Response To Flood Emergency 2013 A MSF Spain Acknowledgement

MSF Spain appreciates the financial support provided by ECHO in assisting the flood affected population in 1 during the long rain season in 2013. It is with their support that MSF Spain was able to assist over 25,000 people with health care services , shelter material, non food items and water and sanitation.

Gabriel Sanchez, Head of Mission, MSF Spain

Disclaimer: The views and opinions expressed in this report are from MSF Spain and do not reflect the position of any other actors during the floods intervention. The information given in the report is based on the experience of MSF Spain during the floods intervention in the period April to May 2013.

Response To Flood Emergency 2013 B MSF Spain TABLE OF CONTENTS

Summary 2 1 Background 3 2 Area of Intervention 3 2.1 Bura 3 2.2 Garsen 4 2.3 Lamu West 4 2.4 Gilgil 4 2.5 5 2.6 Narok 5 2.7 Isiolo 5 3 Intervention Strategy 6 3.1 Tana River area: Bura, Garsen, and Lamu West 7 3.2 Garissa 7 3.3 Narok and Gilgil 7 3.4 Isiolo 7 4 Intervention results 8 4.1 Result 1 8 ¨The flood affected population has an increased access to health care while surveillance of notifiable diseases is reinforced.¨ 4.1.1 Beneficiaries of medical services 8 4.1.2 Surveillance 9 4.1.3 Consultations 10 4.1.4 Morbidity 11 4.1.5 Maternal child health services in Bura and Garsen 13 4.1.6 Referrals 14 4.2 Result 2 “The displaced population has access to shelter material and non-food items.” 14 4.2.1 NFI distribution 15 4.2.2 IEC Sessions 15 4.3 Result 3 “The displaced population has access to a minimum standard of drinking water and temporary sanitation facilities.” 16 4.3.1 Latrines 16 4.3.2 Aqua tablets 18 5 Challenges 19 6 Conclusions - Recommendations 20

Response To Flood Emergency 2013 1 MSF Spain Summary Floods in Kenya are relatively common during the short and the long rains. The long rain season that began in April 2013 was marked by heavy rains that resulted in flooding and mud slides displacing people and destroying their livelihoods. The affected population experienced an immediate food shortage as their stored food was destroyed and their farms were flooded. Access to health care services was disrupted and in some areas, an existing chronic shortage of medical supplies and staff in the health facilities worsened the situation for the affected population. The main needs of the affected populations were rescue from marooned areas, food, drinking water, shelter, non food items and access to health care services in relocation areas. The risk of water related diseases was high as water sources were contaminated and sanitation facilities were missing, stagnant water created a breeding ground for vectors thus predisposing the population to vector borne diseases.

Medecins sans Frontieres (MSF Spain) in close collaboration with the Ministry of Health (MoH), Kenyan Red Cross (KRC), ECHO1 and other actors intervened in Bura, Garsen, Garissa, Isiolo, Nakuru, Gilgil and Narok with an aim of improving access to health care, water, sanitation, shelter and non food items to the affected population. The needs of the flood affected population varied because in some areas other actors were already meeting some of the immediate necessities. MSF adapted to the needs and focused its intervention on internally displaced people due to flooding, achieving the following results:

Area Mobile clinics Consultations Surveillance NFI2 + Shelter Aqua tablets3 Latrines conducted done visits done donated donated constructed Bura 19 3,028 19 1,212 12,240 11 Garsen 3 1,217 23 980 5,840 31 Lamu West - - - 126 1,260 - Garissa - - - 40 - 15 Gilgil - - - 433 - 8 Narok 40 - 10 Donation - - - 255 32,438 - TOTAL 22 4,245 42 3,086 51,778 75

During the two months intervention, MSF provided assistance to over 25,000 people: 4,245 benefitted from medical services of which 1,112 were children below 5 years. A total of 42 surveillance visits were conducted across 15 sites to detect notifiable diseases. MSF supported 3,086 households with non food items, 1,168 households received 51,778 aqua tablets for water treatment and 75 latrines were constructed in the displaced persons camps. In general terms, MSF met its objective to improve access to health care, water, sanitation and shelter for the flood affected population.

1 European Commission Humanitarian Office. 2 Non food items kit is composed of : 1 60 liter container, 2 mosquito nets, 1 turplin (4x6 m), 2 blankets, 1 rope of 25 meters, 1 collapsible jerry can of 20 liters, 5 plates, 5 mugs, 5 spoons, 2 cooking pots, 1 knife, 1 wooden cooking stick, 1 serving spoon, match box and bar soap. 3 Aqua tablets are made from chlorine; they are used to purify drinking water

Response To Flood Emergency 2013 2 3 MSF Spain 1 BACKGROUND

MSF has been present in the country since 1982 with regular projects in HIV, tuberculosis (TB), kala azar (visceral leishmaniasis), nutrition, primary health care, refugees and IDP interventions. MSF has been at the forefront in responding to humanitarian needs during emergencies in the country. MSF in the country is represented by four sections, each section has an assigned area of monitoring and response in the country, that is based on a mutual agreement and sometimes the sections complement each other when need arises.

