[Compa ny name] Assessment Report- Health and Integrated Protection Needs in Kunduz Province
Dr. Noor Ahmad “Ahmad” Dr. Mirza Jan Hafiz Akbar Ahmadi Vijay Raghavan
Final Report
Acknowledgements The study team thank representatives of the following institutions who have met us in both Kabul and Kunduz during the assessment. WHO – Kabul and Kunduz; UNOCHA – Kunduz; MSF (Kunduz); UNHCR- Kunduz; Handicap International Kunduz; Provincial Health Directorate, Kunduz; Regional Hospital, Kunduz; Afghanistan Red Crescent Society (ARCS), Kunduz; DoRR, Kunduz; Swedish Committee for Afghanistan, Kunduz; JACK BPHS team in Kunduz Thanks of INSO for conducting the assessment of the field locations and also for field movements Special thanks to the communities and their representatives – Thanks to CHNE and CME staff and students District Hospital staff of Imam Sahib Our sincere thanks to the District wise focal points, health facility staff and all support staff of JACK, Kunduz who tirelessly supported in the field assessment and arrangement of necessary logistics for the assessment team. Thanks to Health and Protection Clusters for their constant inputs and support. Thanks to OCHA-HFU team for their feedback on our previous programme and that helped in refining our assessment focus and added the components of additional issues like operations, logistics and quality of supplies which were discussed elaborately with the field team of JACK. Thanks to Access and Security team in OCHA for their feedback on access and security sections.
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Abbreviations
IEA Islamic Emirates of Afghanistan
MoPH Ministry of Public Health
ANSF Afghanistan National Security Forces
JACK Just for Afghan Capacity and Knowledge
OHPM Organisation for Health Promotion and Management
UNOCHA United Nations Office for the Coordination of Humanitarian Affairs
WHO World Health Organization
UNHCR United Nations High Commissioner for Refugees
WAW Women for Afghan Women
SCA Swedish Committee for Afghanistan
ALP Afghan Local Police
AOG Armed Opposition Groups
AGE Anti Government Element
ACG Armed Criminal Group
INSO International NGO Safety Organization
HAG Humanitarian Access Group
ACBAR Agency coordinating Body for Afghan Relief and Development
DAC District Administrative Centre
AHF Afghanistan Humanitarian Fund
HFU Humanitarian Funding Unit
IMF International Military Forces
BBC British Broadcasting Centre
UNAMA United Nations Assistance Mission in Afghanistan
MSF Medicine Sans Frontiers
HI Humanitarian & Inclusion/ Handicap International
SIGAR Special Inspector General for Afghanistan Reconstruction
BPHS Basic Package of Health Service
EPHS Essential Package of Hospital Service
CHC Comprehensive Health Center
BHC Basic Health Center
DH District Hospital
PHC Primary Health Centre
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PPHD Provincial Public Health Directorate
TP Trauma Post
FATP First Aid Trauma Post
CSO Community Social Organizer
CBPF Country-Based Pooled Funds
RAF Rapid Assessment Format
HMIS Health Management Information System
IED Improvised Explosive Device
GOA Government of Afghanistan
PHCC Provincial Health Coordination Centre
EPI Expansion Program on immunization
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Glossary Shura Community Development Council Malik Head of Community Development Council IEA/Taliban Islamic Emirate of Afghanistan/Taliban Zakat payment made annually under Islamic law on certain kinds of property and used for charitable and religious purposes, one of the Five Pillars of Islam. Oashar Kind of Tax under Islamic Law in different kinds of cultivation product Rules Statement that establishes a principle or standard, and serves as a norm for guiding or mandating action or conduct. Masuliyat Responsibility Arbaki Afghan Local Police Breshna Electricity provider company in Afghanistan
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Contents Acknowledgements ...... 2 Abbreviations ...... 3 Glossary ...... 5 Section 1 : Background ...... 8 Background of Kunduz Province ...... 8 Background for the Assessment ...... 9 Assessment Methodology ...... 10 Section 2: Summary of the findings ...... 13 General ...... 13 Security ...... 13 Health ...... 14 Access Related ...... 15 Protection ...... 16 Recommendations ...... 17 Section 3: Introduction ...... 18 Security ...... 18 Conflict situation...... 20 Section 4 : Health Assessment ...... 22 Health Facilities in Kunduz ...... 26 Trauma Cases details in Kunduz Province ...... 30 Internal Displacement ...... 38 Recommendations ...... 40 Supporting Referral Sites with capacity to respond mass casualty ...... 42 Coordination with relevant health actors at Kunduz and Kabul ...... 42 Learning key lessons from past experiences of trauma care...... 45 Recommendations from the stakeholders on the recruitment of qualified staff ...... 45 Training of Health Facility Staff on Triage, First Aid and First Responder’s training and Mass Casualty Management ...... 46 Advocacy related to health and trauma care ...... 46 Section 5: Access Assessment ...... 48 Active Fighting in Kunduz ...... 59 Violations of Health Facilities noticed in the assessment by the actors involved in conflict...... 61 Violation are seen but not regular by AOGs ...... 62 Top four violations by ANF ...... 62 Recommendations ...... 64 Key Activities considered for the proposed project ...... 66 Section 6: Protection Assessment ...... 67 Barriers to access schools ...... 69 People’s perception about HF ...... 70
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Barriers to access to health services ...... 70 Protection Risk Analysis ...... 72 Mental Health ...... 73 Protection response ...... 76 Gender Based Violence ...... 77 Recommendations and suggestions ...... 77 Prostatic and Orthotics Care ...... 77 Mental Health in counselling Post Trauma Disorder Syndromes (PTDS) and referrals ...... 78 Gender Based Violence ...... 78 Coordination ...... 79 Section : 7 Key Results from the Needs Assessment for consideration for programmatic intervention .. 80 Establishment of First Aid Trauma Posts in remote and hard to reach districts ...... 80 II. Strengthen the capacity of referral centres for improved trauma care within the districts of Kunduz province ...... 82 Improving access to Mental health care for PTDS and referral systems ...... 83 Gender Based Violence ...... 84 Coordination and Advocacy ...... 84 Annexure 1: Meetings with Stakeholders ...... 87 Annex 2- Rapid Health Assessment Form – Afghanistan ...... 88 Annexure :3 Check List for Focused Group Discussions with Community/Health Shuras ...... 93 Annexure 4 : Principle Violated by Conflict Actors ...... 94 Annexure 5: Verification of Items – TCS equipment (WHO) ...... 95 TCS equipment list that distributed to BPHS HFs in Kunduz province: ...... 95 Annexure 6 ...... 97 Annexure 7: Trauma Care Services Monthly Report Format of WHO ...... 102
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Section 1 : Background 1.1 Background of Kunduz Province
Kunduz is one of the 34 provinces of Afghanistan, located in the northern part of the country 334 km from Kabul, bordering, Balkh, Takhar and Baghlan provinces and Tajikistan. It is the gate way for the North East and lies in the strategic transit route between Kabul and Mazar-e- Sharif. Traditionally Kunduz is known as “the bread basket of Afghanistan”, thus it is an economically important province in northern Afghanistan. The province is dominated by the Kunduz river valley. The Kunduz river flows north into the Amu Darya, which forms part of the border between Afghanistan and Tajikistan. To the south, the province brushes against the northern fringes of the Hindu Kush mountains. A newly constructed bridge crosses the Amu Darya at Sher Khan Bandar. The river, its tributaries, and derivative canals provide irrigation to the irrigated fields that dominate land usage in the agricultural province. There are also rain- fed fields and open range land that span several miles.
Table 1 : District wise Population details
District HQs CDCs Population Demographics[15]
30% Tajik, 30% Uzbek 20% Pashtuns, 20%
Ali Abad Aliabad 39 61,133 Hazara [16] 40% Pashtuns, 35% Uzbek, 15% Tajik, 10%
Archi Archi DAC 75 103,049 Turkman Chardara 45% Pashtuns, 35% Tajik, 12% Uzbek, 8%
Chardara 90 91,201 DAC Turkmen Sherkhan 45% Uzbeks, 25% Pashtuns, 25% Tajiks,
Imam Sahib 124 293,481
Bandar 5% Turkmens Khanabad 35% Tajik, 25% Pashtuns, 20% Hazara, 10%
Khan Abad 115 194,035 DAC Uzbek, 5% Pashai 55% Tajik, 25% Pashtuns, 15% Uzbek, 3%
Kunduz Kunduz city 89 406,014 Turkmen, 2% Hazara Qalay-zal
Qalay-I-Zal 49 88,082 90% Turkmens, 10% Pashtuns DAC Source: CSO 2017-18
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The capital is the largest city is Kunduz. Kunduz province is predominantly rural province with an estimated population of 990,937 (CSO Data 2014-15), which is multi-ethnic and mostly a tribal society. The province has seven districts, include Aliabad, Chardhara, Dasht Archi, Imam Sahib, Khanabad, Kunduz and Qala-e-Zal. Kunduz Province remained relatively stable for most of the following decade until Taliban began to infiltrate the area again in 2009. The security situation in Kunduz is very much volatile, with limited government control and high levels of insecurity in the outlying areas of the province. It is currently one of fragile provinces in the country. Kunduz has been the site of growing insecurity since 2009 as the Armed Opposition Groups (AOGs), non-state actors includes illegal militia groups, began to establish a strong presence in rural and outlying areas of the province. Kunduz city itself has fallen thrice in last four years to AOGs. Currently the city is secure but the suburbs and many of the rural areas including some of the district centres are either under direct control of AOGs or contested. The increased conflict scenario since 2015 has resulted in increased displacement (repeated displacement) of people in the conflict zones to safer locations within the district or to Kunduz or to the neighbouring provinces of Takhar, Baghlan, and Balkh and even to Kabul. The casualties due to conflict has increased phenomenally and the existing health facilities are fully equipped to meet this increased mass casualty effectively and that too after the closedown of Trauma Care Centre by MSF after the airstrike in October 2015. Despite of establishment of FATPs and Mobile health teams funded by CHF (now AHF) in 2016/17 and 2018/19 still there is need for additional trauma care centres and health teams to cover unreached areas.
1.2 Background for the Assessment
Johanniter has various assessments in Kunduz related to the needs in health, protection and vulnerability of IDPs in hard to reach districts since August 2017. It has conducted three such needs assessments in the past. - In August 2017, Johanniter along with Organisation for Health Promotion and Management (OHPM) and Handicap International (now, Humanity and Inclusion) conducted assessment - In November 2017, Johanniter and OHPM have conducted a details assessment on Health, Nutrition and Protection in Kunduz province - In December 2018, Johanniter, OHPM and JACK have conducted an assessment related to health and protection issues All the assessments were conducted for application for CHF/AHF grant or other donor grants. The previous grant of AHF funded project “Provision of life saving trauma care and referral services with protection measures in conflict affected areas in Kunduz province” CBPF Code: AFG-18/3481/SA1/H-APC/INGO/770. This project concluded in March 2019 and the assets were handed over to Provincial Public Health Directorate (PPHD) and the BPHS implementing NGO, JACK. There was greater need for trauma care both due to increased armed conflict in 2019 where Taliban have established strong control over the province and increased military operations by Afghanistan National Security Forces (ANSF) along with International Military Forces (IMF). JACK and Johanniter have consulted Health Cluster since May 2019 to explore funding opportunity for supporting trauma care in Kunduz province. At the backdrop of expecting Second Standard Allocation of Afghanistan Humanitarian Fund (AHF) for 2019, JACK and Johanniter discussed with health cluster and Humanitarian Funding Unit (HFU) and scheduled to conduct detailed needs assessment in Kunduz province. The feedback of previous project in Kunduz and experiences of working with BPHS implementing agency, OHPM; the current assessment focused on trauma health care services in the province and related protection issues. Dr. Noor Ahmed, Health Programme Coordinator in
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JACK; Dr. Sediqullah Akbarzai, Programme Advisor; Dr. Mirza Jan Hafiz, Programme Coordinator; Dr. Waseel Rahimi, Programme Manager - Health and Vijay Raghavan, Head of the Mission, (all from Johanniter) have met at Johanniter Office on 19 September 2019 and discussed about the modalities of the assessment and scheduled for a joint assessment. It was decided that JACK will initially collect all relevant primary and secondary information from the BPHS, EPHS and other stakeholders working in trauma care in Kunduz during the last week of September. Johanniter team will join the JACK team in Kunduz to conduct the assessment which includes meeting different stakeholders, BPHS health staff and communities from the conflict locations. Accordingly, JACK and Johanniter teams have met Health and Protection Cluster leads and discussed their proposed plan to conduct assessment of health and protection risks in accessing health services in Kunduz in September 2019 and accordingly, the field assessments were held in Kunduz during 27 September to 14 October 2019 and Kabul level consultations were held in October with stakeholders and Cluster leads. The Johanniter International Assistance supported the needs assessment in Kunduz from its core funds. 1.3 Assessment Methodology
The assessment was conducted in two phases. The first phase was entirely led by JACK team with distant support from Johanniter team. The second phase was Johanniter and JACK team collectively carried out a joint assessment from 10 to 14 October 2019. Three members from the Johanniter and JACK carried out a joint assessment mission to understand the health needs in conflict zones, the protections risks facing general people, women, girls, boys and other vulnerable groups in accessing health and other development services. These organisations chose to collaborate based on their experience of working in primary health, emergency health and research experience. The team composition includes public health expertise, social anthropology, monitoring and evaluation experience and PCM and research expertise. Assessment Objectives:
To assess the conflict sensitivity impacting health services especially trauma care To assess the needs of the conflict affected population for effective trauma care and prostatic and orthotics care services To assess protection risks, which includes threat analysis, vulnerability and capacity analysis; and identify areas to integrate protection in health services To find out health, nutrition and protection challenges, and gaps and to recommend related for solutions. To reassess high risk conflict-affected districts and locations for establishment of First Aid Trauma Points (FATP)
The mission adopted both quantitative and qualitative research methodologies focused on making direct contact with representatives of the affected communities include, health Shura members, community level health workers, Psycho-social counsellors, Nursing and midwife trainees, health staff working in primary health care units and visiting health facilities. The mission has used various formats include the cluster approved Rapid Assessment Format (RAF) for health and customized sample survey related to trauma care, protection elements and adherence to neutrality principles. The formats used are enclosed to this report Annexure 4. The mission met key stakeholders involved in the trauma care, protection and humanitarian responses include, UN agencies – UNHCR, UNOCHA and WHO; MSF, Handicap
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International, ARCS and SCA; and government agencies like DoRR, PPHD and Director of Regional Hospital, Kunduz. The schedule of the stakeholders’ meetings was enclosed in Annexure 1. The questionnaires addressed health needs in conflict areas, protection risks specific to women and girls in the place of origin and at the current /displaced locations in case of IDPs. The assessment team have carried out field based assessments based on the customized and RAF-Health assessment forms in 14 health clinics. The list of health facilities assessed is enclosed in Annexure 2. The team also interacted with Health Shura representatives of the clinics in hard to reach districts in Kunduz province. The list of community members interacted is enclosed in Annexure 3. The assessment team made detailed observations and documented not only the information collected for the assessments but also factors contributing to the protection risks. The team split up into smaller groups to conduct the interviews and focused group discussions. This was done keeping in view of time factor and also reduce the size of assessment team (as security measure). Smaller groups of interviews facilitated the establishment of trust and minimize the risk of overwhelming the persons interviewed. In addition to the interviews and focused group discussions, the team also reviewed the existing information available with JACK’s BPHS programme team relating to HMIS, Health Facility details, Staff details, Trauma cases by facility in the hard to reach districts, data available with the regional hospital, MSF, UNOCHA, WHO and UNHCR. 1.4 Disclaimer This report was written according to Johanniter International Assistance and JACK’s joint understanding and based on the consultations held with health and protection cluster. The report is based on carefully selected sources of information. All sources used are referenced, as much as possible, and unless otherwise stated. All information presented, except for undisputed or obvious facts, has been cross-checked. The information contained in this report has been researched, evaluated and analysed with utmost care. However, this document doesn’t claim to be exhaustive. The report doesn’t refer to a particular event, person or organisation unless referred. Furthermore, this report is not conclusive as to the determination or merit of any particular person or agency’s claim. This report is based on the assessments carried out before 15 October 2019 drafted. Any event taking place after this date is not included in this report. The information provided under the assessment are based on the interviews held with various stakeholders and is entirely based on the understanding of the assessment team members and doesn’t reflect on the institutions they represent. As these interviews are based on the personal requests and thus may or may not prove to hundred percent correct. There is optimal ignorance of the assessment team members while presenting the report. Some of the information collected are sensitive and thus protected the identity of the individuals. The assessment has limitation as they have used mostly the qualitative methodologies and referred the secondary /primary data of HMIS documents from the health service providers to draw inferences. Such collected information was triangulated with the stakeholders to draw inferences and assumptions. The field visit by Johanniter team was limited to Kunduz, Khanabad and Imam Sahib. The field assessment team of JACK have visited all the seven districts and clinics identified for the assessment. The assessment team have made efforts to discuss with representatives from all the districts, health facility staff, nutrition counsellors, Health Shura members, Psycho-social counsellors and civil society members working in these
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Section 2: Summary of the findings Country Overview1 General UNOCHA’s Humanitarian Needs Overview (2020) states that, “Afghanistan is now the scene of the deadliest conflict on earth. Fighting continues to rage, exposing civilians, particularly women and children, to daily deadly risks, prompting mass displacement and choking the country’s unstable economy. Years of shocks have left an acutely vulnerable population with few economic resources, an eroded capacity to cope with the unfolding crisis and little hope of recovery if the current conditions persist.”
The cumulative impact of conflict and disaster, almost a quarter of the country’s population (9.4 million people out of a population of almost 38 million) is now estimated to be in need of humanitarian assistance in 2020. The majority of those in need are children (56 per cent). Upward adjustments in needs have been made across every sector with Protection needs showing the largest change (2.4 million in 2019, 7 million in 2020).
People’s living conditions have been eroded by years of war and disaster. Inability to access services is a key consequence of the crisis and is a product of a range of factors including conflict, insecurity and fear, poverty and under-investment
About one third of the population (mostly those living in hard-to-reach areas) does not have access to a functional health centre within two hours of their home. The country is facing a protection crisis where people’s rights to safety, security and well-being under international law are regularly threatened. Conflict and displacement have resulted in internally displaced persons (IDPs) and vulnerable people resorting to severe negative coping mechanisms such as early/forced marriages, child labour and begging. Women and girls are deprived of basic rights, particularly education, and gender based violence is pervasive. Afghanistan is littered with landmines and other explosive hazards (new and old), exposing civilians to daily risks.
Security
In 2019, the people of Afghanistan have showed a strong appetite for peace in the country. In a recently published, long running public perception poll,2 almost 89 per cent of people surveyed said they either strongly or somewhat support efforts to negotiate peace with the Taliban, while some 64 per cent of people surveyed believed reconciliation with the Taliban is possible, up 10 percent points on 2019. While the situation is uncertain, the security outlook for at least early 2020 looks mostly unchanged from 2019 which has been characterized by high levels of civilian casualties due to the use of suicide and non-suicide Improvised Explosive Device (IED) attacks in civilian populated areas, a continued escalation of air strikes and, deliberate attacks against civilians and civilian sites, including election related violence. July 2019 recorded the highest number of civilian casualties since UNAMA began systematic documentation in 2009. Women and children accounted for 41 per cent of casualties in the first 3 quarters of 2019. Fighting creates both an immediate and long-lasting burden for civilians, exposing them to sudden and terrifying violence and leaving them vulnerable to
1 UNOCHA, Humanitarian Needs Overview 2020 2 The Asia Foundation, A Survey of the Afghan People Afghanistan in 2019
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Final Report unexploded ordnance, both of which generate significant trauma-related needs. Afghanistan is also witnessing fighting between Non-State Armed Groups (NSAGs) generating new humanitarian needs, compromising access and further complicating developments over the months ahead. Violations of international humanitarian law, including attacks on health and education facilities and protected personnel have continued to be commonplace in 2019. Afghanistan is one of the most dangerous countries in the world for aid agencies and the delivery of assistance continues to be delayed by access constraints and illegal taxation.
The summary of the assessment findings has been shared in the below:
Security
1. Kunduz is one of fragile provinces in the country with almost entire province has witnessed constant conflict between the Taliban (mostly referred as AOGs, Islamic Emirates of Afghanistan –IEA and Taliban interchangeably depending upon the source of the information) and Afghanistan National Security Forces (ANSF). 2. It was noticed that during the peace process, as per the health shuras most of the district centres in Kunduz are controlled by the Government and outside of the district centres are completely under the control of Taliban. 3. Kunduz province has a phone network blackout between 1630 and 0500 hrs which has been in place since September 2017 and it was extended to earlier hours in the winter. During the blackout, only the Salaam network is operational.
Health
4. There was high increase of trauma cases in all the districts of Kunduz have been reported since 2014 and some of the trauma cases were not reported due to remoteness and insecurity. 5. It was reported there was an increase of deaths, wounds, and injuries due to mines in Kunduz. As per the study on the human cost of explosive remnants of war (ERW) in 2010- 18 period casualties are reported as 4,820, which almost 48% of the casualties occurred due to three types of explosive devices used. 6. Since the bombing of MSF Trauma Hospital in October 2015 by IMF, Regional Hospital was the only higher level trauma care facility in the country. German Government supported in modernising the regional hospital’s emergency unit and thus has increased the capacity to deal with higher grade trauma care. MSF is currently running two wound care units, in Chardara and Kunduz. MSF will restart their trauma care unit with 51 bed hospital by end of 2020. This will be more complementary to the regional hospital. However, due to active fighting in the districts and protection violations include that of IHL, most of the injured are not transported to Kunduz. Thus, the trauma care units with Triage, First Aid and Stabilisation facilities are needed at the districts so that primary assessment is done within the district and then transport only emergency cases to higher level of trauma care units in the province to reduce the casualties. 7. There are 75 health facilities managed under BPHS in Kunduz province and is been implemented by NGOs selected through a competitive bidding process. 8. It was identified that inadequate health facilities in BPHS programme to meet the primary health care facilities and lack of human resources to manage trauma care and casualty management. Nearly 25% of the health facilities are run into temporary buildings or rental buildings and about 72% have permanent buildings in the province.
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9. It was identified that a severe shortages of female medical staff to look after the women in labour in Kunduz province. Most of the women don't have adequate access to essential obstetric care, and they can’t afford it. 10. The assessment has been identified and proposed the Infrastructure assessment of FATPs proposed sites. It was identified and listed out white areas and challenges in 5 districts of Kunduz province by the health shuras, BPHS staff, and PPHD. 98% of the locations in white areas are beyond 6 kilometres from the nearest health facility and 41% of them don't have any health post. 77% of the locations in white areas have reported of insecure roads. 86% of the locations in white areas have reported of presence of Taliban 91% of the white areas in Kunduz reported of problem in vaccinations, due to constrains in getting women vaccinators in outreach. 11. Numbers of barriers were identified by the communities in accessing health services such as restriction on women mobility without accompanied by Mahram when visiting health facilities, absence of qualified health staff, absence of women vaccinator in the outreach and male vaccinators are not allowed to vaccinate women. The NGOs cannot afford female vaccinator mahram to send female vaccinators to the outreach work. 12. It was identified that the Persons having disability are more vulnerable than other community have no transportation, no facilities for wheel chair, and no disabled friendly facilities. There are no physiotherapy services in most of the health facilities and the waiting times for the people with disability are not given special consideration.
Access Related
13. The joint assessment has been identified and estimated that 80% of the Kunduz province is in Taliban controls. The control of provincial territory is that their influence in governance. 14. In urban areas, only 63% of the HFs is under the control or influences of Taliban, with 13% are contested and 25% under the influence of the government forces. 15. In the rural areas, 85% of the clinics are under the control or influence of Taliban and only 15% of the clinics are under government control/influence, 86% of the white areas (where there are no health services available) are in Taliban controlled/influence areas. 16. Displacement of IDPs in 2019 is highly increased in Kunduz due to armed conflict, military operation, IHL violation, Tribal conflict/disputes, forcibly eviction, illegal taxation, torturing, and AGEs threats in places of origin and other generalized violence. It was recorded more than 23,000 have displaced due to conflict. In the joint assessment 7,000 have identified as protracted IDPs. 17. Taliban monitor the presence and performance of medical staff and clinics is reported. The government functionaries also monitor the clinics through the health shuras and with the Taliban’s permission, but not as frequently as the Taliban does in areas under its influence. 18. It was identified that there was an exception to Imam Sahib District in past two years. The Taliban controls four major districts– Dasti Archi, Khanabad, Qalai Zal and Chardara. It also controls the surrounding villages of Kunduz district except the city. (This was at the time of assessment, however, most of the district administrative centres are under the ANSF control. But the rural areas are under the control of Taliban. There is severe fighting continue to take territorial control by Taliban and the roads leading to the district centres are contested.)
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19. Gender segregation is typically place in most of the clinics in Kunduz, Female health workers should have their mahrams accompanying them to the work place. Taliban objected when a female health worker departed and was replaced by a man because women would not be able to access the clinic unless another woman was recruited. 20. The majority of civilian’s population especially women and girls have difficulty to access health facilities and hospitals in province. The hospitals are located near to armed checkpoints located at health facilities within 200 meters of these facilities. 21. Impact of health services is identified that the outpatients have reduced in the health facilities in active conflict areas in the province due to displacement of population fearing attacks from ANSF and PGMs. The economic migration due to drought and low economic growth, thus impacting the health targets set by the MoPH for Kunduz. 22. There are no sufficient health workers to meet the needs of the existing population that has many trauma cases includes injuries due to the aerial strikes, as collateral damage to the cross firing, attacks during raids by the ANSF and PGMs and due to mines laid in the field and roads. 23. It was noticed that there is a pressure on NGO health providers to provide trauma care, and doctors and nurses are routinely called in from nearby cities to treat fighters in remote areas. Another common practice has been followed by compelling nurses or clinic staff to perform minor surgeries beyond their qualifications or the capacities of the facility. 24. High Violations by Taliban/AOGs of Health Facilities noticed in the assessment by the actors involved in conflict i.e. 85% of the health facilities assessed stated that AOGs involve in the recruitment of the staff, 69% of the health facilities assessed have stated that AOGs do bring communication materials like radio into the clinic posing threat to IMF/ANSF aerial attacks, 62% violates the principle of No weapon policy (no one should carry weapons inside the clinic)
Protection
25. It was identified that the lower level of health facilities doesn’t have trauma care facilities and community is pressurising to increased number of FATPs in the BHCs and SHCs so that the trauma cases in the remote locations can be mobilized to the nearest health facility under the government control. 26. In all the districts of Kunduz there was practice identified that children and teenagers forcefully recruiting, thus forcing the communities to displacement. In case of refusing to recruit their children, Taliban are imposing fines over the families – 10,000 to 100,000 Afs per family. 27. There are many barriers identified to access schools in the province, i.e. especially girl’s mobility is restricted to only village, and they have no access to go for higher grade schooling located at the district centres. 28. Women and girls in Afghanistan continue to suffer both directly and indirectly from the impact of the conflict and of the displacement. However, lack of female teachers is resulted a great obstacle to stop the girls for education in higher grades. And also there was restriction and control by Taliban girls should go along with accompany of Mahram while going to school.
