directorate general of health services, ministry of health & family welfare welcome to...

Directorate General of Health Services, Ministry of Health &

Family Welfare

Welcometo presentation of

Directorate General of Health Services

Ministry of Health & Family Welfare


Family Welfare

Flood Impacton

Health & Hygieneof Rural Areas :

Mitigation Mitigation OptionsOptions

September 2004, Dhaka


Family Welfare

BackgroundFlooded area of Bangladesh in different yearSource: Bangladesh Water Development Board

Flooded area of Bangladesh in different yearSource: Bangladesh Water Development Board

2004

• Flood hits Bangladesh almost every year or every few years• Only the area or intensity differs• The people in area, where flood hits, suffer the same pain• The relief and medical operation teams in the affected area play the same role• In 1998, flood control room at DGHS office needed to work from June to

December : a full half year leaving aside many important regular activities• Can a country like Bangladesh afford such burden every year?


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The Issues

• How flood impacts the health and hygiene situation in our rural areas?

• How did we handle the 2004 flood?• Can MOHFW alone control those health

and hygiene impacts?• How can we improve medical care

during flood, minimize negative impacts, and continue health development activities?


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FloodTrapFloodTrap

Flood Impact on Health & Hygiene

Home goes under water

Toilets become

unprotected

Human & animal

excreta, rubbish &

contaminated soil mix with

water

Open defecation increases

Tube wells and safe water

sources are submerged

Cooking becomes difficult

People suffer from food shortage

Movement becomes difficult

Rural Area

Bathing, washing

and playing in flood water cause

disease


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Flood-borne Morbidities

• Water & Food-borne diseases

• Respiratory infections

• Skin diseases• Eye infections• Drowning• Snake bites• Accidents• Malnutrition

Flood Impact on Health & Hygiene…

Water & food-borne diseases

Diarrhea, dysentery, cholera, jaundice, typhoid,

helminthiasis

Scarcity in food supply &monotony of uncooked food•Malnutrition of vulnerable groups (children, pregnant and lactating mothers, elderly and sick persons)

•Lower immunity > More infections


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• Many people live in small areas of flood shelters• Sanitary condition is compromised with respect to cleanliness, food hygiene, toilet, safe water and vector control

• Water/food borne diseases, scabies and respiratory infections spread• Privacy problem forces lactating mothers to delay breast feeding their young babies leading to child malnutrition

Over-crowding & Poor Hygiene in Flood Shelters


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•Difficulty in food procurement, and seeking care in medical emergencies and for expecting mothers (antenatal, child birth and postnatal)

•Flood teams find difficulty to move to fields with logistics

•Disruption of normal health, family planning, nutrition and health education activities (center-based and domiciliary)

•Long term outcome: Population, Malnutrition, Maternal mortality, Low birth weight babies, Stunted children

Transportation Problem


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Other Impacts


• Physical damage of health facilities• Deployment of important personnel and staff to field: Delay in routine decision making and services

• Active news media: More attention of Govt. to field Plus Negative international image as flood prone country > Decreased foreign investment

• Alert politicians and public representatives: More attention of Govt. to field > Pressure on limited manpower and resources

• Loss of crop, fish, animal & poultry: Malnutrition affecting specially vulnerable group (children, pregnant women, elderly, sick persons)

• Temporary loss of employment: Poverty and malnutrition• Soil contamination: Intestinal parasites > Malnutrition• Environmental pollution: Health hazards• Loss of household assets: Poverty > Psychological stress


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Flood Impact in Quantitative Terms

Loss of logistics (2004)

Medicines & Supplies

MOHFWMOHFW

Physical damage(2004)

DGHS: ~Tk. 32 crore

Source: DGHS, MOHFW (as of Aug 25, 2004)

No. of deaths (Flood 2004; On 25-8-04)Disease No.Diarrhoea 91Pneumonia 92Snake bite 85DrowningDrowning 202202Dysentery 0Jaundice 0Skin disease 0Eye disease 0Total 475

Flood 2004

No. of cases of different diseases in 2004 flood215,848

19,40051,430

931 2,41835,514

7,976

Diarrhoea Pneumonia Dysentery Jaundice Dengue Skindiseases

Eyediseases


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Flood Impact in Quantitative Terms…

2004 Flood : No. of diarrhoea cases by date


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Comparison of month-wise diarrhoea case load in 1998 and 2004

85,782

84,917

101,846

129,437

132,072

139,671

143,742

199,038189,810195,296

373,525

283,481

135,5

3612

9,802

150,2

92 182,2

5417

7,515

141,8

64

49,954

181,0

80

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Y1998 Y2004 (up to Aug 30, 2004)


Family Welfare


Year-wise number of diarrhoea cases (1998-2004) (as of Aug 30, 2004)

2,215,255 1,958,844

2,599,225

2,287,263

1,081,847

Y1998 Y2001 Y2002 Y2003 Y2004


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Year-wise number of diarrhoea deaths (1998-2004) (as of Aug 30, 2004)