In the past, MSF has responded to floods in Budalangi, in the western part of Kenya, Tana Delta in the coastal area and in urban slums. The last major flood intervention by MSF Spain was 2007 in Tana Delta. Thereafter the effect of the floods haveKenya: not had a majorFloods impact Update until the recent (as long at 9 rainsMay in2013) April 2013, where over 100,000 people were affected and 93 deaths were reported in the country4. The effect of the wet season was widespread in the country, with the most affected Cumulatively, an estimated 100,980 people have been affected and 93 deaths recorded since the onset of areathe rains being in alongMarch, the according course ofto themajor Kenya rivers Red like Cross Tana River,Society Ewaso (KRCS). Nyiro Of and these, River over Nzoia. 87,000 people have been displaced. 2 AREA OF INTERVENTION

ETHIOPIA

Moyale ! Turkana UGANDA NORTH Turkwell Marsabit EASTERN ! El Wak 17,080

RIFT ! Marsabit VALLEY Wajir UPPER 8,935 EASTERN ! Wajir 52 8,775 9 WEST KENYA ! Habaswein Isiolo SOMALIA 24,325 Baringo 9 ! Isiolo Hamisi Laikipia Nzoia Vihiga Dadaab

Kisumu Nyando !Nakuru Nakuru !Garissa Homabay Murang’a Kirinyaga R. Tana Garissa KujaKisii Kiambu Migori Tana-river ! Bura Kitui Narok Nairobi Machakos !Hola CENTRAL R. Athi 925 COAST Lamu ! 2 Kajiado 22,805 9 LOWER TANZANIA EASTERN 4,235 & Kilifi NAIROBI 12 Major river Sabaki Taita-taveta ! Flood prone area Taveta ! !Voi Flood affected area 87,080 People displaced ! Mwatate 93 Deaths Affected County Displacement 19 Injured !Mombasa XXX No. of People 694 Houses destroyed displaced XX No. of deaths TheSource: boundaries UNOCHA and names shown Kenya and the Floods designations snapshot used on this 8th map doMay not imply 2013 official - endorsementFlood Affected or acceptance area. by the United Nations. Creation date: 9 May 2013 Source: Kenya Red Cross (data), IEBC, UNCS Feedback: [email protected] www.unocha.org www.reliefweb.int MSF Spain responded to the flood affected areas in Garissa, Narok, Gilgil, Bura, Garsen, Lamu West and Isiolo districts. The intervention took a period of two months, starting from the first day of April 2013 and ending in the last week of May 2013. The situation in the flood affected areas that MSF intervened was as follows:

4 UNOCHA Kenya floods snapshot 8th May 2013

Response To Flood Emergency 2013 3 MSF Spain 2.1 Bura

Tana River flows through the district and there are seasonal rivers along its course. Following the heavy long rains the river burst its banks, resulting in the displacement of over 2,000 households. The villages along the river course were submerged or marooned by the rising water levels. The main challenges that were faced by the flood affected population were temporary impossibility to live in their own houses as their houses were destroyed or isolated; no access to safe drinking water in almost all areas; absence of sanitation structures; no access to health care, due to a chronic shortage of drugs and medical staff in the health facilities; food access problems and loss of livelihoods.

Main stakeholders in the area were local authorities that assisted with food. KRC assisted in the evacuation of isolated people, distribution of NFI and water and sanitation activities. MSF was assigned to intervene in the area close to the river and KRC intervened in the highland area. As in the rest of the areas of intervention, both organisations complemented their activities in order to prevent gaps in humanitarian assistance. The main activities implemented by MSF Spain were mobile clinics, disease surveillance, NFI kits distribution, aqua tablets distribution, construction of latrines and health education sessions.

2.2 Garsen

This area is in the delta region of Tana River. It has a flat topography and is the point where Tana River flows into the Indian Ocean. The area normally experiences seasonal flooding during the long and short rains. The community has a seasonal pattern of movement depending on the rains. During the wet season the people move to higher ground and after the rains they return back to the river banks for farming. The population in Garsen is adapted to the floods and are used to these seasonal movements during the wet period. In the long rains in April 2013, the usual pattern of movement occurred, however with release of water in the dams upstream, massive flooding occurred in the area which was beyond the coping mechanisms of the population. The main challenges that the affected population experienced were temporary impossibility to live in their own houses, no access to safe drinking water, absence of sanitation structures and poor access to health services for populations that were marooned by water. Most of the affected population in this area still had access to the health facilities.

The main stakeholders in the intervention were local authorities that coordinated actors and provided medical supplies. KRC assisted in rescue of isolated people, NFI distribution, and water and sanitation activities. MSF was assigned to work in the IDP camps area along the road from Garsen to Bura. MSF activities in the area were a mobile clinic to a marooned IDP camp (Odole), disease surveillance, treatment of selected medical cases, NFI kits distribution, aqua tablets distribution, construction of latrines and health education sessions.

2.3 Lamu West

The district is neighbouring Garsen district and is within the Tana Delta area where the river flows into the Indian Ocean. The population in the area is adapted to the floods; however the flooding exceeded their coping measures, forcing the people to leave their houses. For that reason, there was no access to safe drinking water; absence of sanitation structures and loss of livelihood.

The stakeholders in the area were local authorities such as the district commissioner who alerted stakeholders on the situation of the IDP. UN agencies such as OCHA, UNICEF, WHO and WFP supported the response through donation of drugs, aqua tablets and food. The main activities implemented by MSF were distribution of NFI and aqua tablets.

