Civil Society Floods Situation Report (CSFSR)

Health Situation of Sindh after the end of Relief Phase

This is ninth Civil Society Floods Situation Report prepared and released by Peoples Accountability Commission on Floods (PACF). The current report is based on the theme of health comprising synthetic approach through secondary and primary sources of data. The secondary sources used for this report are Multi Sector Need Assessments (MSNA UNOCHA), Health Initial Rapid Assessment report conducted by WHO and National Health Emergency Preparedness and Response Network (HEPRN) and Health cluster updates where as primary sources of data are based on the charter of demands endorsed by concerned stakeholders at District level received through consultations in districts Badin, Mirpurkhas, Tando Allahyar and field visits in District Tharparkar.

Report concludes the three types of the damages occurred on the health situation in flood affected areas causing further deteriorations followed as under.

a. Increase in outbreaks and alerts of diseases (Community suffering)

b. Level of Damages to Health facilities as BHUs, RHCs

c. Environment Health Damages causing unhygienic situation

As per health shelter updates by WHO During flood 2011 (epi week 33-52) 828 alerts and 63 outbreaks regarding Acute Diarrhea, severe Malaria, Cholera, Measles, Pertussis and Tetanus were reported and responded to 38% of total alerts during the flood emergency. With regard to level of damages of basic health facilities out of total of 682 BHUs in 22 Districts 224 were damaged (33%) and 111 RHCs 20 were damaged (11%). (TAY was not accessible) where as in highly hit eight districts of Sindh out of the 256 BHUs 115 were damaged resulting in 45%. Due to the water and sanitation bad situation 666,711 cases of malaria were identified and other diseases due to the saline and contaminated water caused many health issues for flood affected people.

A per report (MSNA) generated by UN OCHA, Government and other UNO agencies 35% communities affected twice in rain flood 2011 with vulnerable members of households 44% as disable, elderly and chronically ill. Governance functions related to the Health were affected 19%. 46% health facilities suffered to some extent. Water borne diseases affected 1.35 Million with Acute Diarrhea, Acute Watery Diarrhea, and Bloody Diarrhea as per DEWS report. Environment health teams reported 86% contaminated water. MNCH services adversely affected 27% of births not attended by any medical professional. Since the floods there is a 10% decrease in number of people getting water from protected sources and 5% decrease in piped water sources. 660,436 people are without access to latrines.

Maternal and child health services were found to be available in around 40% of the total health facilities with acute shortage of basic newborn kits, while 73% and 64% did not have sufficient supply of oxytocysin and anticonvulsants respectively.

As per the data collected 32% of the flood affected health facilities had adequate stocks, medicines, equipments and other consumables at least for one to two weeks while 50% health facilities reported having marginally adequate stocks. However 18% of health facilities had insufficient medicines and consumables to provide effective PHC services to the affected population. Vaccines and other stocks of injectables were found to be 32% in health facilities while 23% of facilities had insufficient availability of vaccines which needed to be replenished to ensure continued vaccination process.

As per 15 situations report currently released by UN OCHA on the prevailing conditions of health and nutrition is followed as at 27.3 per cent cases have been found suffering acute respiratory infections in Sindh. More than 75 per cent of households in flood-affected areas reportedly require continuous medical support. Nearly 99,000 moderately acutely malnourished children and more than 59,000 severely acutely malnourished children under five need to be treated While 9,800 children under five are in stabilization centres, 571,000 pregnant and lactating women need to be screened, while more than 99,900 malnourished women need to be treated.

As per recent survey conducted by UNICEF and Nutrition Cell Health Department of Sindh, It was known that flood affected people were terribly suffering the food insecurity due to the poverty and destruction to the foods stocks and crops damages during the rain flood. Regarding source of drinking water, it was found that 50.8 pc households used tub- wells, followed by 32pc who had piped water, and 17pc who used other sources such as community taps, wells and bottled water. Severe to moderate rate of iron- deficiencies anaemia in mothers was found between 0.6pc and 20.3 pc, while only 16.8 pc mothers had the desirable level of Vitamin D in Sindh. Survey showed that 17.9 pc children under five in the urban areas and 32.8pc children in the rural areas of Sindh faced with severe stunting. Forty-two pc children were found suffering from Vitamin D deficiency, while 38.6 pc were found to be Zinc deficient.

