Zambia, 12-22 February 2000
In the aftermath of the influx of the Angolan refugees in the Zambian Western province, a team of WHO/ AFRO composed of Dr I.Sow (Emergency and Humanitarian Action Unit) and Dr A. Mammo, (Inter country Epidemiologist, Southern African and Indian Ocean Island countries). This field assessment was carried out jointly with Mr S.T Chisanga from the Ministry of health, Mr F. Nyircnd from the Central Board of Health and, Mr Musambo, WHO Country Office, Zambia.
The objectives of the mission were:
i) to assess the impact of the influx of refugee on the health system of the host districts in the western province of Zambia;
ii) to identify priority areas for WHO support of the Ministry of Health to cope with refugee health service demand
The team visited in Kaoma district, Mayukwayukwa refugee camp, MoH health centre, emergency treatment Centre, Mangango referral hospital, and in Shangangombo district, Sinjembela transit camp, MoH Health Centre, and emergency treatment Centre, and a settlement camp in Nangweshi. Furthermore, the team visited Senanga district hospital, which is still providing a referral service to a newly created Shangombo district.
The team had briefing and debriefing meetings with the district and the provincial administrative and health authorities in western province. In addition to these, the team held briefing and debriefing meetings with the following agencies (UNICEF, UNCHR), Ministry of Health (MoH), district and provincial administrative and health authorities, and briefing meeting with NGOs (AHA, MSF), and debriefing meeting with UNDP.
Zambia is known to host refugees of liberation struggle since mid 1960s from neighbouring countries namely: - Zimbabwe, Namibia, South Africa and former Zaire (Democratic Republic of Congo), DRC. Presently, the country is hosting more than 216,783 refugees from Angola, DRC, Burundi, Rwanda and Somalia. The majority of the refugees happen to be Angolans (171, 760, as of 25 January 2000). However these figures are rapidly changing, as the refugees continue to trickle into Zambia, almost on daily basis. More than 21000 new Angolan refugees have entered Zambia since October 1999. The screening has been carried out at transit camps set up in different entry points, to transfer the refugees to safer locations in (Kalabo, Nangwashi and Mayukwayukwa), located in three different districts of the Western Province.
It was not possible to go to Kalabo were the situation is described to have been brought relatively under control, according to the agencies involved in assisting the refugees in this particular camp. As far as health is concerned, actual support provided by MSF- Holland and others.
The demographic composition of the Western Province is being significantly changed, as a large influx of refugees have come from Angola and continue to arrive at a large number, with a ratio 3: 1, in favour of the refugees, at various sites where the refugees are being settled. The refugees who had come earlier have been integrated into the community and are benefiting from some the social and economic opportunities available to the local population (land and health service and education etc). In Nangwashi (Shangombo district) where the 9000 Angolan refugees are being settled, the refugees -to local population ration stands at 2:1, in favour of the refugees.
It has not been possible to have demographic breakdown of the refugees, however, the team has noticed a unique presence of a number of adolescents in the camps opposed to traditionally, predominantly, women, children and the elderly. In the Nangwashi camp, the staff responsible for the registration of the newly arriving refugees estimates that about 15% of the children are unaccompanied.
It is expected that influx of refugee will continue, as far as fighting between the Government of Angola and UNITA forces is continuing near the border. The actual strategy is to settle the refugees as far as possible, away from the border areas, for safety. Thus, transferring them to Mayukwayukwa in Kaoma district and Nangwashi, Shangombo district is in line with such a strategy.
2.Response to the emergency
The district health officers of Kaoma and Shangombo have supported the affected areas and provided adequate response, despite the limited resources at their disposal
From 19 November to 1st February, the Kaoma district health team made four field visits to Mayukwayukwa refugee camp to assess the impact on the local health system and the needs of the refugees. As the influx of new arrivals continues, a plan for additional number of refugees to be transferred from other locations is being co-ordinated. In awareness of this reality, social services, like the health services, are being discussed by partners for strengthening the health system to cope with the new challenge that has been caused by continuous arrival of the refugees into the areas.
As a lead agency, UNHCR is co-ordinating the over all UN response, within the framework of the contingency plan updated in September 1999. The following NGO’s have been identified as potential health care providers to the refugees: MSF Holland in Nangwashi camp, MSF- France covers the area of Sinjembela, AHA (African Humanitarian Action) in the Mayukwayukwa camp. However, AHA is not yet fully operational and, other NGOs are still at the fact- finding stage, and it may take some times before they become fully operational.
