health in transition workshop - world health organization€¦ · scenario in the country. despite...

Transition and complexity are keyterms that could be used todescribe the current public healthscenario in the country. Despitenew conflict patterns along ethno-caste lines, Nepal appears to bemoving towards a post-conflictscenario.

Policy makers in the new interimgovernment and internationalpartner organizations are at animportant juncture, where strategicdecisions on strengthening thehealth system are being made. Inorder to facilitate sound decision-making and policy-planning duringthis period of change, WHO EHArecently organized a Health inTransition and a Disaster HealthWorking Group workshop aiming atpromoting best public healthpractice. On April 7, Nepal alsoobserved the World Health Dayfocusing on international healthsecurity.

By end of March, the EHAprogramme completed the plannedactivities of the SIDA-funded HACprogramme. An active period withan expanded team and extensivefield work had come to an end andit was time to review lessonslearned and evaluate outputs. Thisnewsletter summarizes the mainachievements with a particularfocus on distribution of emergencymedicine to vulnerable populations.Articles from IRC on primary healthcare and UNICEF on community-based therapeutic feeding highlightother pressing public healthconcerns in the country.

Health in Transition Workshop

Ms Olga Bornemisza from the LSHTMsummarizes challenges for Nepal

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Health policy makers encounter manychallenges in a period of transition.During the last ten years, Nepal hasbeen caught up in a civil war which hasgreatly affected health service delivery.Damage to the health infrastructure,inadequate and ill-equipped healthstaff, lack of supervision and limitedoutreach services have reduced thesupply of essential health services. Atthe same time, restricted mobility andlimited access to health facilities dueto security concerns have reduced thedemand for health care, especially inremote districts and among vulnerablegroups. These are some of the mainhealth challenges for the current andfuture governments in the years tocome.

In view of the changing politicalscenario, EHA arranged a one-day‘Health in Transition’ (HIT) workshopto sensitize health planners andprogramme managers on policy issuesand operational priorities related toworking in a post-conflict setting. Inorder to share international experiencesand latest research with keystakeholders, EHA requested theConflict and Health unit at the LondonSchool of Hygiene and TropicalMedicine (LSHTM) to assist in theplanning and implementation of theworkshop.

Discussions primarily focused on theimpact of conflict on the health system,the nature of the post-conflict transition,the gap between policy and reality, andbarriers to policy implementation, in

particular those related to conflict.Views varied widely on the impact ofthe conflict from ‘considerable impact’to ‘less impact than other sectors’, to‘actual improvement in some areas’.

Participants also debated whether Nepalis experiencing a post-conflict transitionor not. Some felt this is the case, whileothers stated that the transition is from

an old conflict to a new conflict. Thisnew conflict pattern was regarded to bepotentially more disturbing than the oldbecause of divisions between themultiple ethnic and caste-definedgroups. Recent Terai protests haveresulted in large scale violence whichhas led to disruptions in health servicedelivery and caused access problems forhealth seekers, health providers and theUnited Nations.

Finally, participants discussed therelevance of the current health policiesand practices. Most participantsexpressed that health policies such asthe ‘Nepal Health Sector Programme -Implementation Plan 2004-2009’ were

Emergency and Humanitarian Action (EHA) Newsletter - Issue XI, April 2007

Emergency Medicine to Vulnerable Populations

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adequate to solve existing problems. Only a minority feltthat the policies should be changed. The main problemidentified was lack of commitment to implement the policy.Barriers to implementation were seen to be mostlystructural, for example, human resources, absorptive

by the Director General of the DoHS, and focal personsfrom the Ministry of Health and Population, Ministry of HomeAffairs, relevant DoHS divisions, UN organisations andexternal development partners participated. The mainobjective of these discussions was to coordinate ongoinghealth interventions to avoid duplication.

