Lesotho + 5 more

WHO Health brief on Southern Africa - Jul 2002

Format
Other
Source
Posted
Originally published


World Health Organization - Department of Emergency and Humanitarian Action
1- Health Brief and WHO's strategy

2- Regional Appeal

3- Financial overview

3- Extracts from Country specific appeals: Health situation analysis and WHO projects for:

  • Swaziland
  • Lesotho
  • Malawi
  • Zimbabwe
  • Zambia

Southern Africa: Humanitarian dimensions of the crisis

Background

The countries of Southern Africa, mainly Malawi, Zambia, Lesotho, Zimbabwe, Swaziland and Mozambique are currently facing an acute and large-scale humanitarian crisis. Drought, floods, economic degradation, increased poverty and political instability in Zimbabwe combined with a large burden of communicable diseases and outbreaks, faltering health systems, malnutrition and the highest HIV/AIDS loads in Africa, have led to increased mortality and wide suffering among at least 10 million people.

Unusually dry conditions together with erratic rainfalls (sometimes flooding) have led to crop failures and limited production, which combined with poor policies for ensuring adequate stocks, resulted in serious food shortages. Governments in Malawi, Lesotho, Zimbabwe and Zambia have declared national disasters. WFP and FAO estimate that the needs will rise more after the harvests of July and August. Adding to the food shortage, the decreasing government budgets to health, the shortage of drugs, the epidemics of cholera (the worst in Malawi for this year with more than 30,000 cases and 900 deaths), the high burden of malaria, malnutrition, diarrheal diseases and respiratory infections, and with the majority of the population (estimated at 70% in general) living with less than a dollar per day, all these make the ingredients for complicated humanitarian situation.

The past history of drought and famine in the regions especially looking back at the 1992-1993 and the 1995-1996 droughts, reminds us that these are recurring problems, that have deep rooted causes ranging from poverty and cutting across land management and governance issues. The humanitarian community usually responds quickly to such emergencies and has in the past averted many humanitarian crises. However the adequate management of these crises cannot be averted by addressing the food situation alone. As mentioned in a WFP information paper to its executive board in February 2002,

"In many of the large scale life threatening natural disasters.... , it was lack of water, poor sanitation and the risk of epidemics that correspondents highlighted in early dispatches... The nutritional impact of food aid is significantly reduced when other root causes of malnutrition are not addressed, such as inadequate health care and practices, lack of education and poor sanitation and water supplies".

Goal:

In the countries mostly affected by the current humanitarian crisis, WHO will work with the Ministries of Health (MOH) and the partners from the health sectors and from the other sectors, to reduce the avoidable loss of life and the burden of disease in this crisis. To achieve this, WHO through its country offices and the regional inter-country team in Harare will at the regional level and specifically in the countries mostly affected, will work on ensuring a Public Health approach for optimal and immediate impact.

Assessment:

The assessments undertaken by WHO and partners in Malawi and Zimbabwe, the hardest hit countries, demonstrated that the crisis is a humanitarian one not just a food shortage issue. People are dying, and not in the health facilities but in their homes (community survey in Malawi revealed a Crude Mortality Rate CMR, of 1.9/10,000). The assessment in Malawi showed that while the number of deliveries at health facilities have decreased by 7% as a symptom of the deterioration in economic accessibility, maternal mortality rates recorded in these health facilities increased by 71%, due to malnutrition and poor health status, lack of prenatal care and the weak capacity of the health system. Lack of food weakens the population, their immune system, already challenged by endemic diseases, cannot fight infections. This is reflected, in Malawi, by the severity of the cholera epidemic and the increased number of deaths encountered.

The economic degradation, that results from crop failures leads to further weakening of the purchasing power. The number of meals are decreased, the quality of the food eaten becomes questionable. With the lack of water, poor hygienic conditions and sanitation problems abound, setting the stage for diarrheal and other diseases. More so, in health facilities, there are no medicines, and also no food, patients if they can reach a health facility are not admitted, and they go home and die. In Zimbabwe, mortality rates in the assessed districts have increased over the past year among the top ten priority diseases, while outpatient attendance has been going down.

The HIV/AIDS pandemic, which has affected the Southern African countries (for instance Malawi has sero-prevalence rates as high as 30% and Zimbabwe as high as 34%) has further complicated the situation with its resulting impact on households, and on productivity. This has led to a vicious circle where malnutrition and disease take the centre stage and where the food shortage, poverty, the drug shortage and the weak surveillance system are the driving forces.