The survey confirmed that maternal and child under nutrition remains the major issue for the province where only 72 pc of the households were food insecure. Mr. Andro Shilakadze UNICEF representatives in Sindh said that a high level prevalence rate of malnutrition among women and children jeopardized not only the health and future of the children but also national security.

With regard to the funding status required for health relief it is to be found through financial tracking services that 43% have been funded in response to Flash appeal which indirectly means that we could just cover 43% health needs of the community.

Data Sources

Primary Source

1. Consultations at District Level in Mirpurkhas, Badin and Tando Allah Yar

2. Field Visits to Tents Cities in Mirpurkhas, Badin and Tando Allah yar

3. Focus Group Discussions in six villages of three districts

Secondary Sources

Rapid Assessment by WHO & HEPRN on 12^th September

Situation Report No. 15 by UNOCHA

Multi Sector Needs Assessment Report by NDMA & UNOCHA

Health Cluster Updates (WHO)

Nutrition Survey (by UNICEF and Nutrition Cell Department of Health Govt of Sindh)

Objectives of the Report

1. To have overview on the damages, responses to health situation arising out of the monsoon flood 2011.

2. To identify the response

3. To analysis the gaps

4. To impart awareness on health issues to the concerned stakeholders

5. To identify and communicate the community feedbacks to the government and humanitarian partners

6. To advocate the flood affected communities’ issues through media

7. To know the Future Planning

Background of Situation

General overview

In the aftermath of Sindh floods 2011, the provincial health department in collaboration with National Health Emergency preparedness and response network (NHEPRN) cabinet division and WHO carried out initial rapid needs assessment in 22 flood affected districts. WHO carried out the assessment throughout these districts through the assessment tool approved by NHEPRN. The objective was to provide a quick overview of health services available to the affected population in different districts and various health issues that have arisen as an aftermath of the devastation.

The information generated through the initial rapid assessment covers the entire geographical dimensions of the disaster, affected population and vulnerable groups as well as the accessibility to health facilities, existing services and information on water quality and sanitation.

The data collection was undertaken from 8^th to 12^th of September 2011 based on information provided by the EDOs-Health in 22 affected districts of Sindh. The information was jointly compiled and analyzed by WHO and NHEPRN.

Highlights as per report

Around 5 million people (4,966,966) have been affected due to the recent heavy monsoon in Sindh; estimates of 31% of flood’s affected population are females as compared to 27% males.

Based on the Initial rapid assessment, out of total of 682 BHUs in 22 Districts 224 were damaged (33%) and 111 RHCs 20 were damaged (11%). (TAY was not accessible)

During flood 2011 (epi week 33-52) 828 alerts and 63 outbreaks were reported and responded to 38% of total alerts during the flood emergency. (WHO report) In highly hit eight districts of Sindh out of the 256 BHUs 115 were damaged resulting in 45%.

Out of the 35 RHCs in highly hit eight districts namely Badin, Tando Allahyar, Tando Muhammad Khan, Sanghar, Mirpurkhas, Umerkot, Shaheed Benazirabad and Tharparkar eight were highly damaged resulting in 23%.

Figure1: Affected population per district (October PDMA&UNOCHA)

S#	District	Affected Population
1	Badin	722,901
2	Shaheed Benazir Abad	983,961
3	Mirpurkhas	195,422
4	T.M Khan	111,037
5	Tando Allahyar	135,256
6	Umerkot	646,257
7	Sanghar	318,809
8	Tharparkar	890,643
Total		4,004,286

Figure-2: Districts with vulnerable groups

S#	Districts	Vulnerable Categories	%
1	Badin	Unaccompanied Elders	18%
2	Mirpurkhas
3	Umerkot

1	Badin	Unaccompanied Minors	18%
2	Mirpurkhas
3	Umerkot
4	Tharparkar

1	Badin	Chronically ill (7 districts)	36%
2	Mirpurkhas	Sever Disability (7 districts)	32%
3	Umerkot	Sever Disability (7 districts)	32%
4	Tharparkar	Marginalized Groups/Political/religious & ethnical and others (7 districts)	32%
5	Shaheed Benazirabad
6	Sanghar
7	Tando Muhammad Khan

