Report on the delivery of health services for the Drought ...
Health Services for the drought-affected populations
in the Somali National Regional State (Gode, Denan and Jijiga)
INTRODUCTION
The Somali National Regional State is one of the poorest regions in Ethiopia. It has an estimated population of 3.5 inhabitants who are predominately agro-pastoralists and pastoralists. Refugees, internally displaced persons and drought-affected populations constitute a large percentage of the region's population. Persistent migration of the population is an important characteristic that renders any development planning for the region very difficult. This is a region characterised by extreme poverty, low levels of education, poor infrastructural facilities, lack of efficient institutional capacities, logistical constraints and recurrent natural disasters such as famine, drought, epidemics (both human and animal) and floods. Communication links with the rest of the country are poorly developed thus making it an isolated region. Any development or investment envisaged for the health sector is heavily influenced by the political, social and economical factors prevailing in the region. However, there is an opportunity that the on-going emergency response for the affected populations will spark off a new momentum and be a magnet for a special focus from development agencies to reform their regional plans. For the region to develop reliable systems for preparedness and response, a special consideration must be given to appeal to a sustained and long-term commitment by the international agencies, NGOs and the central authorities. There are an estimated 200,000 refugees residing in the Region in seven refugee camps along the border with North West Somalia (Somaliland).
TERMS OF REFERENCES
1. To assess the health situation of the drought-affected populations in the Somali National Regional State, and to identify gaps in the health delivery systems.
2. To look into the co-ordination mechanisms that are in place, and how best the regional health authorities are managing to provide technical backstopping to those working in the periphery.
3. To familiarise with the Horn of Africa Initiative for the Cross Border Control of Communicable diseases, and how best this has impacted on the health situation in the border areas.
4. To identify those conditions that hamper the effectiveness and equitable distribution of relief supplies and promote the transmission of communicable diseases.
METHOD OF ASSESSMENT
The method of assessment employed consisted of direct interviews of the beneficiaries, direct observation of the health facilities providing services, and interviews with the services providers including UN agencies, NGOs and local health authorities. Health reports and data at the hospitals, clinics and other health facilities were also reviewed and studied. Individual meetings, group discussions and participation in health co-ordination meetings were also utilized.
INTRODUCTION TO HEALTH SERVICES
Any health services for the drought-affected populations cannot be developed in isolation and without giving due consideration to the health needs of the host population. This implies that inputs intended for the drought-affected populations will also serve meeting the needs of the host populations. The development of the health care system should be entwined as an integral part of the overall development plan of the region. Regional health plans should not be conceived in isolation, and the formulation of appropriate health strategies should be built from the bottom up and embedded with flexibility as dictated by local conditions and circumstances. Emphasis must be given to the empowerment of the community and their ownership of the health services promoted from the outset.
The health care system in the region is at crossroads. Poor planning and management, years of neglect, shortages of qualified health planners and administrators and inadequate financing, characterize it. It is critical that international agencies are committed and ready to provide the thrust needed to effectively address the health problems of the region and to aim at strengthening the local capacity. Quick fixes are not the required answer for a variety of chronic problems faced by the region.
HEALTH INFORMATION SYSTEMS
At present the health information system in the Somali National Regional State is imperfect or quasi non-existent. The situation of the health information system in the region is appalling, and one should consider this as a priority in order that trends of mortality, morbidity, and nutritional status should be closely monitored. It is essential that data collection should be limited to that information that can and will be acted upon. Information that is not immediately useful should not be collected during the emergency phase of a relief operation. Overly detailed or complex reporting requirements will result in non-compliance.
The most valuable data are generally simple to collect and to analyse. Standard case definitions for the most common diseases of morbidity and mortality should be developed and put in writing. This is an area whereby NGOs and UN agencies could help the local regional health authorities and strengthen their capacities for developing an effective health information system.
Data collected from selective feeding centres constituted the main source of health information of which NGOs and others base their decisions and evaluate the effectiveness of their programmes. Comparatively health centres, clinics and hospitals managed by the local authorities are unable to generate reliable data to supplement that from the children centres. This dichotomy may provide a convincing explanation the lack of funds for the overall health care services. A unified health information system is a priority need.
An effective health information system should provide continuous information on the health status of the drought-affected population and comprises both ongoing routine surveillance and intermittent population-based sample surveys. This information is useful for the following requirements:
□ Follow trends in the health status of the community and establish health-care priorities.