2.4 Gilgil

Gilgil is in Rift Valley Province. During the 2007 post election clashes, Rift Valley province was the most volatile area resulting in violence and significant amount of IDPs. In the last years, the Government has been resettling some of these IDPs, whereas some others are still in the camps. In the Gilgil area 430 households distributed in five camps still remain. Four of these camps are near Gilgil town and one is closer to Nakuru. Shelters were in poor condition when the heavy rains started and the number of latrines were few with no assistance from other agencies. We received a request from the District Commissioner to provide assistance to these populations, as their living conditions Response To Flood Emergency 2013 4 5 MSF Spain were bad due to the heavy rainfall. The main challenge faced by the community, was that temporary shelters were in a poor state with water leaking inside and some latrines destroyed.

The stakeholders in the area were the local authorities. The district commissioner gave an alert on the deplorable situation of the IDPs. MSF’s main activities were NFI kits distribution and construction of latrines.

2.5 Garissa

Tana River flows through Garissa County. Following the heavy rains the river burst its banks, over 4,600 households were displaced and the population lost their livelihood completely. Temporary rescue centres were set up in six different areas. The main problems faced by the IDPs were temporary impossibility to live in their own houses, no access to safe drinking water, absence of sanitation structures, food access problems and loss of livelihood. The main stakeholders in the area were the local authorities; the District Commissioner and Ministry of Health. They coordinated the intervention of the different actors, conducted mobile clinics, availed food and did advocacy to ensure free drinking water for IDPs. Kenya Defence Forces assisted in the rescue of isolated people. KRC led the response and conducted NFI distribution and implemented water and sanitation activities. Ministry of health and Mentor Initiative conducted mobile clinics and “Action against Hunger” provided water. MSF’s main activities were construction of latrines and distribution of shelter material.

2.6 Narok

The area experienced flash floods and mud slides. The affected population was forced to leave their homes for safety. The main problems for the affected population were the temporary impossibility to live in their own houses, lack of shelter, problems to access safe drinking water and loss of livelihood. The stakeholders in the area were the local authorities represented by the District Commissioner, who gave an alert on the situation of the IDP. KRC conducted an initial assessment and donated non food items. They also implemented water and sanitation activities. MSF main activities were NFI kits distribution and donation of aqua tablets.

2.7 Isiolo

River Ewaso Nyiro flows through Isiolo, following the heavy long rains the river burst its banks leading to widespread flooding. Regular contact with the District commissioner, District medical officer of health and KRC confirmed that they were able to meet the needs of the population. Access to the flood affected areas was difficult because of the poor state of the road following the rain. The District received support from the government in terms of food and air drops for various supplies. MSF Spain followed the situation without triggering any intervention.

Response To Flood Emergency 2013 5 MSF Spain 3 INTERVENTION STRATEGY

Mobile clinic Garsen Picture by Francis Eiton

MSF Spain’s intervention strategy was to respond to emergency needs of flood affected population in Kenya in its area of monitoring. The most acute phase of the long rains lasted two months – April and May 2013-, affecting different areas at different moments. The first interventions were carried out in Rift Valley Area (Gilgil and Narok) and Bura (), starting in the first week of April. In Mid-April activities in Rift Valley were almost finished, but in Bura were scaled-up lasting for around three more weeks. In Garissa the intervention started in April 24th and lasted two weeks. At the beginning of May, problems in Garsen area and Lamu West became acute and intervention was required for three weeks until the end of that month.

The intervention was possible and timely because of the Emergency Preparedness Plan of MSF Spain in Kenya. MSF utilized in the first period of response the medical items, drugs, NFI kits and logistical material prepositioned in Nairobi in order to respond quickly to any humanitarian need. Required human resources were recruited from our emergency pool. Some staff currently working in Nairobi office were also deployed during the emergency. A total of 21 people worked directly in the field during the implementation of the activities at different stages.

The total budget of the intervention was 219,630 EUR. ECHO contributed with the 71% of the costs trough an agreement signed with MSF Spain. The rest of the expenditures were directly funded by our organization. Human resources chapter counted for around 14% of the total budget. Medical and nutritional items counted for around 6%. Logistical and sanitation materials represented 61% of the total budget. Transport, freight, storage and administrative costs are the remaining 19%.

The general objective of the intervention was to “Reduce the risk of epidemics in flood affected population in Kenya”. This was achieved through improving access to health care, shelter, water, sanitation and non food items for the flood affected population in order to avoid more severe health problems. The expected results were:

• The flood affected population has an increased access to health care while surveillance of notifiable diseases is reinforced. • The displaced population has access to shelter material and non-food items. • The displaced population has access to a minimum standard of drinking water and temporary sanitation facilities.

MSF intervened in various sites trying to complement local capacities and preventing gaps, the intervention strategy was as follows:

Response To Flood Emergency 2013 6 7 MSF Spain 3.1 Tana River area: Bura, Garsen, and Lamu West

MSF worked in close collaboration with the local authorities and other actors. MSF was allocated by the local authorities specific areas to assist the affected population. In its area of operations, MSF targeted flood IDP camps and assisted them with non food items, water and sanitation services that involved donating aqua tablets, building latrines, showers and hand washing points. MSF conducted mobile clinics to populations that could not access health care services.

In Bura mobile clinics were conducted in all the camps in the area allocated to MSF, because the local Ministry of Health facilities were closed, except Bura health centre. At the beginning of the intervention the health centre had a shortage of drugs. MSF advocated for a supply of drugs to the facility and once this was done MSF progressively scaled down mobile clinics in the IDP camps and encouraged the IDPs to use the public facility.