At the time of the visit to Mayukwayukwa, the health centre that had been designed to serve a population of 8000, is providing health service to more than 14,322, and the number is estimated to increase to 21, 000 in near future. The emergency health infrastructures to be set up for the refugees by AHA in Mayukwayukwa and MSF Holland in Nangwashi are not yet, operational. As a result, the refugees continue to depend on the services of the local static health institutions, which are being stretched to a breaking point.
In Nangwashi, despite the presence of a Clinical Officer in the Camp, nearly, 3000 patients have been seen in the local health centre from 31 December 1999 to 16 February 2000. The same situation is observed in the area of Sinjembela where the refugees are using the local health service.
The transfer of refugees from Sinjembela, to Nangwashi camp to a 120-km distance, was not going as smoothly as planners had hoped, due to logistic problems associated to transportation of the refugees. The 120-km distance road takes between 6 to 8 hours to transport 50 refugees per truck. The team was told that finding reliable vehicles was not an easy task for those agencies that are involved in transporting the refugees and settling them in safer areas away from the Zambian-Angolan border areas. .
The refugees basic needs such as food, water, shelter and sanitation facilities were being handled by Lutheran World Federation, Care international , which specialises in logistics on the ground, assisting the refugees with shelter and distribution of the food ration given by the World food programme (WFP). MSF is being established to provide medical care both at Sinjembela transit camp and Nangowashi settlement camp. However, there was still a shortage of food particularly, in Sinjembela, where only half the food and water ration given to the refugees. There was no therapeutic feeding for the malnourished children and was expected to be brought in soon.
UNICEF has recruited additional staff (senior clinical officers and nurses) and assigned them at Sinjembela camp, and has promised to increase number of Clinical Officer (COs), an immunisation campaign is being organised by the district health authorities. Vaccines against polio, measles have been acquired and cold chain has already been supplied. The campaign is to start as soon as all the required logistics are in place.
With the support of UNICEF and MSF Holland, the health situation at the Kalabo refugee camp is under control.
3. Public Health concerns
Background information on pre -arrival health and nutritional status of the refugees was not known. The new population was living in the areas of Angola that were cut off from the humanitarian assistance since the last out break of hostilities between the government and UNITA forces.
With a continuous exodus of new refugee from Angola, extra health services should be made available to vulnerable groups. In the absence of real census, and the demographic profile, articulating the demographic distribution of the refugees may not bean easy task. But, an attempt has been made to estimate the population as indicated in the following summary:
|Women child Bearing age||
3.1.Sustained accessibility to Health Care
The team visited Mangango referral hospital in Kaoma district, health centres of Mayukwayukwa and the emergency treatment enter for the refugees and health centres of Nangwashi and, Sinjembela, Shangombo district.
The effects of the influx on the local health services are already visible through the number of outpatients and inpatients referred to the hospitals in Senanga, Kaoma and Mangongo. The team witnessed how the local health system was over stretched to a breaking point. With the increase of the population up to 14 000 and 10.000 respectively, in the above-mentioned catchment areas. These centres are under an immense stress. The newly arriving refugees need preventive (immunisation, reproductive health etc.) and curative services. Although an sporadic support of 1 or 2 basic health kits being provided, none the less, the burden on the health personnel, the infrastructure and medical supplies, will cause a severe constraint to government health system.
Mangango hospital, which is one of the referral hospitals in the Kaoma district, is already receiving referred refugee patients. Due to the increasing refugee population in the catchment area and the endemic need for a referral system, this structure will need to be strengthened with recruitment of a medical doctor, who will be providing both the in patient and outreach services. WHO has been approached to support the cost for a medical doctor to be recruited for a period of one year. To rationalise the cost effectiveness of health service the team has advised to UNHCR and AHA that a medical doctor provided by AHA be stationed in the Mayukwayukwa health centre. Based on the current reality on the ground, it was suggested to upgrade of the health centre to stage III, as required by the standards of health system for a population more than 10.000.
Twenty five Angolan health personnel have been identified among the refugees with following competencies: medical assistant (4), analyst (1) lab assistant (2) Midwives (2) General Nurses (8), Nutritionist (5), leprosy control Officer (1), Public health specialist (1), Dental clinical Officer (1).
Newly created Shangombo district has a shortage of staffing and a severe logistic limitation, as roads are often impassable during rainy season. As result health service availability, accessibility and referral system in the district are under severe constraint. It is planned that MSF Holland (when comes on board), expected to recruit some of the Angolan staff and a refresher course will be provided by Shangombo district health team. WHO has been solicited to help in the training of these personnel that need to be
Familiarised to the Zambian health care guidelines.
The Senanga district hospital is already receiving referred patient from the Nangwashi Camp. Therefore, this referral structure will need to be strengthened to cope with the increasing patient load.