Figure-3: Status of Damages of health facilities per District

S#	District	BHUs		%	RHCs		%
S#	District	Total	Damaged	%	Total	Damaged	%
1	Badin	37	19	50	11	3	27
2	Mirpurkhas	38	19	50	5	1	20
3	S,B Abad	36	18	50	8	2	25
4	Sanghar	56	28	50	5	1	20
5	T,M Khan	14	7	50	3	1	33
6	T,A,Y	14	6	43	1	0	0
7	Tharparkar	31	9	29	2	0	0
8	Umerkot	30	9	30	0	0	0
Total		256	115	45%	35	8	23%

Figure-4: Brief Description of alerts and outbreaks for most common diseases

Alert/Outbreak	AWD (Cholera)	Measles	Malaria	Pert sis	Tetanus/ Neonatal tetanus
# of Alerts	247	497	13	91	92
# of Outbreaks	96	55	1	15	-
# of Cases recorded	500	1434	666711	534	95

Figure-5: Availability stock of Medicine, equipment, consumables, and vaccines

District	Availability of stock Medicine/Equipments & Consumables	Stock available for	Availability of stocks of Vaccines/Injections & Equipments	Stock available for
Badin	Sufficient	4 Weeks	Sufficient	4 Weeks
Mirpurkhas	Marginal	1 Weeks	Marginal	1 Weeks
Sanghar	Marginal	3 Weeks	Marginal	4 Weeks
T,M Khan	Insufficient	2 Weeks	Insufficient	2 Weeks
T,A, Yar	Sufficient	2 Weeks	Sufficient	4 Weeks
Tharparkar	Marginal	4 Weeks	Marginal	N/A
Umerkot	Marginal	2 Weeks	Marginal	2 Weeks
S,B, Abad	Marginal	2 Weeks	Marginal	2 Weeks

All the districts designated as “Most Affected” required immediate and urgent mitigation measures to safeguard and protect the health of the affected communities. This required close collaboration between departments of health and water agencies as well as partnerships with the other relevant national and UN agencies for taking the appropriate mitigation measures as well raising awareness almost communities in safeguarding and protecting their health.

Current Situation (Figures to ponder on)

AS per current Situation report of UNOCHA 15 (Figures to ponder on)

Acute Respiratory Infections (ARIs), which are the leading cause of morbidity (at 27.3 per cent of the total) in Sindh, are on the rise across the province, and need for an urgent response. The results of the MSNA indicate that flood-affected people remain at risk of vector-borne diseases such as malaria and dengue.

There is a need for a full resumption of primary health-care services in rural areas where people have returned to their homes. More than 75 per cent of households in flood-affected areas reportedly require continuous medical support. 928,000 children under five need to be screened.

Nearly 99,000 moderately acutely malnourished children and more than 59,000 severely acutely malnourished children under-five need to be treated. While 9,800 children under-five are in stabilization centers.

The cluster notes that 180 centres for Outpatient Therapeutic Programme (OTP) and Supplementary Feeding Programme (SFP) as well as eight stabilization centres need to be established.

571,000 pregnant and lactating women need to be screened, while more than 99,900 malnourished women need to be treated.

Current Report of UNICEF on Nutrition status after the flood 2011

On 10^th of January 2011 public health experts called for comprehensive plans and better coordination among various departments to improve the state of the nutrition among children and women in Sindh keeping in view the findings of the National nutritional survey.

DISEASE SITUATION DURING FLOOD 2011 – SINDH PROVINCE (Week 33 to 52)

Since the beginning of flood (week 33 to 52, 2011) from 10 August to December 2.2 million consultations have been reported to the Diseases Early Warning System (DEWS) from the eight severely flood affected districts in Sindh province. Weekly trend for Diarrheal Diseases (DDs) remained lower during flood 2011 compared to flood 2010 but remained higher than DDs trend for non flooding year 2009 for same flood weeks 29 and 52 (2010 & 2011). To respond the situation, DoH established 177 medical camps (66% mobile and 33% fixed) in FADs.

Situation Highlights:

The overall trends were on rise for SD, (DDs) and Sever .Malaria during the year 2011, whereas trend was on slight decline for Acute Respiratory Infection (ARI).

Weekly trend for DDs remained lower during flood 2011 compared to flood 2010 but remained higher than DDs trend for non flooding year 2009 between flood weeks 29 and 52. Burden of DDs during week 52 remained same in comparison with DDs burden during epi week 52, 2010.