In Garsen MSF conducted mobile clinics in one camp that had been marooned by water, blocking access to the nearest health facility. The rest of the IDPs were advised to use the nearest functional health facilities. MSF regularly visited the IDP camps and the health facilities to detect any notifiable diseases. Children that were sick were treated by the team during surveillance visits to the camps.

In Lamu West disease surveillance was done and the IDPs received NFI and aqua tablets, there was no need for mobile clinics in this area.

3.2 Garissa

MSF and other actors responded to floods in the area. Most of the needs were covered by the existing actors, except sanitation facilities. MSF constructed latrines, showers and hand washing points in the IDP camps. The health care needs were covered by the Ministry of Health and other actors through regular mobile clinics. MSF remained on standby in case of disease outbreak and to provide additional support in case the needs were beyond the capacity of the existing actors.

3.3 Narok and Gilgil

MSF donated non food items to the displaced populations, other needs of the IDPs were met by the existing actors. A donation of NFIs was given to Kenya Red Cross to assist them in their response to the affected populations.

3.4 Isiolo

MSF monitored the situation through the local authorities and existing actors. Both the District Commissioner and the local office of Kenya Red Cross, reported that they were able to cover the needs of the affected populations, so MSF did not intervene.

Non food items Picture by Francis Eiton

Response To Flood Emergency 2013 7 MSF Spain 4 Intervention results

4.1 Result 1

¨The flood affected population has an increased access to health care while surveillance of notifiable diseases is reinforced.¨

Expected Indicator Final Result Comment “Frequentation rate: Number of Bura: Bura: MSF achieved its target for consultations/Target Population 2,785 consultations/ 3,080 target the five IDP camps. Subukia data /2 months = More than 0.33 population / 2 months = 0.45 is not included as this was a host (Considering emergency context community that was visited for = at least 2 consultations per surveillance purposes only. person per year)”. We estimate a number of consultations near Garsen: Only one IDP camp benefitted to 4,000 considering a size of 5 527 consultations/ 825 persons/ 2 from a full mobile clinic this was persons per family. months = 0.32 Odole. The rest of the IDP camps were encouraged to use the nearest health facility. “Number mobile clinics / number Bura: Bura: MSF achieved its target the weeks of intervention/ number 6 mobile clinics / 4 weeks /2 months IDP camps were Shika Adabu, of IDP camps assisted (>/=0.5)”. = 0.75 Ndalangu, Subo, Morokani, Each IDP camp should receive Subukia and Furaha. a visit of the mobile clinic every Garsen: Garsen: MSF achieved its target two weeks. 2 mobile clinics / 2 weeks / 2 the IDP camp that MSF provided a months = 0.5 mobile clinic was Odole.

“For each district, weekly disease Surveillance was conducted in Daily and weekly reports were surveillance (done 100% weeks)”. the direct intervention sites this done. Data is summarised in the We follow the normal periodicity were Bura, Garsen, Lamu West and HIS5. established by the Ministry of Garissa. Weekly reports were done Health. every week after visiting the IDP camps, visiting the nearest health facilities and attending coordination meetings in the affected area. MSF achieved all the three indicators, other results are elaborated below:

4.1.1 Beneficiaries of medical services

Medical services Picture by Francis Eiton

Response To Flood Emergency 2013 8 9 MSF Spain Bura Garsen Total % Target Households 1,116 1,059 2,175 - Target Population (HH6 x 5) 5,580 5,295 10,875 39 % treated Number of IDP camps 6 10 16 Number of mobile clinic sites 6 1 7 - Number of mobile clinics 19 3 22 - Number of surveillance sites 6 9 15 Number of surveillance visits 19 23 42 Consultations < 5 yrs 682 430 1,112 26% of the consultations Consultations >= 5yrs 2,346 787 3,133 74% of the consultations Total consultations 3,028 1,217 4,245 100%

In Tana River MSF intervened and provided medical support to 4,245 people in camps with a population of 10,875 people. Among the consultations carried out, 3,028 were from Bura area and 1,217 were from Garsen. 26%, were children below 5 Years. The consultations were conducted in a total of 22 mobile clinics across 7 sites. Garsen had 3 mobile clinics providing healthcare, because facilities in the area were functional, the IDPs were encouraged to seek services in the health facilities and only one site, which was marooned by water (Odole), was targeted for a regular mobile clinic.

MSF also conducted disease surveillance visits in 6 sites in Bura and 9 sites in Garsen. MSF disease surveillance visited IDP camps and the nearest health facilities a total of 42 times.

4.1.2 Surveillance

Week 15 had less consultations compared to the other weeks because only one mobile clinic was conducted in one IDP camp. Week 16 to 18, consultations were conducted in five fixed sites on a weekly basis. All morbidities showed a decreasing trend. One case of acute watery diarrhoea was detected, the patient was treated and recovered well. Four cases of malaria were reported during the entire period of intervention: one case in week 16, two cases in week 17, and one case in week 18. All cases were from different IDP camps. Diarrhoeal disease decreased over time after a distribution of aqua tablets among the IDPs in week 16. The team remained on high alert for dengue, as there was a confirmed outbreak in the coastal area during the intervention period. No case was detected.