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Recommendations
29. Volatile security and increased injuries and trauma incidents in interior locations due to aerial attacks and intensive fighting, the need for trauma care posts in these remote and hard to reach districts. There will be need immediate trauma care at the place of conflict primarily at first aid trauma posts. These centres will ensure lifesaving and refer the trauma cases need surgical treatment to higher grade trauma care centres with in the province. In addition, it is expected that the need for prosthetics, rehabilitation, mental health and psychosocial support will increase due to the cumulative and continuing impact of the conflict. Thus, 6 Trauma Care Posts in Kunduz province are considered for presenting to any donor funding. 30. In addition to physical trauma include assessment, triage, first aid and referral services, triage, first aid and referral services for mental health and psychosocial support (MHPSS); referral for Orthopaedic and prosthetics care for physical rehabilitation services and the provision of assistive devices by providing transportation costs and follow up services in the centre thus facilitating the greater access of health services. 31. Volatile security, as well as harmful cultural and traditional practices which see the rightful place of women as being in the home; the imposition of strict gender segregation rules; and prohibitions on men providing medical treatment to women, all compromise their access to sustained and quality healthcare. This project will have at least two female staff who are expertise in physical trauma care (Trained Nurse) and Physcho-social service counsellor (trained) available in the proposed Trauma posts. 32. Provision of essential supplies, equipment, diagnostic tools and life-saving training to doctors, nurses and health professionals working in hospitals and primary healthcare Clinics on basic lifesaving skills (BLS) and mass casualty management at the referral site identified. 33. Development of health facilities’ and personnel’s capacities for emergency response; and 34. Enhanced coordination and advocacy for improved access of beneficiaries to emergency services and life-saving treatment; and advocacy through Humanitarian Access Group and other NGO stakeholders both at the provincial and national level on protection of health staff and patients in the health facility and Joint Operating Principles developed by humanitarian actors in the country.
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Section 3: Introduction 3.1 Security
According to SIGAR’s April 30, 2019, quarterly report, the U.S. military is “no longer producing its district-level stability assessments of Afghan government and insurgent control and influence. However, BBC report in December 2017 states that Taliban threaten 70% of the Afghanistan. The poor turnout in the recently concluded Presidential Elections has one way or other is the result of the threat of Taliban against the election process. . Civilians continue to be gravely impacted by the highly unpredictable and politicized situation in Afghanistan. Violence along with a number of political processes coming to a head risks impacting not only people in need, but also affects the access of aid workers and their ability to provide essential services to people in need. Months preceding to the US Talks with the Taliban where high expectations were raised of a possible peace deal, which was fallen apart due to high precedence of violence during July-September 2019. From 1 July to 30 September 2019, UNAMA documented the highest number of civilian casualties that it has recorded in a single quarter since it began systematic documentation in 2009.
From 1 January to 30 September, UNAMA documented 8,239 civilian casualties (2,563 deaths and 5,676 injured), similar to the same period in 2018. Anti-Government Elements continued to cause the majority of civilian casualties in Afghanistan and also caused slightly more civilian deaths than Pro-Government Forces in the first nine months of 2019, contrary to the first half year of 2019 when Pro-Government Forces caused more civilian deaths. Forty-one per cent of all civilian casualties were women and children.
Pro-Government Forces from 1 January to 30 September 2019, Pro-Government Forces caused 2,348 civilian casualties (1,149 deaths and 1,199 injured)28, a 26 per cent increase from the corresponding period in 2018. Pro-Government Forces were responsible for 28 per cent of civilian casualties overall. The majority of civilian casualties caused by Pro- Government Forces resulted from ground engagements, followed by airstrikes and then search operations, similar to trends reported in 2018 at the third quarter.
Children continued to be severely impacted by the armed conflict in Afghanistan. Between 1 January and 30 September 2019, UNAMA recorded 2,461 child casualties (631 deaths and 1,830 injured), an overall increase of 11 per cent compared to the same period in 2018. The increase in child casualties resulted primarily from a significant increase in suicide and non- suicide IED attacks as well as ground engagements, including the use of indirect fire weapons systems that had indiscriminate effects on polling day for the 2019 presidential election. Ground engagements remained the leading cause of child casualties, followed by suicide and non-suicide IED attacks, and explosive remnants of war. The mission reiterates concern that children comprised the majority - 77 per cent - of civilian casualties from explosive remnants of war. Children are also disproportionately impacted by attacks on schools and hospitals, which impede their access to education and health services. In relation to incidents impacting healthcare, on 11 April, the Taliban had banned activities of the World Health Organization (WHO), which effectively brought all polio vaccination campaigns to a halt. On 25 September, the Taliban announced that it would lift its ban on WHO activities in areas under its control, which was imposed in April of 2019. However, the resumption of WHO activities was permitted only with conditions. In particular, the Taliban indicated that vaccination campaigns would only
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Kunduz is currently one of fragile provinces in the country with almost entire province has witnessed constant conflict between Taliban (mostly referred as AOGs, Islamic Emirates of Afghanistan –IEA and Taliban interchangeably depending upon the source of the information) and Afghanistan National Security Forces (ANSF). Kunduz has always been the site of insecurity since 2009 as Taliban, few non-state actors include local militia began to establish a strong presence in rural and outlying areas of the province. Kunduz city itself has fallen thrice in last four years to Taliban. Based on field offices of UNHCR and WHO, currently the most of the conflict affected district currently is Chardara, followed by Dasthti archi, Imam Sahib, Khanabad, Qala-e-zal and Aliabad. In Kunduz district, the conflict is intense in most of the outskirt villages of Kunduz city includes, Hazarat Sultan, Kanam, Mula Sardar, Alchin, Telawka, Chaparman, Gul Tepa, Malarghi, Qabri Haji Gulistan, Lodin, Ibrahim Khil, Zarkharid, Baghi Shirkat, Tarnaw, Nasari Ha villages.
Internal Displacement due to conflict in Kunduz (1 January -22 October 2019)
Source: https://www.humanitarianresponse.info/en/operations/afghanistan/idps.)
Till 9 October 2019, the Joint Assessment Team led by UNHCR have identified 10,125 displaced families, of which nearly 32% of them still need assistance. More details of this in the sub-section on displacement in this assessment document. The Johanniter International Assistance (Johanniter) and JACK have conducted a joint needs assessment focusing Emergency health care, protection and access related issues in Kunduz province. The assessment sought to assess to what extent crucial health services are available and accessible to people while also determining the current condition of medical equipment and supplies in health facilities, availability of human resources and the overall preparedness of health centres to respond to medical emergencies of mass casualty and trauma care. The assessment also discussed with stakeholders in Kunduz provincial level and at national level on integrated protection and access aspects. Gaps and solutions are identified through
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Final Report stakeholder consultation to address the weaknesses of the healthcare system identified in this assessment. Strengthening the capacity of health facilities to respond to mass casualty incidents and emergencies remains a core focus the most insecure districts with a high number of trauma cases and mass casualty incidents over the past couple of years so that as preparedness measure and response capacity to meet such eventualities in the year 2019 and 2020,which may witness intensified conflict as the country will go through consultations of peace process and the increased territorial gains made by Taliban in Kunduz province. The health shura representatives have mentioned of deteriorating of security in the province. It is summarized as following There is deterioration of security situation in general in Kunduz province. There are quite a huge number of checkpoints across the province held by both the Taliban and ANSF. The government and AOGs both have check points in different location, fight frequently and the government also undertake search operations and harassing people. The district centres are mostly controlled by the government and outside of the district centres are entirely under the control of Taliban. In some district centres like Imam Sahib which is entirely under control of Afghanistan security forces, but Taliban fighters are present in and around 1 to 2 kilometre distance away. The Taliban presence and control ensures strong measures of respect to law and order and treat people with respect. There is no harassment of the common people in Taliban controlled areas. There is always risk of ground fighting, there are reports of night raids, ambushes and airstrikes engaged by ANSF. In Chardara, among the health facilities, only one i.e. CHC is in the government controlled area. In Archi, communities shared that for last three months, there is active fighting in almost entire district and there was no pause in these months for fighting. The centre, there were 48 casualties reported last month of which 16 killed and 32 injuries. Mines are there in the aeras and road between Arch and Haji Nayeem Jan were also mined. On Khanabad road connecting Kunduz and Taloqan, no one can move during dusk to dawn (5Pm to 6 AM) and the roads are closed. There are reports of the road get mined during the night by Taliban to avoid deployment of army and restricts the movement of ANSF ground operations. During this period, people who need emergency health care and trauma cases can’t reach appropriate health and trauma care centre in time.
Conflict situation
Ground engagement has increased in this year, in 2019. AOGs warned people to leave the areas in case of any anticipated fighting. But the government forces don’t warn such, thus high civilian casualty. Similarly, there is higher civilian casualties due to aerial strikes, which has increased in 2019. Night raids and ambushes are also increased across the province. The night searches are increased by the pro- government forces. The attitude and behaviour of the pro-government forces don’t go well with the local population. The shura representatives have complained of their mis- treatment and abuse. The Pro-Government forces, mostly the PGMs harass people and are hostile to local population. The AOGs do not undertake search operations.
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In Chardara, search Operations are high and surprise attacks and ambushes, heavy artillery firing has killed many civilians. IN Qale Zal and Dasti Archi districts, ground engagements has increased and fighting occurs almost on daily basis. The air strikes have increased and takes place on more frequently. They do not warn people in advance. Recently the night ambushes are also increased. In Imam Sahib, Khanabad and Kunduz districts, Shura representatives mentioned that, along with the ground engagement, air strikes are increased. There has been artillery shelling causing lots of casualties. There is increased search operations by government forces. In Khanabad, the government does not give prior warnings but the AOGs give warning to people to leave the places. However, in Qalezal district, the shura representatives mentioned of decrease in search operations and is due to the fighting has shifted to military bases and out of villages. The government forces don’t enter into residential areas.
Based on the consultations with the community and other stakeholders, the following is the summary of the assessment of security situation. Chardhara DAC and the road leading to Kunduz city are under ANSF/GOA control, while the AOG members are present in the surrounding areas and the rest of the district. Conflict activity is high and the NGO work is generally low with local acceptance. In 2019, there is significant increase of security incidents in comparison to previous years. Conflict activity accounts for most incidents between ANSF/IMF and AOGs involvement. ImamShaib district centre, as well as the surrounding areas, and the Shir Khan Border area are controlled by ANSF and rest of the district are under AOG’s control. The security situation at the moment is considered to be medium-risk. Criminal activity, although going underreported, is assessed to be high, namely in the bordering areas with Tajikistan and along the Kunduz-Emam Sahib Road. Dasht-e-Archi district DAC and almost entire district is controlled by AOGs. The road leading to Emam Sahib DAC, and Kunduz City is partly under ANSF/GOA control. The AOG presence in Dasht-e Archi is assessed to be high, with active members also conducting operations in Khwajaghar and other districts of Takhar Province. Conflict activity is relatively high. Kunduz Province currently faces a phone network blackout between 1630 and 0500 hrs which has been in place since September 2017 and extended to earlier hours in the winter. During the blackout, only the Salaam network is operational. On the other hand, although having a Salaam SIM card is common among the local citizens, AOG members might seize them at AOG checkpoints and there were many reports of punishment leased out by the AOGs for those who carry Salam SIM cards. More information related to security and access in the Section 5: Access Assessment of the report.
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Section 4 : Health Assessment For decades, Afghan women were denied education, which has led to a shortage of female medical staff to look after women in labour. Yet many families will only seek care from a female medical provider, i.e. a trained mid-wife. That’s partly why up to two-thirds of births take place at home without assistance, though this is contested by MoPH, but is a sad reality. Another reason is that, outside big cities, most women don't have adequate access to essential obstetric care, or can't afford it. The need for lifesaving trauma care is extremely high in Kunduz, where little quality medical care is available. The security situation remains volatile and medical needs will continue to increase. The assessment team looked into the data available at Provincial Public Health Directorate (PPHD), Kunduz; BPHS HMIS data; MSF, Regional Hospital Data; Information from other health actors collected during individual interviews; verified this information with health facility staff and discussions with health shura of their perceptions related to health. The assessment team also visited health facilities to observe the facility and administer Rapid Health Assessment Form shared by Health Cluster. Thus, a mix of quantitative data and qualitative data is used for presentation of this assessment. 4.1 Health Actors in Kunduz Kunduz is the regional hub for the north-eastern region of Afghanistan and is known as gate way for northeast. Major health and trauma cases in the region were mostly treated at Kunduz regional hospital and in the past at MSF trauma care centre (before it was bombed in October 2015). There are many agencies working in the health sector in the province, with JACK as MoPH’s Basic Package of Health Services (BPHS) in entire province. They have taken over from Organisation for Health Promotion and Management (OHPM) in January 2019. There are 75 BHPS implemented health HEALTH FACILITES IN KUNDUZ 2005-2019 facilities in the province. The detailed break up is 80 seen in Table 2 below. In 70 addition to these health 60 facilities, OHPM also runs Mobile health 50 teams in three districts 40 with the support of 30 UNICEF (the districts 20 are- Imam Sahib (2 MTs), Chardara (MT) 10 and Dashti Archi (1 0 MT)). In 2019, JACK has 2004 2006 2008 2010 2012 2014 2016 2018 2020 increased 3 SHCs, one each in Dasti Archi, Imam Sahib and Kunduz districts, thus making it to 75 clinics under BPHS. Based on Central Statistical Organisation’s reports on National Risk and Vulnerability Analysis of 2004-5, 2007-8 and 2011-12; Afghanistan Living Conditions Survey of 2013-14 and 2017-18 and BPHS HMIS data as on September 2019 (JACK, MoPH, Kunduz), there is growth of government clinics in the province from 26 (2005) to 75 (2019) and three-fold growth in health service coverage through establishment of health facilities in Kunduz province through BPHS programme of Ministry of Public Health.
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Table 2: Details of health facilities currently present implemented by various actors in Kunduz Province
Sl. Name of the BHCs SHCs CHC DHs Mobile Other Remarks No. Organisatio (Includin Teams s n g CHC+)
1 JACK 29 29 11 4 1 1 Others- Prison Hospital (BHC). In 2019, three new CHCs are included 2 Health Net 4 Mobile health services and psychosocial counselling for IDPs (supporting Kuchis) 3 OHPM 4 Mobile health services and psychosocial counselling for IDPs (now handed over to PPHD) 3 MSF 2 One wound care centre in Kunduz and one stabilization centre in Chardara. Minimal support is given to the later from MSF in 2019. 4 Handicap 2 PSCs along with community Internationa workers per mobile team, for l persons with disability. Physio-therapy and referral mechanisms. Provision of appliances at their workshop in Kunduz 5 ARCS 2 2 4 Their programme is supported by Qatar Red Crescent Society
6 PPHD 3 Regional Hospital at Kunduz. Two clinics in Kunduz 7 Swedish 1 Physio-therapy Clinic in Committee Kunduz with referral points for at Taloqan(Takhar) and Afghanistan Mazar (Balkh) for Orthotics
8 Save the 3 Three mobiles teams are Children currently to support IDPs in Internationa white areas. SCI is planning l to have 3 more mobile teams for covering White areas for ECHO’s proposal Source: Based on interviews held with the stakeholders and PPHD, Kunduz, November/December 2019 Health Net, NGO working in health and nutrition sectors, manage four mobile teams in Aliabad (Mirsheik), Chardara (Ghar-e-Qashlaq) and Qalaizal (Sayed Masoom Sayed and Dorman) focusing on displacement population and white areas but all of these will be closed by end of 2019. MSF who have left after their trauma care facility was bombed in October 2015 have returned back to with wound care clinic in Kunduz in 2016 and a stabilization facility in Chardara in 2017. At the end of 2016, MSF finally obtained commitments that the staff, patients and hospitals would not be attacked, and care could be provided to everyone in need, regardless of their ethnicity, political beliefs or allegiances. MSF now run an outpatient clinic in Kunduz
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Final Report for people with minor trauma-related wounds and injuries, and a small stabilisation clinic in Chardara district outside the city.
- The intension is not to work parallel to regional hospital in Kunduz, but play complementary role to the clinic. However, provide the following services o Set up a criterion for admission (Green, Yellow, Orange and Red cases – triage). The clinic has o 70% of the case load falls within the criteria of treatment of wounds and minor surgical cases o 20% follow up cases o 10% referrals o Capacity – 80 patients per day capacity but are getting between 60-70 cases per day - Stabilization Centre in Chardara o The reason for having this centre in Chardara is as per the feasibility and requirement. It falls on the transitory route of Balkh, Baghlan and Kunduz provinces and the entire casualty in these locations are brought to Chardara. Thus the stabilization centre was planned, however, Islamic Emirates of Afghanistan (IEA), are popularly known as Taliban run demand to have surgeries to be carried out in Chardara stabilization centre. Currently minor surgeries are carried out but will be converted fully into a stabilization centre in near future. - Full-fledged Trauma Hospital (will build a full-fledged trauma hospital in line with the earlier hospital which was bombed by US air attack in October 2015) o After a prolonged negotiation with the Ministry of Public Health and US Military, the location for construction of the Trauma Centre was identified. The constructions were mostly completed and is expected to start by last quarter of 2020. o It will be having 51 bed hospital o Having this hospital is meant for critical health care only and is in process of building the capacity of regional hospital to meet rest of the cases. The regional hospital itself has improvised and has greater capacity than at time of bombing of MSF hospital in 2015 and their return with wound care unit in 2016. o It is negotiating with all parties that MSF will have strict admission criteria this time . It will have only critical cases only . NO burn cases, no head trauma and no other case than RED o Rest of the cases will be referred to concerned hospitals or regional hospital. The capacity of the regional hospital has increased compared to 2015 or even 2017. - Training of medical and non-medical staff in regional hospital to improve their capacity in trauma management
Handicap International, an international NGO, has started its work in Kunduz after the post- Taliban attack of Kunduz and after the bombing and closure of Trauma care of MSF facility. It started a 45 days’ emergency project focusing on psycho-social counselling for the trauma victims in Regional Hospital of Kunduz. It started its first project supported by WHO- CERF fund to carry out PSC, Rehabilitation, prostatic and orthotics, and physio therapy to persons with disability due to war and prolonged conflict in Kunduz at the regional hospital. The initial workshop for prostatic and orthotics were only to maintain and repairs to the appliances and all referrals are made to Swedish Committee of Afghanistan’s workshop in Taloqan and ICRC in Mazar-e-Sharif. This project was for six months’ duration of Mar-Oct 2016 and was extended
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Final Report till end of 2017. All the equipment and other materials were handed over to the Regional Hospital. The current project has three mobile teams covering three districts (Khanabad, Aliabad and Imam Sahib) with each team constitutes - Two psycho-social counsellors (one male and one female) per mobile team, i.e. totally 8 PSCs - 1 community liaison officer and two community workers (one male and one female) - 1 Physio-therapist (Male) and 1 Assistant (female) - HI is providing physiotherapy training for their staff all over Kunduz province. - Accreditation process of the Physiotherapy training runs by HI all over the Kunduz province. - A step wise structure for referral process was presented: Referral mechanism through psychotherapists from other provinces working for HI. - In Imam Sahib district HI has a psychosocial counselling mobile team.
Swedish Committee for Afghanistan (SCA), an international NGO working exclusively in Afghanistan, currently operates one Physiotherapy centre in Kunduz. SCA sends referrals based on the initial assessment of the disabled persons to their workshops in Taloqan, Takhar and Mazar-e-Sharif in Balkh. The feedback from the interviewed patients, the appliances and wheel chairs are heavier in Takhar compared to Mazar workshop. There are no inpatient treatment or practice sessions at Taloqan for 3-4 days so that the appliances are practiced by the patients. The appliances are issued and ask the patient to return back of fifteen days or one month for follow-up. Whereas people prefer to be referred to Mazar.
Afghanistan Red Crescent Society (ARCS), has base operations in Kunduz with about 23 thousand volunteers in Kunduz province alone. They operationalize, 4 MHTs is with ARCS as well; which is active in Qalezal, Imam Sahib and Kunduz. They are members of EPI coordination and also member of PHCC They have 2 BHCs in Kunduz and Imam sahib urban centres; and also have 4 Sub Centres in Kunduz, Archi, Aliabad, and Chardara supported by Qatar RCS They conduct mobile Health Camps in all the districts which is supported by IFRC, based on needs and emergencies.
For prosthetics and orthotics care, ICRC centre in Mazar (which was closed for short period in 2017 after the killing of their staff in the clinic), but now resumed work. ICRC staff is positioned in ARCS regional office in Kunduz and screen the patients who visit the location and refer them to Mazar-e-Sharif. Handicap International is supporting Regional Hospital and the District Hospital in Imam Sahib in extending their services for prosthetics and orthotics care include supply of supportive devices in these two districts of their coverage through their ongoing ECHO supported project.
Save the Children International is implementing four integrated One mobile team is supported by OFDA will end by 31 December 2019, and three teams supported by BMZ will continue until 30 November 2020 (2 in Kunduz centre and 1 in Imam Sahib). The BMZ supported mobile teams operates in 24 service delivery points (12 in Kunduz centre and 12 in Imam Sahib). The project is implemented in sub-agreement with the BPHS implementing NGO (JACK). The mobile teams provide an integrated package of primary and reproductive health, psychosocial support and management of IMAM cases in under five children and PLW. All these are implemented through JACK, the BPHS implementation partner.
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4.2 Health Facilities in Kunduz
There are 75 health facilities managed under BPHS in Kunduz province and is been implemented by NGOs selected through a competitive bidding process. In past six years, four agencies have implemented the BPHS package in Kunduz starting with Merlin, Save the Children (Merlin merged with Save the Children globally), Organisation for Health Promotion and Management (OHPM) and now, JACK. JACK is implementing the BPHS package since January 2019.
Table 3: Details of Health Facilities in Kunduz Total DH and Prison Health Sl.No. Districts CHC+ CHC BHC SHC MT Clinic facilities 1 Aliabad 2 2 1 5 2 Chardara 1 2 3 6 3 Dashti Archi 1 2 1 6 10 4 Imam Sahib 1 3 8 4 16 5 Khanabad 1 1 7 4 13 6 Kunduz 2 7 7 1 1 18 7 Qalezal 1 2 4 7 Total 4 11 29 29 1 1 75 Source: Health Facility Report September 2019, JACK, the BPHS implementing agency In addition to these health facilities, Kunduz has regional hospital with 250 active beds and with other specializations. The health facilities in BPHS programme are not adequate to meet the primary health care facilities and inadequately equipped and less human resources to manage trauma care and casualty management. Nearly 25% of the health facilities are run in temporary buildings or rental buildings and about 72% are run in permanent buildings. One facility status is clearly not known in Khanabad (i.e.at Dahan-e-Dehkalan clinic) and the Mobile team for Kuchis in Kunduz district doesn’t have building status. Even in the permanent buildings, there are spaces related constrains and the buildings were either damaged or inadequate for trauma case treatment. The following table 4, provides district wise information of the health facilities.
Table 4: Status of health facilities Run in own Run in No. of S. Name of the buildings Rented and Health Remarks No. District (permanent temporary Facilities building) building 1 Aliabad 5 4 1 2 Chardara 6 5 1 3 Dashti Archi 10 6 4 4 Imam Sahib 16 12 4 No facility (closed down ??) in Dahan e DehKalan 5 Khanabad 13 12 1 Clinic 6 Kunduz 18 12 5 1 is MHT for Kuchis 7 Qalai-zal 7 4 3 Total 75 55 19 1 Source: BPHS Data, JACK, September 2019
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The condition of the proposed FATPs in Kunduz province is as follows. The infrastructure assessment was carried out to all the proposed health facilities for FATP where the teams have identified the need.
Table 5 : Infrastructure assessment of the proposed FATPs Type of Space S. FATP Health Waiting for Vehicle parking No. District Proposed Facility space Triage Stabilisation Treatment space Remarks 1 Chardara Mirshek BHC The communities have constructed rooms for FATP /Clinic under Hashar. However, these buildings need Space exist but repairs, refurbishing and no proper facility flooring/roofing works needed Yes Yes yes yes (Dressingfor room) parking to be done. 2 Dasti Archi Mula Quli SHC Space exist but no proper facility Yes Yes Yes Yes for parking Full fledged rooms exist 3 Imam Sahib Alif Berdi BHC Space exist but no proper facility No Yes Yes Yes for parking The communities have 4 Khanabad Boin BHC constructed rooms for FATP Space exist but /Clinic under Hashar. no proper facility However, these buildings need No No Yes Yes for parking repairs, refurbishing and 5 Kunduz Bola quchi BHC Yes Yes Yes Yes yes flooring/roofing works needed 6 Qale-Jal Dorman BHC No No No Yes yes to be done. Needs Assessment for FATP proposed sites, JACK /Johanniter, November 2019 Mirshek BHC is actually located in Aliabad, but due to its location, proximity and accessibility for Chardara, the communities of Chardara, the stakeholders in health sector have proposed this BHC for Chardara district and thus mentioned for FATP for Chardara district. The above statements show that the proposed clinics for FATPs have adequate space or the communities are ready to provide additional space for the health facilities located within the existing health facility building locations. The communities have built temporary structures for conducting triage or stabilisation purposes but they are inadequate for proper services under FATP. Thus, the buildings needed support to function as a full-fledged FATPs.