WHO was requested by the Director General of DoHS toassist in providing essential medicines to vulnerablepopulations in and around the cantonments. Respondingto this request, on 6 February EHA supplied four NewEmergency Health Kits to the Logistics Division of DoHS tobe distributed through relevant regional medical stores.These kits are able to treat 40,000 people for three months.The medicines were procured through EHA’s CAP fundsdonated by the Swedish International Development Agency(SIDA).

capacity, financing and decentralization. Some of thereasons identified for low implementation were conflictrelated: lack of access due to insecurity; the interferenceof rebels and security forces in health service delivery;harassment and detainment of medical staff; and politicaldisruption of health sector stewardship.

A sudden influx of population constitutes a public healthrisk. When in November 2006 an estimated 31,000combatants from the People’s Liberation Army settled in 7new cantonments and 21 satellite camps throughout thecountry, health professionals were concerned about theirwell being. These concerns were substantiated by mediareports of outbreaks.

Locations of the 7 main cantonments:

Division VDC District

1 Chulachuli Ilam / Jhapa 2 Dudhauli Sindhuli 3 Jurpani Chitwan 4 Rakachuli Nawalparasi 5 Dhaban Rolpa 6 Dasrathpur Surkhet 7 Masuriya Kailali

Given that Nepal’s primary health care system is not strongenough to support a suddenincrease in people accessingperipheral health facilities,the government needed toidentify innovative methods toaddress public healthchallenges related to thesecantonments. While long termplans for health servicedelivery were being planned,immediate needs had to beaddressed to avoid excessmortality and morbidityamong vulnerable groups.

The Department of HealthServices (DoHS) formed acommittee to manage healthcare in the cantonments andproposed to establish primaryhealth care in these sites.The meetings were chaired

The map below indicates where the medical kits have beensent:

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Highlights of the WHO HAC Programme

EHA team in front of the UN House in Pulchowk, Lalitpur

By 31 March, EHA completed the SIDA-funded HealthAction in Crises (HAC) programme under the ConsolidatedAppeal Process (CAP) 2005-2006. A busy year came to anend and it is time to recap and reflect on the achievementsand challenges for future public health interventions relatedto crises.

The change in the political climate greatly affected thedirection and implementation of the programme. ThePeople’s Movement in April 2006 meant that several roundsof planning was necessary before the HAC programmefound the formula for integration of the four original CAP-proposals as well as combine assessments withinterventions, procurements with training and long-termcapacity-building with short-term crisis response.

To implement the HAC programme, EHA expanded from atwo to a nine member team by August 2006. In-housetraining and baseline field assessments were required toenhance the technical skills and local knowledge of theteam. Consultants from the London School of Hygiene andTropical Medicine contributed to the exercise by highlightingpublic health challenges and priorities.

In summer 2006, the programme scaled up field work byconducting comprehensive assessments in 8 districts inall parts of the country. Collection of both quantitative andqualitative data provided indispensable input to theprogramme and prepared the team to undertakechallenging tasks such as flood response in Septemberfollowed by malaria outbreak response in October 2006.

EHA also designed a consultative training packageconsisting of four modules focussing on disastermanagement training for District Disaster ReliefCommittees, emergency patient care training for healthfacility staff, public health training for Rapid ResponseTeams and disaster drills for all of the above categories.The first three modules were field-tested in Nepalgunj andIlam during November and December 2006.

At central level, EHA strengthened coordination byrevitalizing the Disaster Health Working Group (DHWG),organizing frequent Emergency Health and Nutrition WorkingGroup (EHNWG) meetings, publishing bimonthly newslettersand carrying out a stakeholder analysis. Bringing togetherhumanitarian INGOs and health officials was particularly

rewarding in terms of bridging the gap between developmentand humanitarian interventions. EHA also coordinated thehealth sector input to the transitional support appeal thathas resulted in significant funding for agencies providinghealth interventions in Nepal.

At the beginning of January 2007, a Public Health Logisticianjoined the team to assist in procurements and distributionof emergency supplies as reported elsewhere in thisnewsletter. Simultaneously, EHA pre-positioned essentialsupplies and equipment for future disaster response.

