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Home , Buner District, Swabi District

HEALTH CLUSTER Crisis in NWFP

WEEKLY BULLETIN no. 14 14 October 2009

HIGHLIGHTS

• The Health Cluster partners firm up health interventions in the districts of , Buner, Lower Dir and Upper Dir as the IDP return process is in progress. To date, a total of 236 183 families have returned to their respective districts while 22 920 families are still sheltered in 10 IDP camps and 247 895 families remain living with host communities. Meanwhile, 17 new camps have been established in Malakand, Buner, , Charsadda and Rissalpur, hosting 7594 families. (Source: Provincial Relief Commissionerate and Commissionerate

for Afghan Refugees.)

• From and Tank, 12 629 internally displaced families (94 249 individuals) are seeking shelter in host communities. Population has been displaced from Waziristan due to security issues. (Source: Commissionerate for Afghan Refugees)

• Between 19-25 September, 35 279 consultations were reported from 180 disease surveillance sentinel sites in NWFP. Of the total reported consultations, 19 105 (54%) were female patients, 16 174 (46%) male, and 7217 (20%) children under five.

• The leading causes of morbidity and death among children under five are acute diarrhoea and lower respiratory tract infection (LRTI). Between 19-25 September, there were 7217 consultations with children under five, of whom 1076 (15%) had acute diarrhoea and 290 (4%) suffered from LRTI.

• After four cases of measles were reported from Jalozai camp, a measles vaccination campaign for children under 15 in the affected sector of Jalozai was conducted between 6-7 October.

• As a follow up exercise to the recently conducted health assessment in DI Khan, the health sector has provided one inter-agency emergency health kit (coverinig 10 000 people for 3 months) and five mini emergency health kits (each kit covers 6 000 people for two months).

• A health assessment for was carried out between 13-17 September and data gathered during the assessment is now being analyzed. The health assessment for was conducted between 5-10 October. Reports on the findings of the health assessments for Swat and Buner will be drafted and shared with health partners for further discussion and planning.

• The security situation in Pakistan is volatile and fragile. Security incidents in Islamabad, Peshawar and Rawalpindi over the last week have resulted in temporary closure of UN offices in Peshawar and Islambad. Resumption of operations is subject to advisory from the UNDSS.

ASSESSMENT

The DoH of NWFP in collaboration with WHO, UNICEF and four cluster partners conducted a health assessment in Swat District from 13-17 September. The data gathered during the assessment is now being analyzed and will be shared with the health department/Health Cluster by 20 October 2009. The health assessment for Buner District was conducted between 5-10 October. The data entry is done by the health department of NWFP and will be shared with WHO for its analysis and reporting. Reports on the health assessments for Swat and Buner will be shared with partners.

During the comprehensive health assessment conducted by the Health Cluster in DI Khan on 28 August, the following needs were identified: o For effective implementation of quality MNCH, RH and FP services in all the primary health care (PHC) facilities and hospitals, the lack of female medical staff should be addressed. o Supply of essential drugs and equipment is an ongoing process and proper mechanisms must be put in place to ensure timely delivery. The current situation of medical supplies in the district is not sufficient to cater for the population's needs. Health cluster partners should support the health department in the provision of medicines in primary and secondary health care facilities. o Water supply is available in only 42% of health facilities. WASH cluster should work in collaboration with the health department for immediate restoration of water supply in health facilities of DI Khan. o Provision of standby electric supply in all the PHC facilities. Electric supply is critical for the vaccination cold chain and for all emergency life-saving interventions. There is need for health education and awareness campaigns in the entire district to educate the community on hygiene, safe drinking water and effective health seeking behavior. o Strengthen the referral system to improve hospital capacities in the field of emergency obstetric care (EmOC) as well as the emergency medical/surgical trauma care. Well functioning secondary care hospitals will encourage the PHC network to confidently refer cases through the system.

Based on the recommendations made in the DI Khan health assessment, WHO provided one inter-agency emergency health kit (covers 10 000 people for three months) and five mini emergency health kits (each kit covers 6000 people for two months.)