Bola Quchi Trauma centre built by the Bola Quchi Trauma centre built by the communities, Pic: Dr. Alam communities under Hashar, Pic: Dr. Alam
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4.3. White areas and challenges
Table 5: White areas in Kunduz Province
Distance from nearest health Facility No. of Total locations No. of Total No of District within 5 6-10 11-15 16 and without Locations Population health KMs Kms Kms above health posts post Chardara 11 3976 0 4 6 1 7 6 Archi 7 7962 0 3 0 4 0 7 Imam Sahib 9 4560 0 3 2 4 7 2 Kunduz 11 7665 0 9 1 1 10 1 Qala-eZal 6 3000 1 1 4 5 2 Total 44 27163 1 19 10 14 29 18
As per the above table, except Aliabad and Khanabad districts, rest of the districts has unserved/white areas due to remoteness, inaccessibility, insecurity, geographical and climate related barriers. Johanniter with the support of UNICEF is running four mobile health teams each for providing reproductive health and vaccination services in Qale Zal, Kunduz, Imam Sahib, Chardara and Dashti Archi. Whereas ARCS is implementing Mobile health team in Kunduz but the focus is on the IDPs and returnees, however, their volunteers are associating with supporting vaccination programme in all remote villages in the province. Health Net International runs mobile clinics in Chardara, Qale-Zal and Imam Sahib but all of them are located at the health centres catering to the health needs of the conflict related displaced population, not the white areas. As per the PPHD and health Shura members, there is a gap for reproductive health support in conflict prone district of Qalaizal and Dasti-Archi.
The challenges in white areas were discussed among the health shuras, BPHS staff and PPHD in Kunduz.
98% of the locations in white areas are beyond 6 kilometres from the nearest health facility and 41% of them don't have any health post. This is quite high in Dasti Archi and Chardara 77% of the locations in white areas have reported of insecure roads 86% of the locations in white areas have reported of presence of Taliban Only 20% of the locations in the white areas have reported of presence of government to some extent Even in Kunduz district, there is huge challenge of outreach of vaccinations where 91% of the white areas reported of problem in vaccinations, due to constrains in getting women vaccinators in outreach. Most of the white areas are cut-off geographically due to rivers and flooding, people living in these localities can't access health services during these seasons.
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Table 6 Challenges in White areas Difficulties No. of Insecure AOG Govt. District Locations roads presense Presence Disaster prone Challenges Outreach sessions or activities the TT vaccines are prohibitted (if Chardara 11 11 11 0 administered by Male vaccinators) Heavy rains (5 As above Archi 7 7 - villages) Imam Saheb 9 9 9 6 As above Outreach sessions or activities the River Alchin TT vaccines are prohibitted (if flooding in administered by Male vaccinators) in Kunduz 11 11 11 - summer 10 locations out of 11 Qala-eZal 6 3 3 As above Total 44 34 38 9
The following table 7 and 8 provides information related to the capacity of the health facilities in terms of beds, ambulance services and health professionals available in the districts. Based on the data, there are only 15 health facilities in this large province has capacity for inpatient treatment and have beds and the capacity put together (with exception to Regional Hospital) has171 beds only and this increase was due to upgradation of Khanabad CHC+ into District Hospital. There are only 17 ambulances available for entire population in the province which caters to the emergency cases includes trauma, emergency transportation for referrals and referrals and transportation of critical pregnancy cases.
Table 7: Capacity of Clinics with beds, ambulances Sl.No. Districts Total Health No. of Beds Active Beds and Ambulance Facilities Ambulances availability in HFs 1 Aliabad 5 12 2 2 2 Chardara 6 6 2 1 3 Dashti Archi 10 22 3 3 4 Imam Sahib 16 68 4 4 5 Khanabad* 13 41 3 2 6 Kunduz 18 12 2 2 7 Qalezal 7 10 1 1 Total 75 171 17 15
In Khanabad district, Payanda Mohammad BHC has one active ambulance in addition to that of CHC and DH (2 clinics). The conflict affected districts like Qalai-zal, Chardara and Kunduz have only 2 ambulances or less with the health facilities. Relating to the staff and categories of the personnel at the clinics (Table No.8) 28 Medical Doctors (23 men and 5 women). Of them 23 (18 men and 5 women) are located in 15 so called urban/town level health facilities. Only five qualified doctors are working in rest of 60 health facilities in Kunduz. 100% qualified women doctors and Female nurses (26) are working in 15 of the urban locations. There are only three male and 1 female surgeons available in entire BPHS and those are located in 3 Clinics)
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Anaesthetics are only four, and four physiotherapists for entire BPHS in Kunduz province. 100 percent of psycho-social care providers are present in 14 centres out of 75 clinics run by BPHS. The PSCs are mostly supported by NGOs through support Donors like OCHA-AHF, UNICEF. Table 8: Health Facility Infrastructure and Professional personnel Doctor Paramedics PhysicianMD General Surgeon Pediatrician Dentist
HealthFacilities Nurse CoveragePopulation
M F M F M F MFAnesthetist Physiotropist MF Psychosocialconsultant Lab.Technician Tech.Pharmacy X-Ray DentalTech Aliabad 53,309 2 2 0 0 0 0 0 0 0 0 6 2 2 2 2 0 0 Chardhara 71,405 1 1 0 0 0 0 0 0 0 0 6 1 1 1 1 0 0 Dashti Archee 1,09,248 50010000119533200 Imam Saheb 3,03,423 6 2 2 0 1 0 1 0 1 121 8 3 5 3 1 1 Khanabad 1,70,221 5 0 1 0 1 0 1 0 1 216 6 2 4 3 1 1 Kunduz 3,17,386 300000000019222300 Qalaezal 88,593 1 0 0 0 0 0 0 0 1 0 8 2 1 1 1 0 0 Total 11,13,585 23 5 3 1 2 0 2 0 4 48526141815 2 2 Source: OHPM BPHS Report to MoPH, November 2017 There are only 3 male surgeons and 1 female surgeons in entire province to cater to general and trauma needs and only four anaesthetists and four physio therapists under BPHS programme. Most of the minor surgeries are carried out under the supervision of trained nurses or referred to regional hospital in Kunduz and District Hospitals in Imam Sahib and Khanabad. 4.3 Trauma Cases details in Kunduz Province
All the stakeholders have mentioned that there is reduction in the fighting during the assessment period except for few locations in Imam Sahib, Qalaizal, Chardara, Dashti Archi and some parts of Kunduz, where ongoing fighting was reported and displacement of local population were reported. The above table shows that there is increase of trauma cases since 2014 (above mentioned of use of Afghan solar calendar, April to March, 1393 means 2014- 15). For the current year, the data is from March –September 2019. Some of the trauma cases were not reported due to its remoteness and insecurity.
Table 9: Trauma Cases in the Health Facilities of BPHS (2014-2019)
Sl.No. Districts No. of 2014 2015 2016 2017 2018 2019 Total Clinics (Sept) (2019) 1 Aliabad 5 2294 2611 3598 1910 3845 3359 17617 2 Chardhara 6 2947 1329 1932 1624 2492 2598 12922 3 Dasti Archee 10 4101 5542 5832 3548 7647 7203 33873 4 Imam Sahib 16 11679 13667 16524 7106 16616 14057 79649 5 Khanabad 13 6443 6095 4085 3921 9671 6940 37155 6 Kunduz 18 5196 5327 5782 3530 6558 5503 31896 7 Qalaye Zal 7 2255 3232 3045 2194 3586 2877 17189 Total 75 34915 37803 40798 23833 50415 42537 230301 Source: HMIS Report September 2019, JACK, the BPHS implementing agency
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As per mid- September HMIS data, of overall IP trauma cases in Kunduz regional hospital, 90% of the cases are children, with 22% girls and 68% boys. Summarized Trauma cases reported in the regional hospital at Kunduz are as per the following table-10
Table No 10: Last 21 months out of 69 months has reported 40.4% of the trauma cases in BPHS locality in Afghanistan Sl. No. of 2018 2109 - Up to end of September No. Districts Clinics M<5y F<5Y M>5y F>5y M<5y F<5Y M>5y F>5y 1 Aliabad 5 407 378 2173 887 458 376 1796 729 2 Chardhara 6 356 329 1230 577 560 529 1001 508 Dasti 3 Archee 10 1445 1357 2780 2065 1420 1454 2313 2016 4 Imam Sahib 16 2944 2695 6450 4527 2400 1972 6241 3444 5 Khanabad 13 1715 1364 3881 2711 1087 982 2684 2187 6 Kunduz 18 953 783 3078 1744 885 679 2677 1262 7 Qalaye Zal 7 294 290 2256 746 369 325 1447 736 Total 75 8114 7196 21848 13257 7179 6317 18159 10882 Source: HMIS Report, BPHS – JACK September 2019 The trauma incidents are on rise since 2015 due to intensified fighting for territorial controls between the actors of conflict, the AOGs and ANSF/IMF. Kunduz was fallen in October 2015 and since then there is intensified attacks and thus increase in trauma cases in almost all the districts in Kunduz province. The table no. 09 and 10 above the following diagram shows the increase in trauma incidents with highest been in 2018 and the figures for 2019(till mid- September), it shows quite high than the previous highest in 2016. With active fighting in the province, the figures may cross even 2018 figures as estimated by the health actors in the province.
50415
42537 40798 37803 34915
23833
2014 2015 2016 2017 2018 2019 (Sept)
The 2017 figure shows a dip in the trauma incidents as the ANSF /IMF reduced their operations in Kunduz and were focusing more down in southern regions. Thus, there is a
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Table 11: Trauma cases recorded by FATPs run by Johanniter and OHPM in 2018-19
FATP located Boys Girls Men Women Total Re Refer G. Total Districts attendance Out Char Dara 502 409 741 536 2188 684 76 2948 Dasht_e_Archi 686 608 1153 985 3432 706 75 4213 Imam 383 325 768 473 1949 821 65 2835 Sahib(Echi Keli) Qala Zal 585 429 1134 683 2831 962 103 3896 Total of 4 2156 1771 3796 2677 10400 3173 319 13892 FATPS Source : FATP HMIS report by OHPM for the period of (June 2018-March 2019)
The trend in 2018-19 run FATPs in the four districts shows that 57% of the trauma patients are men and 43% are women. It was estimated that about 10% of the cases are referred out (as per MSF assessment) but in the FATPs case it was only 3%. The health facility staff and the community members shared that the referrals were reduced to District hospitals and Regional hospitals were mainly due to security checks at the city entry points by ANSF and there were reports of arrests and harassment at these checkpoints for those patients coming from fighting zones. Thus, the injured patients were referred and treated within the district by the existing health facility staff. There were reports of health staff been taken by AOGs to conduct minor surgeries in the clinics they control.
Trauma victims in Kunduz (Trend Analysis - Gender) - 2014 to 2019* in % (Source: HMIS)
61 59 60 58 56 57
44 42 43 41 40 39
2014 2015 2016 2017 2018 2019
Men Women
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The above diagram presents the % of men and women were victims of trauma during 2014- 19 period. The assessment clearly shows that men and boys outnumber the women and girls in trauma cases. Table no. 12: Trauma care in MSF Hospital in Kunduz
R Y G O B Total 2018 2019 2018 2019 2018 2019 2018 2019 2018 2019 2018 2019 JAN 17 11 161 128 72 80 72 50 3 4 325 273 FEB 13 6 113 105 59 61 49 49 0 0 234 221 MAR 13 23 132 131 65 51 49 57 2 2 261 264 APR 7 19 103 133 65 44 49 53 0 2 224 251 MAY 2 11 112 115 68 55 55 56 0 4 237 241 JUN 4 17 121 117 70 43 50 53 1 7 246 232 JUL 21 25 141 119 80 46 53 60 1 2 296 252 AUG 16 34 126 141 67 64 57 66 1 5 267 310 SEP 13 124 80 71 4 292 OCT 21 140 63 66 1 291 NOV 14 123 77 70 0 284 DEC 10 126 60 73 0 269 151 146 1522 989 826 444 714 444 13 26 3226 2044 Source : MIS, MSF September 2019
The table above shows the trauma cases based on the triage data of MSF trauma/wound care unit in Kunduz city for 2018 and 2019 periods. Ever since the spring attack of Taliban in 2019, the trauma incidents of Red, Yellow and Orange has increased to that of the same period in 2018. This shows that there is increased conflict and trauma cases in Kunduz in 2019 in comparison to 2018.
Table 13: Type of incidents in MSF clinics 2018 % in 2018 2019 (end of Aug) % in 2019
Trauma violent 948 29.4 394 19.3 Trauma accidental 2266 70.2 1647 80.6
Other 12 0.4 3 0.1 Total 3226 2044
The trauma related to violent incidents reporting to Kunduz Unit of MSF is lower in 2019 (19.3%) comparison to 2018 figure of 29.4%. The reasons expressed by the stakeholders of lesser referrals to Kunduz city due to increased checkpoints of ANSF in all the entry points of the city has reduced referrals from the fighting zone to Kunduz and in turn, shifted the referrals sites to within the district health facilities. Thus, there is increased demand for referral sites and upgradation of CHCs and BHCs in to Trauma Care Units.
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Table 14: Gender segregation of data of MSF trauma cases 2019 (end of August 2018 2019) Male Female Total Male Female Total 2611 615 3226 1607 437 2044 81% 19% 79% 21%
The referrals to MSF trauma cases are more of men and boys than women and girls. This is the likely scenarios in the province when compared the data of all three sources, MSF, Regional Hospital and BPHS /FATP data. The following two tables shows the Kunduz regional hospital information related to trauma caseloads.
Table 15 : Kunduz Regional Hospital (Trauma Care) 2019 (Till 2018 Sept) Trauma care 48492 39378 Wound Treatment 4295 1944 The wound care cases are almost same to that of last year. The wound treatment cases in the regional hospital is lower. The reasons for this similar to that of them mentioned in above for other health service providers based in government controlled areas. The referrals from the fighting zone has reduced due to increased harassment at the checkpoints. The following analysis of the discussions with the health shura representatives also reiterate this observation. Table 16: Trauma inpatient details for 2019 S. No. Trauma indicators Total for inpatients for 2019 (till September 2019) Female Female Male over Male over 5 under 5 5 under 5 1 Weapon Wounded 96 25 595 41 2 Road Traffic Accidents 340 57 1021 104 3 Occupational Injuries 50 3 198 9 4 Burns, scalds and frost-bite 2 54 4 52 5 Fractures and dislocations 140 26 492 41 6 Cerebral Concussions 220 49 347 53 7 Other Injuries 40 7 122 14 Total 888 221 2779 314 Source: HMIS, Regional Hospital, Kunduz (October 2019)
Based on the above trauma cases at regional hospital for the year 2019, till September, traffic accidents are the major trauma incidents with 1522 cases have been reported as inpatient treatment in the regional hospital and counts to 36% of the IPs in this year. Weapon injury inpatients account only for 19% of the cases in the regional hospital with a number of 757 cases been recorded till end of September 2019 in the regional hospital, Kunduz. The regional hospital has the capacity to cater tertiary health care not only to Kunduz province but to the entire north eastern region.
Kunduz Regional Hospital is the Tertiary Care health facility and a teaching hospital in Kunduz Province and also caters to referrals from neighbouring provinces of Takhar and Baghlan. It has 265 Beds with 12 Departments includes Internal Medicine (Physician), General Surgery,
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ENT, Ophthalmology, Paediatric, Dermatology, Gynaecology & Obstetrics., Psychiatric & mental health, Orthopaedic, Neuro-surgeon, Dental and Physiotherapy units. It has fully equipped Intensive Care Unit with 10 beds, four Operation Theatres, with 361 staff, 28 Specialists and 58 GP Doctors (Post-graduate specialisation doctors), 101 Nurses working in the hospital. It has 4 Ambulances and OPD. It is the highest referral health care facility in the North-Easter region and that’s why it is called as Regional Hospital. The assessment team triangulated the data collected from various HMIS and other reports of all the health stakeholders working in Kunduz province and met the key functionaries of these health facilities to discuss on the emerging need for trauma units in BPHS system and to be considered as a humanitarian need to for seeking support from humanitarian actors. The team discussed in detail with health Shuras of these seven districts to understand how the ongoing conflict has increased trauma cases and need for trauma posts within their districts and nearer to conflict locations to get immediate treatment to the causalities and reduce death and loss of limbs. Based on the perceptions of the health shura members, the following analysis per district was collated.
Districts Practices observed Barriers
Aliabad The trauma cases have increased They do not bring their injured to the compared to previous years. Govt. HFs because fear of being chased and arrested by the Trauma patients are carried to local government security forces. clinics. For referrals, most to CHCs and Regional Hospital in Kunduz, However, in The problem associated are Taliban occupied areas, the patients were transportation during the fighting, less carried to some of the clinics located equipped and staffed lower level HFs, within the district. roads blockade during the fighting’s, shortage of equipment and supplies and staffs, skills of surgery in the lower level of HFs. Mines on the roads, checkpoints, delays due to long investigation by the checkpoints and other security risks.
investigation by the security check points cause delay and sometimes death of the injured on the way.
Chardara The trauma cases have increased with Lack of transport during the escalation of war and use of artillery and fighting air strikes by the government. Transportation cost Mines on the toads The trauma cases for management are taken to: Check points delaying the cases Transportation costs
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RH Kunduz, CHC Chardara, MSF trauma Shortage of trauma care equipment post and some private clinics and, supplies and skilled surgeons
To the nearest BHCs in case of roads to other places are closed.
Dasti Archi The trauma incidence has increased in Problem associated include targeting general in the district with increase in the by AOGs when bringing government fighting especially in the last few months. patients, blockage due to rains and snow, mines on the roads.
For minor injuries patients are taken to the CHC, BHC and even SHC. For major injuries they have to take case to the regional hospital.
People do not take cases to private doctors because there are no skilled doctors and people are poor and cannot afford private doctors.
Imam The number of the trauma cases has transport problem during the fighting, Sahib increased this year comparing it to the last mines, airstrikes risk, checkpoints and year. People take the injured to: delays due to their longer investigations, insecurity and road DH in the district itself and some health blocks. facilities like BHC and CHCs. Some people to the private doctors also when the other HFs are not available like in the evenings and nights.
The AOGs take the cases to other locations and clinics in areas under their control.
Khanabad The number of the trauma cases has Fighting, main roads between the increased this year comparing it to the last district and other places especially year. People take the injured to: Regional Kudzu are mined between 5PM and 6A Hospital in Kunduz; DH in Khanabad, M, lack enough drugs and equipment’s sometimes to the CHC, BHC and private in some clinics, check points in some clinics locations delaying patient transfer to appropriate locations. The AOGs take the cases to other locations and clinics.
Kunduz The number of the trauma cases has Active Fighting, increased this year comparing it to the last
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year. People take the injured to: RH in Fear of aerial attacks during the Kunduz; transportation, checkpoints and delays during checking at the check points, CHC in Larkhab roads blocks The AOGs take the cases to other locations and clinics.
Qalezal The trauma related to fighting has The barriers are that during the fighting decreased because the front lines has the cases cannot be transported, roads gone away from the residential places and get blocked, poverty and people they are near the military bases. cannot afford for transportation. There are check points on the way who The people take the trauma cases to the delays cases for investigations and RH Kunduz. interrogations.
4. 5 Increase of deaths, wounds and injuries due to mines in Kunduz Given the high incidents of mine detonations which take place in remote areas or when performing solitary tasks, such as grazing livestock or collecting firewood, it is reasonable to surmise that victims are never found, or only discovered after such an extended period that cause of death is neither apparent nor an issue. An unknown number of Afghans who fall victims to mines in remote areas where there are no rescuers, or even witnesses, nearby. These victims are young boys grazing flocks of sheep or goats, it is apparent that, untreated and stranded, such victims die slow and painful death from loss of blood, shock or exposure. According to news agencies, in April this year, at least four children were killed and seven others were wounded in an explosion in Chardara district, northern Kunduz province of Afghanistan. The children were busy playing in an open area when an unexploded mortar round went off. A study on the human cost of explosive remnants of war (ERW) in 2010-18 period, where the casualties are reported as 4,820, which almost 48% of the casualties occurred due to three types of explosive devices used in Afghanistan (Landmines, ERW and Abandoned Improvised Mines).
During the recent ground engagement between the government forces and the anti- government elements in Kunduz province, many areas have been contaminated by ERW which threatened the limbs and lives of the civilian population in the province. Those hazards, had to be cleared to allow the safe returned of the displaced civilian population.
There are reports of the road get mined during the night by Taliban to avoid deployment of army and restricts the movement of ANSF ground operations. However, Taliban warn the people living in their area of control of the landmines been laid to reduce the civilian casualties. However, there are reports of casualties mostly children.
The Mine Action Program of Afghanistan, in an emergency response provided humanitarian services to the conflict affected civilians in Kunduz. Funded through the UN Common Humanitarian Fund, implementing partners provided mine risk education and destroyed explosive devices.
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4.6 Internal Displacement
The data on internal displacement varies from stakeholder to stakeholder. The following table shows the internally displaced population district wise based on UNOCHA’s reports. Discussion will all the stakeholders revealed that there is serious conflict in all four provinces of north-east region, Baghlan, Kunduz, Takhar and Badakhshan, with greater intensity noticed in almost all the districts of Kunduz province with exception to Kunduz city this year. Due to repeated operations between IEA and ANSF with support from commandoes and air strikes, there is repeated displacement of the same families in the conflict zone to their neighbourhood, district centres or to Kunduz and even to neighbouring provinces to distant locations of Mazar and Kabul. Once the fighting stops, the displaced families are returning back to their place of origin to resume their livelihood activities. IN 2017, displacement happened at different times starting from the spring offensive announcement till November. The recent displacements are reported more from Chardara, Dast-e-Archi and Qalaizal. There is greater number of displacement from Chardara due to airstrikes which led them to displace to Aliabad and Kunduz. Displacement in Kunduz is temporary in nature.
Table 17: Summary of IDP families’ update from 1 January – 9 October 2019
Sum of # families Sum of Total # Sum of # families identified in need individuals identified in Districts assessed so far of assistance need of assistance 2018 2019 2018 2019 2018 2019 Aliabad 79 - 7 - 49 - Chardarah 362 20 155 5 1085 35 Dasht-e-Archi 519 786 216 312 1512 2184 Emamsaheb 3680 2487 1115 540 7805 3780 Khanabad 487 53 339 22 2373 154 Kunduz 19643 6779 4613 2352 32191 16464 Qala-e-Zal 500 382 2674 Total 25270 10125 6827 3231 47789 22617 Source: Summary of NER IDP families Updated as of 09 Oct, 2019, UNOCHA
In 2019, more than 23,000 have displaced due to conflict. However, 7,000 have identified as protracted IDPs in the joint assessments. Joint assessment is done along with the UHCR partners, NGOs and DoRR. Accessibility is the big challenge in case the displacement took place in AOG controlled areas. NGOs do negotiate with the AOGs/IEA. Despite of some AOG commanders and their top leadership appeal to the NGOs to work and start humanitarian work, but some NGOs suspect the intention and fear of operating in the AOG areas. Table no. 18: Displacement History
Year Sum of # families Sum of # families Sum of Total # assessed so far identified in need of individuals identified in assistance need of assistance 2017 26025 7450 52157
2018 25270 6827 47789
2019 10125 3231 22617
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Final Report in 2017, 55% of the NE region displacement was taken place in Kunduz province and it still remained high (with 47%). However, the conflict has spread across to other provinces in North East in 2019, thus Takhar, Baghlan and Badakhshan has higher displacement than Kunduz. The conflict induced displacement has reduced much in Kunduz as the territorial claims over the rural areas are almost been under the effective control of Taliban, where as there is fierce fight between Taliban and ANSF over the control of district centres. Taliban are effectively holding on at least two of the seven District centres and contested in another 2 district centres. Thus, there is displacement from these locations and some of the rural areas where there is a belief of leadership of Taliban exist. During the assessment period, the situation in Imam Sahib, Aliabad and Qalezal have improved. There are few NGOs who could operate in these areas and have acceptability from the opposition groups in comparison to few months back. With Taliban in command, they have established different commissions to work on various sectors. (Please see section on access assessment in the report for more details) During our interaction with Shura representatives, who state that,
- In Aliabad, people come to the district centre from Chardara and Kunduz during the fighting time. The displacement is entirely depending on the ongoing fighting. People displace during fighting and return back when the fighting subsides. - In Chardara, people were displaced during the fighting in and outside the district. People come into the district when there is fighting in Kunduz and neighbouring districts and from Chardara people displaced to Kunduz city, Aliabad and Khanabad districts when fighting occurs in the district. Since last three years fighting has increased and people were on move. - Almost 50% of the people has been displaced once or more times. In Dashti Archi district, the displacements take place from time to time but increases during the fighting. People go out of the district displace within the district, Imam Sahib and Taloqan in Takhar province. This district has highest number of displacement. Last three months noted high level displacement in the region. - In Imam Sahib, the displacement is high during fighting period. There are migrations within the district, mostly to Sherkhan Bandar and to the Kunduz city centre. - In Khanabad district, there is displacement to neighbouring Taloqan and Kunduz city. Some who could afford moved to Kabul. The Arbaki (Afghanistan Local Police, Pro- government Militia) and warlords have moved out from the interior villages to the district centre. People fear more fighting and thus displaced. - In Kunduz, the villages around where there is active fighting has led to displacement. - In Qalezal, there is less displacement and are within the district. Once the fighting ends, people return back to their place of origin. This district is more stable due to almost under the Taliban direct control.
Displacement Locations3 Mostly, IDPs who are displaced to Kunduz city are located in Sedarak, Char Taq, Nomra-e-Shayaf, Koti Gird, Zakhil, Khakani, Qahwa Khana, Zarkadrid, Baghi Sherkat, Chihel Dukhtaran, Qarawal Tepa, Kalapazi, Maidan Pakhta, Seada Family, Charam Gari, Hindo Sozan, Nawabad No. 1, Zeri Bala-Hesar, Karti-Helal, Miskeen Abad, Hafeez Abad, Brinj Bazar, Shaftalo Bagh, Kandak-e-Enayat, Chela Mazar, Khuja
3 Based on the discussions held with UNHCR, Kunduz October 2019
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Mashad, Ibrahim Khil, Zera Dawra, Sari Dawra, Khan Abad Bandar, Imam Sahib Bandar, Kabul Bandar areas. IDPs from Kunduz have settled mostly in Sher Khan Bandar, Dashti Abdan (both in Imam Sahib district) and in Kunduz city. Qalazal IDPs are displaced to Sher Khan Bandar and Dashti Abadan (Both in Imam Sahib district) and in Kunduz City. Khanabad IDPs are diplaced to Khanabad district centre, Aliabad district centre, Kunduz city (all three in Kunduz province) and Taloqan city (in Takhar province) Dashti Archi IDPs have displaced to Khuja Ghar district and Taloqan city (Both in Takhar province), and in Imam Sahib district and Kunduz city (both in Kunduz province) and remote villages within Dashti Archii district. Chardara district IDps are mostly displaced to Kunduz city centre in the locations mentioned above in Kunduz city and in smaller numbers to Aliabad district centre, Shena Tepa and Angur Bagh (later two are located in the outskirts of Kunduz city)
Reasons of displacement The reason for displacement is mostly armed conflict, military operation, IHL violation, Tribal conflict/disputes, forcibly eviction, illegal taxation, torturing, and AGEs threats in places of origin and other generalized violence.
