained Hospitals Balakot Poorly equipped Yes Yes Poor BHU Bandi parao Averagely equipped No No Average BHU Baobandi Averagely equipped Yes No Poor BHU Bartooni Poorly equipped No No Poor Hospitals Battal Well equipped Yes Yes Well maintained BHU Behali Averagely equipped Yes Yes Well maintained BHU Belian Poorly equipped Yes No Average BHU Bher Kund Averagely equipped Yes Yes Well maintained BHU Chakal Poorly equipped Yes No Poor BHU Chandur Poorly equipped Yes No Average RHC Chattar Plane Averagely equipped No No Poor RHC Choki Poorly equipped Yes Yes Poor BHU Danda Shingaldar Poorly equipped Yes No Poor Hospitals Darband Averagely equipped Yes Yes Average BHU Darbani Poorly equipped Yes No Poor BHU Datta Averagely equipped Yes Yes Well maintained BHU Dheryal Averagely equipped Yes Yes Average BHU Dilbori Averagely equipped Yes Yes Average BHU Doga Poorly equipped Yes Yes Average BHU Dure Mera Poorly equipped Yes Yes Poor BHU Gali Badral Poorly equipped Yes No Poor BHU Gandhian Poorly equipped Yes Yes Well maintained Hospitals Gari habibullah Well equipped Yes Yes Poor BHU Hangrai Poorly equipped Yes Yes Poor BHU Hillkot Averagely equipped Yes No Average BHU Jaba Poorly equipped Yes Yes Poor BHU Jabori Averagely equipped Yes Yes Well maintained BHU Jabri Kalesh Poorly equipped Yes Yes Poor

75 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Jared Averagely equipped No No Average BHU Jhalgali Poorly equipped Yes Yes Average BHU Judbah Poorly equipped Yes No Average BHU Kabbal Poorly equipped Yes No Poor Hospitals Kaghan Averagely equipped Yes No Poor BHU Kamiser Poorly equipped Yes No Poor BHU Kandar Shagai Poorly equipped Yes No Average BHU Karori Poorly equipped Yes No Average BHU Kawai Poorly equipped Yes No Poor BHU Khathai Averagely equipped Yes No Well maintained RHC Khawari Averagely equipped Yes Yes Average BHU Kot gali Poorly equipped No No Poor BHU Kotli Bala Averagely equipped Yes Yes Well maintained RHC Lassan Nawab Well equipped Yes Yes Well maintained BHU Lassan Thakral Poorly equipped Yes No Well maintained BHU Mohandri Poorly equipped Yes No Poor BHU Mohar Poorly equipped Yes No Poor BHU Nambal Averagely equipped No No Average BHU Naran Poorly equipped Yes Yes Poor Hospitals Nawazabad Averagely equipped Yes Yes Poor Hospitals Oghi Averagely equipped Yes Yes Average RHC Oghi Poorly equipped Yes Yes Average BHU Pairan Khairabad Poorly equipped Yes Yes Average BHU Panjool Poorly equipped Yes Yes Average BHU Panuderi Well equipped Yes Yes Well maintained BHU Paras Averagely equipped No No Average BHU Parehna Averagely equipped Yes Yes Well maintained BHU Phulra Averagely equipped No Yes Well maintained BHU Plosa Poorly equipped Yes Yes Poor BHU Rajwal Averagely equipped Yes No Poor BHU Sachan Kalan Poorly equipped No No Poor BHU Sandesar Averagely equipped Yes Yes Well maintained BHU Sangarh Averagely equipped Yes Yes Poor

76 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Reporting for Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Shergarh Well equipped Yes No Well maintained RHC Shinkyari Averagely equipped Yes Yes Average BHU Shungli bandi Poorly equipped Yes No Average BHU Sohal Averagely equipped Yes Yes Average BHU Talhatta Poorly equipped Yes Yes Poor BHU Tarangari Averagely equipped Yes Yes Average BHU Trappi Averagely equipped Yes Yes Well maintained

77 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

6. District Neelum

78 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 6.1: Public Health Facilities Assessed in District Neelum