DEWS alert generation system has detected investigated and responded 2199 alerts and 400 outbreaks in Sindh province during the year 2011. Of these, 729 water borne disease alerts (678 AWD) and 202 vector borne disease alerts were reported (135 Dengue cases).

During flood 2011 (epi week 33-52, 2011), 828 alerts and 63 outbreaks were reported and responded, constituting only 38% of total alerts during the flood emergency.

AWD and Dengue were remained leading alerts reported from (Flood Affected Districts) FADs and rest of the Sindh during year 2011.

Most of the measles alerts and confirmed outbreaks were reported between epi weeks 5 and 25, 2011. (Before the rain flood 2011)

WHO Response Flood Response

To respond water borne and vector borne outbreaks, WHO have provided essential medicine support for DoH to cover more than 0.23 million consultations in OPDs since flood emergency started. These supplies include 86 DDKs (Diarrheal Disease Kits), more than 0.25 million anti malarial tablets and more than 2.5million assorted medicines to cover general OPD cases. WHO has also supported Department of Health with 3,050 Anti snake venom (ASVs) for snake bite and 100 ARV for dog bite cases in flood affected districts. WHO continued their support for flood affected people and distributed following items through NGOs/INGOs and/or WHO district teams including DEWS Surveillance Officers.

To respond the situation with worsening diarrheal disease and Acute Respiratory Infection (ARI) burden, WHO responded with establishment of 9 DTC centers and 22 ARI centers in Sindh province, Since emergency WHO has provided following supplied to cover more than 7.2 million population in flood affected districts.

To respond water borne and vector borne outbreaks, WHO have provided essential medicine support for DoH to cover more than 0.79 million population since flood emergency started.

These supplies include 95 DDKs (Diarrheal Disease Kits), 80 EHK, more than 0.54 million anti malarial tablets and more than 3.3 million assorted medicines to cover general OPD cases.

WHO has also supported DoH with 3,150 ASVs for snake bite and 300 ARV for dog bite cases in flood affected districts?

WHO continued their support for flood affected people and distributed following items through NGOs/INGOs and/or WHO district teams including DEWS Surveillance Officers to cover flood affected districts.

Table-6: Frequency of Consultations to each drug and Treatment.

Items	Distribution	Consultations Covered
DDK	95	47500
ASV	3150	630
ARV	300	60
Primaquine	271000	19357
Artimether/Lumefantine	3570	3570
Total	278115	71117

Gaps & Constraints:

Projects under the Health Cluster are funded at 43 per cent only during the relief work. Lack of adequate funding is a major challenge to continued provision of emergency health-care assistance, especially in eight worst-affected districts that require continuous support to improve access to health services, facilitate the resumption of primary health care services and ensure continuous surveillance of communicable diseases. In addition, health-care services need to be complemented with increased water, sanitation and hygiene interventions in the flood-affected districts, including villages with returnees.

BHUs are supposed to be the nearest health facilities to the flood affected communities have been observed lacking the trained staff, medicines, equipments, vaccines and other necessary supplements to cope up with the basic health care community needs in emergency.

Field Findings& Observations

Peoples’ accountability commission on floods arranged consultations in flood affected districts namely Badin, Tando Muhammad Khan, Mirpurkhas and Shaheed Benazir Abad to help the flood affected people to conclude the charter of demands of respective districts. Besides it Nao kot fort camp based at Mithi and tents cities, spontaneous camps were also visited in Districts Tharparkar and above mentioned four districts to observe the critical situations flood affected peoples were undergoing.

A heart breaking situation was observed in Mithi Fort camp where more than 22 children died out of the winter and medical complications. Although a mobile medical camp was established there but with inadequate medicines and trained staff. Only a caretaker of the medical camp was found there. When asked about the medical facilities awarded to them during the emergency, the flood affected community cried over the apathetic response of government and humanitarian partners over the response in health issues.

Mai Changani took us to the graveyard in the camp where graves were found of the children died in the camp and were not assisted medically. Community cried over the unavailability of the Vaccines for snakebites and reported many casualties due to the snake bites.

Due to the contaminated water and unavailability of protected water many water born diseases were found in village lanwari sharif district Badin and it was cried by the akhtar Ali that neither our land nor our drinking water safe due to the attack by LBOD.