Needs of the IDPs - Emergency Needs: Multipurpose Cash Grants to meet food and non-food needs, emergency shelter, PSS/rehabilitation services, emergency health services, WASH, winterisation, education, CFSs, trauma counselling and education in emergenices - Protracted Phase needs: Food, transitional shelter, regular health services, PSS/Rehabilitation, WASH including hygiene and sanitation, education including CBEs and supply of stationaries, livelihoods including income generation activities, information counselling and legal assistance, winterisation, identity documentations, etc.
Recommendations: The assessment team after analysing the findings and based on the suggestions made by the stakeholders summarized this section. a. Increase access to Health Facilities for trauma care in remote areas of Kunduz by establishing trauma units in BPHS health facilities
All the stakeholders include PPHD Kunduz, Regional Hospital, WHO Kunduz region, OCHA and MSF have suggested for establishment of trauma units, at least one per district. There is greater demand from the health shuras and also from Taliban to increase the number of trauma care centres. There was a demand to have at least 8 FATPs. The assessment team felt that, establishment of first aid and trauma posts in existing health facilities in the conflict affected locations will increase access to the emergency health care for the affected population.
Establishment of First Aid Trauma Post (FATP) within the existing health facility with rapid response teams (Ambulance services (two shift drivers) + 2 nurses, one for Day and another for Night shifts), conduct triage, categorise the priorities for emergency transportation and referral to higher trauma care posts (MSF and Regional Hospital in Kunduz or DH Imam Sahib based on the
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The following clinic sites are identified through the consultations held with PPHD, Provincial Council members, BPHS team members, WHO, MSF and IEA’s shadow health directorate. These clinics will also have in addition to FATPs, ambulance facilities for emergency transportation and use for referrals to higher grade clinics for treatment of emergency cases (RED and Yellow). The FATPs will act as first aid and stabilization centres and carry out minor wound care based on triage conducted at the hospitals. Only emergency cases (RED and Orange) will be transferred to identified referral sites or the District Hospital Imam Sahib and Khanabad, Regional Hospital in Kunduz and MSF Trauma care facility (which will be established by mid-2020) and till such time at MSF wound care centre in Kunduz. Based on the agreements with different stakeholders, the following options are presented for intervention of FATP and Mobile teams.
Table No -19 Proposed Health Facilities for First Aid and Trauma Units (FATU) in BPHS facilities Type of Total FATP location Health Coverage Coverage Health Catchment Sl.No. District Proposed Facility villages/CDCs Facilities nearby Population 1 Chardara Mirshek (is BHC 60 Chariabad 29167 actually located SHC, Qaria in Aliabad, but qasab SHC due to its Ghara Qashlaq location, it is (SHC accessible for Chardara) 2 Dasti Archi Mula Quli SHC 66 40939 3 Imam Sahib Alif Berdi BHC 117 Gharaw BHC, 76752 Tazalqi BHC Shahrawan BHC 4 Khanabad Boin BHC 86 46370 5 Kunduz Bola quchi BHC 95 61446 6 Qale-Jal Dorman BHC 166 Yangharooq 68894 SHC, Halqa kol SHC 590 323568
For emergency health care, referrals are provided to for Imam Sahib district to Imam Sahib DH; for Khanabad district to Khanabad DH and for rest of the districts, it will be Kunduz regional hospital and MSF Trauma care Centre in Kunduz (emergency and trauma cases after conducting Triage). Upgrading health facilities to meet the increased trauma cases and reduce caseloads over the regional hospital and future MSF hospital in Kunduz. The caseloads will increase in Kunduz province as ICRC has closed their operations for good in Kunduz which will have negative impact on the trauma case treatment. Thus quality health services can be offered and reduce casualties. During the assessment, a response plan was also discussed with the stakeholders in addition to the problems. The following table explains the referral sites currently used for the proposed First Aid and Trauma Units(posts) by different actors based on their perception of safety and security.
Table No.20: Referral sites identified by different actors (based on their accessibility and control)
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FATP location Referral Sites for Referral Sites for Sl.No. District Proposed Taliban ANSF 1 Chardara Mirshek (is actually MSF Chardara Chardara CHC located in Aliabad, but Sai Dokan Basus BHC Regional Hospital due to its location, it is MSF Kunduz city accessible for Chardara) 2 Dasti Archi Mula Quli Haji Naim Jan CHC Archi CHC+ Kal Bad CHC RH MSF 3 Imam Sahib Alif Berdi Kalbad CHC Imam Sahib DH Echkili CHC RH MSF 4 Khanabad Boin Payenda Mohammad Khan Abad DH BHC RH Nikpay CHC MSF 5 Kunduz Bola quchi Asqalan CHC RH Kanam BHC MSF MSF chardara 6 Qale-Jal Dorman Said Masom BHC RH Aqtipa CHC+ MSF MSF chardara Source: Developed based on the consultations with health shuras and other stakeholders
The civilians use the facilities used by both parties depending upon their accessibility and cost factors.
Supporting Referral Sites with capacity to respond mass casualty
WHO under its Emergency Health Services supported by CERF, AHF and their own grants have increased the capacities to trauma care services in high-risk areas, including supporting hospitals at regional and provincial level to deal with mass casualty management (MCM), provision of additional space, equipment and capacity building to the staff. However, these hospitals have no mechanism to fund the supplies needed for mass casualty and generally prescribe to the patients to fetch these supplies essential for treatment and surgery. The poverty conditions of the patients make them to shift to BHCs and SHCs (now PHCs) for low quality services and risk of fatal incidents. The health shura and the health facility staff have suggested of having provisions for supplies essential for casualty management as buffer stock/contingency. It can also be explored if the facility can provide cash vouchers to the patients to buy the products from the open market and medical shops if they exist in the towns or cities. We found out that only in Kunduz such facilities are available and thus recommend for stocking the supplies as buffer stock/contingency at the referrals. Provision of life-saving medicines and supplies is considered The BOQs will be developed accordingly in consultation with health actors and the cluster.
Coordination with relevant health actors at Kunduz and Kabul
There is need for coordination between different health actors and other agencies for effective programming. The following table states the on-going programmes in the proposed FATP locations.
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Table No. 21: Proposed FATP locations and presence of other stakeholder’s programmes FATP location Nutrition and Displaceme Physiotherap S.No. District Proposed Health Education EPI nt Livelihood y support 1 Chardara Mirshek (Aliabad) JACK (BPHS); HNTPO (Mobile health services and and Save the Children psychosocial (Education counseling for IDPs) Programme) SCA 2 Dasti Archi Mula Quli JACk (BPHS);ARCS Save the Children (Primary health (Education services) Programme) SCA 3 Imam Sahib Alif Berdi Save the Children (Educational program, Mobile WHO and UNMAS: health services and UNICEF Livelihood and psychosocial (through its UNHCR/NR support to counseling for IDPs partners) - C war JACK (BPHS) through JACK) Technical and supporting affected SCA 4 Khanabad Boin Save the Children financial IDPs and civilian and (Education support of EPI returnees physiother JACK (BPHS) Programme) program and apy SCA 5 Kunduz Bola quchi Save the Children survilance services (Educational program, Mobile health services and JACk (BPHS);ARCS and psychosocial (Primary health counseling for IDPs services) through JACK) SCA 6 Qale-Jal Dorman JACK (BPHS); HNTPO (Mobile health services and and Save the Children psychosocial (Education counseling for IDPs) Programme) SCA
Coordination with different actors of health is essential for effective Mass Casualty Management. The assessment team agreed in principle with the different health actors on the following lines Provincial Public Health Directorate The focal point for health related programmes in the province. The Director will be heading the advisory committee for this project and provide all support to the implementing agencies in operationalisation of the project and other linkages with ongoing health programmes of EPHS, Regional Hospital and wiht the provincial Governor's office Regional Hospital, Referrals to Regional Hospital Kunduz - Use of technology by the FATP staff before sending any referral to Regional Hospital o Form a Viber Group – FATP Viber Group and include Regional Hospital and referral hospital focal points o Send the details of the patient and photographs of case sheet/referral sheet and vehicle details o The referral sites will make arrangements with emergency kits and be ready to see the patient immediately on arrival o This real time coordination and reporting will help in preparing for MCIM at referral points Coordination related to the project - Monthly/bi-monthly programme coordination committee meeting to update the core steering group (PPHD, Regional Director, MSF, JACK and Johanniter, can invite OCHA representative to this meeting)
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Afghanistan Red ARCS have quite a good number of volunteers covering all the villages of Crescent Society, Kunduz Province. They are usually the first responders and were trained in First North East Region, Aid and basic triage. They are deployed in case of emergencies and are also Kunduz the ones who conduct joint needs assessment in any natural disasters. These volunteers will be high potential in case of any support for conducting first aid and triage in any hospital/health care facilities. This can be coordinated with ARCS Kunduz office which coordinates with the volunteers. The project can also coordinate with ARCS regional office related to dignified transfer of any dead upon request of the relatives of the diseased, especially in case where there are difficulties of the relatives for a dignified transfer/transportation. The health facility staff can contact ARCS so that the volunteers will respond (but the official request should come from the relatives of the diseased).
MSF Kunduz MSF is one of lead agency for referrals to trauma patients. Many patients and stakeholders prefer to refer the trauma patients to MSF wound care centre. In near future, a 51 bed trauma care centre will be established by MSF and that will increase the case load related to RED (Emergency cases) and more for surgical cases. It will be one of the referral sites after the regional hospital. Secondly, MSF and JACK/Johanniter will coordinate in information sharing of the trauma cases dealt at FATP/BPHS level and referral cases. Thirdly, MSF will provide training to First Aid Trauma Units on Triage and stabilisation and at the referral sites the full scale five day Mass Casualty Incident Management Training.
Save the Children Save the Children supported Mobile units have Psycho-social counsellors and these units can be linked for referral to people affected by mental health and Post Trauma Disorder Syndromes (PTDS). Johanniter/JACK will coordinate with Save the Children in the following areas 1. The MHTs of save the children will refer all the trauma related cases to the FATP of JACK/JUH. 2. During any emergency MHTs of Save the Children seek and ask support from FATPs of JACK/JUH ambulance. 3. During any mass casualty event the MHTs of Save the Children will provide collaboration and cooperation to the FATPs of JACK/ JUH.
To avoid duplications, Johanniter and JACK will not present in the proposal for the white areas. JACK, BPHS JACK has 75 clinics directly under their implementation of the basic package of implementer health services. The facilitation support is there till mid-2021. Thus, there is greater scope to work with JACK for the FATPs in the BPHS clinics. They have established working norms with Taliban and the government in implementation of health programme and thus have access to all these clinics. Thus, the project coordinates with their programme team and medical staff in the clinics for joint planning and coordination.
Johanniter Johanniter international assistance will bring in the support of Psycho-social care International (Mental health PTDS) support to the health facility staff and also hire services of Assistance TABISH for health staff safety (related to stress management) in the proposed FATPs. JUH will also bring in the services of training the physiotherapists.
Swedish SCA has a stabilisation unit in Kunduz and orthopaedic and prosthetic centres in Committee for Mazar and Taloqan. They act as referrals. Afghanistan Handicap The current programme of HI related to community based disability services will International be referred to by the needy population living in Kunduz, Khanabad and Imam sahib district.
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WHO JACK and Johanniter will provide updates related to Trauma cases by location wise with WHO. WHO will also provision Emergency Kits for large scale health emergencies like at least 100+ trauma victims at any given time. Facilitate support whenever they need a resource person to train MCIM and other trainings. UNOCHA, Kunduz OCHA Kunduz is the coordination body for NGOs working in humanitarian responses and also anchors regional HAG. All coordination related to AHF and other humanitarian access and advocacy work can be done through OCT and OCHA office in Kunduz
Coordination of health actors, it is proposed that, regular meetings of all health actors like JACK, Johanniter, Health Net, ARCS, Medical Technical Director of Regional Hospital and MSF (all technical-medical leads) to discuss on the type of services needed for the trauma treatment in Kunduz and who should do what. JACK to update the provincial council office regularly on quarterly bases on the progression of the current project activities, achievements, challenges and recommendations for the sake of well coordination and accountability, as recommended by the Provincial Council
Learning key lessons from past experiences of trauma care The regional hospital in Kunduz was the higher tertiary care hospital for entire North East Region till recently. Now, there are newly built Provincial Hospitals in Taloqan (Takhar) built by KFW, German Government and Faizabad (Badakhshan) built by Agha Khan Health Services (AKHS) programme. The regional hospital in Kunduz itself has underwent huge structural changes with the support of KfW, German Government. Few years back, there was no Emergency Care Unit in the regional hospital. Thus, WHO has started a programme of Mass Casualty Incident Management (MCIM) and started Emergency Medical Services at Regional Hospital. However, the services were run entirely by different management and was more of a parallel programme than integrated with the regional hospital. The one and half year support of WHO has many operational difficulties and thus has limited impact. The difficulties include, First to start is the very name of the project. It is named Kunduz Truman Centre. Separate administration Different salary structure for the staff (in comparison to the regional hospital) Different reporting lines Staff attitude was different working in this project. They consider themselves as higher (Bala) and the regular health staff in the regional hospital as lower (paine). Local Level coordination was quite difficult. The regional hospital didn’t accept patients from the trauma centre to higher treatment. Thus affected the very objective of the centre.
The great lesson learnt from the project is that, any trauma care unit should not be separated from the regular health system. Based on this lesson, now in the regional hospital, the Director has established Emergency Unit as Trauma Unit and deputed staff from EPHS and trained them in MCIM. It was suggested that FATPs proposed should be part of the BPHS and EPHS system and thus establish strong coordination and support system. The project should not be seen as a separate from the administration of BPHS implementer JACK. Consider naming the FATP as First Aid Trauma Unit of the proposed clinic.
Based on the narration by Director, Regional Hospital
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Recommendations from the stakeholders on the recruitment of qualified staff Stakeholders shared that JACK and Johanniter to consider the following while recruiting staff
- Staff should be local - Familiarity with the locality, context and cultural norms - Familiarity with the conflict actors and situation - Ability to work in these conflict zones and work in stressful conditions - Ability to work with both sides and should be independent (that is not to take sides) - Experience of doing Trauma care or relevant clinical experience and trained (qualified staff, approved by MoPH certification)
The recruitment should be done transparently - Not only rely of written test, the final short-listed should be chosen based on their clinical skills (conduct clinical tests)
Training of Health Facility Staff on Triage, First Aid and First Responder’s training and Mass Casualty Management
Training to the medical staff and community health workers (CHWs) on advanced and basic life support (ALS and BLS), triage, ambulance services, safe blood transfusions, mental health and health risk assessment at the FATPs and Mass Casualty Incident Management at the referrals sites. These trainings will be coordinated with MCIM Trainers in Kunduz, WHO, MSF and Regional Hospital in Kunduz.
Director, Regional Hospital reiterated the training of the staff. The staff working in Trauma centres should be trained on how to conduct Triage in all phases. Primary Assessment and triage should categorise patients who are sent for referral to higher health facilities like Regional Hospital of Kunduz. - Preliminary Assessment should be done o In time o Efficiently o Effectively - Patient prioritization at the scene important for casualty distribution - Separates victims into easily identifiable groups. Prioritization of patient distribution and transportation. Identifies patients who need rapid medical care to save life and limb - The nurse accompanying the patient should conduct secondary triage and assessment of the patient - All the assessments should be recorded in a specific format and tagging
Advocacy related to health and trauma care - The BPHS programme implementation has undergone lots of changes in the new phase of the project implemented by MoPH and the donor’s (The World Bank) conditions/guidelines. The implementing NGOs /partners will be paid based on performance of each of the health indicators. If the indicators are not met, the payments will not be made. In case of Kunduz or other provinces where Taliban have greater control, the EPI indicators are not fully accomplished. The targets were set when there was low conflict or no conflict. Now, the situation has changed and there
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is high level of displacement and access related issues due to ongoing fighting. The targets can’t be achieved even if the population utilise the services to its fullest extent. Thus, there is need for advocacy with MoPH and the donors. The NGOs can use the forums like ACBAR to rise the issues. - The programme sustainability is always a challenge for humanitarian supported FATPs and trauma care. There is need to lobby with MoPH and the donors related to support the emergency health care under their ongoing BPHS and EPHS programmes. Thus, the development programmes should also incorporate emergency health care systems which can be part of the comprehensive health care. - JACK, MSF and other health actors to work together to lobby and communicate of the risk of causing harm to the patients, health facility staff and the equipment in the hospitals/clinics due to conflict. Need to lobby with all conflict actors that the facilities should not be attacked (though no guarantee is given in the condition, if the facilities been frequented by the armed groups by IMF). It is found that some of IEA groups visit clinics in the name of supervision and monitoring and also carries patients to the clinics. We have to communicate that they should also be aware of the risk of causing harm to the patients and the facility and staff. We (JUH, JACK and MSF) will involve other health actors and will advocate with IEA that they should protect the hospital staff and equipment. - All the health facilities, include the FATPs proposed should have a communication display which adheres to neutrality and independence. The principles are to be displayed for adherence. The violations of them are to be reported to HAG/OCHA/WHO, so that humanitarian actors lobby with the actors to negotiate such violations are reduced and stopped. o Not to occupy and pose threat to the common public places like Mosques, schools, clinics o No weapon policy (no one should carry weapons inside the clinic) o No high profile visits to the health facility o No communication phone or radio inside the clinic o No vehicles belong to them should be inside the compound o No involvement in the recruitment of the staff o No use or misuse of the clinic’s equipment include ambulances o No armed convoy of the health faculty or ambulances
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Section 5: Access Assessment
The discussions with various stakeholders in Kunduz, in its neighbouring provinces and in Kabul, discussions in different forums at the national level and review of recent research of Taliban’s governance structure as the talks were evolving in July-September 2019 period. Summarising the findings of these discussions were placed here as part of the access related assessment. 5.1 Strong and structured leadership This report doesn’t explore of the leadership structure of its central, its military and other structures other than the provincial and district level structures. The Taliban governance structures have sectoral civilian commissions which were evolved over time in Kunduz since 2009. One of the member of the assessment team who worked in Imam Sahib and Khanabad related to the community based conflict resolutions methodologies with non-state actors during 2008-11 and on social water management in Panj-Amu River Basin during 2013-15, where the evolution of the civilian structures started off with Judiciary and other sectors over the period. Another member of the team hails from Kunduz and extensively worked in health sector for more than half a decade in the province. The assessment report outlines the “rules” for the health sector primarily and to some extent the NGOs working in Kunduz province, analyse the trends and makes recommendations on how the NGOs should respond to these new emerging governance structures. The difference between 2017/18 period to third quarter of 2019 is that Taliban governance is more coherent than ever before, commissions to oversee sectoral functions like finance, health, education, judiciary and taxation, with clear chains of command, which runs from outside the borders to provinces till village level. Reportedly, since the peace talks kicked off in late 2018, the NGOs need to liaise with different IEA commissions to ensure their acceptance. Engaging only with one sector commission, e.g. Health Commission, might not guarantee acceptance by other IEA members. The state programmes and the co-opted programmes by the NGOs like citizen’s charter, BPHS, EPHS etc., are mostly re-organised to suite Islamic Rules and monitored by Taliban. IEA members usually require access to health facilities, medicines, and might also ask the NGOs who are operating closer to one of the IEA’s fund facilities to facilitate support from that specific NGO. In addition, AOG members usually require NGOs to hire employees from their area of control and with whom they have connections or close ties and are confident that they don’t spy on them. Moreover, a common requirement includes the submission of a list of the NGO staff who will be present in the AOG- controlled area (both permanent staff and those who only go on mission, required to communicate this in advance and wait for their approval). In some cases, the government service delivery institutions have struck deals or come to operational understanding with the local Taliban governance structures like health and education. In some cases, few NGOs and institutions have formal or informal understanding on how they operationalise their programme with clearly outlining the terms of cooperation in their controlled areas in Kunduz. Though unconfirmed, but few also stated that the ANSF members usually try to interfere or block the NGO work in AOG-controlled areas, and NGOs sometimes need to contact ANSF high rankings to guarantee their access when they go on missions to AOG-controlled areas (this happens even when NGOs have proper documentation signed by GOA/ANSF). There is a monthly meeting at Provincial level chaired by the Provincial Governor and one of the agenda of it is how to coordinate humanitarian work with ANSF. The Taliban over the years have gained territorial control. They in fact made three attempts to capture the provincial capital, Kunduz city in last four years, with holding the city for two weeks in their first attack in October 2015. Based on the health facilities coverage in their controlled areas, it is estimated that
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Taliban control 80% of the Kunduz provinces. As per the health Shura representatives, the following table shows the actually control of territory in Kunduz province.
Aliabad Chardara Dasti Archi Imam Sahib Khanabad Kunduz Qale Zal
70% 80% 90% 70% 70% 80% 95%
This table can’t be physically verifiable and was based on the perceptions of the health shura representatives of these districts during a consultation meeting held in Kunduz in early October 2019. Based on the health facilities control, the following table was generated. IN November 2017, Johanniter along with then BPHS implementer OHPM conducted similar access and protection assessment and in September and October of 2019, conducted a detailed health services assessment related to trauma care was conducted with current BPHS implementing agency, JACK.
Table No. 22: Health facilities under the control of IEA/AOGs in Kunduz Province %of total health %of BHC and SHCs in IEA % of CHC, CHC+ Name of the facilities under IEA controlled area and DHs in IEA Sl.No. District controlled area controlled area Nov-17 Oct-19 Nov-17 Oct-19 Nov-17 Oct-19 1 Aliabad 20 40 33 67 0 0 2 Chardara 100 83 100 100 100 0 3 Dashti Archi 67 100 83 100 33 100 4 Imam Sahib 73 63 82 67 50 50 5 Khanabad 62 92 64 91 50 100 6 Kunduz 82 78 80 80 100 100 7 Qalai-zal 86 100 100 100 0 100 Source: Johanniter’s assessment of November 2017 and October 2019 The above table clearly specifies that there is significant shift of territorial control of the province in general towards Taliban, with exception to Imam Sahib district in past two years. The notable change is the Taliban controls four major districts – Dasti Archi, Khanabad, Qalai Zal and Chardara. It also controls the surrounding villages of Kunduz district except the city. The control of territory means that their influence in governance. They regulate utilities and communications, collecting on the bills of the state electricity company. They are controlling around a quarter of the country’s mobile phone coverage. Justice provision has also become increasingly far-reaching. The reach of Taliban governance demonstrates that they do not have to formally occupy territory to control what happens within it. Governance does not come after the capture of territory, but precedes it. The Taliban’s influence on services and everyday life extends far beyond areas they can be said to control or contest. E.g. Case of Kunduz City: A narration goes out in Kunduz city, which is not under Talban’s direct administration, however their norms and rules do have a sway over. There were notifications posted on education institutions of having separate rooms for girls and boys, even in private tutorials. The management of these institutions approached them that it will be too expensive for them to meet their norms, the Taliban have settled on a curtain being installed to divide boys and girls attending these tutorial classes.
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The Taliban’s governance approach is both civil and military and it is sometimes difficult to understand the differences between these two as very thin layer differentiates between the two and on some occasions both the functions are held by a single individual. However, there is a significant change in these structures in recent times where the civilian administration has spread widely with new recruitments and responsibilities clearly defined and separated from military functions, especially at the lower levels of administration. The Taliban Code of conduct (known as lahya) is changed based on their experiences from the past. The Taliban’s posture gradually changed as they gained more territory and internal control. The Afghan delegates attended Doha conference state that the Taliban representatives present there were polite, well behaved and well informed of the situation and were seems to be highly trained on how to conduct negotiations. The orientation and training to these Taliban leadership has changed their postures towards aid workers, schools and clinics. In the past, Taliban used to attack schools like burnt them or attack the clinics and aid workers. But, now they deal with these institutions more systematically. The assessment report looks at two components, one is on health and another to some extent on taxation. 5.2 Health: At Provincial level, there will be governor and has a deputy, provincial commissions and Shura comprising elders or religious scholars. The provincial structure is replicated in the districts, with a district governor and is supported by a deputy and a civilian commission of elders or religious scholars of the district. District governors are often the first port of call for dispute resolution, particularly for lesser cases (land or resource disputes, civil cases). Elders play an important role, akin to the government’s district councils, in advocating on behalf of ‘ordinary’ Afghans and providing a connection to local Taliban officials. In Kunduz, the provincial head of the department of the health commission is well acquainted with the health apparatus of the province and a practitioner (not sure whether he has a professional degree to practice medicine. He was holding this position for past couple of years. He has health focal points for the districts and specific clinics. Near areas of frequent fighting, some clinics had dedicated focal points to monitor the clinic and mediate between Taliban patients and clinic staff. Taliban health focal points monitor clinics, checking whether staff show up for work, docking their pay when they do not and inspecting equipment and medicine stocks. They also put pressure on NGOs to expand healthcare access in rural areas and improve the quality of services. Vetting of Staff: Taliban insists that the staff working in the clinics should be generally from the area where they are working. There are some exceptions given to specific posts like physiotherapy, lab technicians and surgeons. they should be professionally qualified for their role and they should be recommended and approved by the local health Shura. In some instances, there is pressure from local health shura to hire some of their health experts (most of them were called as hafiz or ‘haji doctors’, who are not qualified). The health commission will also send a couple of CVs among which the NGO must select their personnel. The BPHS implementers negotiate with the health shura related to the qualifications and the standards to be met by BPHS parameters. During or after recruitment the Taliban conduct background checks. Objections to appointments are usually based on the individual having ties to the government. Monitoring staff attendance. Attendance of staff is monitored and reported to the responsible NGO or Health official at the provincial level, with the recommendation that commensurate salary be deducted for periods of absence. In some instances, there was also pressure on clinic staff to conform to Taliban appearance requirements (beard length and traditional dress).