□ Detect and respond to epidemics
□ Evaluate programme effectiveness and service coverage
□ Ensure that resources are targeted to the areas of greatest need
□ Evaluate the quality care delivered.
Recommendation
• A simple and reliable health information system should be composed and implemented. This must include collection of data from all the facilities (feeding centres, hospitals, health clinics etc.,), and to be collated and analysed by a single centre. The local health authorities are better placed to carry out this function. However, a tangible technical support is needed from the UN agencies and NGOs to strengthen the capacity of the local health authorities to properly establish that unified health information system. It is important that information is shared, and that methods of data collection and analysis are standardised.
MORTALITY AND MORBIDITY OF COMMUNICABLE DISEASES
Densely populated villages and towns with poor sanitation, inadequate clean water supplies, and low-quality housing will contribute to the rapid spread of diseases in these locations (e.g., Denan, Shinnille). In addition, the interaction between malnutrition and infection in these populations, particularly among young children, will also contribute to the high rates of morbidity and mortality from communicable diseases. There are no as such community-based structures, which could enable the early detection of communicable diseases and epidemics.
Measles, diarrhoeal diseases, acute respiratory infections (ARIs), tuberculosis and malaria are the primary causes of morbidity and mortality among the displaced populations in the Somali National Regional State. Epidemic-prone diseases such as meningococcal meningitis, cholera, measles and bacillary dysentery are also well-known health problems in the region. The obvious disproportionate representation of international agencies in affected zones is a determining factor that forced displaced populations to migrate en masse and end up in towns and villages (for example, Gode and Denan) characterised by overcrowding, poor sanitation, substandard housing, and limited access to health care. These conditions hamper the effectiveness and equitable distribution of relief supplies and promote the transmission of communicable diseases. There are no as such community-based structures, which could enable the early detection of communicable diseases and epidemics in the areas visited.
Mortality rates are the most specific indicators of the health status of emergency-affected populations. However, the information on mortality in the region is very scanty, and very few retrospective surveys carried out by MSF (H), ICRC and SCF, in collaboration with UNICEF, have shown mortality rates ranging from 8.9/10,000/day to 3.2/10,000/day in the general population. Another survey carried out by MSF in May in Denan has shown an alarming rate of 27.5/10,000/day among under-fives. Among the many problems encountered in estimating mortality under emergency conditions are the recall bias in surveys, families' failure to report prenatal deaths, inaccurate documentation (overall population size, births, age-specific populations), and lack of standard reporting procedures. In general, bias tends to underestimate mortality rates, since deaths are usually underreported or undercounted, and population size is often exaggerated. However, the limited surveys conducted by NGOs and UN agencies show a trend that indicate communicable diseases significantly contribute to these high rates of morbidity and mortality.
Recommendation
• Efforts should be aimed at reducing the incidence of communicable diseases. This will primarily focus on the provision of adequate quantities of clean water, improvements in sanitation and the establishment of appropriate health services. Dissemination of best practices and proven prevention and control strategies should be advocated.
• Health care services should target the leading causes of morbidity and mortality. The prioritisation of health needs will enable health authorities the better utilization of available resources and the development of a health care system that is appropriate and affordable. Ensuring that emergency interventions are enhancing and strengthening the long-term national health goals is a requirement.
CONTROL OF TUBERCULOSIS
Tuberculosis is a major public health in the Somali National Regional State. The annual risk of infection (ARI) in this region is estimated at 3-5 - 5% and TB is one of the leading causes of both hospital admissions and deaths according to the scant data available in the major hospitals in the region. The incidence rate for smear positive cases is considered to be between 175 - 250 /100,000 population in the region. This is a relatively high incidence.
Because of the limited resources available, efforts to control transmission of TB within an emergency should focus on the primary sources of infection, i.e., those patients for whom microscopic analysis of sputum smears demonstrates the presence of Acid-fast Bacilli (AFB). From the outset of an emergency, the TB control programme should establish a standard policy covering areas of case definition, case finding, treatment protocol, and the supervision of chemotherapy. This policy should be devised by the local authorities and adhered to by all organisations and agencies providing health services to the affected population. In Gode, the TB control programme is not working effectively in the main hospital, and the involvement of the agencies is very minimal. It is an area that needs further additional resources in order to strengthen the programme.