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle BHU Ashkot Ashkot Ashkot Athmuqam 34.4761000 73.8306000 10407 4 X 4 only BHU Changa Changa Neelum Athmuqam 34.7194440 74.0625000 3612 All vehicles BHU Chilehana Chilehana Barrian Athmuqam 34.4004400 73.7732200 13470 All vehicles BHU Dowarian Dowarian Neelum Athmuqam 34.6937600 73.8845200 8000 All vehicles BHU Dudhniyal Dudhniyal Dudhniyal Athmuqam 34.7000000 74.1000000 10000 4 X 4 only BHU Halmat Halmat Halmat Glaise 34.7525000 74.6605600 All vehicles BHU Jagran Kundal Shahi Athmuqam 34.6227800 73.7663900 27000 All vehicles BHU Katha piran Katha piran Shahkot Athmuqam 34.5900000 73.9700000 5421 All vehicles Hospitals Kel Kel Kel Sharda 34.8216700 74.3466700 70000 All vehicles BHU Kel domel pain Kel domel pain Kel Sharda 34.8800000 74.3400000 4700 All vehicles BHU Kundal Shahi Kundal Shahi Kundal Shahi Athmuqam 34.5367500 73.8470100 5000 All vehicles BHU Kutton Kutton Kundal Shahi Athmuqam 34.5633400 73.8027000 2500 All vehicles BHU Lawat bala Lawat bala Neelum Athmuqam 34.7080600 73.9611100 10000 All vehicles BHU Lawat bore Lawat bore Neelum Neelum 34.7500000 73.9600000 9855 By foot only BHU Leswa Leswa Leswa Athmuqam 34.4625000 73.7939000 5300 All vehicles BHU Mirpura Mirpura Mirpura Athmuqam 34.4457900 73.8162800 12244 4 X 4 only BHU Nagdar Nagdar Neelum Athmuqam 34.6825000 73.8016700 20000 4 X 4 only BHU Neelum Neelum Neelum Athmuqam 34.6638900 73.9402800 4 X 4 only Hospitals Neelum Athmuqam Athmuqam Shahkot 34.6638900 73.9600000 100000 All vehicles RHC Sharda Sharda Sharda Sharda 34.7922200 74.1913900 16338 All vehicles BHU Surgun Surgun Sharda Sharda 34.8666670 74.2166670 6619 All vehicles

79 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 6.2: Provision of utilities at public health facilities in District Neelum

Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance

BHU Ashkot Yes Yes No Multiple methods No No BHU Changa Yes No No Thrown No No BHU Chilehana Yes No Yes Burn No No BHU Dowarian Yes Yes Yes Thrown No No BHU Dudhniyal Yes Yes No Thrown No No BHU Halmat No Yes Yes Burried No Yes BHU Jagran Yes Yes Yes Burn No No BHU Katha piran Yes Yes Yes Multiple methods No No Hospitals Kel Yes Yes Yes Thrown No Yes BHU Kel domel pain No Yes No Burried No No BHU Kundal Shahi Yes Yes Yes Thrown No Yes BHU Kutton Yes No No Multiple methods No No BHU Lawat bala Yes No No Burn No No BHU Lawat bore No No No Thrown No No BHU Leswa Yes Yes Yes Burn No No BHU Mirpura Yes Yes Yes Multiple methods No No BHU Nagdar No No No Thrown No No BHU Neelum No No Yes Thrown No No Hospitals Neelum Yes Yes Yes Multiple methods No Yes RHC Sharda Yes No No Burried No No BHU Surgun No No No Burried No No

80 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 6.3: Staff posted at health facility in District Neelum

Dispensar/Medical Facility Name Male MO Female MO LHV EPI tech Technician

BHU Ashkot No No Yes No No BHU Changa No No Yes Yes No BHU Chilehana No No Yes Yes Yes BHU Dowarian Yes No Yes No Yes BHU Dudhniyal No No Yes Yes No BHU Halmat Yes No No No No BHU Jagran No No Yes No No BHU Katha piran No No Yes No No Hospitals Kel Yes No Yes No No BHU Kel domel pain No No Yes No No BHU Kundal Shahi Yes No Yes Yes Yes BHU Kutton No No Yes No No BHU Lawat bala No No Yes Yes Yes BHU Lawat bore No No Yes No No BHU Leswa No No Yes Yes No BHU Mirpura Yes No Yes No No BHU Nagdar No No Yes No No BHU Neelum No No Yes No No Hospitals Neelum Yes No Yes Yes Yes RHC Sharda Yes No Yes Yes No BHU Surgun No No Yes No No