In Garsen, only Odole IDP camp benefitted from a regular mobile clinic during week 21 and 22. This camp had a mobile clinic, unlike the other camps in Garsen, because it had been isolated by floods. MSF team reached the affected population in the camps using boats or treating them on the other side of the river. Fungal skin infections were common among patients, followed by non bloody diarrhoea and gastrointestinal disorders. These diseases were related to poor hygiene conditions and contaminated sources of water. Eight IDP camps were visited by a team consisting of a clinical officer and a nurse. They provided consultation for children below 5 years and managed

Response To Flood Emergency 2013 9 MSF Spain any life threatening conditions as they sought information on the health situation in the IDP camps (surveillance purposes). The team also visited existing health facilities to determine the trend of diseases in the area. In Garsen no notifiable diseases were detected in the IDP camps and among the other attendants in the health facilities.

4.1.3 Consultations

CONSULTATIONS DONE IN BURA IDP CAMPS Shika Adabu Ndalangu Subo Morokani Subukia Furaha Total % Households 176 187 99 95 500 59 1,116 - People (x 5) 880 93 495 475 2,500 295 5,580 - Mobile clinics 4 5 2 4 1 3 19 - Total consulta- 628 571 619 533 243 402 3,028 100 tions (%) (21%) (19%) (20%) (18%) (8%) (13%) < 5 yrs 147 124 181 105 70 55 682 23 >= 5yrs 513 447 438 428 173 347 2,346 77 Utilization 0.36 0.31 0.55 0.52 0.05 0.67 0.26 - Patient to staff ratio 52 38 91 41 81 44 51 -

In Bura a total of 19 mobile clinics were conducted and 3,028 people were treated, 23% (682) of the consultations were children below five years. Most of the consultations were carried out in Shika Adabu (21%), Subo (19%) and Ndalangu (19%) IDP camps. Shika Adabu and Subo had a higher population than the other camps, while Ndalangu had the least population but with a high consultation rate due to the host community going to the IDP camp to receive health care services. Subukia had the highest population and the least consultations conducted, because this was not an IDP camp and a mobile clinic was conducted only once, to determine the prevalence of Malaria in the area. We achieved our target of a utilization rate of > 0.33% in Shika Adabu, Subo, Morokani and Furaha IDP camps. We did not achieve our target in Subukia and Ndalangu IDP camps, this was because we conducted one mobile clinic in Subukia for surveillance purposes, while in Ndalangu the host community went to the IDP camp for other benefits. Globally, without including Subukia, the utilization rate was 0.45 which is within our target. A team of six medical staff composed of one medical team leader, two clinical officers and three nurses conducted

Response To Flood Emergency 2013 10 11 MSF Spain the mobile clinics. The average patient to staff ratio was 1 clinical officer to 50 patients. Task shifting was done when there were many consultations.

CONSULTATIONS DONE IN GARSEN

SITE Odole Baomo Seranguu Marafa Feji Dobale Bura Ongariti Kibaoni Total % Imani HH 165 130 213 85 98 104 159 30 75 1059 People 825 650 1065 425 490 520 795 150 375 5295 (x 5) Mobile 3 2 4 2 4 3 1 1 3 23 - clinics/ surveillance visit < 5 yrs 179 64 56 29 29 43 17 7 6 430 35

>= 5yrs 348 140 60 77 74 36 18 18 16 787 65 Utilization 0.32 0.16 0.05 0.12 0.11 0.08 0.02 0.08 0.03 0.11 Patient to staff 88 51 15 27 13 13 18 13 7 27 ratio

A total of 9 IDP camps were visited for surveillance purposes. During the visits the team encouraged the IDPs to use the nearest functional health facilities. However, cases requiring immediate attention and sick children were treated by MSF in situ. In addition, one mobile clinic was organized in Odole. In total, 1,217 consultations were conducted out of a population of 5,295 IDPs, these represented 23% of the population. Among the consultations 35% were children below five years and 43% of all the consultations were done in Odole IDP camp. Three mobile clinics were conducted by the team after crossing over with boats, the whole population was targeted for health care services and we achieved our utilization target. In the mobile clinic in Odole, a team of six medical staff composed of one medical team leader/ clinical officer, two clinical officers and three nurses conducted this activity. The patient to clinical officer ratio was at 59. The nurses assisted the clinical officers in conducting consultations during triage, thus reducing the patient to staff ratio to 29. Baomo IDP camp had the highest number of consultations after Odole, this was because some people from the host community came to seek services in the mobile clinic during our visits. The rest of the sites had a visit from one clinical officer and one nurse for surveillance purposes. The patient to staff ratio was below 50, except Baomo, where this indicator was slightly higher.

4.1.4 Morbidity

MORBIDITY BURA Disease Total number of cases % out of 3,028 consultations Upper Respiratory tract infections 770 25% Non-bloody diarrhoea 355 12% Gastrointestinal disorder 267 9% Skin disease 231 8% Urinary tract infection 157 5% schistosomiasis 151 5% Intestinal Parasites 126 4% Lower Respiratory tract infections 78 3% Conjunctivitis 50 2% Anemia 32 1% Trauma 24 1% Bloody diarrhea 18 1% Moderate malnutrition 12 0.3% Malaria 4 0.1% Severe malnutrition 2 0.06%

Response To Flood Emergency 2013 11 MSF Spain Out of a total of 3,028 consultations, upper respiratory tract infection (25%) had the highest morbidity. This was related to exposure to weather elements and poor living conditions among the IDPs. Non bloody diarrhoea and gatrointestinal infections followed and this was related to the poor quality of water in the area. MSF distributed and trained the community on use of aqua tablets and the number of gastrointestinal illnesses reduced after distribution of aqua tablets. Other common morbidities noted in the area were urinary tract infections and bilharzia. These were related to hygiene conditions and farming in swampy conditions / stagnant water in the area.