Disease Surveillance A total of 180 sentinel sites of disease surveillance in NWFP (Swat, Buner, Lower Dir, Upper Dir and Malakand Agency) and four districts in southern NWFP (DI Khan, Tank, Lucky Marwat and Banu) have sent their reports during the week of 19-25 September and registered 35 279 consultations. The drop in the total number of consultations is due to Eid-ul-Fir holidays. Meanwhile, a decrease in the number of consultations in camps is expected as large numbers of IDPs from most of the camps have returned to their distrists. From the reported number of consultations, there were 191 visits for antenatal care, 332 consultations for chronic non-communicable diseases and 62 consultations for injuries.

The table below shows the type of patient, number of consultations and the percentage as recorded between 19-25 September:

Type of patient Number of consultations Percentage Female 19 105 54% Male 16 174 46% Children under 5 7 217 20%

• The table below shows the leading causes of morbidity among IDPs inside and outside camps. Health facilities in IDP camps reported Upper Respiratory Tract Infection constituting the highest number of consultations and acute diarrhoea as the following.

Disease Surveillance Most common conditions Percentage Acute Respiratory Tract Infection (ARI) • Acute Upper Respiratory tract Infection (URTI) 19% • Acute Lower Respiratory Infection (LRTI) 3% Acute Diarrhoea (AD) 7% Unexplained fever (UF) 5% Scabies (SCB) 5% Suspected malaria (MAL) 3% Bloody diarrhoea (BD) 1%

• Health facilities in most of the IDP camps reported most consultations were for URTI and the second-most for scabies. An increasing number of consultations for scabies have been reported from two health facilities in Jalozai camp and from a health facility in Jalala Camp. Intensive hygiene promotion and water and sanitation interventions have been recommended in the camps for the prevention of waterborne and water-related diseases. Similarly, health posts in Jalozai IDP camp reported cases of suspected malaria, which also need urgent attention.

The graph below shows the weekly morbidity pattern of the seven most common communicable diseases reported in IDP-hosting districts in NWFP between 19-25 September.

Meanwhile, the morbidity trend, as shown in the graph below, is represented by the number of consultations of each disease per 1000 consultations. Since the start of the year, URTI has been the most common subject of consultations.

Below’s graph shows the weekly morbidity pattern of the five most commonly reported communicable diseases in IDP-hosting districts in NWFP from epidemiological week 1 to week 39 of 2009.

• The common causes of morbidity and leading causes of death among children under five are acute diarrhoea and LRTI. Between 19-25 September, there were 7217 consultations with children under five, of whom 1076 (15%) had acute diarrhoea and 290 (4%) had LRTI.

Environmental Health

One of the major commitments of the Health Cluster during the emergency is to control preventable ill health and ensure that environmental risks are recognized and properly managed. Enhancing the health-related living environment of IDPs and host communities is one of the cluster’s main objectives. In the immediate aftermath of the influx of returnees, WHO as the cluster lead agency stressed the risks of contaminated water supplies. Risks include diseases such as cholera and diarrhea.

• In Swat district, 4 out of 6 water quality tests conducted in water sources in Islampur village were found unfit for drinking. An agreement has been reached with ACTED to start hygiene promotion training in Swat district. • In , WHO's Environmental Health team is supporting the District Headquarter Hospital Swabi to renovate and upgrade the hospital’s WASH facilities. • In Jalala camp, sufficient drinking water is available for IDPs. The camp’s drinking water is free from residual chlorine and found within the WHO standard limit. Sanitary conditions are satisfactory and pit latrines, which are for communal use, are also satisfactorily clean.

COORDINATION

Health Cluster, Swat District The 4th Health Cluster Coordination Meeting was held on 30 September in DHDC, Swat. Highlights: • Executive District Office-Health will conduct monitoring visits to health facilities to assess availability and quality of medicines. • He advised partners to consider assessing lady health volunteers rooms in health facilities for equipment availability and to address any gaps. • WHO has been requested by EDO-Health to hold additional DEWS trainings for all public and private health care providers in Swat district.

The 5th Health Cluster Coordination Meeting for Swat District will be conducted on 14 October 2009 in DHDC.