81 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 6.4: Services provided at health facilities in District Neelum

Time to ANC & Deliveries Family Routine Minor TB Facility Name OPD IPD referral PNC conducted Planning EPI surgery management hospital BHU Ashkot Yes No No No No Yes Yes No 30 BHU Changa Yes No No No Yes No Yes Yes 180 BHU Chilehana Yes No No No No No Yes No 60 BHU Dowarian Yes No No No No Yes No Yes 120 BHU Dudhniyal Yes No Yes No Yes Yes Yes No 120 BHU Halmat Yes No No No No No Yes No 180 BHU Jagran Yes No No No No No Yes No 150 BHU Katha piran Yes Yes No No No No Yes No 90 Hospitals Kel Yes Yes No No Yes Yes Yes Yes 420 BHU Kel domel pain Yes No No No No No Yes No 180 BHU Kundal Shahi Yes No Yes Yes Yes Yes No Yes 20 BHU Kutton Yes No No No No No No No 45 BHU Lawat bala Yes No Yes No Yes Yes Yes No 240 BHU Lawat bore Yes No No No No No No No 60 BHU Leswa Yes No Yes No Yes Yes Yes Yes 45 BHU Mirpura Yes No No No Yes Yes No Yes 30 BHU Nagdar Yes No No No No Yes Yes No 240 BHU Neelum Yes No No No No Yes No No 25 Hospitals Neelum Yes Yes Yes Yes Yes Yes Yes Yes 45 RHC Sharda Yes No Yes Yes Yes Yes Yes Yes 120 BHU Surgun Yes No No No No Yes No Yes 240

82 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 6.5: Status of equipment and reporting at health facilities in District Neelum

Reporting to Monthly Facility Name Status of equipment Reporting to DEWS Status of reporting tools HMIS BHU Ashkot Averagely equipped Yes No Average BHU Changa Poorly equipped Yes Yes Average BHU Chilehana Averagely equipped Yes No Poor BHU Dowarian Averagely equipped Yes No Average BHU Dudhniyal Poorly equipped Yes Yes Average BHU Halmat Averagely equipped No No Well maintained BHU Jagran Poorly equipped No No Poor BHU Katha piran Poorly equipped No Yes Poor Hospitals Kel Well equipped Yes No Average BHU Kel domel pain Poorly equipped No Yes Poor BHU Kundal Shahi Averagely equipped Yes Yes Average BHU Kutton Poorly equipped Yes Yes Poor BHU Lawat bala Poorly equipped Yes Yes Average BHU Lawat bore Poorly equipped Yes Yes Poor BHU Leswa Averagely equipped Yes No Average BHU Mirpura Averagely equipped Yes Yes Poor BHU Nagdar Poorly equipped Yes Yes Poor BHU Neelum Poorly equipped Yes Yes Poor Hospitals Neelum Averagely equipped Yes Yes Average RHC Sharda Averagely equipped Yes Yes Well maintained BHU Surgun Poorly equipped Yes Yes Poor

83 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

7. District Shangla

84 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 7.1: Public Health Facilities Assessed in District Shangla

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle Mala Khel BHU Amnovi Maroof Khail Kotkay Alpuri 34.8239300 72.6035800 11366 4 X 4 only Hospitals Bisham Bisham Butial Alpuri 34.9226600 72.8769200 36072 All vehicles Hospitals Chakesar Chakesar Chakesar 34.7865300 72.7701000 80000 All vehicles BHU Chichloo Chichloo Ranial Alpuri 34.9192800 72.7828600 6000 By foot only BHU Chowga Chowga Chowga Puran 34.6993300 72.6596800 12000 All vehicles BHU Damorai Damorai Damorai Alpuri 34.9860400 72.7441900 19000 All vehicles BHU Gunangar Ghunagar Sarkol Chakesar 34.7710600 72.8491100 10000 By foot only BHU Kabal Gram Kabal Gram Martung Khas Martung 34.6488100 72.7970600 20000 4 X 4 only Hospitals Karora Karora Opal Alpuri 34.8905000 72.7635900 40000 All vehicles BHU Katkor Jauzan Buneer Wall Alpuri 34.7885200 72.7138100 10500 All vehicles BHU Kuz kana Kuz kana Kuz kana Alpuri 34.9263900 72.7527900 13000 All vehicles BHU Maira Saria Maira Maira Bisham 34.8372700 72.9904200 52500 All vehicles BHU Martung Martung Martung Khas Martung 34.6811400 72.7494400 19000 All vehicles BHU Olandar Olandar Pir khana Alpuri 35.0443300 72.7469600 31000 All vehicles BHU Opal Chidam Opal Chakesar 34.8596400 72.8062900 15000 By foot only Hospitals Puran Aluch Aluch Puran 34.7390500 72.6833900 100000 All vehicles BHU Shalizara Shalizara Lilowlay Alpuri 34.9844900 72.6400700 12000 4 X 4 only BHU Titwalan Titwalan Bahalol Khel Martung 34.6183800 72.7240100 20475 All vehicles BHU Towa Towa Puran Puran 34.7956500 72.6802400 7000 All vehicles