MORBIDITY GARSEN Disease Total number of cases % out of 1217 consultations Upper RTI 404 33% Skin disease 133 11% Non-bloody diarrhoea 115 9% Gastrointestinal disorder 90 7% Urinary tract infection 55 5% Intestinal Parasites 53 4% Lower RTI 31 3% Anaemia 25 2% Schistosomiasis 18 1% Conjunctivitis 16 1% Trauma 10 1% Bloody diarrhoea 2 0.2% Moderate malnutrition 2 0.2% Malaria 0 0 Severe malnutrition 0 0

Out of a total of 1,217 consultations, respiratory tract infection (34%) had the highest morbidity; this was related to exposure to weather elements and poor living conditions among the IDPs. Skin conditions (11%) such as heat rash and fungal skin infections, were common among the consultations carried out. This was related to hygiene and high humidity levels in the area. Cases of non bloody diarrhoea and gastrointestinal disorder were related to contaminated water sources and poor quality of water. The team mitigated the situation by providing a donation of aqua tablets and conducting health education sessions on the importance of water treatment and hygiene. Other common morbidities noted in the area were anaemia. Bilharzia was also very present due to farming in swampy conditions in the area.

Response To Flood Emergency 2013 12 13 MSF Spain The most common ailments among children under five years, were upper respiratory tract infections, non bloody diarrhoea and skin diseases. This is related to the quality of water being used and living conditions of the population. Among the adults the most common causes of morbidity were upper respiratory tract infections, gastrointestinal disorders and non bloody diarrhoea, which are attributed to crowding and poor quality of drinking water.

Upper respiratory infections were treated almost equally among children and adults. The other morbidities that were detected in the children below 5 years were skin infections and non bloody diarrhoea, which were related to poor hygiene during feeding. Mothers received health education sessions on importance of hygiene. Among the adults gastrointestinal disorder and urinary tract infections had the highest morbidity, probably due to poor hygiene and use of contaminated water.

4.1.5 Maternal child health services in Bura and Garsen

Immunization Antenatal clinic Post natal clinic Family planning Week 15 0 1 0 0 Week 16 0 0 0 0 Bura Week 17 12 0 0 12 Week 18 0 0 0 0

Week 19 0 0 1 0 Week 20 0 6 0 0 Garsen Week 21 25 0 0 0 Week 22 0 0 0 0 Total 37 7 1 12

The MSF team vaccinated a total of 37 children using MoH vaccines, seven mothers received ANC services, one mother received post natal care services and 12 women received family planning services. Most of the vaccinations and ANC profiles were conducted in Odole as the population was marooned by flooding. Utilization of MCH services in the mobile clinic was low because a member of MoH staff would accompany the team to conduct the immunizations and ANC profiles in Bura, while in Garsen the team encouraged mothers to visit the nearest health facility.

Response To Flood Emergency 2013 13 MSF Spain 4.1.6 Referrals

Area Weeks Number of Referrals Referral site Reason Week 15 1 Molokani – Bura health centre Incomplete abortion/ pelvic inflammatory disease Week 16 0 - - Week 17 0 - - Week 18 3 - Shika Adabu to Bura Acute Watery Diarrhoea BURA health centre Prolonged labour at term and - Molokani to Bura health premature rapture of mem- centre to Hola District branes Hospital Large abscess for Incision and - Molokani to Bura health drainage centre Week 19 0 - - Week 20 0 - - GARSEN Week 21 0 - - Week 22 0 - - TOTAL 4 - -

MSF facilitated the referral of four patients in Bura during the four weeks of mobile clinic in the area. In Garsen most of the health facilities were functioning, except one dispensary that did not have staff on duty. The team encouraged the IDPs to seek health care services in the nearest health facilities, no referral was transported by MSF to a Ministry of Health facility. 4.2 Result 2 “The displaced population has access to shelter, material and non-food items.”

Distributed NFIs Picture by Francis Eiton

Response To Flood Emergency 2013 14 15 MSF Spain Distribution of shelter and non food items Expected Indicator Final Result Comment Amount of families receiving kits 3,086 families received NFI kits/ All IDPs registered by MSF received an NFI kit. / total families registered (by MSF) 3,086 registered families. 100 % = 100% of the families received NFI kits. Our target was achieved Number of IDPs with shelter and Number of IDPs provided non Garsen: a lot of population movements from NFIs in the IDP camps under the food items were 3,086 out of registration lists vs the people found during responsibility of MSF should be 3,587 IDPs that were reported in day of distribution. Movements were due to more than 95%. the camps thus 86% benefitted people looking for other settlement sites and from NFIs new arrivals. IEC sessions about mosquito nets/ 120 sessions were conducted / 3 IEC sessions were conducted in the camps number of IDP camps (>/=1). 46 IDP camps = 3 one on distribution and 2 others during revisits in Bura, Garsen and Lamu west. Garissa, Narok and Gilgil IEC sessions were done once during distribution. Our target was achieved.