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Monitoring clinics. Health focal points check whether medicine stocks have expired and whether equipment is functional. They may also monitor and advise on clinic construction or renovation. In some cases, where there is shortage of funds from BPHS implementing agencies, the Taliban mobilised people to contribute hasher (voluntary contribution) and build additional rooms for the facility. They try to control prices, if the medicines are not given for free, and stocks. The assessment team also noticed that the Taliban also regulate the prices of medicines and some specific services not only in their area of control but even in Kunduz city. The government functionaries also monitor the clinics but through the health shuras and with the Taliban’s permission, but not as frequently as the Taliban does in areas under its influence. Gender segregation. While Access issues - Checkpoints gender segregation is usually already in place in most clinics, the Taliban reports of female 16% health workers should have 4% their mahrams accompanying them to the work place. Also 80% insist of female patients visiting the clinics to have their mahrams present during consultations. The male mahram can only stay if the female staff is not accompanied by other women. Anti-Government Elements Pro-government forces None In Kunduz, there is high level of drop out of female staff and also male staff due to these close monitoring and intimidation. The BPHS implementing agency is working out with the staff and health shura in finding a middle way where both the parties are compromised to minimum standards needed at these clinics. There are instances where the Taliban objected when a female health worker departed and was replaced by a man because women would not be able to access the clinic unless another woman was recruited. In such cases, the Taliban argued that a woman be designated to the position as per the BPHS recruitment guidelines. If there are problems with the Taliban, health providers generally resolve them through health shuras. With all the interviews with health staff in the province, they felt that the Taliban interfered excessively with healthcare or impeded access; however most pointed to government interference and occupation of and theft from clinics by Afghan security forces and militias as being more problematic than Taliban interventions. Access to health centres for the patients and health facility staff Kunduz has witnessed airstrikes and active fighting across the districts affecting health facilities and patients’ referrals services for trauma care at higher grade hospitals. The assessment has focused on the elements of risks for health workers and to the civilian population living in the area. Other than the attacks from AOGs, ANSF and pro-government militia (PGM), checkpoints located nearer to the health facilities restrict civilian population, especially women and girls in accessing health services.
Barriers to access to health services During the interactions with health shura representatives from all the districts of the province as part of the assessment, the following barriers were identified.
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Restriction on women’s mobility and should be accompanied by Mahram when visiting health facilities. Sometimes, there are mines on the way to clinics laid by AOGs. AOGs do warn people not to use these roads. The mines are put on main roads targeting mainly ANSF. The auxiliary roads are difficult and takes longer time than the main roads. There are check points in the auxiliary roads as well. Another important problem is the absence of women vaccinator in the outreach and male vaccinators are not allowed to vaccinate women. The NGOs cannot afford female vaccinator mahram to send female vaccinators to the outreach work. In Chardara district, Sarak-e-Payan has no health facility. There is a health facility located in Sarak-e-Bala, but the people of Sarak-e-Payan can’t access this facility due to river. Accessing higher health facilities in Regional Hospital in Kunduz and District Hospital of Imam Sahib involves need for transportation and related costs, mines on the roads and the existence of checkpoints of AOGs and ANSF. There is high risk for people working with the government on the main roads connecting the various district centres to Kunduz and to other provinces, due to presence of check points and Taliban’s watchfulness for the government employees. So many of the government staff use auxiliary roads, but there was always a fear of a surprise checkpoints by AOGs. In Archi, there is army positioned in one of the CHCs and staffs are driven out of the facility. Due to mines on main roads, people have to travel on auxiliary roads which are difficult and risky to travel on. There are check points in the auxiliary road and delays caused by the investigation by the check points. In Qale-zal, the Health Shura representatives shared that bridge was destroyed by AOGs and the connection to the CHC due to river bas also cut. The patients come through local made boats which are not available during the night and emergency cases cannot be brought to the CHC. Persons with disability: transportation, the structure in some HFs where there are no facilities for wheel chair and are not disable friendly. There are no physiotherapy services in most of the health facilities and the waiting time for the people with disability are not given special consideration.
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Access to Clinics - Checkpoints (% of health facilities) 120 0 8 100 17 6
80 0
60 100 92 78
0 83 63 40
40 20
16 13 18 6 10 0 0 5 Districts Aliabad Chahar Darah Dashte Archee Hazrat Imam Khanabad Kunduz Sahib
Checkpoints near the health facilities Verified the risk factors, where the health facility staff and the communities (beneficiaries) identified check points as the major protection and access issue. 60 health facilities have reported of having AOG checkpoints which monitors the traffic inflow to the city as most of the clinics are located on the road side and mostly at the entry point of the city or village. Only 3 health facilities have government check point. The armed checkpoints on the main roads either by the AOGs or Pro-Government Forces, the purpose was to establish their control over their locality and control traffic flow into the area. Often these checkpoints are the target of any attacks. If the checkpoints are located close to the health facilities or schools, then the access to these service institutions are severely affected. In Kunduz, most of the hospitals are located on these access roads and the check points are located within 200 meters of these facilities. Thus, the facilities are difficult to access by civilian’s population especially women and girls. There is close scrutiny of the civilians passing these locations to access services and thus many are denied of the services. In some instances, the health facility comes under cross fire between the AOGs and ANSF fights and cause severe damage to the health infrastructure.
Table No. 23: Checkpoints located at health facilities in Kunduz No. of Anti- Pro- Health Government Government None Districts Facilities Forces Forces exist Aliabad 5 2 0 3 Charah Dara 6 5 1 0 Dashti Archee 10 10 0 0 Hazrat Imam Sahib 16 10 0 6 Khanabad 13 12 1 0 Kunduz 18 14 1 3 Qalaye Zal 7 7 0 0
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Total 75 60 3 12
The above table clearly states the location of checkpoints by different actors and the analysis of it is as follows: Only 14 Health facilities have no check point out of 75 clinics, however for two clinics, there is check point on the way to the clinic (not near the clinic) thus impact access 60 clinics have AOG check points Only 2 checkpoints are managed by the Government, this specifies the control of the territory in Kunduz Province There is occasional Arbaki (ALP) presence in one clinic (in Khanabad district) there are two check points where AOG control during the day and in the night few criminal elements take over these check point to rob the passengers. 80% of the clinics have AOG's check points Only 4% of the clinics have ANSF, ALP and Pro-government militia controlled check points exist
Impact of the Taliban’s influence in health sector
The assessment discussed with the health workers and the Shura members. It is noted that health services are improved in the areas where Taliban have greater control where they closely supervise the attendance of the health staff, remove the ghost staff4, monitoring quality of medicines and medicine stock, etc. The AOG members try to have the control of the staff, stocks, and other things, and require the NGO to help them if needed (e.g. with provision of medicines to their own facilities). However, their norms and rules have restricted access to the clinics. Access related issues for Medical staff in Kunduz 40
35
30
25
20
15
10
5
0 AOGs insist on Femal AOGs stop Fighting and Armed Under Control of Pro- No Problem Patients to bring Vaccination Outreach Clashes between Government Militia Mahram to visit clinic AOGs and ANSF but no major threat
4 There is practice of a staff is recruited for a clinic but is also paid from other clinics in other district so that some preferred staff get higher salaries or as the health package is chosen based on the bidding of the contract and the lowest bid gets the contract to implement BPHS programme and it is difficult to hire staff to all the locations to pay the salaries. So, the implementing agency adjust the salary by assigning a staff to two or more clinics
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The following were broadly identified as the concerns
- Insistence of having Mahram (male relative) to accompany female patients to visit the clinic. It is not only for the patients but also for the female health workers. - Outreach services of vaccination is restricted and thus affecting the coverage and also unable to meet the health targets by the clinic staff
- Active fighting between AOGs and ANSF and frequent air strikes create fear among the civilians accessing the health facilities and for the health workers to be present in the clinic - The PGMs and ANSF presence cause some discomfort but not a problem to work, however there are complaints in some clinics that these PGMs and ANSF rob the medicines and equipment.
Access problems for health facility staff in different districts in Kunduz province 100 80 80 60 62 60 57 50 55 60 43 40 38 38 39 4237 33 31 40 23 20 17 20 20 8 6 3 4 0 Aliabad Chahar Dashte Hazrat Imam Khanabad Kunduz Qalaye Zaal Overall % Darah Archee Sahib
AOGs insist on Femal Patients to bring Mahram to visit clinic AOGs stop Vaccination Outreach Fighting and Armed Clashes between AOGs and ANSF Under Control of Pro-Government Militia but no major threat No Problem
The province wise status is represented in the above graph.
Impact on Health Services in Kunduz - The outpatients have reduced in the health facilities in the active conflict areas in the province due to displacement of population fearing attacks from ANSF and PGMs, economic migration due to drought and low economic growth, thus impacting the health targets set by the MoPH for Kunduz. This is impacting the release of instalments for the BPHS implementing agency as the payments are linked to performance at the health facilities. There was no instalment released for the BPHS implementing agency thus most of the health facility staff have not received their salaries for past three to four months. This is impacting the motivation levels of the health facility staff. - The number of health workers is grossly inadequate to meet the needs of the existing population that has many trauma cases includes injuries due to the aerial strikes, as collateral damage to the cross firing, attacks during raids by the ANSF and PGMs and due to mines laid in the field and roads. There are only 6 trauma care centres located in entire provinces during the assessment and is entirely inadequate to meet the case load. Lack of access to medical supplies (those in the clinics are inadequate as well), makes it impossible for these clinics to provide even the bare minimum care to patients.
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- Taliban Health focal point in Kunduz repeatedly mentioned that there is need for improved health care across the province. The Taliban also demonstrated comprehensive knowledge of the Basic Package of Health Services (BPHS), the national healthcare programme led by the government and implemented by NGOs. Though, the new conditionality of the MoPH and the donors of performance based payments were not known to them. Part of the problem with health access is that most major facilities, as per BPHS planning, are located in cities and district centres. (Please see the table no.) This makes sense to the extent that this is where the most people live, but these areas are also generally controlled by the government. The Taliban’s Health focal person’s argument was that government areas had better access and better-quality healthcare than Taliban areas. Taliban demands included more staff, new equipment and the establishment of hospitals or sub-centres in areas with inferior facilities. If these are not adhered to, then they would close down these facilities (it was demonstrated in some cases). However, in Kunduz province, these challenges were addressed through negotiations and settlements were quietly reached.
Table No 24.: Health facilities, coverage and staff in Urban Centres (DH, CHC+ and CHCs)
Doctor Paramedics
P h y si S u rg e P e di a D e n ti Nurse n No. Health Health Districts Facilites Coverage Coverage Populatio M F M F M F M F Anesthetis t Pharmacis t Physiotro pist M F Midwife Communit Midwife y Psychosoc ial Lab.Tec hnician Pharma cy X-Ray Dental Tech Vaccinator Nutrition Counselor CHS Admin Supportiv staff e Aliabad 2 27558 22000 0 0000032132220042229 Chardhara 1 26440 11000 0 0000011021110021014 Dashti Archee 3 55856 3 0 0 1 0 0 0 0 1 0 1 4 5 4 4 3 3 2 0 0 6 3 4 317 Hazrat Imam Saheb 4 166373 6 2 2 0 1 0 1 0 1 1 1 9 8 2 8 3 5 3 1 1 9 4 4 4 29 Khanabad 2 50740 30101 0 10102763323311522213 Kunduz 2 80626 200000 0000022312120042228 Qalaezal 1 27350 10000 0 0010022211110021117 Total 15 434942 18 5 3 1 2 0 2 0 4 1 4 28261522141614 2 2 3215151587 % of coverage 20 39 78.3 100 100 100 100 100 100 100 100 32.9 100 33.3 42.3 100 88.9 93.3 100 100 32 20.5 33.3 93.8 49.2 Source: HMIS Data, BPHS, MoPH, September 2019 - There has been clear pressure on NGO health providers to provide trauma care, and doctors and nurses are routinely called in from nearby cities to treat fighters in remote areas. Another common practice is compelling nurses or clinic staff to perform minor surgeries beyond their qualifications or the capacities of the facility. - Taliban rules based on lahya, impose a tighter restriction on women’s visibility and participation in life outside the home. In health facilities, the main rules are segregation of rooms for men and women, all women include women health workers should wear burkha or chador, should be accompanied by her male relative (Mahram). The following diagram shows, the districts where such measures are imposed. It is important to note that even the district like Aliabad which is outside Taliban control but impose the rules strictly. In Qalaye Zal our assessment was more limited to the urban centres only and thus seen low in analysis.
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AOGs insist on Femal Patients to bring Mahram to visit clinic
80 70 60 62 50 43 36
6
Aliabad Chahar Dashte Hazrat Khanabad Kunduz Qalaye Zaal Overall % Darah Archee Imam Sahib
- Impact on Vaccination, Taliban commanders suspect that the health workers especially the vaccinators collect information used to find and kill Taliban supporters and leaders in special forces raids and air strikes. The Taliban every year block or ban the WHO and ICRC from operating in areas under their control, so too the vaccinators of BPHS. As per the BPHS guidelines, 16,000 Afs per clinic is paid only if the outreach of vaccination is covered. In Kunduz, this has impact on the payments to BPHS implementer and also the coverage is poor.
57
40 39 38 37 33 31
20
Aliabad Chahar Dashte Hazrat Khanabad Kunduz Qalaye Zaal Overall % Darah Archee Imam Sahib
The vaccination outreach was discussed extensively with the health shura representatives from all the seven districts of the province. The following were their observations on the issue. People perception and access to vaccination
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In general, there is positive opinion of the vaccination and immunization programme among the people, government officials and also with the Taliban. AOGs don’t have any problem in administering vaccination at the clinic, but have some reservations of the polio campaigns carried out the government in the villages. Taliban are suspicious of the vaccinators who make house to house visits. The AOGs does not allow polio campaign because they think there may come some government informers among these people. They worry that they were either threatened or lured by the ANSF and international forces in sharing information of the Taliban leaders’ presence in the villages. Thus, Taliban imposed total ban on Polio Campaigns in Kunduz province. However, after negotiations by WHO and UN at different levels, the ban is lifted. However, they have laid new rules for vaccination. There is problem with outreach because AOGs does not allow men in the outreach to immunize female. The NGOs cannot afford the Mahram of female and therefore do not send female to the outreach. Taliban have banned NIDs and vaccination of women by men. women cannot get vaccine in the outreach site because there are no female vaccinators, traveling long distances and having mahrams are some of the barriers There were media reports stated the misuse of the vaccination campaign. One of them by the vaccinators themselves not reporting honestly the vaccination coverage. There were some instances found where the vaccinators simply dumped vaccines in the garbage, but counted them as administered, in order to reach their targets. This is possible because there were no means to verify the number of vaccinated children. The Taliban blame the National Emergency Action Plan for Polio Eradication of 2019, where the campaign states to “maintain dialogue with Taliban at local, provincial and highest level on the programme’s neutrality for polio eradication”. The spokesperson, Zabiullah Mujahed, reportedly spoke to a media and research agency5, that the polio vaccination had most recently been misused in Helmand, Kandahar, Ghazni, Uruzgan and all other areas where fighting was intense. “The enemy was misusing vaccinators for collecting intelligence data,” he said. Adding to the above, the report also carried his statement, which is quoted as following, “Several people were arrested, who had entered Taleban-controlled areas, calling themselves vaccinators, but actually collecting intelligence data. Such had been appointed to identify the houses [and] residential areas of Taleban commanders and leaders. The vaccinators would leave chips [GPS tracking devices] in houses, so that the government would identify that house and locate it for targeting. This clearly shows that the enemy was seriously misusing the polio vaccination drive.”
Another research document6 quotes a former Taliban official involved in discussions around the Taliban’s code of conduct stated, “with the lahya, we needed to show we could be accountable” and thus impose such restrictions in their area of control. Negotiations at various levels, that includes, Doha and Quetta Shura, the attitudes towards aid agencies and service providers appear to have shifted. Taliban leaders gave the World Health Organisation (WHO), the UN Children’s Fund (UNICEF) and their implementing partners permission to conduct polio campaigns; a letter issued with directives for subsequent campaigns, instructed fighters to allow vaccinations and urged parents to have their children vaccinated. Polio vaccinations helped demonstrate the benefits of engaging with the international community on
5 https://www.afghanistan-analysts.org/one-land-two-rules-5-the-polio-vaccination-gap/ 6 Ashley Jackson- Life under the Taliban shadow Government, ODI, 2018
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Final Report humanitarian issues.7 But, in Kunduz province, the vaccination drive is restricted only at the clinics and don’t encourage outreach services, i.e. vaccinators are blocked to do door to door vaccination. The Taliban health focal points at the districts in Kunduz instruct the vaccinators to administer vaccines at the village mosque. The health agencies like WHO and MoPH officials in Kabul state that such measures would not reach enough children to stamp out the virus.
Taliban lifts the ban on WHO vaccination campaign in their controlled areas in Afghanistan Taliban militants in Afghanistan have lifted a ban on World Health Organization (WHO) activities in areas they control, another apparent move by the extremist group to improve their image following the collapse of peace talks with the United States. The move announced on September 25 reversed a decision made in April when the extremist group barred the WHO and the International Committee of the Red Cross (ICRC) from operating in its occupied territories, accusing the groups of carrying out "suspicious" activities associated with polio-vaccination campaigns. "After realizing its shortcomings and following constant contact and meetings with our representatives, the WHO received permission for their activities," Zabihullah Mujahid, a spokesman for the Taliban, said in a statement. The ban had threatened to intensify a major humanitarian crisis in Afghanistan, one of three countries in the world where the disease is endemic.
Source : https://www.rferl.org/a/taliban-lifts-ban-who-red-cross-polio-operations- afghanistan/30183907.html (dated 24 September 2019)
Mistrust has led to low levels of immunisation acceptance in some communities, although acceptance has improved over time. There is need for developing strong credibility for the vaccination programme after the claims of Taliban of using this programme to spy on them and the programme was badly discredited after a campaign was used as cover in the US efforts to find Osama in Pakistan. In some provinces in the east, the Government is using Islamic Clerics to negotiate with AOGs to ensure immunization campaign goes without any hindrance. Active Fighting in Kunduz The shura representatives consulted in Kunduz, stated that, the ground engagement has increased in this year, in 2019. AOGs warned people to leave the areas in case of any anticipated fighting. But the government forces don’t warn such, thus high civilian casualty. Similarly, there is higher civilian casualties due to aerial strikes, which has increased in 2019. Night raids and ambushes are also increased across the province. The night searches are increased by the pro-government forces. The attitude and behaviour of the pro-government forces don’t go well with the local population. The shura representatives have complained of their mis-treatment and abuse. The Pro-Government forces, mostly the PGMs harass people and are hostile to local population. The AOGs do not undertake search operations. Even the WHO and UNHCR representatives in Kunduz have observed that there is heavy fighting were reported in Chardara, followed by Dasti Archi, Khanabad, Imam Sahib and Kunduz.
7 Ashley Jackson- Life under the Taliban shadow Government, ODI, 2018
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Fighting and Armed Clashes between AOGs and ANSF
Overall % Qalaye Zaal Kunduz Khanabad Hazrat Imam Sahib Dashte Archee Chahar Darah Aliabad
0 2 4 6 8 10 12 14 16 18
Active conflict continues to threaten the physical safety and health of Afghans, disproportionately so for women and children. Attacks against health facilities, patients, medical staff and vehicles continue to disrupt and deprive people of life-saving treatment. As per Afghanistan Needs Overview (2018), around 4,00 hours of health care delivery have been lost and 335,000 consultations missed due to the forced closure and destruction of health facilities, as attacks against health workers and medical assets mount in both frequency and deadliness.8 In the first six months of 2019, 68 attacks on healthcare were reported resulting in the closure of 101 health facilities, where only 27 of them were re-opened. 18 healthcare workers and patients were killed and 33 others injured.9 The following diagram states that the active fighting in two of the districts, Chardara and Khanabad is impacting access to health services in Kunduz, as of October 2019. Another problem is that donors have often funded misguided programmes in this area, such as teacher training colleges in provincial capitals that most rural women have no hope of ever getting to. A multigenerational approach that trains rural women teachers from the communities they work in is urgently needed, similar to approaches to training community midwives in conservative (mostly Taliban) areas of the country. In most provinces aid agencies were able to reduce Taliban demands through negotiation. Much depended on the cohesiveness of local Taliban command structures, and how good the aid agency involved was at negotiating. Fewer demands were placed on smaller Afghan NGOs, which pleaded poverty while making some minor upgrades or accommodations. Other NGOs appeared largely to accede to Taliban demands, pointing to the fact that access to healthcare was indeed worse for civilians in areas under Taliban influence. There was also a concern that the Taliban would simply shut them down if they refused their demands. Few aid agencies pressured by the Taliban coordinated or shared experiences; most kept the demands they faced to themselves and negotiated unilaterally. Most donors to the BPHS appear to have little or no knowledge of the Taliban’s campaign. Was the push for better healthcare about battlefield concerns or about services to civilians? The answer is probably a little of both. Better treatment for fighters and their families improves battlefield resilience, morale and recruitment, and the Taliban have certainly got better in this regard. In the past fighters were transported to Pakistan, but this was dangerous and insufficient to address
8 https://reliefweb.int/sites/reliefweb.int/files/resources/afg_2019_humanitarian_needs_overview.pdf 9 http://www.emro.who.int/afg/afghanistan-infocus/situation-reports.html (August 2019 Situation report)
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Final Report critical trauma. Now each of the Taliban’s ten military command zones has medical treatment corridors and mechanisms with dedicated focal points to manage transport and treatment.56 There has been clear pressure on NGO health providers to provide trauma care, and doctors and nurses are routinely called in from nearby cities to treat fighters in remote areas.57 Another common practice is compelling nurses or clinic staff to perform minor surgeries beyond their qualifications or the capacities of the facility. The Taliban and its NGO and government counterparts are generally in direct communication, with contact usually initiated by the Taliban when there is a specific issue to discuss. Table No. 25: Summarised assessment of 14 health facilities assessed in seven districts of Kunduz province on violations of principles to be adhered to protect the health facility and health workers’ safety in conflict. Violations of Health Facilities noticed in the assessment by the actors involved in conflict. High Violations by Taliban/AOGs 85% of the health facilities assessed stated that AOGs involve in the recruitment of the staff 69% of the health facilities assessed have stated that AOGs do bring communication materials like radio into the clinic posing threat to IMF/ANSF aerial attacks 62% violates the principle of No weapon policy (no one should carry weapons inside the clinic). Guidelines Implementation Status (based on MSF ) Assessed with health facility staff during the visited by JUH and JACK team 11-15 October 2019. Violations by Taliban/AOG Violations by ANSF Violated not Violated not regularly, due to regularly, due to S. Regularly community/Health Not Regularly community/Health Not No. Principles Violated facility rules Violated Violated facility rules Violated No weapon policy (no one should carry 1 weapons inside the clinic) 8 4 1 4 1 2 No high profile visits to the health facility 1 6 6 1 4 No communication phone or radio inside 3 the clinic 9 1 2 4 1 No vehicles belongs to them should be 4 inside the compound 5 6 2 4 No involvement in the recruitment of the 5 staff 11 1 1 2 No use or misuse of the clinic’s equipment 6 include ambulances 2 5 6 1 1 3 No armed convoy of the health faculty or 7 ambulances 8 4 1 2 2 Not to use the clinic as place of 8 safety/night stays 1 1 10 1 2 2 No Clinic staff is intemidated (e.g. take 9 staff to treat the injured) 2 10 3 2
Out of 14 facilities (includes 2 DHs, 2 CHC+, 2 CHCs and 7 proposed FATPs)
1. The hospitals which are under the government control, but the AOGs are located at about 1-2 KM radius from the hospital 2. Out of 14 facilities assessed, 11 under AOGs control and 3 in Government control) 3. There are no IMF presence at the clinics but are seen in operations in some of the districts 4. The above statements are truefor the only clinics assessed and as per the Health Facility Staff and focal points
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Violation are seen but not regular by AOGs 62% of the clinics assessed have stated that armed convoy follow come to the health faculty or follow the ambulances by AOGs (not regular, but occurs on occasions depends upon the casualty size and significance of the injured) 46% of the assessed health facilities stated that the high profile from AOGs visits to the health facility occasionally 46% of the assessed health facilities have mentioned that vehicles belong to AOGs enter inside the compound occasionally. Some have mentioned that if the health staff requests them not to bring the vehicles inside the clinic compound, they adhere, unless it is a high profile visit. For more details on the violations by conflict actors can be seen in the table no. 22 above. The summary of the table as follows. Top four violations by ANF No weapon policy (no one should carry weapons inside the clinic) No communication phone or radio inside the clinic No vehicles belong to them should be inside the compound No Clinic staff is intimidated (e.g. take staff to treat the injured)
5.3 Taxation Information on the fiscal and financial aspects of Taliban governance is both closely guarded and routinely distorted, both in the Taliban’s own accounts and by others in their own shaky estimates of Taliban revenues. One frequently hears the same income estimates –$10 million a month in Kunduz, yet it is never clear how reliable these figures are. While the Taliban are seeking to expand their tax base, trying to compel any entity they can to pay taxes through coercion, threats and violence, in numerous cases they have either relented, at least temporarily, or reduced their demands where they encountered sufficiently organised and determined resistance. E.g. At one private clinic/pharmacy in Kunduz City, the Taliban request a list of specific medicines as a form of in-kind payment, and the clinic pushes back stating that it is quite costly for them to meet such demand and taken help of community elders and clerics to negotiate and Taliban agreed to reduce their request. There were similar stories heard about private businessmen, media and teaching institutions, who have also faced demands, but several seem to have got away with refusing to pay after talks held by the clerics and elders. Taxes on construction are also common, whether new building or renovation. OHPM, the previous BPHS implementing agency faced similar problem when they started the repairs to few damaged clinics and painting all the clinics in Kunduz. A flat 10% was imposed by Taliban’s department of taxes. The negotiations with Health Directorate in both government and Taliban’s succeeded in waiver of the tax. Development and construction projects can be held up for months or even years where requests to pay taxes (10% tax) are refused, and road-building in particular can be blocked if it is deemed to threaten the Taliban’s military objectives, no matter how lucrative the potential tax revenues might be. The recent trend is that the NGOs have to register themselves with the NGO directorate of Taliban who them based on the type of project will refer to that specific commission, e.g. education to Education commission, health to health commission. The recent abduction of
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NGOs’ staff in north-eastern region demanding payment of Emirate Tax (10%) by the NGOs working in community development work include the national priority programme of Citizen’s Charter is one of such examples where the Taliban demand from NGOs. Zakat and oshr Zakat refers to the religious obligation on Muslims to donate 2.5% of their disposable income to the poor. Some described the Taliban’s collection of zakat as a mandatory 25 Afghanis (AFN) from every 1,000 AFN earned, while others explained it in more voluntary terms, or described it as arbitrary. Some Taliban indicated that it might be used to support the families of poor Taliban fighters, but no one could explicitly outline how it was redistributed. Oshr is a tax of one-tenth of whatever produce or harvest is being brought to market, collected in kind or in cash. However, it is not necessarily as precise in practice as the one-tenth rule might suggest. Collection might involve looking over a truck’s load and asking for a flat fee, as was reported to be the case at quarries in Kunduz (where a flat rate of $350 USD for large trucks and $70 USD for smaller trucks). Businesses, ranging from shops in the bazaar to private clinics, are routinely taxed at least one-tenth of their income, including in district centres and cities not commonly considered as under Taliban control. These taxes may or may not be referred to as oshr and sometimes they are referred as Emirate Tax (Taliban Tax). The private mobile/cell phone companies appear to routinely pay taxes. They are also subject to Taliban regulation of their services. This entails dictating when cell phone services should be provided, with the most common stipulation being that they be shut down after dark (presumably to reduce tip-offs to international and Afghan forces). The government mobile provider, Salam, is banned in Taliban areas, and the Taliban check mobile phones for Salam sim cards. Being caught with one will likely result in the card being destroyed and the owner being beaten. The Taliban are collecting on the vast majority of electricity bills and in Kunduz, the state- owned electricity company Da Afghanistan Breshna Sherkat estimates that this amounts to approximately $50,000–$57,500 in lost revenues every month.10 The Taliban do not necessarily read meters per se, but levy what they estimate is fair and issue a payment receipt similar in appearance to the one provided by the state electricity company. The Taliban have also attacked towers in government-controlled areas to coerce the state electricity company to restore power where it has been cut off. In case of not adhering to the payments, the Taliban will blow up the towers, e.g. attacks on electricity infrastructure in Baghlan. Taxes, in theory, imply a social contract. Taliban taxes are not arbitrary, although they do vary and are open to negotiation. They are designed to make the Taliban look like a state. When they meet resistance, whether from individuals, NGOs or private companies, they often argue that they provide security in return. 5. 4 Implications for NGOs: dealing with the Taliban There were many discussions among the humanitarian and development NGOs, but most of these discussions are pragmatic and have many dilemmas in dealing strategically with the Taliban. Most of the information were not shared fully to avoid any kind of leakages which may impact these agencies access to their programmes in their provinces. There are many donor RED LINES like that of DFID and USAID of high level restrictions of cash programming in the hard to reach districts fearing aid diversion.
