HUMANITARIAN HEALTH ASSESSMENT IN DIFFA REGION
DR FATOU F R A N C E S C A MBOW , SAVE THE CHILDREN 26.11.13 ASSESSMENT TEAM
• Dr Fatou Francesca Mbow, Save the Children WCA Regional Humanitarian Health Adviser [email protected] +221 777406701
Dakar-Niamey-Dakar: 18-27 Nov. 13 Niamey-Diffa-Niamey: 21-26 Nov.13
• Anda Oumarou, Save the Children Health and Nutrition Program Manager , Diffa
Excused -sick leave -(Diffa): Aicha Taybi (UNHCR)
METHODOLOGY
1. Literature review
2. Face-to-face discussions with key informants: Ministry of Health (Direction Régionale de la Santé, Health Facilities’ staff), Diffa Health District Head, Diffa Urban Health Centre Head, Mental Health Co. Diffa Regional Hospital*, NGOs (Save the Children, IRC) UN agencies (UNHCR), patients in health facilities *phone conversation
3. Direct observation: Bosso health centre, Kablewa health centre, Diffa’s regional hospital (paediatric ward including CRENI), Maine Soroa district hospital (paediatric ward and CRENI), Maine Soroa health center
Limitations: -MoH and Save the Children staff very engaged in “Journées Nationales de Vaccination” - SAM/MAM Save the Children program not evaluated quantitatively
Niger 17 million DIFFA Diffa REGION 600,000 http://www.stat- • 6 departments niger.org/statistique/file/rgph2 • 3 health 012.pdf districts Diffa 48% below age 15 http://www.snis.cermes.net/downl oad/Annuaire_%20statistique_2 011.pdf CARTE SANITAIRE DIFFA REGION AND DEPARTMENTS
Diffa REGION 600,000 people 157,000 km² 50 CSI 127 cases de santé N’Guigmi: 83,100 people Maine Soroa: 135,000 km² 216,600 1 District Hospi. people 12 CSI 15,000 km² 27 cases de 1 District santé Hospi. Diffa: 20 CSI 224,000 people 43 cases de 7,000 km² santé 1 regional hospital 17 CSI 57 cases de santé
HUMANITARIAN CHALLENGES IN DIFFA
OVERVIEW http://reliefweb.int/report/niger/sahel-operation-diffa-situation-niger- november-2013 TRANS-BORDER MOVEMENTS DIFFA HEALTH DISTRICTS: 37,000 PEOPLE, ¼ NIGERIAN (UNHCR)
HEALTH # %NIGERI DISTRICT HEALTH FACILITY SITE NAME # MOBILE POP. NIGERIA A Health Centre (urban) BOSSO 10913 1863 17% MAMOURI 1582 277 18% GARIN AMADOU 1294 420 32% BOULAGANA 991 164 17% GAMGARA 1 250 250 100% GAMGARA 2 644 27 4% BOULABRINE 162 162 100% ABADAM 2218 1117 50% TCHOUKOUJANI 1936 588 30% Health Centre (rural) BAROUA 1247 381 31% NGUELKOLO 1252 117 9% Health Centre (urban) DIFFA 4638 963 21% Health Centre (rural) TOUMOUR 837 47 6% Diffa TOTAL Diffa 27964 6376 23% Health Centre (rural) KABLEWA 5225 790 15% N'Guigmi TOTAL N'Guigmi 5225 790 15% Health Centre (urban) MAINE-SOROA 2890 1013 35% ABASSARI 304 47 15% YABAL 58 75 129% Health Centre (rural) TAM 443 68 15% ABOUNGA 24 16 67% TOTAL Maine Maine Soroa Soroa 3719 1219 33% TOTAL Diffa Region 36908 8385 23% FLOODS
http://reliefweb.int/report/niger/flash-update-no1-du-15- novembre-2013-inondations-diffa-suite-la-crue-de-la- komadougou
FOOD INSECURITY
http://www.fews.net/pages/country.aspx?gb=ne
HUMANITARIAN HEALTH CHALLENGES IN DIFFA
OVERVIEW SAM PREVALENCE THE HIGHEST IN THE COUNTRY AND INCREASING SINCE 2011
5 Prevalence of SAM per Niger Region, SMART 2007-2013
4,5
4
3,5 Agadez Diffa 3
Dosso
2,5 Maradi