The strategy to respond to the situation in the Southern Africa region should incorporate an integrated approach for response. People are either dying or are sick and suffer from malnutrition. Reports from surveys conducted from Save the Children UK and UNICEF in Malawi report very high incidences of severe malnutrition on exacerbated by a situation of chronic malnutrition. Besides ensuring food or any other form of assistance(rations, food for work, etc.), there is a need to prevent further deaths, follow up on the diseases and outbreaks, and address the health problems of the most vulnerable (young children, pregnant women and mothers, aged persons). WHO will ensure that the quality and the contents of the food basket are according to standards, especially for essential micronutrients. Addressing malnutrition requires an integrated approach to household food security, health and care." Meeting food needs in these situations is essential, but also important is protecting people from illness and ensuring that young children and other vulnerable groups receive good care." (The silent emergency, The State of the World's Children 1998- UNICEF).

Strategy:

WHO's strategy is a two- pronged:

  • Build on a regional team that is based in Harare as part of an inter-country support team to support activities in Zimbabwe and in the region and

  • Focus intensively on Malawi, which is the hardest hit among the countries of the region.

As a first step, WHO will recruit 2 epidemiologists and 2 nutritionist to reinforce and ensure the quality of surveillance as well as increase capacity through training.

WHO will also increase its advocacy efforts to ensure that the donors give adequate attention and support to the need to invest and support agencies involved in providing health services and interventions.

WHO is coordinating with UNICEF both at regional and at country level regarding the delivery of the key Survival components of the appeal, especially health and nutrition issues (the support needed to nutrition and disease surveillance, monitoring the nutrition situation and assessing impact and progress of interventions, and water sanitation interventions, information sharing and dissemination).

Approach:

1- Strengthen the capacity of WHO to support the Ministries of Health (MOH) and health concerned partners to identify priority health and nutrition related issues and to ensure that they are properly addressed in an integrated primary health care approach that preserves and strengthens the local system.

2- Strengthen health and nutrition surveillance systems (including HIV/AIDS surveillance) to enable monitoring of any changes, early warning of deterioration and immediate life-saving approach through outbreak response and technically sound nutrition interventions.

3Advocate for the delivery of basic preventive and curative care including essential drugs and vaccines for all, giving priority to the most vulnerable areas

4- Ensure that the lessons learnt in a crisis are used to improve the health sector preparedness for future crises and disaster reduction.

Activities

For this, WHO will be starting in Malawi and in Zimbabwe, and then extending after assessment of needs in the other countries with the following:

1- Recruitment of an epidemiologist to strengthen the Country office and support MOH and partners in surveillance, training and building capacity as well as early warning for epidemics, including HIV/AIDS

2-Recruitement of a nutritionist to support the Country office, the MOH and partners in assessing the problem of malnutrition and devising adequate programs to respond to the needs.

3- Ensure a stock of essential drugs and supplies for responding to outbreaks and also supplies for safe blood transfusion (HIV/AIDS screening)

4- Strengthen and support Reproductive health programs and Integrated management of childhood illnesses (IMCI), which would ensure that diarrheal diseases and Acute respiratory infections, the main causes of infant morbidity and mortality are addressed.

The team in Zimbabwe will support the region for epidemiological surveillance and nutrition issues.

REGIONAL ACTIVITIES

WHO is planning to reinforce the inter-country team in Harare in order to support the concerned countries in the Southern African humanitarian crisis for the following :

- epidemiological surveillance, outbreak response and Nutrition surveillance through the collection, analysis, compilation and dissemination of sub-regional epidemiological Health situation

- liaising with the regional information management in Johannesburg and providing a regional picture

- ensuring that complementary approaches between the countries and cross-border activities are coordinated (including surveillance)

- Monitor Crude Mortality Rates (CMR) and one or two major indicators for Nutrition.(MUAC)

- Providing surge and field technical support if needed especially that with the start of the rainy season in November and December, all the ingredients are there for a cholera outbreak.

For these activities WHO will adopt an integrated approach by using the regular budget and the external funds for reducing mortality, morbidity due to humanitarian situation and within a sub-regional framework support the country offices as needed ensuring the link to development. WHO actions will strive to be sustainable and implemented with local human resources.

WHO inter-country team in Harare will support the ongoing collection of information related to epidemic prone diseases and will support any necessary response. WHO and UNICEF will collaborate to ensure ongoing nutritional surveillance in order to monitor the impact and progress of relief assistance.