10 Ashley Jackson- Life under the Taliban shadow Government, ODI, 2018
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NGOs worry about the unclear attitudes of the Afghan government on engaging the Taliban. Local staff often do not share information with NGO managers about the compromises they make to keep programmes running, and nor do agencies subcontracted by international NGOs and the UN to implement programmes. Only few NGOs talk about these issues frankly with each other. Donors, which provide nearly all of the funding for basic services in Afghanistan, face similar dilemmas. There are many government programmes like the World Bank supported Citizen’s Charter and BPHS which has different strategies for hard to reach areas and are technically and strategically not allow to support work in ‘Taliban-controlled areas’. If one sees the coverage of CCAP in Afghanistan, most of their first phase coverage districts are mostly in government controlled areas. NGOs and UN agencies are discussing on access issues, but are hesitant to engage the Taliban directly, worried this may lead to ‘legitimise’ the Taliban or encounter legal or funding penalties. There were other subtle deviations from official policy evident at the local level. Senior and provincial Taliban leaders asserted that where an aid agency obtains its funding does not influence access. In practice, however, many local commanders exhibited negative attitudes towards and suspicion of funding from International Security Assistance Force (ISAF) troop contributing countries. In general, but particularly pronounced at local level, there is deep and prevalent hostility towards aid organisations and a general difficulty in distinguishing between different actors (NGOs, UN agencies, the UNAMA11) for-profit contractors. Recommendations The assessment findings demonstrate that there is need for NGOs and its donors include the ministries and their back donors to enhance their understanding on the current changes in the governance and the rules of engagement, and pursue more structured approaches of working in Taliban controlled or influenced areas (their influence is high even outside their controlled areas). There is high level development and humanitarian needs in the Taliban controlled areas of Kunduz province (that’s where the study focuses more into) and thus there is need to engage with the Taliban. The following recommendations are based on the context to Kunduz and reflect more of the health sector needs. For NGOs - Improve internal transparency and openness, particularly between the senior management in Kabul (also in their HQs) and staff /partners at the local level, on the risks, policies and tactics for engagement –directly or indirectly, through “acceptance”, “neutrality”, “independence”, or other approaches- with the Taliban. - Keeping in view of Taliban’s engagement with the local shuras (elders and clergy), it is important to have local level transparent and open communication with these local shuras at the village, district and provincial level. Taking clue from the health and education programmes, it is found successful to engage these community institutions in negotiations for access in Taliban controlled areas.
11 There is a notion of Blue UN and Black UN, which means that Blue UN means the humanitarian mandated UN and the Black is the military and political one. This understanding is different for the local Taliban authorities where they see both as one, i.e. that they are sided with the Western backed government in Afghanistan
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- The Taliban NGO focal points and the NGOs in the field are generally in direct communication, with contact usually initiated by the Taliban when there is a specific issue to discuss. The messages should be very simple and clear to ensure consistency and transparency. - Simple communications without any hidden agenda and consistency in its communication and approach will enable the NGOs to work safely in Taliban controlled areas. Evolving such guidelines could substantially improve access negotiations over the long term – if adhered to. NGO networks like ACBAR to play a valuable role in assisting NGOs to communicate their mandate and to monitor the risks and opportunities for humanitarian engagement with the Taliban. ACBAR should continue to publicly communicate the role and mandate of aid agencies. Under the proposed project of the Johanniter/JACK, there should be one focal point for access and communication with Taliban counterparts in NGOs and Health. To the UN: - UNOCHA should do more in developing information, coordination and management to help the NGOs and aid agencies about the risks of, and prospects for, talks with the Taliban on humanitarian access. OCHA should keep aid agencies abreast of any relevant political developments that may affect their work. - OCHA should do mapping accessibility and providing greater understanding, even simple mapping of agencies present, local needs and the prospects for intervention, could greatly assist aid agencies in planning appropriate and safe programming. To the Government, here in this case for MoPH - Protect the independence and neutrality of NGOs who are working in the Taliban controlled areas from harassment and prosecution. - There were violations by security forces (ANSF and IMF) for the health workers and the ambulances used to bring patients from Taliban controlled areas to the urban clinics. At the provincial and district level, coordination to be headed by the Governors to ensure safety of health workers and ambulances and reduce harassment of civilians seeking health services. - MoPH to review their financial plans and release of funds linked to performance especially in these hard to reach districts and on-going conflict, like in Kunduz and thus not impact the BPHS implementation as the performance based payments and targets (which were laid when the conditions were normal and currently there is high displacement, security issues which restricts civilians accessing health services, and thus has low achievements to revise the targets based on the realistic figures). - MoPH should lobby with the donors like The World Bank, USAID and the European Commission to consider the real situation in the country and redesign their implementation methodology. To donors and its HQs: - Provide funding and support for further research on developing approaches on access. Encourage frank and confidential discussions about the risks and prospects of intervention, and provide support and guidance to assist agencies in efforts to maintain and expand access. The donors should not create an environment of withdrawal or restrict their funding in fear of aid diversion. - Provide greater clarity on counter-terror restrictions. Providing clear guidance on engagement with the Taliban would be a positive step.
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Through Shuras and negotiators, to request Taliban, that - To stop all attacks on humanitarian and development NGOs (as most of the NGOs do both of them). Create enabling policies and procedures down to the villages so that all the concerned authorities in their controlled areas adhere to improve access to humanitarian work without any levy of taxes. - Continue to disseminate the rules clearly and routinely down to the rank and file Key Activities considered for the proposed project - Discuss with other stakeholders and UNOCHA at the regional HAG on introducing Joint Operating Principles or Red Lines for humanitarian actors with both the government and the armed opposition groups and their commissions. This JOPs need to be operationalised once it is agreed with the humanitarian actors and discussed with both IEA commissions in Doha and with the government in Kabul. Johanniter and JACK are members of the Humanitarian Access Group both in INGOs and NNGOS. And JACK represents both JACK and Johanniter in the regional HAG at Kunduz. They can take this matter at HAGs. - JACK will recruit community Liaoning officer who is mutually agreed by IEA commissions and the community shuras in the province and will discuss with the Health Shuras and the community elders related to access and gaining movements in the districts where FATPs are operational. - JACK/Johanniter will follow their own organisational policies related to recruitment and please look at the recommendations of Health Section where the stakeholder’s recommendations were considered. - JACK and Johanniter will report to HAG and Health Cluster related to any violations by either parties and also at the regional HAG at Kunduz for any support needed for access and security and safety of the staff - Johanniter will develop Actor wise risk mapping for the proposed locations and districts and come up with mitigation plans. The mitigation plans will be shared with HAG, concerned clusters and donors.
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Section 6: Protection Assessment
The protection assessment was entirely based on the discussions the assessment team had with health facility staff of BPHS including women staff, consultations held with Health Shura representatives for all the districts of Kunduz, visit to health facilities and interactions with Psycho-social counsellors, discussions with protection actors in Kunduz, like UNHCR, Handicap International (HI). Some sections of this report will be repeating of what was written in access assessment section. However, only relevant information and tables are used for analysing the protection concerns in Kunduz province. The analysis includes the following sub-sections. 1. Protection concerns emerging from the conflict 2. Barrier analysis (based on community’s perceptions) 3. Protection Risk Analysis 4. Protection Response
6.1 Protection concerns emerging from the conflict Taliban clearly have greater control of the province which has increased the high rate of fighting reported in almost entire province for past two years and more so in 2019 with increased use of air strikes, ground operations, night raids and increased use of mines (the latter was mostly by the Taliban). The analysis was done with the BPHS implementing teams and cross verified the data with other health stakeholders and UN agencies. Increase of the conflict scenarios
- Increased checkpoints by the government and AOGs (in most cases, it is the check point occupied by either AOG or Pro-Government armed forces or ANSF) - High night rides (thus, Taliban has banned the services of telecommunication services from 4 PM to 6 AM, to reduce the impact of night operations of ANSF and reduce their communication mechanisms. The use of radio by army can be tracked through the same frequency) - Increased bombardment through air strikes (which is increased in 2019) - Occupation of schools and other facilities by armed forces and Taliban. Communities from Chardara stated that the schools except in the district centre were closed down entirely as these schools were occupied by actors involved in the conflict. Similarly, the communities from Dasti Archi mentioned of evicting the staff and patients from a clinic by conflicting actors (ANSF in this case) and occupied this for their military operations. In Qalezal, the communities mentioned that one Primary Health Service Centre (known previously as sub-centre) was occupied by a local war lord till the Taliban entry made the warlord and his band of militia have fled to Balkh province. - People are caught in severe cross fire - Recruitment of young people on rise by both the parties, mostly by the Arbakis *Pro- government militia
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The following table shows the influence of IEA/AOGs over the territories where the health facilities exist. Table No. 26: Who controls what (health facilities) in Kunduz Province
No. of Anti- Pro- Health Government Government Districts Facilities Forces Contested Forces Aliabad 5 40 0 60 Chahar Darah 6 83 17 0 Dashte Archee 10 100 0 0 Hazrat Imam Sahib 16 63 0 38 Khanabad 13 92 8 0 Kunduz 18 78 6 17 Qalaye Zal 7 100 0 0 Total 75 80 4 16 Source: Based on the discussions with Community Supervisor, Programme Coordinator of BPHS implementing agencies, cross verified with other actors and community representatives in health shuras of all seven district (October 2019) This table shows that the Taliban occupy 80% of the territory in Kunduz province, contested in another 4% of the locations, which are more in Chardara and Khanabad districts. About 16% of the territory under the government control. In urban areas, only 63%of the HFs are under the control or influence of Taliban, with 13% are contested and 25% under the influence of the government forces. Where as in the rural areas, 85% of the clinics are under the control or influence of Taliban and only 15% of the clinics are under government control/influence. When one looks into the data available, 86% of the white areas (where there are no health services available) are in Taliban controlled/influence areas. The lower level of health facilities doesn’t have trauma care facilities as they are basically for mother and child health care and overseeing institutional deliveries and basic primary health care. Thus, there is greater pressure from the communities, Shura members and armed opposition groups to have increased number of FATPs in the BHCs and SHCs so that the trauma cases in the remote locations can be mobilized to the nearest health facility rather than shifting to urban centres which are mostly under the government control and the patients may face harassment and arrests in the name of suspicion.
Summary of Impact of IEA/AOGs controlled areas on health facilities and health delivery (more details in the previous section on access) Affecting Vaccination outreaches and patient flow to the clinics Affecting patients to visit the clinic and damaging assets of the clinic Disruption of services during the fighting period, as the clinic is closed and staff are moved into safe location in the community. Only after the fighting is closed the clinic services and ambulance services are resumed work During fighting, the roads connecting to the towns and cities are blocked and closed During fighting period, the communications get closed. So people can't communicate about injury to others Lack of transportation (Ambulance services) during fighting, disrupt the movement of patients
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Sometimes, at least two occasions, the IEA supporters or PHD has taken the ambulances and the staff to their clinics and returned back the assets and the staff after completion of their work (surgeries) Access of women are sometime condition to having Mahram
As per the Health Shura members from Imam Sahib, Khanabad and Qalaizal, the increased presence of check points and heavy presence of armed personnel near the clinics or approach road to clinics. - Reduced attendance of health seekers especially women, girls and children (though most of the Shura members stated that the clinic staff are available 24 hours some times and are sometimes mobilize staff from other neighbouring clinics in case of emergency and high case load of injuries). In some places which are under the government control, e.g. in Etchkhali, out of 5 clinics four of them have such problems. - So far ambulances are not targeted, but sometimes the ambulances are used by the AOGs and return back after few days (Source: BPHS team) - District Hospital in Imam Sahib caught in cross fire between the ANSF and AOGs Recruitments of young/children In our previous assessment held in Kunduz during November 2017, reports of AOGs forcefully recruiting children or teenagers, thus forcing the communities to displacement. In case of refusing to recruit their children, Taliban are imposing fines over the families – 10,000 to 100,000 Afs per family. However, during the consultations held with Shuras members in October 2019, they have mentioned that, - In all the districts, there is practice of recruitment of children in their armed forces, especially by the AOGs, PGMs and to some extent ALPs. Not much in the regular Afghanistan Army. - There were reports of exploitation of children, especially young boys by the PGM commanders and warlords in Khanabad district. - However, they never heard of the fines by Taliban for the families who didn’t enrol their children into the forces - In some cases, young and teenage boys voluntarily join Taliban due to various factors o Escape from increased work load at home o Feel like holding guns and ammunition as a hobby o Highly influenced by the teachers in madrasas during their talims o Attracted towards their ideology and see the failure of the government to solve their problems o No economic benefits and unemployment 6.2 Barriers to access schools Boys have no problem in accessing schools except during fighting period. However, girls can go to the school up to Sixth grade. The girl’s mobility is restricted to only village and thus can’t access higher grade schooling located at the district centres. This is due to lack of female teachers but more of social norms. In the centre of district which are controlled by government there are no barriers and girls attend up to 12 grade. Most importantly the lack of female teachers because the AOGs have put condition and without female teachers the girls cannot attend high grades, like in the case of Dasti Archi district. In addition, in Archi, the girls are not supposed to have Mahram while going to school because usually they travel in groups. But Hijab is mandatory in Taliban control areas.
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In almost all the districts, the Shura representatives have mentioned that there are some mines placed on the main roads and girls go through long auxiliary routes In Chardara, AOGs post warning of children not to attend schools due to fighting and the schools were mostly occupied by the Taliban. There are three high schools functional in Chardara and other schools are closed. For people with disability there are transportation cost and transportation and some schools structures are not disability friendly for easy movement of people with disability.
People’s perception about HF
- People perception about HFs in general is good and they are satisfied with the services. However, they complain about shortage of drugs. Some people had complaints from different staff. - Persons with disability are faced with transportation, transportation costs, structural problems in some areas are not friendly, no physiotherapy services in most of the HFs.
Barriers to access to health services Restriction on women’s mobility and should be accompanied by Mahram when visiting health facilities. Sometimes, there are mines on the way to clinics laid by AOGs. AOGs do warn people not to use these roads. The mines are put on main roads targeting mainly ANSF. The auxiliary roads are difficult and takes longer time than the main roads. There are check points in the auxiliary roads as well. Another important problem is the absence of women vaccinator in the outreach and male vaccinators are not allowed to vaccinate women. The NGOs cannot afford female vaccinator mahram to send female vaccinators to the outreach work. In Chardara district, Sarak-e-Payan has no health facility. There is a health facility located in Sarak-e-Bala, but the people of Sarak-e-Payan can’t access this facility due to river. Accessing higher health facilities in Regional Hospital in Kunduz and District Hospital of Imam Sahib involves need for transportation and related costs, mines on the roads and the existence of checkpoints of AOGs and ANSF. There is high risk for people working with the government on the main roads connecting the various district centres to Kunduz and to other provinces, due to presence of check points and Taliban’s watchfulness for the government employees. So many of the government staff use auxiliary roads, but there was always a fear of a surprise checkpoints by AOGs. In Archi, there is army positioned in one of the CHCs and staffs are driven out of the facility. Due to mines on main roads, people have to travel on auxiliary roads which are difficult and risky to travel on. There are check points in the auxiliary road and delays caused by the investigation by the check points. In Qale-zal, the Health Shura representatives shared that bridge was destroyed by AOGs and the connection to the CHC due to river bas also cut. The patients come through local made boats which are not available during the night and emergency cases cannot be brought to the CHC.
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Persons with disability: transportation, the structure in some HFs where there are no facilities for wheel chair and are not disable friendly. There are no physiotherapy services in most of the health facilities and the waiting time for the people with disability are not given special consideration.
6.3 Protection issues of IDPs
There are instances of domestic violence and gender based violence and protection issues for girls and women but mostly are not reported due to cultural factors Overcrowding (5-10 families in one compound). Repeated displacement. People displace to safer places as and when the fighting commence and return back to their place of origin when the fighting subsides. Now with Taliban having control over the territories in most of the districts, there is reduced displacement in 2019. During the conflict, many have lost their homes, destroyed and few were burnt by the pro-government forces and the aerial attacks. Regarding health, most of the IDPs especially pregnant women and children miss their vaccinations and immunization schedules The health Shura members and the BPHS health staff mentioned that ANCs and PNCs are missed out due to conflict Face severe psychological stress and problems at the place of displacement They displace to new locations with minimum assets and are entirely dependent on support and aid. Inadequate access to aid will lead to stress and may affect their coping mechanisms and adapt negative coping mechanisms For disabled, there are no supply of specialized appliances. With the closure of ICRC centre, referrals for prostatic care is not fully exist in Kunduz and referrals are provided to Mazar. They are very difficult to access as the referrals needs advanced appointments. Access to physio-therapy services are low for injured and persons with disability Handicap International, SCA have such programmes and need to explore what ‘s the status of referral systems exists in Taloqan Provincial Hospital Children are unable to attend schooling at the displaced locations and also in the districts of active conflict and war, e.g. Chardara The trauma incidents due to displacement (conflict) o Worrying o Flashback o Fear o Sleeplessness o Hopelessness o Helplessness Handicap International, work only in Kunduz city, refers them after initial counselling to mental ward in Kunduz regional hospital based on its severity. The regional hospital admits the severe cases for three to four days in their mental ward and provide treatment which is mostly medical care and counselling. They will be released after the treatment and only ask them to come on OPD for follow up. Concerns at regional hospital in Kunduz and District Hospital in Imam Sahib (also includes the district centre hospitals), where there is increased presence of Afghanistan security forces and also frequent visits of NDS to check of IEA fighters or supporters in the clinics. The situation is similar at the entry and exit points of the district centres and Kunduz city. This reduces the
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Based on the interactions with Health Shura members, BPHS staff includes RPH Officer, CME and CHNE Coordinator, CHW supervisor (all female), district focal points of BPHS, WHO, UNHCR, UNOCHA, DoRR and NGOs – MSF, ARCS and Handicap International, the protection risk analysis was carried out by the assessment team. Since, the second allocation of AHF grant for 2019 needs integrated protection along with inter-cluster assessment and response, Johanniter and its partner, JACK have conducted protection Risk analysis as part of the needs assessment. The risk approach to humanitarian protection has become a standard approach adopted by the protection cluster and other donors (ECHO) and NGOs. Risks are understood wider than something that may happen; it also implies what is happening, has happened or might happen repeatedly. Risk analysis approach helps in identifying protection needs of a given target population by determining the threats faced, and the vulnerabilities and capacities possessed in relation to those threats. In this analysis, the threats are posed by actors who – with a purpose of pursuing their own interests- either target or negatively affect the target population (analysed population). Inter-relatedness of these factors can be illustrated through the following equation Threats X Vulnerabilities Risk = Capacities This is not a mathematical equation, but a tool that serves to illustrate that the protection risk faced by the target population is directly proportional to threats and to vulnerabilities and infernally proportional to capacities. The more the vulnerable the population is the greater the risks and vice versa.
Risk Reduced access to the health facilities for trauma care due to violation of human rights/IHL and patterns of abuse/restrictions Threat - During the fighting period, the clinics are closed and thus can’t access health facility - Land mine threats on the main roads which is meant for the armed forces but the same road is also used for ambulances and people for commuting to hospital/clinics - Vehicles don’t ply during the fighting due to road closures and increased checkpoint - Harassment of security forces while checking the ambulances (suspicious of the IEA fighters) - AOGs takes out ambulances to ply their supporters who were injured during the fighting and return them back to the BHC - Afghanistan armed forces will allow the injured patients for medical treatments but are closely observed and are arrested immediately after their release from the clinic - AOGs sometimes take medicines from the stock of the clinics and thus there are times that shortage was reported
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- US armed forces (especially the air attacks) attack the health facility or ambulances if they suspect of any high profile IEA (the usual practice of the PPHD of IEA visiting and visibly seen in some of the clinics) E.g. Airstrikes on Mirsheik Clinic in May 2018 - In 2018, Qarluk health facility was bombed by ANSF and the whole clinic building was damaged and burned all the equipment - In 2018, the ANSF ground operation unit entered the Imam Sahib District hospital once during night and searched everywhere and went back without waking up of the hospital staffs. - In 2018, during cross firing the hospital roof was hit by a rocket and part of the roof was damaged in Khanabad, Dasti Archi and Imam Sahib - In Qalezal, a girl high school in Aq Tepa was burnt but no one took responsibility for it. Vulnerability - During fighting, people have to travel longer distances and different routes to visit another health facility - Due to insecurity and local IEA commanders’ orders, the vaccination coverage is low and as a result, approximately 40-45% of rural population are outside of the vaccination coverage in Kunduz - Injuries and wounds (trauma) patients increase during the fighting which demands and very few stabilization and wound care facility exist in Kunduz - Mine risk - People with disability inability to travel to Mazar and Taloqan for health care and services. Capacity - 55 health facilities are run in well-built permanent buildings and are well connected by road - Presence of over 1000 CHWs in the province - 4 Surgeons (two are in Imam Sahib DH) - Five MD female - UNICEF’s (OHPM), Health Net and ARCS mobile clinics to cover white areas and underserved areas - People are aware of the landmines laid in certain location and always try to use different routes to reach the clinics - Health Shura to advise health administration of both parties, government PPHD and Taliban health commission and are influential - Community contribution in building additional rooms for trauma care in remote areas - Presence of MSF and Regional Hospital (with expected improvements in both the Trauma Care Units) - Acceptance of health staff by all parties of conflict
Mental Health (need to analyse the reports from TABISH)
Usually displacement, especially war-related displacement, is accompanied by several main stress factors. These include economic constraints, security issues, breakdown of social and
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Table No 27: Mental Health in Kunduz (Both in BPHS HFs and Kunduz Regional Hospital)
No. of Cumulative in Cumulative 2019 Sl.No. District HFs 2018 (till end of Sept) 1 Aliabad 5 2704 1324 2 Chardara 6 1688 722 3 Dasti Archee 10 4387 5575 4 Imam Sahib 16 6184 4648 5 Khanabad 13 7026 5043 6 Kunduz 18 4914 4122 7 Qala-e-Zal 7 1322 905 Total 75 28225 22339
8 Regional Hospital 9296 5867 Overall 37521 28206 Source: BPHS and Regional Hospital HMIS, September 2019
The above table clearly state that there is high number of PTDS and mental health related issues at the BPHS and EPHS (Regional Hospital) in Kunduz. Discussions with TABISH, an NGO working in building capacities of health staff and NGO’s staff working in Psycho-social and mental health care in Afghanistan, where they state that nearly 50% of the population living in conflict prone areas like Kunduz struggle with depression, anxiety, and post-traumatic stress, but fewer than 10 percent receive adequate psychosocial support. IN Kunduz, only at CHC level there are psycho-social care providers and there are only 14 of them present in the entire BPHS clinics. In addition, the HN TPO, Save the Children and Handicap International’s support psycho-social service providers in the mobile health units and thus additional 8 PSC counsellors exist. The psychiatrics department in Kunduz Regional Hospital provides mental health care for serious mental health and trauma treatment and counselling. The field mission to Imam Sahib and Khanabad, the Psycho-social counsellors shared that,
Emotional problems include: sadness, grief, fear, frustration, anxiety, anger, and despair. Cognitive problems, such as: loss of control, helplessness, worry, ruminations, boredom, and hopelessness are all widely reported, as are physical symptoms such as: fatigue, problems sleeping, loss of appetite and medically unexplained physical complaints.
12 Study on Disability and Mental health by Handicap International, Kunduz 2018
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Social and behavioural problems, such as: withdrawal, aggression and interpersonal difficulties are also common. The assessment identified following major symptoms about psychosocial aspects in IDPs families. According to the Psychosocial counsellors, the main concerns which emerged from the counselling sessions that, the patients’ complaint that the traumatic/complicated grief is linked to the difficulties faced due to the war context. Change in sleeping pattern Images reflect during sleep of the violent events experiences repeatedly Feeling being isolated Changes in appetite Changes in behaviour
According to the observations made by the PSS workers in Kunduz province, - Anxiety and worry of the household of the security situation, the loss of a stable environment, their home etc. - Anxiety and sadness due to the loss of a family member or relative during the conflict, sometimes coupled with household isolation - Some family members' shared their pain during the assessment (IDP situation, psychological distress.) couple sometimes with a lack of communication with the family - Parental anxiety and concern for children who cannot attend school and / or the inability to support the family - During our discussions with other warring elements and stakeholders working on health, there are some gaps or fears expressed by IEA for getting access to regional hospital o The hospital is heavily guarded by security forces, intelligence forces and NDS visiting each ward. This pose risk for the pro-IEA injured to get treatment in the hospital. Even MSF can’t guarantee the safety of the injured pro-IEA or people living in IEA controlled locations of the consequences in post-release of the patient from the hospital. The government forces also agree to have the treatment of the pro-IEA groups or people from IEA controlled areas get medical treatment but may like to question them after their treatment and mostly get arrested after coming out of the clinic. This concern is high among the IEA groups. o Thus, the IEA groups insist of having more casualty treatment mechanisms located in their controlled territories and convert the stabilization centre in Chardara into surgical sites.