Axis Axis Title Tahoua 2 Tillabery Zinder 1,5 Niamey 1 Niger
0,5
0 2007 2008 2009 2010 2011 2012 2013 GAM PREVALENCE DECREASING
HIV PREVALENCE POSSIBLY THE HIGHEST IN THE COUNTRY DHS 2006*
*HAVE NOT BEEN ABLE TO GET SENTINEL SURVEILLANCE DATA BUT IT APPARENTLY EXISTS AND CONFIRMS THE ABOVE
• DHS 2006
http://www.measuredhs.com/pubs/pdf/HF16/Niger_HIV_F actSheet.pdf
ENQUÊTE SOCIO COMPORTEMENTALE ET DE PRÉVALENCE DES IST ET DU VIH/SIDA DANS LE BASSIN DU LAC TCHAD A DIFFA AU NIGER, JUL. 2011
Hommes Femmes Ensemble
Intervalle de confiance à Intervalle de confiance Intervalle de confiance à 95% HIV-1 95% Effectif HIV-1 Effectif HIV-1 à 95% Effectif Inf Sup Inf Sup Inf Sup Milieu de résidence Urbain 0,0% 0,0% 1,5% 321 3,00% 1,3% 6,3% 236 1,3% 0,5% 2,7% 560 Rural 2,00% 0,7% 4,8% 254 3,70% 1,6% 7,8% 189 2,7% 1,5% 4,8% 447 Age 15 - 19 0,0% 0,0% 6,7% 68 0% 0,0% 4,5% 103 0,0% 0,0% 2,7% 171 20 - 24 0,0% 0,0% 5,3% 87 5,70% 2,1% 13,5% 87 2,9% 1,1% 6,9% 174 25 - 29 1,1% 0,1% 6,9% 90 1,10% 0,1% 7,1% 88 1,1% 0,2% 4,4% 178 30 - 34 2,2% 0,4% 8,4% 92 3,70% 0,6% 13,8% 54 2,7% 0,9% 7,3% 146 35 - 39 0,0% 0,0% 5,8% 79 6,80% 1,8% 19,7% 44 2,4% 0,6% 7,5% 123 40 - 44 2,8% 0,5% 10,7% 71 8,10% 2,1% 23,0% 37 4,6% 1,7% 11,0% 108 45 -49 0,0% 0,0% 10,9% 40 0,0% 0,0% 30,1% 12 0,0% 0,0% 8,6% 52 50 - 54 0,0% 0,0% 14,6% 29 - - - - 0,0% 0,0% 14,6% 29 55 - 59 0,0% 0,0% 20,9% 19 - - - - 0,0% 0,0% 20,9% 19 ND - - - - 0,0% 0,0% 43,9% 7 Niveau d’instruction Aucun 3,10% 1,2% 7,6% 159 4,70% 2,4% 8,7% 214 4,0% 2,4% 6,7% 373 Primaire 0,0% 0,0% 5,1% 90 2,90% 0,2% 16,6% 35 0,8% 0,0% 5,0% 125 Secondaire 1er cycle 0,0% 0,0% 5,3% 86 1,60% 0,1% 9,5% 64 0,7% 0,0% 4,2% 150 Secondaire 2nd cycle 0,0% 0,0% 9,1% 49 9,10% 0,5% 42,9% 11 1,7% 0,1% 10,3% 60 Supérieur 0,0% 0,0% 32,1% 11 0,0% 69,0% 3 0,0% 0,0% 26,8% 14 Autres 0,0% 0,0% 2,6% 180 1,00% 0,1% 6,4% 98 0,4% 0,0% 2,3% 278 ND 0,0% 0,0% 43,9% 7 HIV IN DIFFA REGION
Diffa Regional Hospital • 2013: 198 on ART, 11 of them caseload 2008-2013 children (Diffa regional
500 hospital is the only ART site in 450 the region) 400 350 • We don’t know how many on 300 ART are lost to follow-up since 250 HIV+ Northern Nigeria crisis 200 ART 150 • Assoc. of PLWHA: at least 300 100 people in Diffa Health District 50 (>50% from Nigeria) 0 2008 2009 2010 2011 2012 2013 • HIV+ in SAM seems to be overlooked issue
MENTAL HEALTH IN DIFFA REGION
• 323 mental health patients in Diffa’s regional hospital Jan.-Nov. 2013 (no data trends*). This is the only health facility with mental health capacity (1 “licencie en sante mentale”)in the Diffa region. • 1 in 10 patients is displaced from Nigeria (no data stratified by age nor sex*) • “majority” suffers from depression linked to husbands, children, other family members brutally killed (beheaded) in front of patient prior to fleeing Northern Nigeria. • No info. on treatment* *very short phone conversation HEALTH IN DIFFA
LITERATURE REVIEW DHS 2012 PRELIMINARY REPORT: DIFFA
• Vaccination: 12-23 months who received all vaccines: Diffa lowest (42%) after Zinder (41%). Country is 52% • Monitoring and evaluation: Data on ARTI, fever and diarrhoea treatment for Diffa is incomplete • SAM and under-nutrition -3ET weight/height: Diffa 21% (Niger 6.2%) – worst of all regions. Similarly worst of all regions for -3ET weight for age and height for age • HIV Men knowledge on condoms’ protection against HIV is the worst in the country