The selection of a first-line chemotherapy regimen should generally be consistent with the national policy set forth by the Ministry of Health. The strategy to employ a short-course therapy is the right policy to address the abnormally high rate of transmission observed in overcrowded conditions of the affected population. The constraints faced by the region comprise mainly of management problems, shortages of essential drugs, lack of laboratory facilities and non-compliance with control policies.
MSF (B) is supporting an effective TB pilot project in the Jijiga Zone and plans are underway to further extend the programme to other zones. The impact of the project is encouraging with nearly 80% cure rates for both new and re-treatment cases and less than 10% of the cases listed as defaulters for 1998. The problem with the programme is one of sustainability as it has been developed independently in its first phase with less integration to the overall health programme. One would like to see that the local health authorities assume a full responsibility of the implementation of the programme with technical support and backstopping from the MSF (B).
Recommendations
• The success of the MSF (B) project can be replicated in other areas. However, further support and additional inputs from other agencies and the national tuberculosis programme (NTP) are highly recommended.
• There is an urgent need to closely associate the project with the regional health authorities. It is imperative that the regional health authorities are actively engaged in the implementation of the project, and ensure that it is being fully integrated into the regional health plan.
• The World Health Organisation (WHO) should associate itself with the programme, and ensure providing technical and material support as needed. It must use its leverage with the regional health authorities that the TB programme is an integral component of the overall health care.
• Within the strategies of the Horn of Africa Initiative, the programme should develop carefully planned linkages with the TB programme in North West Somalia. This will imply standardisation of treatment regimens, referral systems and common tracing procedures for defaulters.
ROLL BACK MALARIA
Malaria is one of the leading causes of morbidity and mortality in the region. Its prevalence varies from area to area with seasonal fluctuations. This is a disease with major public health significance, and its current prevention and control strategies in the region need to be strengthened. Knowledge of the epidemiology of transmission, including local vectors, is essential to a malaria control effort. Preparedness for possible outbreaks of malaria during the coming season is essential. Immediate inputs are needed for the standardisation of treatment protocols, provision of technical support to the regional authorities, supply of essential drugs and strengthening the laboratory services.
Recommendation
• The prevention and control of malaria in the region should be considered as a health priority. International agencies (UN and NGOs) should provide the needed support to the regional and zonal health authorities as deemed necessary. The control of the disease should be multifaceted and comprehensive including the introduction of appropriate vector control techniques.
HIV/AID/STI
HIV spreads fastest in conditions of poverty, powerlessness and social upheavals- conditions that are prevalent in the Somali National Regional State, and further exacerbated by the effects of the drought. A massive migration of drought-affected populations from rural areas into the heavily populated areas in the outskirts of towns (e.g., Gode) has occurred. This phenomenon of population movement could facilitate a dramatic increase of the risk of infection, as the drought-affected people with rural background are less aware of the means of prevention.
Recommendation
• This is an area that needs an immediate attention. There are no programmes to combat the spread of HIV/AIDS in the region, and a very little is known on its magnitude. However, there are obvious signs, which point to that the problem of HIV/AIDS in the region is serious. The regional health authorities should treat this issue as a major public health problem, and seek technical support from specialised agencies such as UNAIDS, WHO and the National AIDS Programme (NAP).
SELECTIVE FEEDING PROGRAMMES.
The current humanitarian intervention strategy is primarily food-driven, and constitutes mainly of general food distribution and selective feeding programmes. There is a very limited input in the overall health care services, and in other vital sectors such as water, sanitation, livestock, agriculture and shelter. However, one should underline that the response of the international community has been very effective in accessible areas, and have certainly averted unnecessary deaths. The task now is to develop sustainable programmes that will remain viable over a number of years with diminishing human and material resources from outside sources.
Recent nutrition surveys suggest that the previously documented high malnutrition rates are in the decline, and improvements of the nutritional status of the children have been detected in many of the operational areas. However, the present rates are still high, and remain in the territories of concern.