Health Cluster, Buner On 30 September, the 2nd Health Cluster Coordination Meeting was held at the PAIMAN hall, DHQ Daggar in Buner • DEWS implementation, trainings & reporting of DEWS data to WHO was discussed. • EDO requested partners to initiate activities in accordance with pledges made. WHO was given the task to coordinate with health teams and evaluate the performance of partners working for Buner’s health sector.

Health Cluster, health cluster meeting was held on 29 September in EDO office. • Contracts of four mobile teams of CAMP organizations ended on 1 October and to avoid gaps, one team has retained the contract for the provision of health services to Bara IDPs settled in host communities, mainly in villages adjacent to Bara.

Health Cluster, Swabi On 30 September, a coordination meeting was held with the EDO-Health to discuss how to improve DEWS reporting which is currently at 58%.

Health Cluster, Lower Dir On 1 October, the Health Cluster Coordination Meeting was held with MS THQ Hospital Samar Bagh. Issues discussed were: • At present, there are only 6 doctors, and 12 posts are still vacant at the hospital in Samar Bagh. The hospital is facing problems in dealing with paediatric and gynaecological cases because of the unavailability of specialists. The average consultations at the outpatient department (OPD) of the THQ is more than 300/day but there isn’t enough space available to accommodate the OPD patients. The Health Cluster will further discuss in the next meeting on partners’ logistics capacity to strengthen the health facility in Samar Bagh. • Coordination meeting conducted with EDO Health, MS DHQ Hospital Dir Lower, and MS THQ Hospital Samar Bagh. EDO-Health ensured that DEWS refresher training would be conducted in October. MSF (B) data sharing issue was also discussed with EDO Health.

Health Cluster, Charsadda • During a coordination meeting with the MS DHQ Charsadda, WHO was informed of the free treatment and life-saving drugs being provided to IDPs in host communities through health facilities including mobile health clinics and facilities run by implemententing partners. Life-saving drugs were donated by WHO.

Who does what where? The maps "Who Does What Where" for in-camp and outside camp, updated on 12 October, are attached.

FILLING GAPS

American Refugee committee continued its health activities in Union Council and RHC Yar Hussein Lahore, Union Council and BHU Zaida, and Union Council and RHC Marghuz for IDPs and for host communities in . A total of 2833 patients were consulted during the last week. For its extended immunization programme, a total of 215 vaccinations were performed during the reporting week.

Care International is providing health care services through two mobile teams in five union councils: , Koga, Makhrani, Nawagai and Karapa of Buner district. A total of 1568 patients were treated in these health facilities out of which 430 were females and 703 children.

International Medical Corps is providing 24/7 comprehensive primary health care services in Palosa camp, Charsadda district including mother and child health (MCH), health education and referral services. The morning and evening shifts include a male and a female doctor, LHV, health educator and dispenser while the night shift consists of a male doctor and a male paramedic. Between 2-9 October, consultations totalled 332. IMC is also providing health care services to IDPs living with host families in Charsadda district through two mobile medical units operating out of government health facilities. The total consultations during the week of 9 October were 236.

In Buner District, IMC is providing comprehensive primary health care services including health education, MCH and referral services in DHQ Daggar, BHU Tor Warask, BHU Deewana Baba (in two shifts), and RHC Bagh. A total of 1411 consultations were conducted during 2- 9 October.

IMC is also providing services at the MCH center of through a Female Medical Officer and Two LHVs in two shifts in RHC Khazana and in one shift in BHU Manyar. The total number of consultations during the reporting week was 1698.

MDM–F continues to support health service delivery through a medical mobile team in Swabi district working in 6 different locations: Naranji, Amankot, Qamar Dand, Palodand, Goati and Kotai. Another team is running an OPD clinic for IDPs in Swabi DHQ hospital.

One medical mobile team is working in Buner district in the villages of Dargalai, Mangaltana and Dakara in Sawari Union Council. In Daggar of Buner district, there is also a mobile medical team working in the Union Council Ellai. In all these health facilities, a total of 1716 curative consultations were performed last week, out of which 54% of the total consultations were female and 23% children under five. A total of 75 children between 6- 59 months were admitted in the MDM nutritional programme (CMAM).

World Health Organization (WHO) provided 5 MEHK and 1 cholera kit to DHQ Daggar. Medicines and medical supplies were also provided to its health partners – Save the Children, IMC and Johanniter – for provision of health services to communities in Swat and Charsadda.