OCHA is proposing the creation of the Southern Africa Humanitarian Information Management Service (SAHIMS), an inter-agency information and data clearing house, be established within the Regional Support Office (RSO). SAHIMS will liase with and support existing information systems such as FEWS and those of SADC and other technical bodies in the region. UNICEF and WHO will support this facility in order to achieve a more coherent approach to information management and advocacy in their areas of expertise, particularly in the area of nutrition surveillance and health information dissemination.

Summary Table of Funding Requirements for Regional Activities( as extracted from the appeal and pending completion by other agencies) :

Sector/Activity
OCHA
WHO
UNDP
Coordination
450,000
300,000
6,180,000
Logistics
1,000,000
(drugs and vaccines)
Information Management
430,000
100,000
Assessments
250,000
Total
1,650,000

Financial Overview of the Country Appeals

Country - Malawi

Population at risk: 3.2 million
Total Appeal Figure: 152,614,060
Health and nutrition
WHO Appeal: 2,931,123

WHO Projects

  • To reduce malnutrition $206,700
  • Strengthening disease surveillance $635,152
  • Strengthening of cholera epidemic response $605,366
  • Reproductive health services $442,263
  • Improving response to disease outbreaks $691,862
  • Health coordination $$349,800

Country - Lesotho

Population at risk: 500,000
Total Appeal Figure: $42,795,800
Health and nutrition: $6,816,200
WHO Appeal: $1,272,000

WHO Projects

  • Control of malnutrition and related diseases in under fives $816,200
  • Provision of safe water and proper sanitation $455,800

Country - Zambia

Population at risk: 2 million including 400,000 children and 440,000 women
Total Appeal Figure: $71,443,530
Health and nutrition: $4,235,000
WHO Appeal: $1,805,000

WHO Projects

  • Disease surveillance prevention and control

Country - Zimbabwe

Population at risk: 3 million
Total Appeal Figure: 280,837,032
Health and nutrition
WHO Appeal: $12385000

WHO Projects

  • Building health sector partnerships $378,420
  • Disease surveillance $593,600
  • Strengthening health service delivery $21,200
  • Procurement of drugs and supplies $7,763 ,175
  • Cholera epidemic response $1,113,000
  • Malaria epidemic response $1,855,000
  • Reducing maternal mortality $1,484,000

Country - Swaziland

Population at risk: 144,000
Total Appeal Figure: $19,800,640
Health: $436,500
WHO Appeal: $316,500

WHO Projects

  • Preparedness and response to cholera

Swaziland

Priorities

In this appeal, the most vulnerable and/or socially marginalized groups will be targeted. This population usually bear much of the disease burden in harsh conditions such as those associated with food shortages. They include people with less access to safe water and proper sanitation, pregnant women, children under five years of age, and people living with HIV/AIDS. In this context, priority interventions are: Diarrhoeal diseases (cholera) / water and sanitation, reproductive health, EPI, and HIV/AIDS.

Objectives

To reduce the number of avoidable deaths and the suffering among the affected population through:

Cholera prevention and control

  • To empower people at risk for cholera to prevent and manage infection with vibrio cholerae.
  • To assess water quality in affected districts and ensure provision of safe water
  • To increase health facilities' capacity to quickly detect and respond to cholera epidemics.

Integrated Management of Childhood Illnesses
  • To strengthen the capacity of health services to reach the most vulnerable communities with information and basic medicines for management of childhood diarrhoea, ARI, malaria, and skin diseases.

Reproductive health
  • To alleviate the negative impact of the food crisis on reproductive health

Analysis of need

According to the 1999 Health Statistics Report, the top four major causes of outpatient consultations were respiratory diseases, skin disorders, diarrhoeal diseases, and genital disorders. The five top major causes of inpatient mortality in the same year were pulmonary tuberculosis, diarrhoeal diseases, AIDS, pneumonia, and malaria. These data indicate that diarrhoeal diseases are amongst the most common causes of morbidity and mortality in Swaziland. Before 2000, cholera epidemics occur every 10 years but now cholera has become more frequent and its severity has increased. When people are desperate for food, hygiene practices and preventive measures against food and water-borne diseases, such as cholera, are no longer a priority. Since 2000, the health sector has struggled to establish a functional disease surveillance for early detection of cholera epidemics and timely action. Health facilities in mostly affected areas are not well prepared for rapid response to cholera epidemics and coordination mechanisms for cholera prevention and control are not functioning.