DHS 2012 PRELIMINARY REPORT: NIGER
• Fertility index 7.6 children/woman (rural 8.1, urban 5.6) has increased since 2006. Adolescents contribute 15% to fertility index in rural areas.>80% women want another child “soon” or “later” regardless of number of living children already had. 86% women no contraception (usage has increased from 11% to 14% since 2006) • 83% ANC but then only 30% delivery in health facility/assisted by health professional (Anthropo. Study French Red Cross 2012: no knowledge of danger signs/symptoms – neither health staff nor pregnant women) • 6 months exclusive breastfeeding: 13% (with water added, 52%) • 60% households owns an insecticide treated bed net yet ¾ children do not sleep under one • 73% anaemia in children (43% severe), 46% anaemia in women (1/3 mild) • U5MR declined since 2006 from 198 to 127 per 1,000 live births ANNUAIRE STATISTIQUE 2011: DIFFA
• Diffa worst region for: o % assisted deliveries (12% versus country 24.75%) o % maternal deaths (0.66% versus country 0.13%) o % Diffa regional hospital higher number of consultancies compared with all other regional hospitals (including Niamey) • Transfusion not in hospitals but in “centres régionaux de transfusion sanguine” in Diffa, Tahoua, Dosso, Niamey HEALTH IN DIFFA
DATA FROM HEALTH FACILITIES UNEVEN DISTRIBUTION OF HEALTH FACILITIES AND STAFFS ALTHOUGH SPHERE STANDARDS BROADLY RESPECTED
Ce Ho CSI CSI Cas Tot Health Staff Diffa ntre p. 2 1 e al Public Private Region Hos de de p. dist san Reg rict té
# Drs 18 (13 4 (3 urbain) urbain) Diff 1 0 2 15 57 75 a # Nurses 213 (109 33 (26 urbain) urbain) MS 0 1 2 18 43 64
# Midwives 32 (24 5 (4 NG 0 1 2 11 27 41 urbain) urbain) Tot 1 2 6 44 127 180 Effectif total du al personnel 263 42 HEALTH STAFF MOBILITY AND RETENTION CHALLENGES
- Out of 17 CSI in Diffa Health District, 9 are staffed by 1 single person only – a nurse. Diffa urban CSI has 30 health staffs (but no lab. Technician). Female health staff should “follow their husbands” so very hard to place them in rural settings.
- All health actors highlight very high turnaround of staff and long gaps for staff coverage (ex. Lab technician in Dosso health centre – 6 months’ gap). We recently lost our protection officer to IRC and have also experienced relatively high turnover of staff. Diffa is a very expensive city compared to other cities in Niger- 80,000 XOF rent for 1 room in Diffa town, salaries of our national officers around 300,000 XOF
- Female staff usually located in towns since policy is that “they follow their husbands”
DIFFA URBAN HEALTH CENTRE
36,000 (60% within 0-5km of the 47,000 consult. (17,000 new) # total pop. health facility, none >15km) 2,200 references # pregnant 3,200
Jan.-Oct. 2013 # U5 7,000 10000 5000 0 12,000 consul. 3 diseases Jan.-Oct. 2013 1500 Nvelles consult Total consult 1000
500
622 assisted deliveries 0 Jan.-Oct. 2013 100 50 GAM moins de 5 ans depistes # total 0 accouch Total palu.
