Overview of Recovery challenges in Pakistan post October 8 earthquake 05

Rayana Bou- HakaEmergency and Humanitarian Action Coordinator-WHO Pakistan

Outline of the presentation

Brief review of the context UN-ERRA Early recovery plan Initial denial of a “transition phase”WHO action and interventionsLingering humanitarian needsChallenges ahead for the health sectorWHO exit strategies and options

Earthquake

Death Injuries Evacuation

Destruction of facilities Interruption of essential services

Displacement camps Shelter problems Food needs

Disrupted water and sanitation

Psychological trauma

Disrupted district health systems

Save lives and minimize suffering

MOH Medical teams for on site management of injured and sick

Tented Field hospitals, clinics National, international , civil , military

Prefabs BHUs and RHCs

Mental health teams, counseling activities

Cluster for coordination

Management of mass casualties in tertiary hospitals Convalescent

Risk of outbreaks

Disease Early warning system and alert response

PHC package

Training

Vaccinations

Health impact and response components

Relief Achievements Health services coverage in most affected areas with better service delivery Vaccination campaignsPHC package developedEfficient disease early warning system, preparedness measures against outbreaksMore than 50 health partnersHealth cluster coordination at central and field hubsTemporary facilities initiated

WHO BaghDr. Musa Khan03005018515

WHO BattagramDr. M. Siddiq

0300856 4575

WHO MansehraDr. Daw Myint Sein

0300501 0495

WHO MuzaffarabadDr. Abdinasir Isse

0300856 5564

WHO RawalakotDr. Jafer Ilyas0300951 5803

The UN-ERRA early recovery plan

ERRA : Earthquake rehabilitation and reconstruction authorityMandate and organizational structureERRA health strategy The health cluster plan in ERPHardware and software

Proposed strategy Coordination:

ERRA Health core group (ERRA, FMOH and Provincial health departments, ADB, WB, WHO, UNICEF, UNFPA, Donors), Adoption of the Islamabad health cluster: advisory/ working group and Adoption of the field clusters (AJK, NWFP) with inclusion or linkages to DRUs and PERRAs

Health services delivery (PHC, reconstruction, NGOs and contracting)Health system (districts, DEWS, Essential drugs, HMIS and preparedness planning)

Strategy for Health

during theEarly Recovery Phase

inEarthquake Affected Areas

AJK and NWFPMay 2006

Health Emergency Cell - WHO Pakistan - House # 6, Street # 20, F 7/2, IslamabadTel. + (92) 51 – 250 5175 / 926 3240 Fax: + (92) 51 – 26 53053-5 health@eqpak.emro.who.int

http://www.whopak.org/disaster

Ministry of HealthGovernment of Pakistan

WHO mission

on Health System

Recovery

Consultation

with

Partners & Donors

Revitalizing disrupted health system Revival of DoH/AJK and District Health Management Structures of AJK & NWFPIntegrating additional health services Coordination among stakeholders Emergency preparedness and responseAligning health with related sectorsPhasing out Early Recovery

Strategy for Health (report)- pillars

WHO action and interventions (April 06-January 07)

Assessments and monitoringDisease alert and early warning system (DEWS)Environmental health activitiesSummer AWD and winter contingency planningRevitalizing PHC services: PrefabsDistrict health system planning

In-depth Assessment of Health facilities and IDPs camps

Planning and participation of all partners , Kaladhaka areas: specific options Muzaffarabad: joining forces with Merlin and ICRCUse in winter planning and contingency needs analysis with partnersProviding district authorities with snapshot of situation (300 facilities)

Map of health facilities and IDP camps in Muzaffarabad

Map of health facilities and IDP camps in Mansehra

Development of the surveillance Form.

Guidelines and case definitions.

More than 270 reporting units.

Software application.

Training and Deployment.

Rumor verification and investigation.

Drugs and laboratory supplies

Feedback and WMMR

Monitoring and evaluation.