4.2.1 NFI distribution

SITE No of camps No. of MSF registered NFI distributed + shelter Percentage IEC sessions IDPs for NFI material Gilgil 5 456 433 422 + 11 95 % 5 Narok 2 40 40 40 100 % 2 Donation 100 KRC Narok Bura 20 1,638 1,212 1,212 74 % 60

Garsen 15 1,287 980 980 76 % 45 Donation 155 KRC Garsen Lamu West 2 126 126 126 100 % 6 Garissa 2 40 40 0 + 40 100% 2 TOTAL 46 3587 3086 3035 + 51 86 % 120

All the families that were registered to receive NFI kits were given a kit during the day of distribution. Among all the IDPs in the camps, 86% received NFI/ shelter material. This numeric gap was because the IDP population was having a lot of movements, so the number of people in the camp on a daily basis was varied, as there were new arrivals and others were moving to other areas.

In Garissa KRC had distributed NFIs in all the IDP camps. During MSF assessment 40 families were identified as lacking shelter materials, as they arrived after KRC distribution took place. A total of 40 shelter pieces (tarpaulins) were given to 20 families in Madogo and 20 in Bura Algy. Tarpaulins were also distributed to 11 families in Gilgil in addition to the NFI kits distribution.

4.2.2 IEC Sessions

IEC sessions were conducted during all NFI and Shelter materials distributions, follow up visits were conducted on a weekly basis after the distribution of NFI kits, construction of latrines and donation of aqua tablets. The medical team during the mobile clinic and surveillance visits also provided health education to the IDPs.

Response To Flood Emergency 2013 15 MSF Spain IEC Session Picture by Lois Muturi

4.3 Result 3 “The displaced population has access to a minimum standard of drinking water and temporary sanitation facilities.”

Expected Indicator Final Result Comment Number of latrines: 1 per 40 A total of 3,038 households benefitted Latrines constructed also had hand wash- IDP households per camp from construction of latrines the latrine ing points constructed. Gender was consid- need was 76 and in total 75 latrines ered when constructing the latrines such were constructed. MSF achieved its that each sex had an allocated latrine. target Litres of water treated with All sites MSF supported received not Some donations were done to KRC to Aqua tabs: 140 l. per house- less than 1 week supply of aqua tablets ensure follow up of water treatment in the hold per week. in enough amount for 140 litres. A total IDP camps. of 19,378 aqua tablets were distributed.

4.3.1 Latrines

IDP camp/village Est. HH Latrine need Latrines con- Comment structed Wanaruona Baraka 136 3 2 This were additions Kihoto 118 3 2 to the existing ones Gilgil Mabaki Ya Wanaruona 49 2 2 Gema Begi 34 1 2 FTC (Ziwani) 320 8 1 Garissa Modogo (Maroro) 882 22 14

Response To Flood Emergency 2013 16 17 MSF Spain Cont. IDP camp/village Est. HH Latrine need Latrines Comment constructed Subo 99 2 5 The IDPs were settled in two camps Subo A and Subo B each camp needed its own latrines Bura Morokani 95 2 3 Camp had a scattered settlement due to distance an additional latrine was constructed Ndalangu 187 5 3 Access to the built latrines was easy. Adaad 86 2 2 -

Baomo 130 3 3 - Dobale 130 3 2 Culturally the men were not using latrines. Only the women and children used the latrines. Kokani Farm 101 3 2 There were other existing facilities Feji 98 2 4 Spread out settlement due to distance additional latrines were constructed

Luluta 41 1 2 Additional latrines due to gender Garsen Babahani 35 1 2 Additional latrines due to gender Bura Imani 159 4 3 Tribal and cultural influenced the deci- sion. Mnazini/kibaoni 75 2 7 Population was close to town and the town facilities were not functional thus in essence more population needed the facility Riketa 76 2 2 - Tserakuu C 213 5 2 Culture factors influenced the decision

Narok Donation KRCS 10 TOTAL 3,038 74 75

MSF donated a total of 12 latrines slabs to district steering groups5. This was done in order to set up new latrines when the need arises and to cover the gap in Tseraku IDP camp. The IDPs were involved in the construction of latrines and supported the activities with voluntary work. Cultural and economic factors influenced the construction of latrines. Some communities demanded payment while others did not see the importance of latrines. Community education was done on the importance of using latrines with success. All latrines were constructed with shower and hand washing points.

5 A district committee is composed of all the stakeholders in the district. It is chaired by the District commissioner.

Response To Flood Emergency 2013 17 MSF Spain 4.3.2 Aqua tablets

IDP camp/village Est. HH No. of tablets No of weeks Comment distributed Sindagara 38 38 1 day One day presence, MSF gave a Narok donation to KRC for follow up on the distribution of aqua tablets Donation 10, 000 KRC Narok Shika Adabu 176 2,816 2.3 Water tracking done by GoK Subo 99 1,584 2.3 River water subsided bore hole water was accessible through a water pump Morokani 95 1,520 2.3 Water tracking done by GoK8 Ndalangu 187 2,992 2.3 Water tracking done by GoK Bura Mtobini 45 720 2.3 Water tracking done by GoK Walini 81 1,296 2.3 River water subsided bore hole water was accessible through a water pump Ngomeni 82 1,312 2.3 River water subsided bore hole water was accessible through a water pump Adaad 86 1,740 2.9 MSF donated aqua tablets to KRC to continue follow up. Garsen Baomo 78 2,600 4.7 Marooned villages were issued more tablets due to access challenges. kibaoni 75 1,500 2.9 Access to bore hole water in a school Donation 22,400 KRC Garsen Chalauluma 50 500 1.4 Access bore hole water in a dispensary Lamu West Riketa 76 760 1.4 KRC took over the follow up