The prevalence of acute malnutrition acts as an indicator of the adequacy of the relief ration. A high prevalence of malnutrition in the presence of an adequate daily ration may indicate inequities in the food distribution system, or high incidence rates of communicable diseases (e.g., measles and diarrhoea). There are indications that suggest both these factors exist in the region whereby the overall health care system is very weak, and that the distribution of food in certain villages and locations of the region requires close attention and monitoring. It is important to recognize that comparatively WFP and UNICEF are doing an exemplary job with all the apparent difficulties that exist in the region.
This is an indication that the situation is still fragile, and a full recovery of the population from the drought consequences will take time and a concerted effort to broaden the response in other vital sectors is warranted.
Recommendation
• There is a need to develop a phased exit strategy of the food aid programme and a corresponding increase of inputs in other vital sectors such as health, water and sanitation, livestock and agricultural programmes. The exit strategy should be based on coverage, impact indicators and food security in the region.
THE ROLE OF NGOs
The role played by NGOs in the emergency response including all vital sectors has been substantial. They are widely represented in the field and they constitute the frontline relief workers. The systematic inclusion of NGOs in the decision-making process for the emergency as key partners is fundamental. Equally important is the role of WHO as a bridge between NGOs and the Ministry of Health (MOH). We need to promote a unified approach encompassing all potential players, and one that ensures complementarity, pooling of resources and joint planning. NGOs constitute a powerful group to reckon with, and their prominent position necessitates that they are indispensable for any humanitarian response. WHO should play a proactive role to bridge the gap that currently exists between the MOH and NGOs?
The disproportionate representation of international and local relief organisations in certain locations (e.g., Gode) may have resulted in the apparent en masse migration of displaced populations into these towns and villages. Also it is true that the response of the international agencies (UN and NGOs) to the impact of the displaced populations is varied and characterized by different approaches and capabilities. Standardization of procedures and sound policies for health interventions is essential and should be streamlined. This is an area whereby WHO could play a leading role, and facilitate along with the MOH an effective co-ordination among all actors.
Recommendation
• WHO should look into the possibility of designating someone to become the focal point for NGOs? This function will undoubtedly enhance a close cooperation and collaboration between WHO, NGOs and MOH and will facilitate forming a strong partnership among the parties. Soliciting an alliance with NGOs will strength the leading role of WHO in the health sector.
COORDINATION, CAPACITY BUILDING AND HEALTH FACILITIES
Setting up an effective co-ordination mechanism of the health services by the regional health authorities at Jijiga level is still to take shape. There are obvious deficiencies within the existing regional structures. The lack of effective co-ordination mechanisms has resulted in the application of different standards and health policies by key health agencies. The limited presence in the field by UN specialized agencies in the health sector is unfortunate. The need to capacitate the local health institutions with the provision of technical support is essential, and this should be addressed carefully and intelligently.
The overall coordination among the UN agencies and NGOs operating in Gode Zone is very good with structured forums of communication, information sharing, standard settings and the development of shared objectives. However, the local government entity is very weak and need to be strengthened. It is crucial that outside resources, including central health authorities, complement and support the local initiatives and realities and are not devised as parallel systems to substitute the local response. Outside assistance should always enhance rather than hinder the development of local capacity and attempts to foster self-sufficiency among the affected populations.
The high salaries offered by international agencies have encouraged key health staff to leave local clinics and hospitals and seek employment in the selective feeding centres. This example reveals how the desire to save lives in the short term may have a long lasting detrimental effect on the health of the region.
The health infrastructures along the border areas are very weak, understaffed and poorly managed. Absence of qualified personnel in health management, administration and health planning has been evident. The situation has also been complicated by the presence of a diversity of NGOs who depend on recruiting qualified staff with high salaries, thus creating a vacuum in the government institutions. Limited resources and logistics support, shortage of critical health manpower worsen the situation and limit the impact of the health care delivery systems on the health status of the displaced populations. In general the health facilities in the whole region are not fully utilized.
Recommendations:
• A sustained commitment of technical support to the regional health authorities by UN agencies and the central Ministry of Health (MOH) is imperative. This could be provided in the form of seconding health planners and public health experts on communicable diseases to the region for a substantial period of time, approximately up to two years. The involvement of the specialized health agencies is a pre-requisite to initiate the attainment of effective institutional capacity in the long-term.
• Structured lines of communication and the establishment of an effective networking between political entities (DPPC, DPPB and DPPD) and the health authorities at central and regional levels should be devised. At present the interaction between DPPC and MOH is very weak. There should not be any duplication of functions, roles and responsibilities between these institutions and the need to introduce an organizational system that guarantees checks and balances is urgent.