85 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 7.2: Provision of utilities at public health facilities in District Shangla

Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance

BHU Amnovi No No No Burn No No Hospitals Bisham No No No Multiple methods No No Hospitals Chakesar No Yes Yes Thrown No Yes BHU Chichloo No No No Burn No No BHU Chowga No Yes No Thrown No No BHU Damorai No No Yes Burn No No BHU Gunangar No Yes Yes Thrown No No BHU Kabal Gram No No No Thrown No No Hospitals Karora No Yes No Multiple methods No No BHU Katkor No No No Thrown No No BHU Kuz kana Yes No Yes Burried No Yes BHU Maira No No No Thrown No No BHU Martung No Yes No Burn No No BHU Olandar Yes Yes No Multiple methods No No BHU Opal Yes Yes No Thrown No No Hospitals Puran Yes Yes Yes Multiple methods No Yes BHU Shalizara No No No Burn No No BHU Titwalan No Yes No Thrown No No BHU Towa Yes Yes Yes Multiple methods No No

86 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 7.3: Staff available at facility at time of visit in District Shangla

Dispensar/ Medical Facility Name Male MO Female MO technician LHV Epi Technician BHU Amnovi Yes No Yes Yes Yes Hospitals Bisham Yes Yes Yes Yes Yes Hospitals Chakesar Yes No Yes Yes Yes BHU Chichloo No No Yes Yes Yes BHU Chowga Yes No Yes Yes Yes BHU Damorai No No Yes Yes Yes BHU Gunangar No No Yes No No BHU Kabal Gram Yes No Yes Yes Yes Hospitals Karora Yes No Yes Yes Yes BHU Katkor No No Yes No Yes BHU Kuz kana Yes No Yes Yes Yes BHU Maira Yes No Yes No Yes BHU Martung Yes No Yes No Yes BHU Olandar No No Yes Yes Yes BHU Opal No No Yes Yes No Hospitals Puran Yes No Yes Yes Yes BHU Shalizara Yes No No No No BHU Titwalan No No Yes Yes No BHU Towa Yes No Yes Yes Yes

87 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 7.4: Services provided at health facilities in District Shangla

Time to Facility ANC & Deliveries Family Routine Minor TB OPD IPD referral Name PNC conducted Planning EPI surgery management hospital BHU Amnovi Yes No Yes No Yes Yes Yes No 360 Hospitals Bisham Yes No Yes Yes Yes Yes Yes Yes 300 Hospitals Chakesar Yes Yes Yes Yes Yes Yes Yes Yes 122 BHU Chichloo Yes No Yes Yes Yes Yes Yes Yes 180 BHU Chowga Yes No Yes No Yes Yes Yes No 45 BHU Damorai Yes No Yes Yes Yes Yes Yes No 360 BHU Gunangar Yes Yes No No Yes No Yes No 45 BHU Kabal Gram Yes No Yes Yes Yes Yes Yes No 360 Hospitals Karora Yes Yes No Yes Yes Yes Yes Yes 24 BHU Katkor Yes No No No No Yes No No 120 BHU Kuz kana Yes No Yes Yes Yes Yes No No 390 BHU Maira Yes Yes Yes Yes Yes Yes Yes No 45 BHU Martung Yes Yes Yes Yes Yes Yes Yes No 300 BHU Olandar Yes No Yes Yes Yes Yes No No 420 BHU Opal Yes No No No No Yes Yes No 240 Hospitals Puran Yes Yes No No Yes Yes Yes Yes 240 BHU Shalizara Yes No Yes No Yes No Yes Yes 60 BHU Titwalan Yes No Yes Yes Yes No Yes No 240 BHU Towa Yes No Yes Yes Yes Yes Yes No 40