Needs:

• To date, there still remains a gap of female health care providers in health facilities in returnee districts. Security conditions remain a challenge to provide health care services in returnee districts. • There is a shortage of doctors at the hospital in Samar Bagh. At present, there are only 6 doctors, and 12 posts are still vacant. The hospital is facing problems in dealing with paediatric and gynaecological cases because of the unavailability of specialists.

Funding situation As of 8 October, the Health Cluster has received 37% of required funds as indicated in the UN Pakistan Humanitarian Response Plan (Revised) document. (Needs identified: US$ 42 065 870. Funds available: US$ 15 480 917) (Source: OCHA Pakistan, Financial Tracking System, 8 October 2009).

Communication and advocacy activities Efforts are being made to increase visibility of the health response to the crisis through: • Preparatory activities for the Pakistan Donor Event • Distribution of NWFP crisis intervention brochure • Pakistan health in photos • Production and distribution of Health Cluster bulletins • Packaging disease surveillance film for distribution • Updating health cluster website • Production of NWFP crisis slide show

Web links:

WHO HQ: http://www.who.int/hac/crises/pak/en/index.html Health Cluster Pakistan: http://www.whopak.org/idps Provincial Relief Commissionerate: http://www.helpidp.org Pakistan MoH: http://www.health.gov.pk WHO EMRO: http://www.emro.who.int/eha/pakistan Relief Web FTS: http://ocha.unog.ch/fts/pageloader.aspx

Contacts: For further information please contact:

WHO Pakistan Country Office Dr Khalif Bile Mohamud WHO Country Representative to Pakistan E-mail: [email protected]

Dr Hendrikus Raaijmakers Emergency Preparedness and Humanitarian Action Coordinator E-mail: [email protected]

WHO Regional Office for the Eastern Mediterranean Dr Irshad Shaikh EHA Regional Adviser E-mail: [email protected] Tel.: + (202) 2276 5525 Mobile: + (201) 01733924 http://www.emro.who.int/eha/

WHO Headquarters Mr Paul Garwood Communications Officer Health Action in Crises E-mail: [email protected] Tel. : +41 22 791 3462 Mobile: +41 79 475 5546 www.who.int/disasters Acronyms

AWD: Acute Watery Diarrhoea ACD: Association for Community Development BHU: Basic Health Unit CD: Civil Dispensary CERD: Centre for Excellence for Rural Development DART: Disaster Assistance Response Team DEWS: Disease Early Warring System DHQ: District Headquarter DTC: Diarrhoea Treatment Centre DSM: District Support Manager EDO: Executive District Officer EMRO: Eastern Mediterranean Regional Office ERU: Emergency Response Unit FP: Family Planning IEHK: Inter-agency Emergency Health Kit HRDS: Human Resource Development Society HTH: High test Hypochlorite INGOs: International Nongovernmental Organizations LHV: Lady Health Visitor LHW: Lady Health Worker LSS: Logistic Support System MCHC: Maternal Child and Health Centre MEHK: Mini Emergency Health Kit MMT: Mobile Medical Team NIH: National Institute of Health MNCH: Maternal, Neonatal and Child Health NWFP: North West Frontier Province MSU: Mobile Service Unit OFDA: Office of Foreign Disaster Assistance ORS: Oral Rehydration Salts ORT: Oral Rehydration Treatment PHRP: Pakistan Humanitarian Response Plan PIPOS: Pakistan Institute of Orthotics and Prosthetics Sciences, PPE: Personal Protective Equipment PPHI: People's Primary Healthcare Initiative PRC: Provincial Relief Commissionerate PRCS: Pakistan Red Crescent Society PWDs: Persons With Disabilities RH: Reproductive Health RHC: Rural Health Centre THQ: Tehsil Headquarter WMO: Woman Medical Officer

Pakistan: Who is doing What and Where (health sector) in IDP Camps- North West Frontier Province