2,752

823 1,022

1,282

471

Y1998 Y2001 Y2002 Y2003 Y2004


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Bacterial Pattern of diarrhoea stool samples(IEDCR, Dhaka; 2004 Flood]

Division No. of samples E. coli Vibrio cholerae 01 Salmonella typhiDhaka 34 33 0 1Sylhet 20 20 0 0Chittagong 4 4 0 0Rajshahi 29 26 2 1Barisal 4 3 0 1Total 91 (100.0%) 86 (94.5%) 2 (2.2%) 3 (3.3%)

Sensitivity• No bacteria were found sensitive to tetracycline, ampicillin,

erythromycin and cotrimoxazole• Nalidixic acid and cefalexin were also less sensitive• Ceftriaxone, pefloxacin and ciprofloxacin worked well to kill the

bacteria


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Year-wise Average Daily No. of Diarrhoea Cases

5916626671219305

1998 2002 2003 2004

Year 2004 data are as of Aug 25, 2004

Year-wise diarrhoea case-fatality rates (1998-2004)

0.12%

0.04% 0.04%

0.06%

0.04%

Y1998 Y2001 Y2002 Y2003 Y2004


Family Welfare


Medical supply Quantity supplied

Water Purifying Tablets 71,17,500 pcs

Clotech solution 10,698 Lits(10,69,80,000 Lits water)

IV Saline 54,41,388 Lits

ORS 1,17,61,650 sachets

Antibiotics cap & tab 95,63,300 pcs

Antibiotic syrup 10,450 bottles x 100 ml

Eye preparation 26,700 tubes

Benzyl benzoate 38,000 bottles X 100 ml

Multi vitamin Syrup 4,800 bottles

Anti-histamines 32,54,300 pcs

Paracetamol 41,95,500 pcs

Anti snake venom 1,125 vials

Medical supplies directly from DGHS

Transport Grants

>Tk. 10 million

Flood 2004


Family Welfare

Indirect Flood ImpactFlood 2004

Time given by Hon’ble Minister, MOHFW: 11d/22d(50% days)

(Jul 23–Aug 15, 2004)Time given by Hon’ble State Minister, MOHFW: SignificantTime given by Secretary, MOHFW: SignificantTime given by Director General (Health): Full time

supervisionDeployment of senior officials: 54

DGHS: 36MOHFW: 18

No. of medical teams: 4,353(~13,059 persons)


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Indirect Flood Impact …EPI service loss

BCG: 41,544 dosesMeasles: 41,544 dosesDPT: 1,24,632 dosesOPV: 1,24,632 dosesHepatitis B (25 dist &

5 City Corps): 4,800 dosesTT: 2,18,064 dosesEPI out-reach sessions(not held): 10,384 Nos.

NNP service loss• Programme Upazila affected: 70• Community Nutrition Centre (CNC)

did not function: 3,802• Nutrition gardens damaged: 88,369• Nursery damaged: 985• 1-day old chick died: 62,355• Chicken died: 51,807

Family planning service loss• Mother & child care• Ante-natal, natal & post-natal care• Sterilization camps• Clinic based services (IUD,

Injection, Norplant)• Home visits

Postponement of health & FP training/workshop/seminars: Many

Postponement of examinations in medical institutions: all in this period

Flood 2004


Family Welfare

Diarrhoea loadcaused by flood?

Observations

Diarrhea case load (%) between mansoon/flood months and non-mansoon months

51% 41% 46% 45% 39% 42%

49% 59% 54% 55% 61% 58%

0%

20%

40%

60%

80%

100%

120%

Y1998 Y2001 Y2002 Y2003 Y2004 Expected

Mansoon months Non-mansoon months

Monsoon moths: Jun-Oct; Non-monsoon months: Nov-May


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Government Initiatives …

Flood 2004One of the best

Flood Medical Care Managements

Approach to Management• DGHS opened 24-h Disaster

Monitoring Cell• Control Room at DGHS & National

Monitoring System were strengthened

• CMSD kept open for 24h• A 24h Drug Sub-Depot established

at EPI directorate under direct supervision of Director of Primary Health Care, DGHS > Quick supply

• DG (health) closely monitored all activities


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Government Initiatives …Approach to Management

• Quick decision: Switching from water purifying tablets to solutions

• Extra production of ORS & IV fluid at IPH & in 5 NORPs in different districts under DGHS by increasing daily shifts from 1 to 3 and also by EDCL

• Outside sale of all the productions from IPH, NORPs & EDCL was cancelled and reserved for use by DGHS

• DGHS provided allocation of extra fund for boat & transportation to all districts

• Good coordination & collaboration between MPs, administration and health managers at district and upazila levels

Flood 2004


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Government Initiatives …

Approach to Management• 4,353 medical teams and

36+18=54 senior health officials deployed to work in fields

• Lists of medical team members were given to local MPs and local administration for close monitoring & supervision