The economic stress on families due to food shortages also affects families abilities to access health services. Even though fees for primary health care services have recently been lifted, the costs of transport and time to access services in the health facilities remain too high for those most affected by the emergency, at the very time when nutritional stress increases the vulnerability especially of young children. Emergency support will seek to enhance the outreach capacity of the health services for delivery of immunization services, and to provide supervision for the initiation of growth monitoring and enhanced care by community volunteers, targeting especially the orphans and vulnerable children.

Statistics demonstrate that in times of crisis, reproductive health problems also increase. Normal social patterns are disrupted, there is an increase in sexual violence, promiscuity, and risky behaviors all of which lead to an increase of STI/ HIV transmission. Family planning activities are threatened.

Operational Objectives

  • Provide anti-cholera kits (including water jugs, disinfectants, chloramines, oral rehydration salts) to 60 communities with limited access to safe water and proper sanitation in drought-stricken areas between July and December 2002.

  • Provide 15 peripheral health facilities around drought stricken areas with emergency health kits between July and December 2002.

  • Assist Regional Health Management Teams (RHMT) to develop regional cholera epidemic preparedness and response (EPR) plans between July and August 2002.

  • Train health staff on basic epidemiology and disease surveillance between July 2002 and August 2002.

  • To reduce the likelihood of cross-infection of communicable diseases through provision of protective equipment to community health care workers.

  • To provide support for community outreach and supervision visits by health workers, and training and equipment for community cadres to carry out growth monitoring activities for children under five years.

  • To increase access to reproductive services through training and upgrading voluntary counseling and testing.

  • To reduce maternal mortality by providing emergency reproductive health kits for clinics.

Swaziland-Projects
Appealing Agency World Health Organization
Project Title Preparedness and Response to Cholera
Project Code
Sector Health
Themes Preparedness and contingency planning.
Information management.
Objective Prevent cholera and prepare adequate response to cholera epidemic in drought-stricken areas between July and December 2002
Targeted beneficiaries 60 communities and 15 health facilities around drought-stricken areas
Implementing partners WHO, MOH, NGOs, CBOs
Project duration 12 months
Total Project Budget
Funds requested US$ 316,500

In recent years, cholera has become endemic in most areas which are currently affected by the food crisis. Decreased access to water and mainly safe water, together with the weak health system at the rural level, coupled with severe economic constraints and the food shortage contributed to exacerbation and frequent recurrence of epidemics of diarrheal diseases and mainly cholera. The situation is likely to worsen if preventive measures are not put in place and if the health system's capacity to detect and respond to cholera epidemics is not strengthened. This project contributes to the overall CAP strategy to alleviate the suffering of those affected and to increase the capacity of the health system for ensuring that the affected population receive proper public health services, with preventive and curative activities. It aims also at monitoring the health situation, documenting the impact of the food shortage and collecting information needed to detect epidemics and respond to them in a timely and appropriate manner.

Project strategy & complementarity

WHO proposes to assist drought-stricken communities in a two pronged approach: Supporting and empowering the communities to prevent infection with vibrio cholerae and strengthening the health system's capacity to plan and prepare for an adequate response to cholera epidemics. The need exists to strengthen the outreach capacity of the health services through the training and use of community volunteers to deliver care when needed, monitor situation, identify epidemic prone diseases, monitor growth and disseminate health education messages. The health workers in the affected peripheral health services will receive appropriate training and will develop cholera epidemic preparedness and response plans. This intervention will build on the previous activities already undertaken when the first cholera outbreak was declared in 2001, and when UN agencies, EU, Italian Cooperation, Chinese Embassy assisted the Ministry of Health and Social Welfare to mitigate the impact of the outbreak. WHO has continued to provide technical and financial support to the Ministry of Health and Social Welfare, UNICEF is supporting training on participatory methods (PHAST), EU is running a water and sanitation project in one of the most affected areas. Additional assistance in water and sanitation is being provided by DFID and Japanese Cooperation.

Main activities

  • Mobilise human resources for coordinating emergency health activities and ensuring follow-up
  • Assess water quality in most affected districts
  • Provide anti-cholera kits to 60 communities in drought-stricken areas
  • Provide emergency health kits to 15 health facilities around drought-stricken areas.
  • Develop cholera epidemic preparedness and response (EPR) plans
  • Train 20 health staff on basic epidemiology and disease surveillance

Major outputs
  • Emergency health coordinator posted
  • Water quality assessed in the affected districts
  • 60 communities provided with anti-cholera kits
  • 15 peripheral health facilities provided with emergency health kits
  • Cholera EPR plans available in Lubombo and Shiselweni regions
  • 20 health staff trained on data management, analysis, and reporting
FINANCIAL SUMMARY