88 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 7.5: Status of equipment and reporting at health facilities in District Shangla

Reporting for monthly Facility Name Status of equipment HMIS Reporting to DEWS Status of reporting tools BHU Amnovi Averagely equipped Yes Yes Poor Hospitals Bisham Poorly equipped Yes Yes Poor Hospitals Chakesar Averagely equipped Yes No Well maintained

BHU Chichloo Averagely equipped Yes No Poor BHU Chowga Poorly equipped Yes No Average BHU Damorai Averagely equipped Yes No Average

BHU Gunangar Averagely equipped Yes No Poor BHU Kabal Gram Averagely equipped Yes No Average Hospitals Karora Poorly equipped Yes Yes Average BHU Katkor Poorly equipped Yes No Poor

BHU Kuz kana Averagely equipped Yes Yes Poor BHU Maira Averagely equipped Yes No Poor BHU Martung Averagely equipped Yes No Average BHU Olandar Averagely equipped Yes No Average BHU Opal Poorly equipped Yes No Poor Hospitals Puran Averagely equipped Yes No Average BHU Shalizara Poorly equipped Yes No Poor BHU Titwalan Averagely equipped Yes No Average BHU Towa Poorly equipped Yes No Poor

89 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006

8. District Kohistan

90 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 8.1: Public Health Facilities Assessed in District Kohistan

Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle BHU Baja Baja Bariyar Dassu 35.1722200 73.2555600 11000 By foot only BHU Baneel Baneel Sigayon Pattan 35.1327800 72.9763900 14797 4 X 4 only BHU Bankad Bankad Bankad Pattan 35.1800000 72.8200000 14700 By foot only BHU Bar Sheryal Maidan Bar Sheryal Palas 34.9800000 73.1100000 25000 By foot only BHU Baryar Baryar Baryar Dassu 35.1708300 73.3916700 3000 By foot only BHU Battara Battara Battara Palas 34.9476100 72.8852400 14000 4 X 4 only RHC Dassu Dassu Dassu Dassu 35.2699800 73.2224700 125000 All vehicles BHU Doga Doga K Parwa Dassu 35.3027800 73.0986100 3500 By foot only BHU Dubair Bala Dubair Bala Dobair Khas Pattan 35.1438600 72.9116100 25000 4 X 4 only BHU Gabral Gabral Gabral Dassu 35.5591667 72.8855556 30000 By foot only BHU Goshali Goshali Goshali Dassu 35.2263900 73.2069400 16726 By foot only BHU Harban Harban kote Harban Dassu 35.5041700 73.6069400 17400 4 X 4 only BHU Jalkot Jalkot Kuz Jalkot Dassu 35.2472000 73.2124000 4000 4 X 4 only BHU Jashoi Jashoi Kareen Dassu 35.4529000 73.0629000 14000 4 X 4 only BHU Jijal Jijal Jijal Pattan 35.0408300 72.9253400 15000 All vehicles BHU Jog Jog Dobair Khas Pattan 35.1084000 72.9325600 70000 All vehicles BHU Karang Karang Karang Dassu 35.4763900 72.9661100 15000 4 X 4 only BHU Kayal Kayal Kayal Pattan 35.1617600 73.0296200 16229 4 X 4 only BHU Kheel Kheel Kheel Palas 35.0611100 73.0911100 7850 By foot only BHU Kolai Batangi Palas 35.0501100 72.9692200 16000 4 X 4 only BHU Kuz paro Kuz paro Kuz paro Palas 35.0522200 73.1227800 9370 By foot only BHU Mahreen Mehreen D M Kheel Palas 35.0307400 72.9353300 7000 4 X 4 only BHU Majgali Majgali Dubair bala Pattan 35.1763700 72.9081900 12000 4 X 4 only BHU Mandrazu Mandrazu Kyad Pattan 35.2233500 73.1512300 16229 By foot only BHU Mani Khel Bela Bella Ranolia Pattan 35.2100000 72.8100000 14092 By foot only RHC Pattan Pattan Pattan Pattan 35.1069600 73.0024900 60000 All vehicles BHU Peech Bela Peech Bela Peech Bela Palas 34.9958300 73.3180600 18715 By foot only BHU Ranolia Ranolia Jijal Pattan 35.0490700 72.8911500 8000 All vehicles BHU Razika Seo Razika Sigloo Dassu 35.3061100 73.1227800 14890 By foot only BHU Sargari Khar Kareen Dassu 35.4625000 73.1336100 2500 By foot only BHU Seo Seo Seo Dassu 35.3067100 73.1888900 10000 4 X 4 only BHU Shalakanabad Shalakanabad Shalakanabad Palas 35.1143200 73.0233900 5000 4 X 4 only