• All types of leaves, workshops, seminars, both in home & abroad were cancelled

MOHFW & DGHS managed the entire

medical care service without taking

assistance from armed forces unlike in

previous floods

Flood 2004


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Approach to Management• Comprehensive and improved reports

were sent to PM’s Monitoring Cell, MOHFW, and Disaster Monitoring Cell at MOFDM on daily basis

• Key health education messages were disseminated in flood camps and flood affected areas

• All of MOHFW staffs donated 1-day’s salary to PM’s Relief Fund

• News media were kept updated

Government Initiatives …Flood 2004


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Donor & Private Initiatives

UNICEFWHOUNFPABMA medical teams

Flood 2004

UN Flood Appeal


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Policies and Regulations

Strengths• Standing Order of MOHFW for

disaster management• Standing Guidelines of MOHFW

for Emergency Preparedness and Response

Weakness• GOB & MOHFW Orders and

Guidelines need more adherence

Flood 2004


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Status of Institutional Capacity

National Public Health Institutions (viz. IEDCR, NIPSOM, IPHN, IPH)do not have adequate fundingfor flood outbreak investigations and research

Flood 2004


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Observation&

Recommendation


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RecommendationManpower strength• Fill up vacancies at rural

centersFund and Authority• Provide adequate fund and

authority to district and upazila health managers for emergency purchase, repair or rental

• Provide adequate fund to National Public Health Institutions for flood outbreak investigations and research

• Vacancy (doctors and other staff) at rural centres

• District and upazila health managers do not have fund or authority for emergency purchase, repair or rental

• National Public Health Institutions do not have fund for flood outbreak investigations and research

Observation


Family Welfare

Better Transportation• Ensure jeeps for all Civil

Surgeons and Upazila Health Managers

• Raise fuel ceiling for field managers

• Provide motor bikes, bicycles, speed boats, river ambulances, country boats, floating hospital, etc. for field service

• Many Civil Surgeons don’t have vehicles

• Fuel ceiling for field managers is very low (200 L/month)

• No UHFPO has vehicle

• Motor bikes, bicycles, speed boats, river ambulances, country boats, etc. for field service are not available

Recommendation

Observation


Family Welfare

• Many Upazila Health Complexes don’t have digital phones

• Phone ceiling is low for residence of DGHS to CS and UH&FPO

• Most district and upazila health offices don’t have fax, computer, email and photocopier, etc.

Information Communication• Provide digital phones to all

Upazila Health Complexes• Withdraw residence phone

ceiling for CS, Div. Dir (health), like DCs and Div. Commissioners

• Withdraw residence phone ceiling for DG (Health)

• Provide fax, computer, email and photocopier, etc. to all district and upazila health offices

• Provide mobile phone for field service

Recommendation

Observation


Family Welfare

Recommendation

Logistic Support• Provide umbrella,

rain coat, gum boot, life jacket and BCC materials to field staff

• Provide generator/IPS to cope with power supply problem

• Maintain adequate buffer stock of medicines and supplies in all districts

• Field staff don’t have umbrella, rain coat, gum boot, life jacket and BCC materials

• Health facilities suffer from frequent interruption in supply of electricity - These don’t have generator / IPS

• Inadequate buffer stock of medicines for disaster management in some districts

Observation


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Recommendation

Coordination• Improve inter-

sectoral coordination between different departments (viz. with customs)

• Weak inter-sectoral coordination (viz. with customs)

Observation


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Training & Drills• Provide EPR

training to health personnel and staff

• Hold regular drills

• Inadequacy of trained health manpower on Emergency Preparedness & Response (EPR)

Observation

Recommendation


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RecommendationOrientation

• Conduct orientation programme for journalists and people’s representatives

Stakeholder involvement• Involve community

people, journalists and people’s representatives in flood planning process

Responding Proportionately

• Active news media

• Alert politicians and public representatives

Observation


Family Welfare

5 crucial factors

in flood impact managements

1. Keeping people above water level

2. Preventing water contamination

3. Maintaining hygiene & sanitation

4. Supply of adequate food

5. Health care & educationMinistry of Health & Family Welfare

looks after only the last factor


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Beyond MOHFWCombating

Flood Safely

Appropriate PlanSafe housingSafe water

Safe environmentSafe and adequate food

Imaginationis more importantthan knowledge !

Alb

ert

Ein

stei

n• Integrated local flood contingency

plan prioritizing flood prone zones• Appropriate river and water

reservoir management programme• Clustered community with housing

at high levels• Innovative and safe latrines• Innovative source for all time safe

water• Standard guidelines for food supply

during and after flood• Standard guidelines for flood

shelter setup and operation• Strong and sustained health

education campaigns• Better inter-sectoral collaboration

WeNeed


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If we don’t care for River Management


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Thank you

directorate general of health services, ministry of health & family welfare welcome to...

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