During the visit the team learned that malnutrition among the under five was a serious concern. When the team visited the newly arrived refugee camps in Mayukwayukwa 24 % of the 402 children screened presented severe malnutrition. The children observed during the visit presented obvious signs of protein energy malnutrition (PEM) and kwashiorkor. The team provided technical suggestion for an expedited intervention to prevent their situation from further deterioration. Different partners such as district health authorities and NGOs such as Lutheran World Federation (LWF) and African Humanitarian Action (AHA) responsible for health responded to the suggestions made by the team, positively:
- AHA will take responsibility for feeding the moderately malnourished children
- The severely malnourished children will be referred to intensive care at the Mangango hospital and the district health facilities to help in the provision of HEPS
- LWF in charge of food and logistics will provide the transport from the camp to the referral hospital. LWF will ensure those necessary quantities of High Energetic Porridge Supplement (HEPS) and milk for malnourished children will be made available on time. LWFP will reimburse the stock of HEPS taken from health district
These arrangements should be maintained as long as viable structures are not put in place to meet this need.
In the Sinjembela transit camp and Nangwashi camp, the level of malnutrition is reported to be low however monitoring of nutrition status of the vulnerable population should start as soon as infrastructure is in place in the Nangwashi settlement camp.
3.3 Threat of epidemic outbreak
Malaria is the most frequent encountered disease among the refugee; there is an increase in the consumption of anti malaria drugs particularly in Sinjembele camps. High number of fever of unknown origin is also reported.
There is a high incidence of bloody diarrhoea; the nature of the bloody diarrhoea appears to be crosscutting problem in the refugee population in Mayukwayukwa, Sinjembela, Nangwashi and Kalabo. Laboratory examination carried out, upon the request of the team, at the Mangango hospital confirmed shigella dysentery, type 1.
At the health centre of Nangwashi, the team identified a peculiar increase of cases of bloody diarrhoea (4 cases in 45 days with one death) among the refugee (1,800). None of these cases in the refugee population were reported as recommended by early warning system, linked to the district health information system. The Team has worked out with the Ministry of health the modalities of an investigation team to be dispatched on the 23 February with support of WHO. A protocol (Annex 2) was elaborated and agreed.
As far as the local health system is concerned, malaria, meningitis, anthrax and measles are the main public health threat reported in this area. The last epidemic of meningitis occurred 5 years ago. The province has not experienced cholera outbreak; however, shigella dysentery is known to be endemic in the province. Nalidixic Acid is the drug recommended by the Ministry of health.
The health authorities at district and central level have highlighted the need to have a support in the area of epidemic preparedness and response..
Cases of tuberculosis have been diagnosed among the refugees in Sinjembela camp. There is a fear in the districts that cases will rise overwhelmingly beyond their capacity to respond. The district is experiencing a shortage of anti tuberculosis drug for the local population. The team has also been informed that the shortage of some anti tuberculosis drug is at the national, as well.
UNHCR and the Government of Zambia undertake the overall co-ordination of intervention in favour of the refugees. However, during the field visit the team observed that co-ordination between the different partners, at the operational level needs to improve. There is communication problem among the various partners in Mayukwayukwa to address the urgent needs of the severely malnourished children. In Shangambo district a few partners stopped over at the district office to introduce themselves to the district health authorities. The provincial administrative authorities highlighted during the briefing and debriefing meetings, the importance of the co-ordination of activities, involving the government authorities at all levels, i.e. central, provincial and district. Involving the National Disaster Mitigation and Management Committee (NDMMCs), working with UNHCR and other agencies and NGOs, will enhance co-ordination and collaboration. Co-ordination benefits all the concerned parties, as it brings cost effectiveness, cohesion and consistency of the response.
4. Recommendations on priority actions for WHO support
Although the UN updated contingency plan for Zambia highlights, only the role and responsibilities of UNHCR, UNICEF and WFP, in case of influx of refugees, the team looked at areas of WHO support in the prevailing situation. This support is aimed at strengthening the national health system to be able to cope with burden due the influx of the Angolan refugees and will focus on:
- Enhance the epidemiological surveillance and epidemic management system in Kaoma and Shangombo districts through capacity building in an epidemic preparedness, response, and outbreak investigation.
- Support Kaoma and Shangombo districts to strengthen monitoring of a and supervision to improve preparedness and response to epidemic.
- Strengthen the referral system in Kaoma district through recruitment a medical doctor for Mangango mission hospital
- Provide additional drug and supplies to Mangango and Senanga district hospitals, and strengthen supervision of the district health facilities
- Support training of the Angolan human resources with health profession in the refugee settings to familiarise them to the Zambian health care delivery system.