Ibrahim colony near the city TandoAllahyar is yet under water due to contaminated water standing and people are suffering in hygiene situation and malaria has been considerable reported during the Focus group discussion. More than four months have crossed the flood but yet UC Bukera Sharif, Jhando Mari and Chamber were found under contaminated water causing many environmental and health issues.

Health situation has been found rather worse where people has returned to their place of origin yet under contaminated water and saline water with no food and health assistance in season of winter. The cases of Malaria and waterborne deceases were found in village judo and others in District Mirpurkhas.

With regard to unhygienic practices of bathing and hand washing adopted particularly in the areas where houses have been completely destroyed or in spontaneous camps the people are suffering viral diseases especially malnourished children and elderly ill.

In villages sindhri and Hussain bux mari the situation of malnourishment was found where specifically pregnant women, lactating women. Elderly and children under five were suffering inadequate medical facilities and nutritious diet.

Due to the unsound diet taken by children and pregnant women it was found that children were lacking sound immunization to face the awkward situation and frequency of breast feeding was declining.

EDO Health representative while in consultation demanded vaccines for dog biting because flood affected people could not buy this expensive vaccine amounting one thousands to be injected fourteen times.

Mr Gul bahar Chandio living in the village karim dad legari in District Mirpurkhas complained that BHUs are the nearest health facilities for the villagers but there are many gaps to respond the medical needs of the people as medicines, equipments and trained staff is not found there. He commentated that flood affected peoples are either diagnosed wrongly or referred to other facilities which is beyond the affordability potential for flood affected people. He requested and advised to government and humanitarian partners for makings the BHUs more strong facilities so that vulnerable and flood affected peoples can attain the proper treatment.

Charter of Demands of flood affected Communities and Recommendations

1. Provision of safe water supply by ensuring water quality and Environmental Health

2. Sustain and strengthen Disease Early Warning System (DEWS)

3. Maintain continuous supply of essential medicines and vaccines to the affected districts.

4. Establishment of diarrheal treatment centers should be sustained.

5. Measures to be taken for the control of vector borne diseases like malaria in the affected districts

6. Provision of Maternal and Child Healthcare services ensuring Minimum Initial Service Package (MISP)

7. Management of malnutrition including establishment of sentinel sites for severe malnutrition

8. Deployment of mobile clinics for areas with poor accessibility to health facilities

9. Strengthening of referral services to secondary health facilities for patients with life threatening conditions and for emergency obstetric and newborn care through provision of ambulances

10. Rehabilitation/temporary arrangements at the health facilities for the provision of primary health care services

11. Health Education/ Awareness through social mobilization and mass communication

12. Provision of psycho‐social and mental health services for the affected population

13. 180 centres for Outpatient Therapeutic Programme (OTP) and Supplementary Feeding Programme (SFP) as well as eight stabilization centres need to be established.

Future Planning

As per health cluster input it has been found that early recovery framework would be prioritized in place of relief phase in health sector from 1^st January. Early recovery framework priorities the sustainable structures for health facilities for the mid and long term interventions in health sector.

In support to ministry of health, Government of Pakistan, the World Health Organization as the health cluster lead, along with cluster partners, is ensuring the early recovery framework that

The communicable disease surveillance and outbreak response system is expanded and is robust for timely detection of disease, and prevention of outbreaks.

Stocks of necessary medicines and supplies are delivered to District warehouses, as requested by the Federal Ministry of Health (MoH) and Provincial Department of Health (DoH).

As Officially relief phase has ended up till December 2011 but yet no early recovery interventions has been made in the field. Long terms planning have been made by WHO with regard to enhance the coordination mechanism, improving access and availability of life-saving medicines, Expansion and expanding Early Warning, Accessibility to essential PHC services including MNCH/RH and immunization coverage, Restoration of the functionality of damaged/destroyed health facilities and strengthening of referral mechanisms.

With regard to meet the specific needs of the health UNICEF would focus on the nutrition issues, IOM would be responsible for health education and WHO would support health facilities with the life saving medicines, medical equipments and functionality of the basic health facilities. Yet the damaged facilities are to be recovered and flood affected peoples are lacking medicines for the diseases people undergo due to the unhygienic living context and food insecurity.

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Peoples Accountability Commission on Floods (PACF)

9th CSFSR