assistes Diarrhees
mars…
janv.…
sept.…
août-…
juil.-13
juin-13
avr.-13 mai-13
oct.-13 Pneumonies févr.-13 DIFFA URBAN HEALTH CENTRE MEASLES AND PENTA VACCI. DIFFA URBAN HEALTH CENTER TETANOS AND BCG VACCI. DIFFA HEALTH DISTRICT VACCINATION : YELLOW=50-80% COVERAGE, GREEN=>80% COVERAGE
DTP3, Sept. 2013 Polio, Sept 2013 MAINE SOROA URBAN HEALTH CENTRE
11,300 consult. (10,100 new) 150 references # total pop. 24,000 Jan.-Oct. 2013 # pregnant 1,000 2000 # U5 5,000 1500 1000 500 0
3,900 consult. 3 diseases Nvelles consult Total consult Jan.-Oct 2013 300
GAM moins de 5 268 assisted deliveries 250 ans depistes Jan.-Oct 2013 200 Total palu 50 150 40 Diarrhees 100 30 # total Nombre cas de 50 20 accouch Pneumonies assistes 0 10 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 KABLEWA HEALTH CENTRE
6,800 consult. (6,300 new) 10,400 (2/3 live >15 km from 33 references # total pop. health facility) Jan.-Oct. 2013 # pregnant 510 1200 # U5 2,200 1000 800 600 400 Nvelles consult 200 Total consult 0
2,812 consult. U5 3 diseases
Jul-13
Jun-13
Apr-13
Jan-13
Feb-13
Sep-13
Oct-13
Mar-13 Aug-13 May-13 300
250 96 assisted deliveries Jan.-Oct 2013 GAM moins de 5 ans depistes
(122 2013) 200 Total palu 20 150
15 Axis Title Diarrhees 100 10 # total accouch 50 Pneumonies assistes 5 0 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 10 11 PROPORTIONAL MORBIDITY U5 3 DISEASES 3 HEALTH FACILITIES DIFFA REGION JAN.-OCT. 2013
Diffa Urban Health Center Maine Soroa Urban Health Center
ARTI 23% GAM 33% GAM ARTI 22% Diarrhea 36% 10% Malaria Malaria. 19% 34% Diarrhea 23% Diffa Kablewa GAM 1 17% Food economy zones 1 Desert Nguigmi 3 Zone Pastorale Malaria 4 Zone Agropastorale 14% 3 ARTI 5 Zone pluvio-agricole 51% 0 50 100 7 7 Zone de culture- de rente de la rivière Komadougou et du Lac Tchad
Kilometers Diarrhea 4 18% Maine-Sorda 5 Diffa PMTCT BOSSO HEALTH CENTRE FEB. -AUG. 2013
Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 • Data from Bosso health ANC 114 214 179 460 424 477 640 HIV test 58 43 382 107 152 57 centre seems to be ANC HIV+ 0 2 2 4 2 2 0 CMX 2nd trimester 0 2 4 4 2 2 0 completely unreliable with AZT 0 2 4 4 2 2 0 tritherapy 0 0 0 0 0 0 0 very little compiled data husband tested 0 0 0 1 0 0 0 husband HIV+ 0 0 0 0 0 0 0 apart from PMTCT data and total women tested in the some data from the lab. HIV maternity ward 19 9 31 21 17 7 HIV+ in maternity 2 2 0 1 2 0 test ruptures seem to have delivered 42 35 20 33 43 54 51 HIV+ delivered 0 0 0 1 1 1 0 been frequent AZT and NVP durinf delivery 1 1 0 AZT and 3TC post-partum 1 1 1 newborn AZT+3TC+NP syrup 1 1 1 J4 to J15 taking AZT+3TC+NP syrup 1 0 1 born alive 1 1 1 • 13 Sept.-21 Nov., lab. data: 8 HIV+ out of 23 requests. Out of 13 TB+, 4 were also HIV+ coinfected.
EPI IN NIGER NOW TARGETING 0-23 (PNEUMO1,2 AND 3, ROTARIX 1AND 2) AND 9 Y/O GIRLS RECEIVE HPV 1, 2 AND 3 HEALTH SUPPORT TO DIFFA
HEALTH; HUGE GAP IN PRESENT HUMANITARIAN RESPONSE IN DIFFA SC THE ONLY NGO CONSISTENTLY ACTIVE ON “HEALTH” IN DIFFA THROUGH SAM AND MAM SUPPORT
• In Northern Nigeria healthcare is either not free or health facilities are not functional. SC supports health and nutrition activities in Northern Nigeria through HPI who themselves work via national consultants. No technical visit of those projects for the last 4 years due to insecurity.
• Populations from Niger and from Nigeria are used to using each others’ territories and services – and have family ties in both countries - this did not change during the March-April crisis, putting a strain on health services in areas of acute short term mobility.
• Save the Children started activities in Diffa in 2010 following HKI’s departure (HKI had supported SAM and MAM in Diffa region since 2005). It supports MAM and SAM in Diffa Region since 2010 (Maine Soroa and N’Guigmi) and since September 2013 Diffa district (Diffa urban health centre and Bosso). Cholera, measles and shigellosis’ response kits also donated to Diffa Region (Direction Régionale de la Santé) by Save the Children .