91 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Catchment Accessibility Facility Name Village Union Council Tehsil Latitude Longitude Population by vehicle BHU Sharaid Sharaid Sharaid Palas 35.0600000 73.2000000 16683 4 X 4 only RHC Shatyal Shatyal Sazin Dassu 35.5284000 73.5439800 100000 All vehicles BHU Soyal dara Soyal Kareen Dassu 35.4194400 73.0938900 4500 By foot only BHU Thooti Thooti Thooti Dassu 35.4702400 73.1526600 12000 4 X 4 only

92 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 8.2: Provision of utilities at public health facilities in District Kohistan

Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance BHU Baja No No No Thrown No No BHU Baneel Yes No No Multiple methods No No BHU Bankad Yes Yes No Multiple methods No No BHU Bar Sheryal Yes No No Thrown No No BHU Baryar No No No Thrown No No BHU Battara Yes No No Burried No No RHC Dassu Yes Yes Yes Burn No Yes BHU Doga Yes No No Thrown No No BHU Dubair Bala No No No Thrown No Yes BHU Gabral Yes No No Thrown No No BHU Goshali No No No Thrown No No BHU Harban Yes No No Multiple methods No No BHU Jalkot No No No Thrown No No BHU Jashoi No No Yes Burn No No BHU Jijal No No No Burried No No BHU Jog No No No Burried No No BHU Karang Yes Yes No Thrown No No BHU Kayal No No No Multiple methods No No BHU Kheel Yes No No Multiple methods No No BHU Kolai Yes No No Thrown No No BHU Kuz paro No No No Multiple methods No No BHU Mahreen Yes No No Multiple methods No No BHU Majgali No No No Burn No No BHU Mandrazu No No No Burn No No BHU Mani Khel Yes No No Thrown No No Bela RHC Pattan Yes Yes Yes Burn No Yes BHU Peech Bela Yes No No Multiple methods No No BHU Ranolia No No No Multiple methods No No BHU Razika No No No Multiple methods No No BHU Sargari Yes No No Thrown No No BHU Seo No No No Multiple methods No No

93 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Toilet Water Supply Electricity Post EQ Access to Facility Name Waste Disposal functioning present present construction Ambulance

BHU No Yes No Thrown No No Shalakanabad BHU Sharaid No No No Multiple methods No No RHC Shatyal Yes No No Burried No No BHU Soyal dara No No No Burried No No BHU Thooti No No No Burried No No

94 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 8.3: Staff posted at health facility in District Kohistan

Dispensar/ Medical Facility Name Male MO Female MO LHV EPI Technician technician BHU Baja No No No No Yes BHU Baneel No No Yes No Yes BHU Bankad No No Yes No Yes BHU Bar Sheryal No No No No No BHU Baryar No No No No Yes BHU Battara Yes No Yes No Yes RHC Dassu Yes No Yes Yes Yes BHU Doga No No Yes No Yes BHU Dubair Bala No No Yes No No BHU Gabral No No Yes No Yes BHU Goshali No No Yes No Yes BHU Harban No No Yes No Yes BHU Jalkot No No No No No BHU Jashoi No No Yes No No BHU Jijal No No Yes No No BHU Jog No No Yes No No BHU Karang No No Yes Yes Yes BHU Kayal No No Yes No Yes BHU Kheel No No Yes No Yes BHU Kolai No No Yes No Yes BHU Kuz paro No No Yes No Yes BHU Mahreen No No Yes No Yes BHU Majgali No No Yes No Yes BHU Mandrazu No No Yes No Yes BHU Mani Khel Bela No No Yes No Yes RHC Pattan Yes No Yes Yes Yes BHU Peech Bela No No Yes No Yes BHU Ranolia Yes No Yes No Yes BHU Razika No No Yes No Yes BHU Sargari No No Yes No Yes BHU Seo No No Yes No Yes BHU Shalakanabad No No Yes No Yes