Turkmenistan Tajikistan Tajikistan China Upper Dir F.A.N.A. IDPs: 1,536 Samar Bagh P.A.K. Aksai Chin Al-khidmat Foundation N.W.F.P. Q National program, WHO Afghanistan Disputed Area Afghanistan F.A . T. A . Upper Dir China/India China Satbar Kallay Helping Hand, Relief Development, IMC, Merlin IDPs: 2,508 Q Save the children, Malteser int. , Care int. PUNJAB UNFPA, National program IDPs: 4,596 CERD, I.D.E.A, National programs PRCS, WHO Timergara PRCS/ ICRC, National Program BALOCHISTAN Al-khidmat Foundation, WHO Lower QDir Swat Iran (Islamic Republic of) India Q Shangla IDPs: 3,345 Wali Kandaw SINDH Q National Program, WHO Khungi IDPs: 3,119 Bajaur Agency National Program Sr. No. District Name of IDP camp Static Clinics NGOs working 1 Nowshera Benazir complex, Risalpur 1 PRCS 2 Peshawar Kacha Garhi 1 2 Merlin, CERD 3 Peshawar Kacha Garhi 2 2 Merlin, CERD (UNICEF supported) 4 Charsadda Palosa 1 1 IMC, National Programs, Hashoo Foundation Jalozai 1 1 Merlin Jalozai 3 1 CAMP 5 Nowshera Jalozai 4 1 Merlin 6 Jalala 1 Merlin Samar Bagh 1 Al-Khidmat Foundation Sadbar Kallay 3 UNFPA, PRCS, Al-Khidmat Foundation 7 Lower Dir Wali Kandaw 1 National Programs

2007-08 (in 2007-08 (in DISTRICT DISTRICT 1998 (Census) thousands) 1998 (Census) thousands) 880666 1094 LAKKI MARWAT 490025 608 CERD, Helping Hand, Relief Development BANNU 677346 841 LOWER DIR 717649 891 BATAGRAM 307278 381 MALAKAND 452291 562 Malakand PA IMC, Merlin, Save the Children, National programs BUNER 506048 629 1152839 1432 CHARSADA 1022364 1269 MARDAN 1460100 1812 CHITRAL 318689 396 NOWSEHRA 874373 1085 DERA ISMAIL KHAN 852995 1058 PESHAWAR 2019118 2506 Buner HANGU 314529 391 SHANGLA 434563 540 HARIPUR 692228 859 SWABI 1026804 1275 Mohmand Agency KARAK 430796 535 SWAT 1257602 1561 562644 699 TANK 238216 296 KOHISTAN 472570 587 UPPER DIR 575858 715

Jalala Legend IDPs: 950 Q Mardan Merlin, UNFPA, WHO IDP Camps and origin of IDPs Q Bajaur/ Mohmand Charsadda Q Bajaur/ Mohmand/ Swat Q Swat/ Buner/ Dir IDPs: 2,701 Palosa 1 IMC, UNICEF, National program Neighbour country Q Hashoo Foundation, WHO Swabi District boundary IDPs: 5,509 Benazir Complex Q Other Districts Kacha Garhi 2 Merlin, UNICEF, CERD IDPs: 1,762 Q National program, EDHI, WHO PRCS, UNICEF Kacha Garhi 1 Peshawar IDP Hosting Districts Khyber Agency Q National program, WHO Nowshera Haripur Military Operation in process

IDPs: 8,647 IDPs: 92,064 Jalozai 1, 2, 3 Military Operation in some areas Merlin, UNICEF, CERD Q Merlin, UNICEF, EDHI, CAMP Attock National program, EDHI, WHO National program, WHO Military Operation completed

Produced by: Information Management Unit, WHO-Pakistan Date created: October 13, 2009 WHO Map Num: WHO-Flood-226 02 4 8 12 16 Scale: 1:524,333 Source: HIC, WHO Kilometers The boundaries, names and the designation used on this map do not imply official endorsement or Population Data Source: Commission for Afghan Refugees 1 inch equals 13 kilometers acceptance by the United Nations. Dated: October 13, 2009 . World Health Organization, Chak Shehzad, NIH Premises, Park Road, Islamabad. Email: [email protected] Website: http://www.whopak.org Pakistan: Who is doing What and Where (health sector) in host communties- North West Frontier Province Tajikistan Tajikistan China Chitral Deolai Turkmenistan G F.A.N.A. P.A.K. Matta Madyan Aksai Chin Bar Thana N.W.F.P. v Dherai G Kohistan Afghanistan Disputed Area Upper Dir Beha Rahatkot F.A . T. A . GFatehpur G China/India Parrow (! China Chuprial G PUNJAB Khawazakhela Lilownai v Kuzkana G GChungai Kuz Kana Lower Dir Swat G BALOCHISTAN