The following analysis is consolidated from the discussions held with stakeholders and review of our previous assessments. The following table illustrates how different people in the same location face different threats.
Category Protection Issues Health Youth (12-25 Increased pressure to join armed opposition Proper clinical and psycho- years) groups. social response mechanism is boys/young needed men in all Harassment from security forces while they seven districts have moved to the cities. of Kunduz
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Fear of arrest and harassment while transferring injured youth in ambulances or private vehicles at check points
Injured and Fear of accessing health centres due to Inadequate staffing and low traumatized harassment and fear of arrest capacity in health facilities to persons treat trauma patients Distance of the trauma facilities and lack of Lack of adequate ambulance transportation services for emergency transportation for treatment or referrals
Girls and SGBV in and outside. Need male relative to Adolescent Taliban instruct them to travel with a male accompany to access health Girls mahram (a close relative) while going to facility. health facility or education or for livelihood purpose Proper clinical and psycho- social response mechanism is needed
Women SGBV (*though not many of them are Constant fighting between reported to the agencies, but close government and opposition assessment of WAW/UNHCR mentioned of groups has made them not to the increased incidents. Need male access clinics relative/mahram to accompany outside Proper clinical and psycho- social response mechanism is needed, especially for PTDS
IDPs Increased occupation of their homes in the Increased diseases due to place of origin made them to displace, overcrowding, restricted constant fighting is making them to displace mobility of girls and women repeatedly, loss of livelihoods and livelihood thus poor access to health assets making them traumatized facilities. Proper clinical and psycho-social response mechanism is needed
The local leaders and Shura members do negate with both the warring groups to get access to health facilities especially for maternal health care and that’s one of the reasons why all the clinics have reported high institutional deliveries and is also confirmed by the Health Shura members and health staff of the clinics. However, the trauma cases treatment is still remains a challenge due to access issues and availability of capacitated health professionals.
Protection response: Based on UNHCR representative’s response, in Kunduz there are different levels of protection interventions/advocacies for IDPs, Refugee returnees and others through Protection Cluster Meeting, Sub- Clusters like GBV, meeting with local authorities including the ANSFs, Civil Military Coordination meeting, OCT, PDMC, IDP coordination at field level, and also refer to other clusters at regional and national level for further interventions.
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Monitoring mechanism of UNCHR UNHCR has protection monitoring partner in all NER provinces, and they are monitoring the IDPs situation in different condition through focus group discussion, KI, regular protection missions, Baseline survey, joint assessment and multi-sectorial assessment.
UNHCR is a protection mandated agency leading Protection & ES/NFI clusters globally. Providing protection advocacy, emergency shelter, none food items, RHUs, and live saving assistances through its PSN project, and durable solution for refugee/returnee, IDPs, asylum seeker and statelessness people.
Gender Based Violence: JACK implements the Family Protection Centre in Kunduz with the support of UNFPA. The latest report from the centre is as following.
Table No. 28 Report of GBV cases reported in Regional Hospital, Kunduz Kunduz (from Family Protection Centre -FPC) HMIS report December 2019 Physical assault 143 Rape 1 Sexual assault 11 Forced marriage 132 Denial of essential resources 430 Psychological & emotional violence 664 Total Female 1362 Total Male 19 Men 19 Women 1367 Boys 0 Psychosocial counselling Girls 53
Number of GBV cases registered by focal Girls 13 points in 30 BPHS HFs Women 4012 Men 5 Referrals out to FPCs Women 67
Gender-based violence throughout Kunduz has remained largely unheard of since no reference was made to the come up with GBV case identification and referral, while there was no referral mechanism so long, but Women of Afghan Women (WAW) it is currently the only authority working on GBV and launching the referral mechanism by coordination with protection cluster. The family protection centres recorded high number of Psycho-logical and emotional violence (664 in Year 2019) and 4012 Gender Based Violence is reported in 30 BPHS Health Facilities. Most of these BPHS facilities don’t have qualified counsellors. Thus, there is need to have female PSS counsellors trained to deal with this high case load.
Recommendations and suggestions Prostatic and Orthotics Care - The Shura members have clearly recommended for considering protection issues for disabled persons; not just for conflict affected but also naturally disabled population as ICRC is no longer working in Kunduz. Referrals for prostatic care is not fully exist in
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Kunduz and referrals are provided to Mazar and with the closure of ICRC in Mazar will have impact on this. Access to physio-therapy services are low for injured and persons with disability. Handicap International, SCA have such programmes and need to explore what ‘s the status of referral systems exists in Taloqan Provincial Hospital. - Strengthen the currently in practice referral systems exist with the following approaches in close coordination of Regional Hospital, Handicap International, Swedish Committee for Afghanistan and ICRC Mazar-e-Sharif. o Referral to physio-therapy clinic of Swedish Committee of Afghanistan in Kunduz o Referral to Orthopaedic and mental health units of Regional hospital o Referral to Swedish Committee of Afghanistan (SCA)’s workshop in Taloqan, Takhar (however, the feedback from the patients is that the Takhar workshop of SCA is not that effective. The appliances and wheel chairs are heavier. There are no inpatient treatment or practice sessions at Taloqan for 3-4 days so that the appliances are practiced by the patients. The appliances are issued and ask the patient to return back of fifteen days or one month for follow-up) o Referral to ICRC centre in Mazar (which was closed for short period after the killing of their staff in the clinic), but now resumed work. Here the equipment and appliances are satisfactory for the people. They are lighter. SCA also has a unit in Mazar. Some of the cases are also referred to SCA in Mazar - IN case of any difficulties, propose for having a physiotherapy and orthopaedic care facility made available in Imam Sahib District hospital. For appliances, coordinate with ICRC and Swedish Committee for Afghanistan in accessing them.
Mental Health in counselling Post Trauma Disorder Syndromes (PTDS) and referrals
Getting effective treatment after PTSD symptoms develop can be critical to reduce symptoms and improve function. Psychosocial and physical rehabilitation should be combined in a care package tailored on the immediate needs of the person and their environment Mental health and psychosocial support (MHPSS) support plays a particularly important role during armed conflict and emergencies and considered the limited time of the intervention in a situation of overwhelming needs and scarce resources, this support should be guided by a “do no harm” approach Training the health workers in the health facility on PTDS and MHPSS is essential and Johanniter/JACK will collaborate with technical institutions like IPSO and TABISH to provide training, follow up and refresher trainings to the health facilities in the proposed FATPs and referral sites. Higher referrals will be made to Psychiatric /Mental Health unit of Regional Hospital in Kunduz.
Gender Based Violence However, directly dealing in the health facilities GBV will invite wrath from the Taliban who have their own norms for women and men to behave socially. Thus, the discussions around gender based violence and protection concerns of women patients will take up by the PSS/Physiotherapist female in the proposed FATPs. Consultations with Health Shura, Family Health Action Groups (women members) and religious clerics (Mullahs) in developing appropriate gender messages and will refer the cases with UNHCR for further support. Coordinate with WAW (women for Women) organisation that are involved in assessing SGBV in the province and coordinate with them to identify cases of SGBV and use existing Psycho-social counsellors available in the health facilities for counselling and follow up.
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Coordination - At Project Level: Johanniter and its sub-implementing partner, JACK in Kunduz will coordinate with different stakeholders includes, Regional Hospital, PPHD, Save the Children, Humanity and Inclusion (formerly Handicap International) and WAW/UNHCR related to referrals and follow up of the PSS Trauma cases and GBV cases. These are covered under protection monitoring reports submitted to the UNHCR and the clusters on monthly basis. - National Level: Johanniter and JACK will take part in the protection cluster and its sub-clusters and in Mental Health-Psycho-Social Services Working Group (MHPSS WG) and share the progress and challenges of the proposed activities in the WG for finding solutions. - Capacity Building: Johanniter will engage with its technical partner in MHPSS in Afghanistan, TABISH in providing trainings to health facility staff in the proposed project area and coordinate with the partners in follow up of these capacity building action plans and study the impact of the increased capacities of the health facilities in dealing with PTSD and GBV incidents.
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Section : 7 Key Results from the Needs Assessment for consideration for programmatic intervention This section, Johanniter and its partners have consulted stakeholders, clusters and donors related to who does what and what is the core essential programme development planned for response to the needs identified. The list of stakeholders met in Kabul is enclosed in annexure Johanniter has done a separate analysis for security and access was carried out with INSO, HAG and national partners and also sought help from Security Advisor from its HQ in Berlin.
1. Establishment of First Aid Trauma Posts in remote and hard to reach districts Increased trauma cases in conflict prone districts of Chardara, Dashti Archi, Imam Sahib, Khanabad, Kunduz and Qala-e-Zal, needs First Aid Trauma Posts in each of these districts. The remote rural health facilities don’t have the capacity to provide services related to trauma and injuries/wounds. The access to urban facilities are low as the roads leading to the urban clinics are either closed down or on going fighting denies access, IEDs prevent people to access during fighting time. Fear by the patients or injured/wounded persons going to health facilities in urban areas/district centres which are predominantly controlled by the pro- government forces (harassment, fear of arrest or prosecution) – Protection Issue.
Table No. 28: Trauma Care coverage in proposed FATPs Average Trauma Case load (2014-19) Type of Coverage Total FATP location Health villages/ Coverage Health Catchment S.No. District Proposed Facility CDCs Facilities nearby Population M<5y F<5Y M>5y F>5y 1 Chardara Mirshek (is BHC 60 Gharaw Qushlaq 41909 actually located in SHC, Aliabad, but due Qarya Qasab SHC, to its location, it is Charyabad SHC, accessible for Arbab Ramazani Chardara) BHC 485 503 1787 1017 2 Dasti Archi Mula Quli SHC 66 Nari Jadid SHC, 54223 Sharawan BHC, Haji Naem Jan CHC, Kalbad CHC 1248 1150 2610 1873 3 Imam Sahib Alif Berdi BHC 117 Echkili CHC, 67531 Koldaman BHC , Quturbulaq BHC, Gumbad SHC, 639 533 779 556 4 Khanabad Boin BHC 86 Pyenda 60916 Mohammad BHC, Jan Qataghan BHC, Nickpay SHC, Nekpay CHC 432 384 1062 715 5 Kunduz Bola quchi BHC 95 Kanam BHC, 78508 Khwaja Ghaltan BHC , Kobahi SHC, Mullah Sardar SHC 266 250 636 407 6 Qale-Jal Dorman BHC 166 Said Masoum 56063 Shahid, Kolokhtipa BHC, Halqakol SHC, Yangharuq SHC 290 257 827 385 Total 590 359150 3360 3077 7701 4952 % 18 16 40 26 Source: Analysis of Trauma cases per health facility and its coverage area facilities in Kunduz province (JACK and Johanniter), November 2019
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2. Based on the mapping, the analysis of trauma cases in the selected FATP and its coverage areas were calculated and assessed from 2014-2019 data sets from HMIS information available with PPHD and BPHS teams. Accordingly, the average Trauma cases were arrived at. The above mention Table No.28 about the average trauma cases recorded with the BPHS facilities for the period of 2014-2019 as of end of October 2019. Thus, it was roughly calculated that about 19091 persons will be addressed per year for trauma care due to active conflict since 2014 and about 3360 boys and 3077 girls 7701 men and 4952 women are covered under the Trauma care. 3. Establishment of First Aid Trauma Post (FATP) within the existing health facility with rapid response teams (Ambulances) + 2 nurses, one for Day and another for Night shifts, conduct triage, categorise the priorities for emergency 4. Transportation and referral to higher trauma care posts (MSF and Regional Hospital in Kunduz or DH Imam Sahib based on the location’s accessibility and distance), first aid and stabilization services, evacuation, referrals, minor wound care. - The discussions held with Provincial Health Directorate (both of Government and opposition groups), BPHS teams, with UNOCHA Kunduz team and the health cluster, identified eight health facilities in these districts (two each) and after consultations and negotiations, it was reduced to one FATP per district. Along with BPHS team and the health directorate, we have mapped the catchment of the health facilities i.e. no. of villages it covers and no. of other health facilities fall under their catchment area. 5. In addition, these FATPs will have additional facilities provided like additional beds for trauma care, stabilization purpose and psycho-social counselling. The FATPs five out of six in Kunduz will be provided with additional space and request the donor to consider of building two room FATPs with two Toilets (one for men and another for women) in the proposed Health Facilities, except for Mula Quli in Dasti-Archi. The WHO standard FATP structure and the BoQs will be considered and there will be location specific plan for this assistance.
Health Facility built by the communities at BolaQuchi for FATP under Hashar (Pic: Assessment team), need repairs and refurbishment as per WHO’s FATP standards.
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II. Strengthen the capacity of referral centres for improved trauma care within the districts of Kunduz province
1. The trauma referrals were calculated based on the assessment of emergency trauma cases in MSF wound care unit in Kunduz, where in 10% of the actual cases referred to them are emergency cases, about 60% of the case load falls within the criteria of treatment of wounds and minor surgical cases and rest of 30% are follow up cases. Thus based on this data, Johanniter and JACK have proposed for critical referrals and for transportation of emergency cases, 10% of the Trauma cases were considered and thus arrived at the number of 1145 for the referrals to Kunduz/Imam Sahib. The catchment beneficiaries were calculated based on the general practice of BPHS OPDs and IPDs, which is covering about 40% of the catchment population for trauma and Psycho-social counselling. Thus the following table No. 29, was developed (based on HMIS data) for the MH-PSS beneficiaries from the catchment. Table No 29: Trauma Case and PSS Counselling Coverage S. FATP location No. District Proposed M<5y F<5Y M>5y F>5y Total 1 Chardara Mirshek 116 121 429 244 910 2 Dasti Archi Mula Quli 300 276 626 450 1651 3 Imam Sahib Alif Berdi 153 128 187 133 601 4 Khanabad Boin 104 92 255 172 622 5 Kunduz Bola quchi 64 60 153 98 374 6 Qale-Jal Dorman 70 62 199 92 422 806 739 1848 1189 4582
2. The following were the referral sites identified by all actors. These referrals sites will be regularly being consulted. Monthly meetings will be held with the referral sites to provide feedback and seek programmatic support Table No.:30 Referral sites identified by the actors FATP location Referral Sites for Referral Sites for Sl.No. District Proposed Taliban ANSF 1 Chardara Mirshek MSF Chardara Chardara CHC Sai Dokan Basus BHC Regional Hospital MSF Kunduz city 2 Dasti Archi Mula Quli Haji Naim Jan CHC Archi CHC+ Kal Bad CHC RH MSF 3 Imam Sahib Alif Berdi Kalbad CHC Imam Sahib DH Echkili CHC RH MSF 4 Khanabad Boin Payenda Mohammad Khan Abad DH BHC RH Nikpay CHC MSF 5 Kunduz Bola quchi Asqalan CHC RH Kanam BHC MSF MSF chardara 6 Qale-Jal Dorman Said Masom BHC RH Aqtipa CHC+ MSF MSF chardara
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3. Based on Handicap International's vulnerability study (June 2017), about 0.5% of the population actually need referrals and treatment for prostatic and orthotic cares. Thus, the following table was estimated for targeting persons with special needs for referrals and prostatic and orthotic care from ICRC Mazar, SCA in Mazar and Taloqan, and regional hospital in Kunduz. Thus, the following is a tentative assessment of the referrals per year for prosthetic and Orthotic referral care. Table No.: 31 Prosthetic and Orthotic Referrals for PwDs S. FATP location No. District Proposed M<5y F<5Y M>5y F>5y Total 1 Chardara Mirshek 2 3 9 5 19 2 Dasti Archi Mula Quli 6 6 13 9 34 3 Imam Sahib Alif Berdi 3 3 4 3 13 4 Khanabad Boin 2 2 5 4 13 5 Kunduz Bola quchi 1 1 3 2 8 6 Qale-Jal Dorman 1 1 4 2 9 20 18 46 30 115
III. Improving access to Mental health care for PTDS and referral systems
1. There were many protection issues identified through protection risk assessment include, Increased checkpoints by Pro-government forces and IEA (denies access to the location due fear of fighting, harassment and IEDs on the way); High night rides; Ban on telecommunication by IEA during evening and night (no communication to share information related to emergency needs); Air strikes causing damage to property and life, increased injuries; Affecting patients visits; Damage to the assets of the clinic; 2. Disruption of health services in the community (clinic is closed during active fighting); 3. During fighting, roads connecting to the clinics are closed; Access to the clinics especially in rural and remote areas for women without Mahram is denied. This will be difficult of single woman, women headed households, women (whose husband or male relatives have migrated) to access health clinics. Gender based violence like, Domestic violence is increased as means of trauma by men (negative coping strategies – wife/daughter beating, drug addiction, etc.); Girls are not allowed to attend schools (especially in IEA controlled areas), even in case of IEA encourage, parents out of fear don’t send girls to school; Women are not allowed to go out even to clinics without Mahram 4. Due to the above factors, Given the high incidents of mine detonations which take place in remote areas or when performing solitary tasks, such as grazing livestock or collecting firewood, it is reasonable to surmise that victims are never found, or only discovered after such an extended period that cause of death is neither apparent nor an issue. Awareness on mine risks education has emerged as the major felt need. Johanniter will coordinate with UNMAS in facilitating training of trainers for the health facility staff and provide awareness at health facility for men, women and children through facility staff and CHWs. 5. Johanniter will closely work with its technical capacity building partner in MH-PSS, TABISH in providing training and on job support to the psycho-social counsellors and nurses in the health facilities (FATP locations). The trainers will also conduct periodic monitoring of the locations and provide inputs for the PSS counsellors and conduct exit interview to know the impact of the PSS counselling services. The referral sites will be visited by Johanniter and its implementing partners to seek their feedback and continued support.
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6. Gender Based Violence - However, directly dealing in the health facilities GBV will invite wrath from the Taliban who have their own norms for women and men to behave socially. Thus, the discussions around gender based violence and protection concerns of women patients will take up by the PSS/Physiotherapist female in the proposed FATPs. Consultations with Health Shura, Family Health Action Groups (women members) and religious clerics (Mullahs) in developing appropriate gender messages and will refer the cases with UNHCR for further support. - Coordinate with WAW (women for Women) organisation that are involved in assessing SGBV in the province and coordinate with them to identify cases of SGBV and use existing Psycho-social counsellors available in the health facilities for counselling and follow up.
7. Coordination and Advocacy 1. Health: Consultations held during the needs assessment and its follow up with the stakeholders both at the provincial level and at the Kabul level, the following generic agreement of support and cooperation will be planned with various stakeholders include National and International NGOs, UN agencies, Government authorities, Anti-Government groups and Clusters. Table 32: Actors coordination in Proposed facilities FATP location Physiotherapy S.No. District Proposed Health Education Nutrition and EPI Displacement Livelihood support 1 Chardara Mirshek (Aliabad) JACK (BPHS); HNTPO (Mobile health services and and Save the Children psychosocial (Education counseling for IDPs) Programme) SCA 2 Dasti Archi Mula Quli JACk (BPHS);ARCS Save the Children (Primary health (Education services) Programme) SCA 3 Imam Sahib Alif Berdi Save the Children (Educational program, Mobile UNMAS: health services and WHO and UNICEF Livelihood and psychosocial (through its support to counseling for IDPs partners) - UNHCR/NRC war JACK (BPHS) through JACK)Technical and supporting IDPs affected SCA 4 Khanabad Boin Save the Children financial support and returnees civilian and (Education of EPI program physiother JACK (BPHS) Programme) and survilance apy SCA 5 Kunduz Bola quchi Save the Children services (Educational program, Mobile health services and JACk (BPHS);ARCS and psychosocial (Primary health counseling for IDPs services) through JACK) SCA 6 Qale-Jal Dorman JACK (BPHS); HNTPO (Mobile health services and and Save the Children psychosocial (Education counseling for IDPs) Programme) SCA
a. At Kunduz: The project steering group is formed with Director, PPHD; Director, Regional Hospital; WHO focal point in Kunduz; Focal point of BPHS implementing agency (in this case JACK) and the Project Focal point of Implementing Partner (JACK). This steering group will be overseeing the implementation modalities and address any challenges faced by the project. The group will get monthly update of the project and also share the referrals cases and its follow up updates. JACK will
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have a focal person from the project to coordinate with various commissions include NGOs and Companies Commission, Customs & Tax levy commission, Health Commission of Taliban in smooth implementation. At Kunduz, for provisioning of mass casualty management trainings at the referral sites (mostly DH and CHCs) and triage & stabilisation in close coordination with MSF team. The referral services will be closely coordinated with MSF Wound care centre at Kunduz and in future to its full-fledged Trauma Centre at Kunduz, Regional Hospital and District Hospitals with BPHS. Referrals related to Psycho-social services (PSS) will be done through WAW/UNHCR, Save the Children and Handicap International. Referrals for PwDs will be coordinated with SCA and HI in Kunduz and ICRC in Mazar-e-Sharif. All these referrals are recorded for follow-up. The partners will regularly attend and participate in OCT meetings at UNOCHA Kunduz and also coordinate in reporting to WHO and relevant stakeholders at Kunduz. The details of local level coordination are as per the table No. mentioned above.
b. At Kabul: Johanniter and the implementation NGO partners coordinate with MoPH in registration of the project and submission of progress report regularly. Johanniter and the partners regularly attend the Health Cluster meetings and so too Protection Cluster and GBV sub-cluster meetings, MH-PSS working group meetings, to share the progress of the project and also related to the challenges of the project. Seek guidance from the stakeholders. Johanniter will coordinate with departmental heads and Head of missions of the NGOs working in Kunduz for close coordination of this project.
2. Access: The Implementing partners and Johanniter have discussed with the stakeholders include the armed opposition groups and sought acceptance of implementation of this project if approved by the donors. The relevant head of departments of the opposition groups and Director PPHD Govt. of Afghanistan were consulted while selecting the locations for FATPs. Though the government functionaries don’t admit in public but have acknowledged the presence of opposition groups and have their own communication channels for contact and operations. As the sub-implementing partner JACK has presence in Kunduz and is currently implementing BPHS project and thus have access strategy for all the health facilities. Similar access will be worked out with all conflict actors and regularly monitor the situation. JACK will appoint one Community Liaison Officer who will coordinate with community level shuras and coordinate in access and movements of the health facility staff and ambulances. Closely coordinate with INSO, Humanitarian Access Group (HAG) at Kunduz and Kabul in discussing the issues of access and also coordinate with the above group related sharing the Joint Operating Principles (JOPs) or red tape for NGOs working in humanitarian work to gain acceptance of all actors and seek their support.
3. There were many protection issues identified through protection risk assessment include, Increased checkpoints by Pro-government forces and IEA (denies access to the location due fear of fighting, harassment and IEDs on the way); High night rides; Ban on telecommunication by IEA during evening and night (no communication to share information related to emergency needs); Air strikes causing damage to property and life, increased injuries; Affecting patients visits; Damage to the assets of the clinic; Disruption
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of health services in the community (clinic is closed during active fighting); During fighting, roads connecting to the clinics are closed; Access to the clinics especially in rural and remote areas for women without Mahram is denied. This will be difficult of single woman, women headed households, women (whose husband or male relatives have migrated) to access health clinics. These issues will be brought to the discussion with the health shuras in the clinics and with commissions and with government stakeholders to find ways to access and improve the services in trauma care at the health facilities and at the referral points.
4. Jointly advocate with various networks and forums related to safety and security of staff and facilities in Kunduz, like ACBAR, HAG and HCT.