95 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Dispensar/ Medical Facility Name Male MO Female MO LHV EPI Technician technician BHU Sharaid No No Yes No No RHC Shatyal Yes No Yes No No BHU Soyal dara No No No No Yes BHU Thooti Yes No No No Yes

96 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 8.4: Services provided at health facilities in District Kohistan

Time to Facility ANC & Deliveries Family Routine Minor TB OPD IPD referral Name PNC conducted Planning EPI surgery management hospital BHU Baja No No No No No Yes No No 80 BHU Baneel Yes No No No No Yes Yes No 45 BHU Bankad Yes No No No No Yes Yes No 180 BHU Bar No No No No No No No No 240 Sheryal BHU Baryar No No No No No Yes No No 60 BHU Battara Yes No Yes Yes No Yes No No 120 RHC Dassu Yes Yes Yes Yes Yes Yes Yes Yes 2 days BHU Doga Yes No No No No Yes No No 15 BHU Dubair Yes No Yes No No Yes No Yes 120 Bala BHU Gabral Yes No No No No Yes Yes No 360 BHU Goshali Yes No No Yes No No 25 BHU Harban Yes No No No No Yes Yes No 480 BHU Jalkot Yes No No No No Yes No No 60 BHU Jashoi Yes No No No No Yes No Yes 600 BHU Jijal Yes No No Yes No Yes No Yes 30 BHU Jog Yes No Yes No No Yes No Yes 45 BHU Karang Yes No Yes No No Yes No Yes 240 BHU Kayal Yes No No No No Yes Yes No 60 BHU Kheel Yes No No No No Yes Yes No 30 BHU Kolai No No No No No Yes No No 240 BHU Kuz Yes No Yes Yes Yes Yes No No 360 paro BHU Yes No No No No Yes Yes No 60 Mahreen BHU Majgali Yes No No No No Yes Yes No 720 BHU Yes No No No No Yes Yes No 300 Mandrazu BHU Mani Yes No No No No Yes Yes No 120 Khel Bela RHC Pattan Yes Yes Yes Yes Yes Yes Yes Yes 300

97 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Time to Facility ANC & Deliveries Family Routine Minor TB OPD IPD referral Name PNC conducted Planning EPI surgery management hospital BHU Peech Yes No No No Yes Yes No 3600 Bela BHU Ranolia Yes No Yes No No Yes Yes Yes 1 day BHU Razika Yes No No No No Yes Yes Yes 240 BHU Sargari Yes No No No No Yes Yes No BHU Seo Yes Yes Yes Yes No Yes No Yes 60 BHU Shalakanaba Yes No No No No Yes Yes Yes 60 d BHU Sharaid Yes No No No No Yes No No 60 RHC Shatyal Yes Yes Yes Yes Yes Yes Yes Yes 60 BHU Soyal Yes No No No No Yes Yes No 90 dara BHU Thooti Yes No No No No Yes Yes Yes 70

98 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006 Annex 8.5: Status of equipment and reporting at health facilities in District Kohistan

Reporting for monthly Facility Name Status of equipment HMIS Reporting to DEWS Status of reporting tools BHU Amnovi Averagely equipped Yes Yes Poor Hospitals Bisham Poorly equipped Yes Yes Poor Hospitals Chakesar Averagely equipped Yes No Well maintained

BHU Chichloo Averagely equipped Yes No Poor BHU Chowga Poorly equipped Yes No Average BHU Damorai Averagely equipped Yes No Average

BHU Gunangar Averagely equipped Yes No Poor BHU Kabal Gram Averagely equipped Yes No Average Hospitals Karora Poorly equipped Yes Yes Average BHU Katkor Poorly equipped Yes No Poor

BHU Kuz kana Averagely equipped Yes Yes Poor BHU Maira Averagely equipped Yes No Poor BHU Martung Averagely equipped Yes No Average BHU Olandar Averagely equipped Yes No Average BHU Opal Poorly equipped Yes No Poor Hospitals Puran Averagely equipped Yes No Average BHU Shalizara Poorly equipped Yes No Poor BHU Titwalan Averagely equipped Yes No Average BHU Towa Poorly equipped Yes No Poor

99 An assessment of public health facilities in Earthquake affected districts of Pakistan- 2006