Shangla Gawalerai Iran (Islamic Republic of) India G Mingorav Qambar(! G (!(! Batagram Bajaur Agency Kokarai SINDH Udigram Chitor G G Kokarai Afghanistan Manyar(!G G Talang(! Maragai QGv Khazana Barikot G Mobile Static Pangir District Jowar Batara Sr. No. Clinics NGOs Working Q G G Clinics Tor Warsak Amnawar IMC/ DFID, Johanniter Mohmand Agency G Daggar (! Charsadda 2 P (! Shal Bandai 1 4 international, Merlin/ WHO Malakand PA Buner Deewanababa G 2 Mansehra 0 1 Church World Services Mansehra Baffa Town 3 Abbottabad 1 0 Church World Services Jamalabad Muzaffarabad Church World Services, Q Swabi 1 N.W.F.P. Mansehra City No.1 4 1 ARC international Mansehra City No.3 Dhaki Bagh Total 4 6 G Mardan Q Datta Sherapao Charsadda Q Registration Outside Camps (12 OCT 2009) Khanmai S.No District Families INDIVIDUALS ORIGIN Remarks G 1 Mardan 106623 639738 Buner / Dir / Swat NADRA Verified Data G Sheikhabad 2 Swabi 46365 278190 Buner / Dir / Swat NADRA Verified Data West 3 Charsadda 20923 125538 Buner / Dir / Swat NADRA Verified Data Q 4 Nowshera 11491 68946 Buner / Dir / Swat NADRA Verified Data F.A.T.A. G Yar Hussain East Rajjar 5 Peshawar 42579 255474 Buner / Dir / Swat / Orakzai NADRA Verified Data Total 227,981 1,367,886 Mera Prang Southern Districts ORIGIN Remarks Abbottabad 6 Kohat 1578 9468 Orakzai NADRA Verified Data Swabi Registration stopped since G Q 9 Tank 2,923 16646 South Waziristan Agency Peshawar Marghuz 16-08-09. Zaida Registration stopped since 10 D.I.Khan 9,706 77648 South Waziristan Agency Gar Munara Haripur 16-08-09. Total 14,207 103,762 Hazara Division ORIGIN Remarks 12 Abbottabad 964 5,784 Swat NADRA Verified Data Nowshera 13 Haripur 863 5,178 Swat NADRA Verified Data 14 Mansehra 2,866 16,549 Swat Mirpur Khyber Agency 15 Battagram 1,014 8,844 Swat Total 5,707 36,355 Grand Total 247,895 1,508,003

Legend Kurrum Agency Tribal Area Peshawar ISLAMABAD Location of organization in host communities Events Tribal Area Kohat Islamabad TYPE P DHQ Orakzai Agency THQ v CH Q RHC G BHU (! CD Kohat Attock MCH Hangu Organizations working in Union Council Care International Johanniter international Church World Serivces Rawalpindi N. Waziristan Agency PUNJAB ARC International CORDAID Merlin, Malteser International Church World Services, ARC International Tribal Area Bannu boundary F.A.T.A. Other Districts IDP Hosting Districts Military Operation in process Chakwal Mianwali Military Operation in some areas Bannu Jhelum Military Operation completed Mandan Province boundary Lakki Marwat Neighbour country

Produced by: Information Management Unit, WHO-Pakistan Date created: October 14, 2009 WHO Map Num: WHO-Flood-254

Source: HIC, WHO 04 8 16 24 32 Scale: 1:1,053,905 Kilometers The boundaries, names and the designation used on this map do not imply official endorsement or Population Data Source: Commission for Afghan Refugees 1 inch equals 27 kilometers acceptance by the United Nations. Dated: October 12, 2009 . World Health Organization, Chak Shehzad, NIH Premises, Park Road, Islamabad. Email: [email protected] Website: http://www.whopak.org