Total 13 1,168 51,778

In general, the water quality was very bad. Use of aqua tablets improved the water quality to some extent, even if the water was very turbid. Some sites benefitted from water trucking and borehole water when the water level subsided. 6

6 GoK – Government Of Kenya

Response To Flood Emergency 2013 18 19 MSF Spain 5 Challenges

Feji Garsen Picture by Lois Muturi

• Food was the immediate need for the affected population and this was not available on time as the trucks delivering food got stuck on the way, due to bad road condition during the rains. Action taken MSF advocated for an urgent distribution to the populations among the key actors in the country including the World Food Program. • The health facilities in Bura were closed, the district did not have enough staff to restart services in the district neither did they have drugs and medical materials to meet the needs of the flood affected population. Action taken MSF advocated for a drug supply and UNICEF made a donation to Bura health centre in order to guarantee the access. • The majority of places lacked emergency preparedness plan at local level. Recent set-up of the new local administrations (county governorates, for instance) did not facilitate the emergency operations despite the recurrence of floods in some of the areas of intervention. Action taken MSF used its own emergency preparedness plan, incorporating local actors and other agencies in the phase of design and planning but utilizing its own human and material resources. • It was difficult to reach the affected populations in some areas due to the floods and access through the river was not safe. Accessibility to affected populations by road was difficult. The road conditions were bad following the rains. Action taken MSF advocated for an aerial assessment for the flood affected populations and where it was possible MSF used boats to reach the populations. In addition to that, alternative routes were explored and the community rehabilitated parts of the road in order to facilitate access. KRC assisted in evacuating marooned populations by air and using boats. • List of affected populations were not accurate to determine genuine and non genuine IDP. Action taken MSF conducted registration of houses before NFI distributions • Community involvement in some of the camps was challenging as they were demanding payment. Action taken Negotiation with the community was done with success in a majority of cases. • Some of the affected populations wanted food assistance before receiving any other type of assistance. Action taken MSF prioritized advocacy for food assistance as requested by communities. • Language barrier resulting in challenges in communicating clearly with people. Action taken Translators were incorporated to our teams. • Community has tribal and religious differences thus in some instances resources were used more in order to attend to each community at a time. For example, Feji and Seranguu areas in Tana River are 2 km away but ethnically different. In order to avoid conflict, MSF planned activities in situ and separately. Action taken Intervened in one community at a time in their area of settlement.

Response To Flood Emergency 2013 19 MSF Spain 6 Conclusions - Recommendations

Marafa Garsen Picture by Lois Muturi

• MSF has an objective to assist humanitarian needs in the country and with the heavy long rains experienced in April 2013 MSF set out to respond to this emergency. The objective was to reduce the risk of epidemics in flood affected population in Kenya, which was achieved by MSF in its area of monitoring by implementing a disease surveillance system, ensuring the flood affected population had access to health care services, providing livelihood materials to enhance coping mechanisms and providing facilities and materials such as latrines and aqua tablets in order to prevent the affected population from contracting diseases. This was done in collaboration with local, national and international actors capable to respond. The intervention strategy was relevant because during the intervention no waterborne or vector borne disease outbreak occurred among the displaced population.

• Timely intervention during emergencies is of importance as most interventions were delayed and services were not provided at the acute moment. Some delays were related to long bureaucratic processes, among the key actors in the country. Another important reason was the absence of contingency plans at local and regional level. Some components that needed immediate attention were food, water and ensuring availability of health care services in the existing facilities.

• MSF focused its intervention in health related aspects. Other acute needs were not incorporated in our intervention because our mandate did not include components such as food security, infrastructure or reconstruction. MSF tried to coordinate with other agencies and advocate for more help without much outcome. In some places, the priority for the affected population was food and they did not accept assistance in other needs (ex. Health, water…), causing some unnecessary tension during the intervention.

• Due to inaccessibility to the nearest health facilities (structural problems sometimes), MSF covered the need in health assistance, conducting mobile clinics temporarily. The pathologies observed during the intervention were not especially complicated or severe. These diseases could be managed by functioning health facilities. However, in the areas with traditional shortage of staff and drugs

Response To Flood Emergency 2013 20 21 MSF Spain MSF had to take the responsibility and populations remained at risk. MoH should carry out efforts improving the coverage in situations like this emergency.

• Districts urgently need to have contingency plans for responding to emergencies to avoid adverse consequences during these episodes. None were in place despite the regular occurrence of floods in these areas. Despite the majority of the local authorities reacting quickly in terms of advocacy and coordination, they lacked material and human resources, management tools and prepositioned items. With the “devolution” process already in progress, it is essential to clarify responsibilities between the different administrative levels in order to facilitate the existence of contingency plans at local, regional and national level as well as urgent response in case of need.

• Coordination mechanisms between different agencies at local level worked very well and should be further developed. MSF collaborated very closely with the first responder, Kenya Red Cross, in all the different areas of the country. Local authorities played an important role facilitating this approach. At national level the coordination mechanisms were not so strong.

• Community involvement in disaster management is important so that they adopt appropriate and timely coping measures in the earliest stages. The lack of this involvement was evident when an alert was given to the communities to move to higher ground in the Tana River area and the community did not cooperate. They moved only when they were suddenly engulfed by flood water. Problems in some camps were also present when agencies asked for voluntary cooperation in the construction of latrines or showers.

MSF team Picture by Francis Eiton

Response To Flood Emergency 2013 21 MSF Spain Response To Flood Emergency 2013 22 PB MSF Spain