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Annexure 1: Meetings with Stakeholders Stakeholders met by the Assessment Team members In Kabul - Dr. David Lai, Health Cluster Coordinator (before visiting Kunduz) - Dr. Abdul Rahman Shahab, Health Net - Protection Cluster - Sean Ridge, Brian and Nadja, HAG, OCHA - Reuben, SA NE-INSO - Julianna Westerblom, Head of Desk, Swedish Red Cross - Fiona Gall, ACBAR - Dr. Mansoor Staniczai, Senior Health and Nutrition Advisor, Save the Children - Kelly-Elizabeth Thayer, Emergency Coordinator, Handicap International - Prue Coakley, Pascal Duchemin and Gabriela Das, Médecins Sans Frontières – Afghanistan (MSF) In Kunduz - Mohammad Yusuf Khedam, Head of Department of Refugees and Repatriation (DoRR) - Dr Ishanullah Fazli, Director, Provincial Health Directorate, Kunduz - Ahmed Reshad Ahmedzai, UNOCHA - Barak Osman, UNOCHA - Bisanukuli Huliro Lexis, HAO, UNOCHA - Dawood Salimi, Head of Office, UNHCR - Hayatullah Sobman, Protection Focal Point, UNHCR - Gulamshah Hodman, Team Leader and Mohammad Issa Polad, Base Coordinator, Handicap International - Dr. Yousuf, Afghanistan Red Crescent Society, Kunduz - Eng. Ahmed Farid, Afghanistan Red Crescent Society, Kunduz - Dr. Abdul Nazar Ahmadi, WHO - Dr. Saifullah Shinwari , Emergency officer - Shafiq Imran, ACTED - Abdullah Yaqubi , Education Project Manager, SCA - Samuel, Gabriela Das and Dr. IsmatullahAzizi, Médecins Sans Frontières – Afghanistan (MSF) - Dr. Naim Mangal, Director, Regional Hospital - Communities of Six districts shura members (List is not enclosed due to security purpose, but is available with Johanniter and JACK) - Core Health Facility Staff of BPHS, JACK, Kunduz - Health Facilities staff of Aliabad CHC, Khanabad CHC and
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Annex 2- Rapid Health Assessment Form – Afghanistan فورم ارزيابی سريع صحی توضيحات ساحه I. Site Description Name of reporting person: Name of Reporting Agency:______اسم نهاد زارش ری نام شخص زارش ر 1. Date: GPS:N______E______تاريخ 3. District(s) affected: 2. Region: ولسوالی متاثر شده ساحه 4. Sub-district: 5. Town/village: قسمت ولسوالی شهر، قريه
7. Number of shelters: 6. Name of Camp : تعداد پناه اه اسم کمپ Huts...1 ساختمان های Block Buildings…3 خيمه Tents...2 کلبه ها 8. Type of Shelter: بﻼک ساختمانی درحال ساختن Block Building under construction..4 نوع پناه اه دي ر مشخص کنيد Others: specify………………….…5
10. If Accessible, by هوايی Air…2 سرک Road…1 در دسترس Access to the area (please Accessible…1 .9 (please tick): دست رسی به ساحه ل ُطفآ نشانی :(tick ا ر قابل دسترس باشد ،لطفآ دي ر Others…4 کشتی Boat…3 دردسترس نيست Not accessible…2 نمايد نشانی نمايد بيخطر Security status in the area: Secure…1 .11 12. If Insecure, explain (please tick): ا ر نا امن باشد توضيح بدهيد نا امن Insecure…2 وضعيت امنيتی در ساحه
٢-آرزيابی نفوس - II. Population Assessment نفوس مجموعي :Total population .13 تعداد خانواده ها :Total Households .14
بيجاشده ان داخلی IDPs…1 16. Origin of majority of Population مهاجرين Type of Population (please tick all Refugees…2 .15 (Specify one Region): applicable): نفوس اصلی اکثريت ميزبان Host Community…3 نوع نفوس ،لطفآ تمام موارد قابل اجرا نشانی نماييد لطفآ يک زون مشخص کنيد جامعه 18. Total New Arrivals (last 7 تعداد بيدون سرپناه :Total homeless .17 تعداد مجموعی ورودی جديد :(days 19. Total number of deaths (last 7 20. Number of births (last 7 days): تعداد مرګ ومير که درمدت ٧ روز ذشته فوت :(days تعداد نوزاد ها که در ٧ روز اخير تولد شده اند کرده اند 22. Total number of children under 5 تعداد مجموعی :(Estimated number of children under 5: deaths (last 7 days .21 اطفال فوت شده زير سن ۵ ساله درمدت ٧ روز تعداد تخمينی اطفال زير سن ۵ ساله اخير 24. Total number of females deaths تعداد :Estimated number of females .23 تعداد فوت شده اناث که در :(last 7 days) تخمينی اناث اخير ٧ روز فوت کرده
٣- آب وبهداشت III. Water and Sanitation 26. If available, specify the بلی Water supply available: Yes…1 .25 source: (please tick) Hand Pump…1 Engine well…2 ﻗسمی please tick) Partially…2) Pipe Water…3 Shallow well…4 ا ر موجود باشد،لطفآ منبع مشخص نخير No…3 تامين آب در دسترس است River…5 Water Trucking…6 کنيد 27. Walking time to the available source of water: 28. What is the cost of a Barrel:___ دقيقه min / 2 هزينه يک بيرل چند است مدت پياده روی به منابع موجوده آب Number of latrines .30 بلی Latrine available: (please Yes…1 .29 تعداد بيت الخﻼ تا حدی tick) Partially…2
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نخير No…3 بيت الخﻼ موجود است، لطفآ نشانی نمايد 31. Number of Non- 32. Availability of garbage موجوديت :Functioning latrines: management مديريت زباله تعداد بيت الخﻼ غير فعال
مصونيت غذايی IV. Food Security :If available, type of food .34 بلی Food distribution in last Yes…1 .33 تغذيه مرطوب Wet feeding…1 (please tick) اهی month: (please tick) Sometimes…2 غذا خشک Dry food…2 ا ر موجود باشد ،نوع غذا نخير No…3 غذا توزيع شده در مدت ماه اخير 35. Walking time to the available source of food: دقيقه min / 40 مدت پياده روی به منابع موجوده غذايی
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مشکﻼت صحی عامه V. Public Health Problems جواب بايد از طرف پرسونل صحی داده شود Answers to be given by the health facility staff
لطفآ نشانی نمايد (Main health problems affecting population/: (please tick .36 مشکﻼت اساسی صحی که مردم را متاثر ميسازد a. Diarrhea/AWD Yes…1 If Yes; Number b. Injuries/trauma Yes…1 If Yes; Number
( No…..2 (last 7 days جروحات، تروما ( No…..2 (last 7 days اسهاﻻت c. Suspected Measles d. Skin Diseases/ Yes…1 If Yes; Number Yes…1 If Yes; Number Infections سرخکان مشکوک No…..2 (last 7 days) No…..2 (last 7 days) عفونت های امراض پوست e. Acute upper Yes…1 If Yes; Number f. Acute Malnutrition Yes…1 If Yes; Number Respiratory Infection ( No…..2 (last 7 days سوتغذيه شديد ( No…..2 (last 7 days مشکﻼت سيستم تنفسی علوی h. Pregnancy related g. Pneumonia Yes…1 If Yes; Number Yes…1 If Yes; Number conditions ( No…..2 (last 7 days) No…..2 (last 7 days سينه بغل شرايظ مربوط بارداری i. TB Yes…1 If Yes; Number j. Diabetes Yes…1 If Yes; Number
( No…..2 (last 7 days شکر ( No…..2 (last 7 days توبرکلوز k. Eye Infections Yes…1 If Yes; Number l. Hypertension Yes…1 If Yes; Number
( No…..2 (last 7 days فشار خون ( No…..2 (last 7 days غفونت چشم n. Others: specify: m. Suspected Malaria Yes…1 If Yes; Number Yes…1 If Yes; Number دي ر مشخص کنيد ( No…..2 (last 7 days) No…..2 (last 7 days مﻼريا مشکوک ______o. Urinary Tract Yes…1 If Yes; Number Infections No…..2 (last 7 days) عفونت های سيستم ادرار
خدمات صحی و تسهيﻼت ارزيابی VI. Health Services & Facilities Assessment (ONLY FOR FUNCTIONING AND ACCESSIBLE FACILITIES) 37. Distance to nearest health facility (KM): فاصله تا نزديک ترين مرکز صحی(کيلو متر) 38. Access to health facility / health services :Explain .39 بلی Please tick): Yes…1)
توزيح نخير No…2 دسترسی به تسهيﻼت صحی، خدمات صحی، لطفآ انتخاب نمايد
جواب ها که از طرف پرسونل تسهيﻼت بايد داده شود Answers to be given by the facility staff
b. No of d. No of Health Facility Type a. Name / Staff c. Services provided[1] Consultatios e. Main diagnosis Agency تشخيص اساسی day/ خدمات ارايه شده تعداد نوع تسهيﻼت صحی اسم /نهاد تعداد مشاوره ها پرسونل 40. Health Post
پوسته صحی 41. Sub Health Center
مرکز صحی فرعی 42. Mobile Health Team
تيم صحی سيار 43. Basic Health Center
مرکز اساسی صحی
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44. Comprehensive Health Center
مرکز صحی جامع
45. District Hospital
شفاخانه ولسوالی 46. Provincial Hospital
شفاخانه وﻻينی 47. Regional Hospital
شفاخانه حوزوي 48. Private Clinic
کلينک خصوصی
لطفآ حروف مناسب را انتخاب کنيد :(Please select appropriate letter(s [1] A. Outpatient services, . Growth monitoring/Nutrition G. Oral rehydration therapy I. Antenatal care / Delivery مراقبت قبل از وﻻدت دوا دهن ودندان نظارت بر رشد تغذيی خدمات صحی سراپه B. Inpatient services E. Distribution of food rations H. Wound dressing J. Drugs دوا پانسمان زخم توزيع جيره غذايی خدمات بستری C. Laboratory F. Immunization خدمات واکسين ﻻبراتوری
درمورد شفاخانه اين بخش را تکميل کنيد In case of Hospital, complete this part .49 b. Bed capacity: 250 بلی a. Specialized services: Specify Yes ظرفيت پذيرش خدمات تخصصی، مشخص کنيد
51. Referral service available: (please دولتی Health facility manager: (please tick) Government...1 .50 tick) نخير No…2 بلی Yes…1 نهاد غير دولتی NGO(s)…2 امر تسهيل صحی ،لطفآ انتخاب نماييد خدمات ارجاع موجود است، خصوصی Private…3 لطفا نشانی نماييد
53. If Yes, specify the type of routine 52. Existence of routine immunization Measles...1 Penta...2 vaccines: (please بلی Yes…1 programme: (please tick) Polio…3 BCG...4 (tick ﻗسمی Partially..2 DPT...5 Tetra...6 نخير No…3 موجوديت برنامه های معمول واکسيناسيون Rota virus...7 ا ر بلی، نوع واکسين معمول را مشخص کنيد
55. Availability of safe 54. Availability of ambulance: water supply: بلی Yes…1 بلی Yes…1 نخير No…2 موجوديت آب سالم نخير No…2 موجوديت امبوﻻنس اشاميدنی
56. Availability of latrines: بلی Yes…1
نخير No…2 موجوديت بيت الخﻼ
موجوديت وسايل طبی Availability of medical supplies ا ر بلی ، مقدار b. if Yes Quantity موجود ?a. Available نوع Item
ﻗسمﻲ Partially…2 بلی Antibiotics Yes…1 .57
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نخير No…3 ضد ميکروب ﻗسمﻲ Partially…2 بلی Syrups (child) Yes…1 .58
نخير No…3 شربت(طفل) ﻗسمﻲ Partially…2 بلی Analgesics Yes…1 .59
نخير No…3 ضد درد ﻗسمﻲ Partially…2 بلی ORS Yes…1 .60
نخير No…3 او ار آس ﻗسمﻲ Partially…2 بلی Ointments Yes…1 .61
نخير No…3 ملهم ﻗسمﻲ Partially…2 بلی Iron for anemia Yes…1 .62
نخير No…3 اهن برای کم خونی ﻗسمﻲ Partially…2 بلی Vitamin A Yes…1 .63
نخير No…3 ويتامين ای 64. Drugs for chronic diseases ﻗسمی Partially…2 بلی Yes…1 دوا برای امراض مزمن نخير No…3
ﻗسمی Partially…2 بلی Yes…1 انواع دي ر Other Items .65 نخير No…3
موجوديت برنامه های صحی تخصصی :Availability of specialized health programmes 66. Communicable disease surveillance: نخير No…2 بلی Yes…1 نظارت بر امراض عفونی 67. Health Education programmme: نخير No…2 بلی Yes…1 برنامه تعليمی صحی 68. Nutrition assessment and treatment programme: نخير No…2 بلی Yes…1 ارزيابی تغذيي و برنامه معالجه
۴-نياز سنجی VII. Needs Assessment 69. Health priority needs: نيازهای اولويت صحی a. Amount:
b. Amount:
c. Amount:
d. Amount:
70. Additional manpower needed: (please tick) 71. Specify نخير No…2 بلی Yes…1 مشخص کنيد نيروی اضافی مورد نياز است ، لطفآ نشانی نماييد 72. What must be put in place immediately possible to reduce avoidable mortality and morbidity? چه بايد انجام خواهد شد برای کاهش مرګ ومير و امراض ممکنه
نظريات دي ر Other remarks .73
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Annexure :3 Check List for Focused Group Discussions with Community/Health Shuras
Information provided by Health Shura Members through District Responsible Date: District Name: Shura Member(s) Facilitator/Presenter
SN Questions Responses A Location Situation 1 Security 2 Displacement 3 Drought 4 Water 5 Access to services 6 Barriers to Access to Health services 7 Barriers to Access to Schools 8 Conflict situation 9 Warlords Presence in the area 10 AOGss Presence in the area 11 Child involvement in war 12 People perception about HFs and staffs 13 Barriers to access HFs 14 Barriers in access to schools 15 Immunization perception and Barriers 16 Trauma cases 17 Negotiation 18 Perception about JACK People with disability participation in the program 19 Women and girl’s participation in the program 20 HF staffs Attitude 21 Attack on schools last one year 22 Attack on HFs last one year 23 Any other points hey want to share?
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Annexure 4 : Principle Violated by Conflict Actors
Guidelines Implementation Status (based on MSF ) Assessed with health facility staff during the visited by JUH and JACK team 11-15 October 2019. Violations by Taliban/AOG Violations by ANSF Violated not Violated not regularly, S. regularly, due Principles Regularly due to Not Regularly No. to community/ Not Violated Violated community/ Violated Violated Health facility Health facility rules rules
No weapon policy (no 1 one should carry weapons inside the clinic)
No high profile visits to 2 the health facility No communication 3 phone or radio inside the clinic No vehicles belongs to 4 them should be inside the compound No involvement in the 5 recruitment of the staff No use or misuse of the 6 clinic’s equipment include ambulances No armed convoy of the 7 health faculty or ambulances Not to use the clinic as 8 place of safety/night stays No Clinic staff is 9 intemidated (e.g. take staff to treat the injured)
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Annexure 5: Verification of Items – TCS equipment (WHO)
TCS equipment list that distributed to BPHS HFs in Kunduz province: Imam Sahib DH
availability Functionality Remarks SN TCS Equipment Name QTY Yes No In use Stored 1 Oxygen Concentrator 1 2 Suction Machine electrical 4 3 Monitor, Vital Signs - portable, model Light or 4 similar 4 Defibrillator 1 5 Large size Autoclave 1 6 Ultra Sound machine (portable) 1 7 Dressing Trolley 4 8 Hydraulic OT table 2 9 Digital Processing system for X-Ray 1 10 Orthopaedic patient bed 2 11 Tourniquet 4 12 Plaster cutter 2 Ambu Bag Artificial Resuscitator, Silicone, 13 6 Autoclavable - Deluxe Quality 14 Bed side screen 4 15 Stethoscopes Dual Headed Regular Brass 5 16 Blood Pressure apparatus 5 17 Stretcher 10 18 IV stand 20 19 Ventilator Portable transportable 3 20 Electrocardiograph machine (ECG) 1 21 Anaesthesia Machine 2 22 Amputation set 2 Portable OT light (rechargeable) shadow less 23 3 lamps type LED 24 Laparotomy set 2 25 Vascular Surgery set 1 26 High speed electric drill for Orthopaedic 1 27 Wheel chair manual 10 28 Laryngoscope set 2 29 Suture set 4 30 Dressing set 10 31 Surgical Gown 20 32 Staff uniforms 54 33 Washing machines 2 34 Patient body Warmer 6 35 Death Body Keeping Freezer 1 36 Air-condition 24000 BTU 2
Khan Abad DH
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availability Functionality Remarks SN TCS Equipment Name QTY Yes No In use stored 1 OT table 1 2 Suture set 15 3 Pneumatic tourniquet 2 4 Wheel chair 4 5 BP set portable 4 6 Stethoscope 4 7 ECG machine 1 8 Plaster cutter 1 9 ventilators 1 10 Laryngoscope set 2 11 Beds for patients 5 12 stretcher 4 13 Autoclave large size 1
Aliabad CHC
availability Functionality Remarks SN TCS Equipment Name QTY Yes No In use stored 1 Washing machine 1 2 Suture set 5 3 Pneumatic tourniquet 1 4 Wheel chair 3 5 BP set portable 2 6 Stethoscope 2 7 ECG machine 1 8 Plaster cutter 1 9 Ambu bags different sizes 1 10 Laryngoscope set 1 11 Beds for patients 3 12 stretcher 2 13 stabilizer 1
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Annexure 6 Rapid Assessment of Health Facility (actually was carried out in 12 health facilities and referrals points), here enclosed on District Hospital assessed by Johanniter and JACK team
Rapid Assessment of Health Facility: Imam Sahib, District Hospital Date: 10 October 2019
The Johanniter and JACK teams visited the Imam Sahib district hospital on 11 October 2019 for need assessment. The finding comes from the health cluster rapid health need assessment template and also observations of the team and extensive discussion with the hospital technical and support teams. The following are the important findings:
1. The participants were introduced to each other followed by explaining the purpose of the meeting by the JACK team program manager health Dr. Noor Ahmad.
2. It was clarified that the purpose and the contents of the meeting will not be disclosed to anyone apart from the humanitarian workers and will be used for humanitarian need assessment, project planning and implementation only.
3. Trauma cases number, types and trends: the team has provided reports of the last three months July-September 2019 based on the WHO provided format and the summary shows the following:
Trauma Care Services Three Months Report Province Name: Kunduz District Name: Imam Sahib Implementer Name: JACK Name of Trauma Care Center: Imam Sahib DH Reporting month (From/To): May-July 2019
Service Type # of civilian Casualties by Age Breakdown # of Armed people casualty
M< 18 M> 18 F < 18 F > Total Govt AGE 18 forces forces Trauma Cases 494 247 228 124 1093 342 0 OPD Trauma Cases 335 109 78 78 600 14 0 IPD Death bodies 32 11 2 2 47 35 0 brought to hospital Cases died after 4 0 0 0 4 4 0 admission to the hospital Major Surgical 72 44 30 24 170 28 0 Operation Minor Surgical 741 540 471 418 2170 307 0 Operation
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Number of cases 24 68 4 19 115 40 0 received blood transfusion Number of cases 2 41 4 29 76 12 0 received Physiotherapy Number of cases 6 13 2 22 43 2 0 received psychological counselling Total
Although there is large number of war related trauma cases, but there is also large number of cases due to conflict between the people related to land, water and other problems reporting to the hospital. The district has 500,000 populations and there is high trauma caseload. There are increased road accidents that also adds to the problem. 4. When asked about the mass casualty they said that during the last three months they have managed six mass casualties and each with more than 15 cases. 5. Conditions in which the patient’s/trauma cases are brought to the hospital: trauma cases brought to the hospital ranges from minor trauma cases who are provided with dressing and sent back to their homes. Serious cases that need stabilization and surgical interventions are operated upon in the hospital and some patients are brought dead to the hospital. 6. The hospital referral point: the patients are referred to the regional hospital in Kunduz that is almost 70 KM away from here. There are large number of patients referred to the hospital for different reasons such as 1) The army people do not want to stay in this hospital due to fear of being attacked by AOGs 2) Patients with eye injuries are and orthopaedic cases are referred because these services are not available in this hospital. When asked about the number of orthopaedic cases they said 30 patients in last three months. 7. Transportation means: majority of the cases are brought to the hospital by the relatives of the trauma patients or community members. 8. Facilities available and the capacity of this referral point and their needs: According to the staffs the hospital has suffocate space and rooms, equipment and supplies and need only one additional ambulance because their higher referral facility is Kunduz regional hospital that also 70Km away. Once this ambulance is taken there, there is no other ambulance in the hospital for the emergencies. There are two surgeons and anaesthetists: There are one surgeon in the BPHS, but due to heavy caseload they have taken permission from the MoPH to have two surgeons in the hospital. Likewise, there are two anaesthetist and four nurses.es in the hospital 9. Equipment, drugs, supplies and capacity building: They said that they have enough of these materials and there is no need for additional ones. They were provided five tents by UNHCR which can be used for multiple purposes. 10. Follow up of the cases referred to regional hospital: people are not happy when they come from regional hospital. Because, 1) there are no enough drugs and patients have to purchase them from private pharmacies 2) The care taker are not allowed to stay with
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the patients and they do not have place in the city to stay and have to spend more money in hotels.
Problems:
1. There are no mortuary services in the hospital and a large number of cases are brought to the hospital who are already dead. The relatives are forcing the staffs to wash the dead bodies and a lot of nurses’ times is wasted on washing dead bodies which is not their part of job. 2. WHO has constructed a small room with adjacent open hall? They have been told to use this room for triage. However, this cannot be used during the winter times and both the rooms are nor furnished and equipped yet. Therefore, they had to do the triage during mass casualty in the corridor now because the emergency room is very small. 3. Both minor and major trauma cases are coming to the hospital which takes their time. The minor injuries should go to other health facilities. 4. The hospital strength and the staff available during the nights: they that during the day the staffs are adequate but the problems are mainly during the night hours for two reasons. First, the fighting usually take place during evening and night hours and second there are less staffs during the night. The staffs available during the night shift are one doctor/surgeon, 2 nurses, one pharmacist with a surgeon and anaesthetist on call. There are two surgeons in the hospital living close to the hospital and they remain on call. The team said they have enough equipment and supplies present and there is no need for additional ones. 5. Long duty hours by the staffs and in some cases even up to 30-36 hours in one go they have to do their duties 6. The hospital OPD section is located in separate locations and there is poor coordination between the two parts of the hospital. 7. There are no safe rooms in the hospital for the staffs during the fighting because there is chance of fighting anytime since the AOGs are positioned one Km away from the hospital. 8. The staffs said they are faced with the shortage of two surgical nurses, a two security guards and additional ambulance.
Protection
There are many problems in this regard which need interventions;
1. Domestic violence. Usually the women and children are the victims but majority of the cases are among the women. They experience domestic violence for various reasons by their husbands, in-laws and their own family members. They come with their relatives when there are wounds and women who are not wounded are not coming to the hospital. Large number is also referred by police for opinion. There may be many cases going to the private clinics to avoid police cases which are hidden from our eyes. 2. Early and forces marriage: this is also due to various reasons like poverty and parents get dowry for it, that is about 3-6 hundred thousand AFS, and other cultural issues. The early marriages also take place due to fear of war lords and powerful people that they may harass the parents to marry their daughters to the war lords.
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3. Suicidal attempts; many women and girls attempt suicide by taking poisons, acid and in most cases, these are the poisons for insects, mice, acids and other accessible to women and girls. 4. Suicide is also common within boys and the main weapons are fire arms and usually they do not mention the reasons for their actions. 5. Access to education: in both government and Taliban controlled areas girls are allowed to go to schools up to six grades but for the higher classes they are not allowed in Taliban control areas. In Taliban controlled areas, there are strict controls over women movement as well in going to the schools and health facilities. 6. Access to Health Care: in the government areas women can go to health facilities and access services, but in Taliban controlled areas which starts after 1 km from the hospital women usually are advised to go with Mahrams.
9. The Gaps according to the staffs are: 1. There is need for additional two surgical nurses and two security guards. 2. One more ambulance is needed because the next referral hospital is 70 KM from here and once one ambulance goes to that centre, there remains no ambulance for emergency cases.
Findings from the Rapid assessment:
A. Location Description: The hospital was built by SCA and has enough space, rooms and bathrooms. It was clean and well organized. The hospital has block building. The hospital catchment area has 13000 HHS and total about 90000 people live there. The shelters are mostly mud houses. It is referral point for almost 15 other HFs. Accessible by road and location is insecure
B. Population: There are around 90000 people mainly host community and some IDPs There were 1150 births last 7 days, and one <5 years child death. The number <5 children is 7120 and females 3600.
C. Water and Sanitation: Water in available in the district both for drinking and irrigation. People take water from hand pumps, piped water and engine wells. The distant to water is usually not more and a barrel of water costs 30 AFS. The hospital has 12 latrines and four of them are non- functional.
D. Public Health Problems Affecting people:
Problem # of cases Problem # of cases Diarrhoea/AWD 259 Injuries/trauma 140 Suspected Measles 0 Skin diseases 71 Acute upper respiratory 252 Acute 13 infections malnutrition
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Pneumonia 43 Pregnancy 61 related conditions TB 3 Diabetes 3 Eye infection 13 Hypertension 62 Suspected malaria 2 Others 105 UTI 151 Access to HFs Distance to HF 1-15 km Access Accessible
E. Type of Facility and services provided:
This is a district hospital and the services provided are as per the recommendations of BPHS. It is operated by JACK, has 53 staff members. The services provided are mainly 1) OPD; 2) IPD, 3) Lab 4) Growth monitoring 5) Food distribution 6) Immunization 7) Oral rehydration therapy 8) wound dressing 9) ANC 10) Delivery and 11) dressing 12) referral services 13) specialized services. They have specialized services as well. It has a 50-bed capacity with ambulance services. There were 12 latrines out of which four are non- functional. It has good water supply facilities. All drugs and supply for acute and chronic diseases are present. Communicable diseases surveillance system exists, health education sessions are held and nutrition assessment and treatments programs are also run by the hospital.
F. Health Priority Needs: Primary health care services Trauma care services Physiotherapy services Reproductive health services
G. What must be put in place to reduce avoidable mortality and morbidity Two Additional surgical nurses, 2 security guards and a driver Additional ambulance Properly equipped triage room A properly equipped and staffed trauma care centre in the district:
Prepared by Dr. Noor Ahmed (JACK) and Dr. Mirza Jan Hafz (Johanniter)
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Annexure 7: Trauma Care Services Monthly Report Format of WHO
Trauma Care Services Monthly Reporting Format Province Name: Kunduz District Name: Imam Sahib Implementer Name: JACK Name of Trauma Care Center: Imam Sahib DH Reporting month (From/To): May-July 2019
# of civilian Casualties by Age Breakdown# of Armed people casualty # of Casualty by governm Service Type AGE Cause Male < 18Male > 18Female < Female18 > 18 Total ent forces forces Explosion/sucidal 0 0 000 0 0 Gun Shot 52 20 6 7 85 49 0 Chemical Attack 0 3 003 0 0 Rocket Attack 13 4 2 3 22 11 0 Trauma Cases OPD Occupational Injuries 417 215 217 112 961 321 0 Road Traffic Accident 10 4 3 219 1 0 Other 2 1 003 0 0 OPD total 494 247 228 124 1093 382 0 Explosion/sucidal 0 0000 0 0 Gun Shot 39 17 3 3 62 5 0 Chemical Attack 0 0000 0 0 Rocket Attack 13 7 2 123 1 0 Trauma Cases IPD Occupational Injuries 279 80 72 72 503 6 0 Road Traffic Accident 4 5 1 212 2 0 Other 0 0000 0 0 IPD total 335 109 78 78 600 14 0 Explosion/sucidal 0 0000 0 0
Gun Shot 29 9 2 2 42 32 0
Chemical Attack 0 0000 0 0
Rocket Attack 0 0000 0 0 Death bodies brought to hospital Occupational Injuries 0 0000 0 0 Road Traffic Accident 0 0000 0 0 Other 3 2005 3 0 total 32 11 2 2 47 35 0 Explosion/sucidal 0 0000 0 0
Gun Shot 4 0008 4 0 Chemical Attack 0 0000 0 0 Cases died after admission to the Rocket Attack 0 0000 0 0 hospital Occupational Injuries 0 0000 0 0 Road Traffic Accident 0 0000 0 0 Other 0 0000 0 0 total 4 0004 4 0 Major Surgical Operation 72 44 30 24 170 28 0 Minor Surgical Operation 741 540 471 418 2170 307 0 Number of cases received blood transfusion 24 68 4 19 115 40 0 Number of cases received Physiotherapy 2 41 4 29 76 12 0 Number of cases received psychological counseling 6 13 2 22 43 2 0 Grand Total 845 706 511 512 2574 389
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