WHO Emergency Program Disease Early Warning and Response

WHO Emergency Program Disease Early Warning and Response

Percentage of AWD consultations in earthquake affected areas

Weekly trend of percent of consultations for ARI and AWDNovember 2005 – 12 Jan 2007

Weekly Alerts Earthquake Affected Areas, Pakistan, 15 October – 23 December, 2006 Weekly Alerts Earthquake Affected Areas, Pakistan, 15 October – 23 December, 2006

Outbreak Alerts and ResponseEarthquake Affected Areas, Pakistan, 15 October – 23 December, 2006

Outbreak Alerts and ResponseEarthquake Affected Areas, Pakistan, 15 October – 23 December, 2006

DEWS does not cover whole population, nor are all

diseases included in the system.

Limited accessibility due to landslides and snowfall.

Limited epidemiological capacity due to a lack of staff

appropriately trained on outbreak investigation.

Lack of adequate transportation and communication

between the reporting units and district level.

Delays in shipping samples from field to NIH and delay in

receiving laboratory confirmation from NIH

No laboratory capacity at district level.

DEWS - Challenges Earthquake Affected Areas, Pakistan DEWS - Challenges Earthquake Affected Areas, Pakistan

• Expand DEWS and insure agreement on communicable diseases under surveillance;

• Enhance decentralization for decision-making to facilitate outbreak response and control;

• Strengthen epidemiological and management capacities of the epidemiological surveillance and related coordination;

• Strengthen case detection at peripheral level, including laboratory screening and confirmation process;

• Improve data management data analysis and interpretation;

DEWS - Future Plans Earthquake Affected Areas, Pakistan DEWS - Future Plans Earthquake Affected Areas, Pakistan

• Improve supervision and monitoring;• Strengthen epidemic preparedness through

timely and regular interpretation of health data and rumours, and stock piling of drugs and supplies, preposition of drugs/supplies for selected epidemic prone diseases;

• Strengthen and expand laboratory networking for safe collection, transport, processing and testing of specimens of suspected outbreaks;

• Insure the national authority’s commitment to ensure sustainability of the system once the project is finished;

DEWS - Future Plans Earthquake Affected Areas, Pakistan DEWS - Future Plans Earthquake Affected Areas, Pakistan

AWD planning and contingency preparedness Summer 2006

Contingency planning developed for each district under the leadership of DHO/EDOPartners committing to provide needed resources: stocks of medicines, beds, additional human resources, and equipment for additional clinics or field hospitals Complementarity between investigation of alerts, immediate response, hygiene promotion , water testing and treatment

WHO interventions: revitalizing facilitiesPart of the winter plan commitment in partnership with UNICEF and UNFPA in response to the need to provide functioning facilities instead of tents in areas where highest destruction occurred, where displaced were located and where winter snow and landslides threatened collapse of tentsProvision of temporary prefab structures, seismically resistant,equipping them and providing essential medicines for an initial period of 3 monthsWHO built 35 BHUs with 23 in AJK and 12 in NWFP and handed them over to local authorities in June 2006. Currently they are seeing a load of more than 50,000 patients/month and cover around half a million people20 RHC have been constructed (catchment area 50,000-100,000) using a pre-engineered structure, 10 are complete and the rest are expected end of January 2007. They have a laboratory, inpatient capacity of 10 beds and have a surgical theater for basic emergency surgery and obstetric emergency care

Prefab Structures Constructed by UN/INGOs

WHO’s Pre-Engineered Rural Health Center (RHC) - Chattar Kalas

Admin Block of RHC

Operating Bed – RHC Banjosa

Female Ward – RHC Banjosa

Component - 1:Consolidation and expansion of the PHC coverage

Component -2:Rehabilitation and recovery of the district and state health systems

Component - 3:Establishment of district level emergency preparedness and response

Infrastructures

Resources (Human

& material)

Services (Preventive

&curative)

WHO’s role for DHS Rehabilitation & Strengthening

Assistance in capacity

building, HR development and filling up some gaps

Technical support for

maintenance of services and quality care

Support for assessment,

quality control, environmental

health and prefab facilities

in recovery phase

DHS

Heath System

Technical support for

district health system

rehabilitation and

strengthening

DHS Planning Workshops for Earthquake affected areas

NWFP 04 – 07 July, 2006

AJK 25 – 28 July, 2006

DHS Planning Workshop- Objectives

1

2

Enhancing capacity of Earthquake affected districts & related provincial authorities in planning of health system

Preparing need based district master plans for early recovery phase, as per ERRA strategy

DHS Planning Workshop NWFP- Participants

Provincial health authorities District health teams Programme managers DRUsERRA officials UNFPA (one facilitator)WHO operation officersWHO technical officers

DHS Planning Workshop NWFP- Outcome and follow up

district health master plans developed and launched DHPs are being shared with partners / stakeholders Districts will jointly review and update plans WHO, ERRA and MOH/DOH will assist Funding through regular budget and by ERRA Activities requiring funding will be advocated Local coordination will be around DHPs.