Health facilities in Diffa region In red, supported by Save the Children (SAM and MAM)
Centre Hop. de CSI2 CSI1 Case de Total Hosp. district santé Reg.
Diffa 1 0 2 (Diffa 15 57 75 and Dosso)
Maine 0 1 2 18 43 66 Soroa N’Guig 0 1 2 11 27 46 mi (9) HEALTH IN DIRE NEED FOR SUPPORT
• Health is presently not really supported except punctually (MSF donated medicines, ICRC supported surgical treatment of war casualties and gave a steriliser to Bosso HC, Save gave cholera/measles/shighella treatment kits to the region etc.). Save the Children supports GAM activities and through them health activities (mobile clinics, drugs, staff) and is consistently identified as “the NGO concretely supporting the MoH in Diffa” QUALITY OF NUTRITION SERVICES NEEDS ASSESSMENT
• Quality of CRENAS nutrition activities is difficult to assess since they occur daily and not weekly • Kwash. seems to have unexpectedly high prevalence – needs broad data review. • Quality of CRENI activities needs urgent and serious technical support. The strategy of “integration” with MoH shows its limits here (staff recruitment and trainings, supervision etc.). “Espaces amis enfants” needs clear ToR and on that basis, evaluation. • In-patients’ paediatric services share CRENI staff and medicines but other than that seem to basically limit themselves to beds, mattresses and little more unless patients pay for their own medicines when stock ruptures occur.
UNIVERSAL PRECAUTIONS AND WASH ISSUES EVERYWHERE
Bosso Health Centre latrine Maine Soroa Health Centre UNIVERSAL PRECAUTIONS AND PATIENTS/STAFFS’ SAFETY
Bosso health centre Bosso health centre CHALLENGES IN REHABILITATING EQUIPPING HEALTH FACILITIES
Kablewa health centre Intensive Care Diffa entrance door Regional Hospital PROPOSED ACTION
ON HUMANITARIAN HEALTH IN DIFFA FOR SAVE THE CHILDREN TARGETED HEALTH FACILITIES
HEALTH DISTRICT HEALTH FACILITY SITE NAME # MOBILE POP. # NIGERIA %NIGERIA Health Centre (urban) BOSSO 10913 1863 17% MAMOURI 1582 277 18% GARIN AMADOU 1294 420 32% BOULAGANA 991 164 17% GAMGARA 1 250 250 100% GAMGARA 2 644 27 4% BOULABRINE 162 162 100% ABADAM 2218 1117 50% TCHOUKOUJANI 1936 588 30% Health Centre (rural) BAROUA 1247 381 31% NGUELKOLO 1252 117 9% DIFFA (+ LADA Case de Health Centre (urban) Sante) 4638 963 21% Health Centre (rural) TOUMOUR 837 47 6% Diffa TOTAL Diffa 27964 6376 23% Health Centre (rural) KABLEWA 5225 790 15% N'Guigmi TOTAL N'Guigmi 5225 790 15% Health Centre (urban) MAINE-SOROA 2890 1013 35% ABASSARI 304 47 15% YABAL 58 75 129% Health Centre (rural) TAM 443 68 15% ABOUNGA 24 16 67%
Maine Soroa TOTAL Maine Soroa 3719 1219 33% TOTAL Diffa Region 36908 8385 23% OBJECTIVE 1: IMPROVE ACCESS TO QUALITY PRIMARY HEALTH CARE PROGRAMMES INCLUDING THROUGH OUTREACH ACTIVITIES
- Free healthcare services for U5, pregnant and lactating women, emergencies - Universal precautions are met; essential quality medicines are available; national clinical protocols are adhered to and laboratories are functioning and providing quality services; qualified staff are trained and retained - Strengthen PMTCT in all sites - Condoms’ promotion and distribution - WASH in health facilities is strengthened OBJECTIVE 2: IMPROVE ACCESS TO SECONDARY HEALTHCARE SERVICES
- Referrals - Paediatric ward in CRENI (maternity and emergencies also if funding allows) Universal precautions are met; essential quality medicines are available; national clinical protocols are adhered to and laboratories are functioning and providing quality services; qualified staff are trained and retained - Mental Health: support to be determined (staff and medicines) - HIV (tracing of PLWHA on ART lost to follow-up; sensitization to mobile populations and to health staff for enough supplies of ART to be provided in relation to displacement)
OBJECTIVE 3: IMPROVE MONITORING AND EVALUATION
• Staff • Data collection tools • Dissemination of evaluation data