Building on a nation-wide assessment of zonal, regionaland central hospitals throughout the country, EHAintroduced emergency planning and triage at majorhospitals in the country. Distribution of triage tags wasfacilitated by the design of triage kits for district and centralhospitals. Another highlight of the programme wascollaboration with Nepal Red Cross Society (NRCS) tostrengthen the capacity of 20 district chapters to providefirst aid services.

Most importantly, almost one thousand trainees took partin SIDA-sponsored courses organized by the B P KoiralaInstitute of Health Sciences (BPKIHS), Society of PublicHealth Engineers Nepal (SOPHEN), NRCS, HospitalPreparedness for Emergencies (HOPE), Epidemiology andDisease Control Division (EDCD) and EHA.

Although the HAC programme delivered significant resultsthere is still a long way to go before the health system iscapable of providing adequate assistance to people in need.


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Quality Health Care in Surkhet- By Mr Chip Barnett, Nepal Health Coordinator, IRC

The International Rescue Committee(IRC) has been working in Surkhetsince August 2006 on an ECHO-funded one-year emergency projectto address degraded health care inSub-Health Posts (SHPs) in remoteVillage Development Committees(VDCs). The deteriorated buildings,insufficient drugs, inactive localmanagement committees, absenceand poor training of health staff havecontributed to ad hoc health caredel ivery provided to the ruralpopulations.

Drug re-supply in Kalyan VDC SHP

Participatory training exercise in MaintadaVDC, February 2007

After conducting an initial assessmentlast year in 24 out of 50 VDCs inSurkhet, IRC and its localimplementing partner (Dalit PiditMahila Kalyan Samaj – DPMKS)decided to concentrate on 15 VDCs.The strategy has been two-pronged:make immediate improvements andsimultaneously build capacity for thefuture. As a ‘quick-fix’ to the accessissue, IRC is rehabil itating SHPbuildings, making one-time donationsof drugs and equipment, andproviding kits and equipment to femaleSHP health staff and volunteers.

To facilitate lasting change, the drugdonation acts as a seed in supportingthe government’s Community DrugProgram (in which patients pay fordrugs to support future purchase ofdrugs; drugs will be provided free topeople who cannot afford them). Toaddress staffing issues, IRC in

conjunction with the District PublicHealth Office provides training to allSHP staff and female volunteers. Thisincludes sending doctors to the fieldto spend a week at a time enhancingthe clinical skills of the persons incharge at the SHPs. The project alsoworks with trained HealthManagement Committees (HMCs) toenergize them and encourage themto take responsibility for their SHPs.

A key component of the project’sstrategy is to enable long-term change

Assessments:√ Baseline assessments of the capacity of health facilities

in 8 districts to respond to crisis √ Assessments and response to the floods in

September and the malaria outbreak in October2006

√ Assessments of mass casualty managementcapacity in all zonal, regional and central hospitals

Coordination and Information Management:√ Disaster Health Working Group revitalized√ Emergency Health and Nutrition Working Group

established√ Stakeholder analysis conducted√ Bi-monthly newsletters publishedGap-filling:√ Emergency medicine for 40,000 people distributed to

vulnerable populations√ 20 remote district chapters of Nepal Red Cross Society

equipped with basic supplies and equipment to deliverfirst aid and respond to crisis

√ 10,000 triage tags printed, 100 triage kits designedand distributed to 19 major hospitals throughout thecountry

√ Emergency planning introduced at zonal, regional andcentral hospitals

√ Basic logistics in place to respond to recurring seasonalemergencies including field equipment, diarrhoeal kitsand water quality testing equipment

√ Operational capacity to field 2 public health teamsCapacity-building:√ Public health research collaboration established with

the Conflict and Health unit at the London School ofHygiene and Tropical Medicine

√ 15 district Rapid Response Teams trained on publichealth in emergencies

√ Innovative training on disaster management, emergencycare and public health in emergencies delivered toDistrict Disaster Relief Committees, hospital staff andRapid Response Teams in 2 districts

√ Almost 1,000 health professionals and first responderstrained in public health in emergencies

√ 1,000 posters on myths and realities in natural disastersand dead body management printed in Nepali anddistributed to health facilities

√ Existing public health guidelines and a new environmentalhealth in emergencies publication distributed to healthofficials

Key Achievements of the HAC-programme


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Disaster Health Working Group WorkshopThe Disaster Health Working Group (DHWG) workshop tookplace 21-22 March 2007. The meeting was organised bythe Director General of the Department of Health Servicesin collaboration with the Epidemiology and Disease ControlDivision (EDCD) and the EHA programme. Participantsincluded health officials and representatives from UNorganisations, international organizations and NGOs.