• The regional health authorities should play the lead role to effectively co-ordinate the response and maximise impact in the region. There is a room for the Office of the Coordination of Humanitarian Affairs (OCHA) to assist the government in co-ordination modalities and effective mechanisms that could be utilized to bridge the existing gap among governmental entities.
• The provision of sustained training of the nationals and the introduction of evidence-based interventions are key requirements for any success. The training programme should focus on the priority health needs of the region including the following issues:
▪ Development of a simple and effective health information system.
▪ Standardisation of case management in all zones.
▪ Capacity building geared towards health management, administration, planning and co-ordination requirements.
▪ Prioritisation of health needs based on well-defined indicators.
• Further expansion of the health facilities coverage should only be undertaken with a very strong justification based on a quantified need. This will mean that there should be a moratorium on new constructions of hospitals, health centres and other infrastructural facilities in the whole region. We need to address the health development of the region within the context of available resources and the absorptive capacity of the local institutions. All efforts should be geared towards making existing facilities to be fully utilized and properly functioning. It is easier to build a health facility but to make it fully operational is a daunting task.
• An important area that needs to be strengthened, equipped and properly staffed is the laboratory service. This area should specifically targeted, developed strategically taking the realties on the ground.
EARLY WARNING SYSTEMS AND PREPAREDNESS
At present the region is not prepared for any disaster or emergency. Preparedness for sudden population displacement is critical and should be targeted at the most important public health programmes identified in previous emergencies: malnutrition, measles, diarrhoeal diseases, malaria, ARI, and other communicable diseases (e.g., meningitis) that result in high death rates. Preparedness requires that planning for emergencies be included as an integral part of routine health development programmes in countries where sudden displacements might occur. These programmes include:
• Effective health information system
• Diarrhoeal disease control programmes
• Expanded Programmes on Immunisation (EPI)
• Control Programme for endemic communicable diseases
• Nutrition programmes
• Continuing Education Programmes for health Workers.
National public health programmes should include detailed contingency planning for sudden emergencies and population movements, both internally and from neighbouring countries. This was not the case for the regional health authorities in the Somali National Regional State, and the region was not prepared for the emergency. No allocation of resources was made within the regional budget for the fiscal year of 1999 - 2000.
OTHER VITAL SECTORS (Water, Sanitation etc.,)
An adequate water supply and an appropriate sanitation programme are crucial components of attempts to prevent disease and protect health and, as such, should be among the highest priorities for relief workers and the local authorities in the region. Urgent inputs are needed particularly for the water, sanitation, livestock and agriculture.
The emergency situation is not yet over and a full recovery of the population from the drought consequences will take longer. This implies that a concerted effort is needed to broaden the response in other vital sectors rather than food aid. It is time that those developmental agencies such as WHO, UNDP, FAO and others should step in, and consolidate the gains of the emergency response with the application and implementation of best practices. This must include the provision of appropriate training of the local authorities and enhancing institutional capacities for setting up sustainable systems
CONCLUSIONS.
The response of the international community and the Government of Ethiopia has been very effective. Surely it has averted unnecessary deaths that may have otherwise would have occurred. However, the overall health situation of the drought-affected populations is far from being staple. The potential for outbreaks is still imminent and communicable diseases such as diarrhoeal diseases, acute respiratory infections and dysentery remain the leading causes of morbidity and mortality. This is also compounded by the weak capacity of the regional and zonal health authorities. The emergency response is not yet complete, as the health situation of the targeted population still remains very critical and fragile.
ACKNOWLEDGEMENT
The author will like to express his appreciation to the regional health authorities for their unlimited support, and their willingness to share their constraints, weaknesses and strengths with transparency. Also is important to extend thanks to the Emergency Unit Co-ordinator, UNICEF and WFP teams in Gode town who unreservedly offered unequivocal support during the mission. Finally my sincere appreciation goes to the drought-affected populations in Gode, Denan and Shinnile who diligently and uncomplainingly coped with so many surveys and assessment missions by outsiders asking the same questions all the time.
Mohamed W. Dualeh MD MPH
WHO Special Public Health Adviser for OCHA
Ethiopia/Addis Ababa.
3 - 12 September 2000
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