Integrated District HealthSystem – a model approach

DHO Office RHC

MCH

BHU

BHU

FAP CD

BHU

BHU

BHU

THQMCH

BHU

BHU

FAP CD

BHU

BHU

BHU

DHQMCH

BHU

BHU

FAP CD

BHU

BHU

BHU• Communication• Referral • HMIS and DEWS• Information flow

• Mobile health services• Logistic support• Supervision / monitoring• Management support

RHCMCH

BHU

BHU

FAP CD

BHU

BHU

BHU

Health system in early recovery phase - the opportunities

Pretest of various modalities in the EQ affected areas Success experiences can be the entry point for improving health system in PakistanVarious Adaptation of management systems for finance, drugs and logistics Replication of District Health Planning approach and tools health partners collaborating Equity issues (EQ areas and other districts)

Lingering Humanitarian needs

Camps and populations in “temporary” sheltersMEDIA : “deaths from pneumonias”

Next monsoon season, floods and landslidesDisabled

Distribution of camp-wise population

Camps and supporting agenciesAll camps except 5 are supported by at least one agency

The 713 Amputees Admitted in The Hospitals of Islamabad, Rawalpindi, Lahore, NWFP and AJK

(By Gender and Age)

23 26

109 108

163

189

5144

0

20

40

60

80

100

120

140

160

180

200

M F M F M F M F

< 5 5-18 >18 Age Not Listed

The 741 Spinal Injury Patients Admitted in The Hospitals of Islamabad, Rawalpindi, Lahore, NWFP and AJK

(By Gender and Age)

3 3

40

104

205

295

3754

-

50

100

150

200

250

300

350

M F M F M F M F

< 5 5-18 >18 Age Not Listed

•Amputations (=713) Spinal Injuries= (n=741)

Earthquake Related Disabilities Earthquake Related Disabilities

Post-relief health status of the EQ affected population preserved during the transition phase

Avoidable mortality and morbidity averted

Local and district health services enabled to implement acomprehensive package of essential services and,

A functional referral support linking the PHC network of services developed

1. Large number of primary and secondary care international and national providers might leave the scene and create gaps and uneven health coverage

2. ERRA leadership of health recovery and reconstruction coordination requires redefinition of health sector and partners’ roles at district, provincial and federal levels

3. Large population groups returning to their villages with disrupted social services face the challenge of accessing to health services especially maternal and newborn care

4. DEWS and epidemic response interventions will require reorganization, capacity building and full integration to DHS functions

5. Shrinking access to safe drinking water will pose additional risks of disease outbreaks

6. Severely disrupted district health systems with no relief-phase back-up services and depleted human resources require technical and managerial capacity building for their revitalization

7. Emerging challenges related to shelter and livelihoods constrained by the forthcoming monsoon and harsh winter will have direct effect on health and nutrition

8. Emerging demand for community based rehabilitation (CBR) for the disabled and the greater need for psychosocial support and mental health will require the development of new skills and capacities

9. Logistic support system (LSS) for maintaining a well managed supply chain of medicines, other supplies and logistics will need to be Integrated as a core function of the DHS

Table : Cadres of staff available at all facilities

195 (66)Vaccinator

171 (42)LHV

262(88)Dispenser/male technician

38 (13)Medical Officer (female)

123 (41)Medical Officer (male)

Facilities with staff available (N=297)

n (%)

Staff Cadre

Moving towards recovery and rehabilitation

Implementation of the PHC package in a comprehensive manner, model facilities and quality orientedEnsuring the appropriate health staffing needs in numbers and quality: more training, on the jobProposing to link up and integrate services from BHUs with RHCs and secondary facilities at each districtCommunity involvement and participation in supporting of health facilities District health systems : managerial, planning, and supervisory capacities