The objective of the meeting was to bring together theDHWG members and key stakeholders working on healthsector disaster management to discuss how tooperationlise the ‘Emergency Preparedness and DisasterResponse Plan for the Health Sector’ (2003) and decidethe future direction of the working group.

The workshop was scheduled to be held at Hyatt RegencyHotel but due to an industrial strike, day one’s technicalprogramme had to be cancelled and the venue for daytwo changed to the Staff College Hall in Jawalakhel.Restricted access, uncertainty about venue and logisticchallenges limited the number of the participants to 50.Furthermore, the change of Director General the nightbefore the event meant that the workshop took place inabsence of the chairperson of the DHWG.

The chief guest of the opening ceremony was the HealthSecretary, Mr Ramchandra Man Singh. Dr Kan Tun, WHORepresentative to Nepal, was the special guest and Mr

The official opening ceremony at the workshop at Hyatt Regency

Health action planning in Neta VDC,March 2007

in order to facilitate communitydevelopment and implementation ofhealth action plans. Mr Bimal KumarPhuyal, a Nepali participatory planningconsultant, conducted a training in lateFebruary for IRC and DPMKS staff aswell as HMC members from 14 of the15 VDCs. This training was immediatelytaken to the field and applied to develophealth action plans in each VDC.

Amod Dixit, Executive Director of the National Society forEarthquake Technology-Nepal (NSET) chaired the openingsession.

Dr M K Banerjee, Director of EDCD delivered the welcomespeech. He briefed the members on the progress of theDHWG since its inception in 1993 until it was institutionalisedin 2003-2005. He noted that this group is responsible forcomprehensive and effective inter-agency emergencyplanning as well as initiation, implementation and evaluationof necessary preparedness programmes and responsemechanisms. According to Dr Banerjee, the keyachievements of the group are:

√ Design of a national triage tag

√ Computer-based mass casualty managementtrainings

√ Development of a health sector emergency plan

√ Seismic assessments of health facilities

During the technical sessions, participants were dividedinto six groups covering coordination, logistics, emergencypatient care, environmental health, disease control, andfood & nutrition. The main output of the workshop was 12draft matrices of key preparedness and response activitiesin each technical area along with a list of actors, constraintsand an implementation plan. These matrices constitute astarting point for operationalising the health sector planand will feed into future health sector contingency planningexercises.

The health action plans includeexplicit provision for emergencyreferral networks in each VDC toensure that emergency patients andpregnant women showing dangersigns can be sent quickly to referralcenters at an affordable cost,cementing the project’s efforts toimprove access to quality healthcare even in these remote areas.

Technical session at the Staff College

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International Health Security

Every year on April 7 the World HealthDay focuses on an important publichealth issue that needs globalattention. This year, the theme wasinternational health security with theslogan ‘invest in health, build a saferfuture’. Nepal joined the celebrationsby carrying out various publicawareness campaigns.

The theme focused on howglobalization accentuates the relationbetween health and security byredefining old threats in a newcontext (e.g. polio, malaria, TB, HIV/AIDS, environmental degradation,disaster management and terrorism)as well as confronting new publichealth challenges (global warming,global ageing, double burden ofdisease, and risk of avian influenzapandemic).

Modern technology has broughtpeople from different parts of theworld together. It is no longerpossible to be oblivious to publichealth concerns of a particular

Celebration of the World Health Day at the National Health Training Centre, Teku

community or country. Similarly,communicable diseases affecting avillage in one location could threatenthe safety of a much larger populationin another location if preventiveaction is not taken. In 2003, expertswere amazed at the pace at whichthe SARS outbreak spread from HongKong to other parts of the world.

