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Health Interventions in Crisis-Affected Communities of Nepal

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Health Interventions in Crisis-Affected Communities of Nepal Health interventions in crisis-affected communities of Nepal Mission report October 2006 Conflict and Health Olga Bornemisza ([email protected]) Programme Francesco Checchi ([email protected]) Department of Public Health and Policy Upon request of the: Emergency and Humanitarian Action programme World Health Organization, Kathmandu Executive summary WHO-EHA Nepal commissioned the Conflict and Health Programme at the London School of Hygiene and Tropical Medicine (LSHTM) to assist it with the orientation of its current and future programming. The overall objective of LSHTM’s participation in the WHO CAP programme was to provide conceptual input into field-based humanitarian public health research and Health as a Bridge for Peace Programming. The stated mission objectives were as follows: 1) contribute to the establishment of an applicable and appropriate humanitarian public health monitoring system in Nepal; and 2) propose a conceptual framework for 'Health as a Bridge for Peace' in Nepal and contribute to developing a related programme and advocacy strategy. LSHTM was also asked to review evidence and data sources relevant to crisis detection and monitoring in Nepal, and assist with further intervention design and priority-setting within the scope of the WHO-EHA 2006 CAP programme. The consultants visited Nepal from August 24 to September 3, 2006. While in Nepal, they conducted numerous interviews with key stakeholders related to the objectives of the mission, and reviewed numerous surveys and other data sources. Public health monitoring systems and surveys were assessed and were found to be lacking. The health information management system of Nepal is very sophisticated, but there are credible concerns about the validity of incoming data. The nutrition and health surveys that were assessed were found to be problematic in terms of methods, and too few and far between to serve purposes of crisis evaluation and monitoring. As a result, information about key crisis indicators, such as acute malnutrition and mortality, are largely missing in Nepal. This has led to disagreements between the humanitarian and development communities as to whether there is a humanitarian crisis, and what the response should be. In addition, the possible impacts of the conflict on the Nepali health system were explored, as well as proposed systems to measure this. From existing data, it is impossible to deduct with any certainty what the role of the conflict has been on the health system, and proposals to measure this have been dropped due to difficulties in attribution and changing health sector priorities. WHO-EHA’s current and planned activities with regards to natural disaster preparedness, response and mitigation were assessed. WHO-EHA has built up substantial expertise in natural disaster preparedness and response training over the last few years, and should continue to pursue this as a primary activity. It should expand its training, possibly by taking a national partnership approach, however pragmatic considerations may limit it to a small number of districts. It could also play a role in strengthening the rapid health assessments that are done by various actors by working with the government and the Nepal Red Cross when conducting these types of assessments. Finally, a preliminary investigation of the role of health as a bridge for peace programming in Nepal was conducted. LSHTM concluded that more information needs to be sought about the nature of the conflict, and the ways in which the health sector plays a role in the conflict. This will inform at what level HBP workshops should be held, for instance with district health personnel or with senior Ministry of Health policy makers. It is important to consider whether health sector reform can play a role in peace-building, and to what extent district health officials will benefit from HBP training. To conclude, WHO-EHA should assume increasing responsibility for nationwide, effective coordination of humanitarian health issues in both the natural disaster and complex emergency domains. It should also stimulate a systematic approach, and promote methodologically rigorous methods for the collection of data for crisis detection and monitoring nationwide, if necessary filling in gaps. Finally, it should continue and reinforce activities in the area of natural disaster preparedness. ii Acknowledgments This mission was carried out within the framework of the WHO EHA 2006 Consolidated Appeals Process programme, thanks to funding from the Swedish International Development Cooperation Agency (SIDA). The authors are very indebted to Erik Kjaergaard (Programme Manager, WHO Emergency and Humanitarian Action, Nepal) and Dr Kan Tun (WHO Representative to Nepal) for supporting and facilitating our mission. We are also grateful to the many governmental and other agency staff who gave freely of their time and provided us with much-appreciated information. Most of all, we wish to thank the entire WHO-EHA team (Damodar Adhikari, Prahlad Dahal, Erik Kjaergaard, Saku Mapa, Dr Sara Ritchie, Sunita Sharma, and Budi Bahadur Tamang), as well as its dedicated drivers (Surya Sapkota, Ram Shrestha) for their touching hospitality, professional spirit and extremely generous help. We hope that this report will make a concrete contribution to the team’s immensely important activities in Nepal, and that future months and years will bring about a strengthened mandate and greater resource availability for WHO-EHA’s life-saving work. iii Table of contents Executive summary................................................................................................................................................ii Acknowledgments .................................................................................................................................................iii Table of contents ...................................................................................................................................................iv List of abbreviations .............................................................................................................................................vi 1 Background and objectives .......................................................................................................................... 1 1.1 Overview of potential humanitarian issues in Nepal 1 1.2 The WHO EHA Nepal programme 2 1.3 The LSHTM-EHA collaboration 3 1.4 Objectives of mission 4 1.5 Method of work 4 2 Sources of data for crisis detection and monitoring .............................................................................. 5 2.1 A framework of data sources 5 2.2 Numerator data 6 2.2.1 Data on health system functionality 6 2.2.2 Data on disease cases 7 2.2.3 Data on disaster and conflict events 8 2.3 Denominator data 9 2.3.1 Census figures 9 2.3.2 Catchment populations 9 2.3.3 Crisis-affected populations 9 2.4 Sample surveys 10 2.5 Rapid assessments 11 3 Evidence on the effects of conflict on health in Nepal..........................................................................12 3.1 General consequences of armed conflict on health 12 3.2 Forced displacement 12 3.3 Food insecurity and malnutrition 13 3.4 Disruption of health services 14 3.5 Impoverishment 15 3.6 Isolation of civilian populations 15 3.7 Is there a humanitarian emergency? 15 3.7.1 What is the profile of Nepal’s conflict? 15 3.7.2 The bottom line: excess mortality 16 3.8 Scope for “Health as a Bridge for Peace” initiatives 17 4 Natural disaster preparedness and response........................................................................................ 19 4.1 Health sector capacity 19 4.2 WHO-EHA interventions 19 4.3 Partnership with other agencies 21 iv 5 Discussion and recommendations.......................................................................................................... 22 5.1 Humanitarian versus development approaches in Nepal 22 5.2 General orientation of the WHO-EHA programme 22 5.3 Nationwide coordination of stakeholders 22 5.4 Detection and monitoring of crises 23 5.5 Natural disaster-related activities 25 5.6 Health as a bridge for peace 26 5.7 Future funding for WHO-EHA activities 26 References............................................................................................................................................................. 28 6 Annexes.................................................................................................................................................... 30 6.1 Annex 1: List of stakeholders consulted 30 6.2 Annex 2: Proposed algorithm to detect and monitor crises in Nepal 31 v List of abbreviations ACF Action Contre la Faim CAP Consolidated Appeals Process CPN-Maoist Communist Party of Nepal – Maoist DHS Demographic and Health Survey DHWG Disaster Health Working Group EDCD Epidemiology and Disease Control Division EHA Emergency and Humanitarian Action programme EHNWG Emergency Health and Nutrition Working Group EWARS Early Warning and Reporting System GAM Global Acute Malnutrition HMIS Health Management Information System IFRC International Federation of the Red Cross/Red Crescent INSEC Informal Sector Services Centre IPD Programme for Immunization Preventable Diseases LSHTM London School of Hygiene and Tropical Medicine MCM Mass Casualty Management MSF Médecins Sans Frontières NGO Non-governmental organisation NRCS Nepal Red Cross Society OCHA United Nations Office for the Coordination of Humanitarian Affairs RRT Rapid
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