The health of a population also affectsother sectors such as trade,agriculture, and defense. The factthat the UN Security Council in year

2000 for the first time put a publichealth issue on the agenda is a casein point; it had become obvious thatthe HIV / AIDS epidemic constituteda threat to peace and security.

Not only epidemics but also extremeclimate events can pose a globalsecurity threat and have far reachingconsequences for public health.Global warming is likely to disruptrainfall patterns, compromisefreshwater supply, increase thefrequency and intensity of floods anddrought, decrease the production ofstable foods and trigger increasedmalnutrition.

Global public health challenges canno longer be addressed only by afew activists; governments,international organizations, businessand civil society need to workcollectively to confront them.Collaboration is vital to improvepreparedness and response,information sharing as well asstrengthening public health systems.

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Community-based Therapeutic Care- By Ms Eleonora Genovese, Health & Nutrition, UNICEF

Child malnutrition rates are persistently high in Nepal. Acutemalnutrition (or wasting, an indicator of sudden and acutenutritional deficit) defined by low weight-for-height hasincreased over the past five years from 9.6 percent in2001 to 11.7 percent in 2006 (Nepal Demographic andHealth Services Survey). UNICEF surveys conducted in2006 in drought-affected areas reported wasting rates ashigh as 10, 15, and 12 percent in, respectively, Humla,Jumla, and Bajura districts. A prevalence of 10 percentwasting is the conventionally accepted threshold for anutrition emergency.

Aiming at addressing malnutrition morbidity in Nepal,UNICEF recently conducted a feasibility assessment forCommunity-based Therapeutic Care (CTC) as a cost-effective strategy for malnutrition rehabilitation. The CTC-approach focuses on early identification and treatmentthrough simple medical protocols and ready-to-usetherapeutic food (RUTF) that can be administered atcommunity and household level, rather than in medicalfacilities. Experiences from other countries indicate thathigher treatment coverage, recovery rates, andsustainability can be achieved through the CTC-approach.

In view of exploring the opportunity to introduce the CTC-approach in Nepal, UNICEF reviewed current nutritionactivities, including practices for severe acute malnutrition(SAM) treatment, costs, and potential partnerships. Thefindings of the assessment indicate that treatment forsevere malnutrition is currently available through a smallnumber of NGOs and government facilities with limitedcoverage and impact. Moreover, screening methods andtreatment protocols vary significantly among providers andfrequently divert from approved standards. On the otherhand, many nutrition activities have the potential tointegrate a CTC-component, including screening andrehabilitation for severe malnutrition cases, along withcommunity-based nutrition promotion to gradually reducethe frequency and severity of malnutrition cases.

Based on consultations with nutrition stakeholders in Nepaland the findings of the assessment, UNICEF plans topromote the establishment of a task force to pilot the CTC-approach in Nepal. Stewardship by the Ministry of Healthand Population and partnership with relevant implementingand technical agencies will be crucial to effectively integrateand manage the CTC-approach.

The EHA programme at the WHO Regional Office inDelhi is preparing an online roster of national expertsfor the countries in South and South East Asia. Theobjective of the roster is to enable quick deploymentof public health specialists in the event of disasters.

Interested experts may forward their CVs to Mr ErikKjaergaard ([email protected]) indicatingareas of expertise from the list below.

Emergency public health disciplines:

a) Emergency operation managementb) Emergency communicationsc) Emergency logistic managementd) Emergency information managemente) Communicable disease control during

humanitarian situationsf) Water, sanitation & environmental healthg) Post-emergency psycho-social careh) Emergency hospital operation &

managementi) Emergency patients care management:

i) Trauma surgeonsii) Anesthesiologistiii) Orthopedic surgeonsiv) Burns care specialistsv) Public-health nursesvi) ICU/CCU trained paramedicsvii) Reproductive health specialistsviii) Emergency pediatricians

j) Forensic experts

Nepal Public Health Experts

A child recovering from severe malnutrition in a rehabilitation facilityin Kathmandu (Courtesy of the Nepal Youth Opportunity Foundation)

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