BUDGET ITEMS
US$
Human resources for coordination, training and water testing
120,000
Water testing , purification supplies and equipment
30,000
Anti-cholera kits
180,000
Identification of households, distribution and training on anti-cholera kits
6,500
Emergency health kits
125,000
Training and distribution
2,000
Training of Regional Health Motivators to develop cholera plans
1,000
Training health staff in drought areas
2,000
Monitoring, reporting and visibility
46,650
Project support cost (6%)
30,789
TOTAL
543,939

Lesotho

Analysis of need

The health status of Basotho, especially of women and children has declined significantly in the last decade. The combination of the increased levels of poverty, the declining access to quality health services and the impact of HIV/AIDS have adversely affected the health and nutrition situation of traditionally the most vulnerably population groups, women and children. The rates for infant and child mortality have not improved substantially, and the maternal mortality rate has never been so high with 738/100,000 (1997), with the 15-19 years olds and women above 35 years of age groups at highest risk, although this data was collected in 3 districts only.

The major cause of child mortality and morbidity are still vaccine preventable diseases, diarrhoea, acute respiratory infections and malnutrition. Micronutrient deficiencies are still prevalent. With lack of green leafy vegetables in the diet and the low vitamin A supplementation coverage of 17 per cent (EMICS, 2002) vitamin A deficiency is estimated to still be a public health problem. Although, substantial gains have been made in the battle against iodine deficiency disorders, with 69 per cent of household using adequately iodised salt (EMICS, 2002), the challenge is to remain at this level, in the present situation that households have no money to buy iodised salt. The 1996 Multiple Cluster Indicator Survey reports that 67 per cent of children under the age of 1 year were fully immunized, which is a decline compared to the 1993 coverage of 71 per cent. As of end 2001 the overall routine immunisation coverage was 62.4 per cent. The fundamental underlying cause for the decline in health and nutrition status, especially of women and children, is the increased poverty.

The major problems encountered by the health system are the persistent shortages of staff, poor incentives for community health workers, equipment shortages, as well as shortages of drug supplies. These problems have undermined the sustainability and quality of health service delivery and the capacity of the health system to respond to the current emergency. Health workers are also demoralised and/or highly de-motivated because of the problems and especially the community health workers because they work on a voluntary basis. The impact of HIV/AIDS will further exacerbate the situation, particularly with increased demand for services. An additional problem, which heavily affects the implementation of the projects and programmes within the health system, is availability of quality routine data on childhood illness, malnutrition, and immunization.

The present emergency situation has increased need of the population, especially women and children for access to and quality health services. However, the health system is not able to cope with this increased need, and is already having problems to cope with the increase number and care for HIV/AIDS related cases. The situation calls for immediate measures to ensure that the health and nutrition status children and pregnant and lactating women is not deteriorating any further to avoid the need for facility-based care. As part of the emergency relief operation there is a need for an integrated approach to provide essential basic health and nutrition services to the most vulnerable at community level, in combination with a health and nutrition surveillance system to adequately and timely respond on changing situations.

Objective

Provision of essential quality basic health and nutrition services to children under five and pregnant and lactating women with appropriate and timely monitoring and evaluation in order to adequately respond on emerging issues.

Proposed action

  • Accelerate an integrated approach to provide the basic nutrition and health services to children under five at community level, including the supplementary food, immunization, growth-promotion, early identification and referral, and follow-up after hospitalisation, through ECD centres, NGO's and faith-based organizations.

  • To strengthen the capacity and skills of the ante-natal care programmes to assess the nutritional status of pregnant women, identify women at risks and provide early referral, at community level.

  • Support the provision of therapeutic feeding and essential drugs to the most vulnerable groups and implement the Integrated Management of Childhood Illness (IMCI) concept to improve early recognition and effective case management of the major childhood illnesses.

  • Strengthen the skills and capacity of the health workers, the NGO's, Peace Corps and Community-based organizations to implement an effective nutrition and health surveillance system.

LESOTHO-PROJECT 1
Appealing Agency World Health Organization
Project Title Control of malnutrition and related diseases in children below the age of 5 years
Project Code
Sector Health
Theme Control of malnutrition and related diseases
Objective 1. To control malnutrition among children under five years of age through training of health workers including community health workers and initiation of nutrition surveillance system by December 2002
2. To control communicable diseases including diarrhoeal diseases, TB and ARI
3. To strengthen the capacity of the MOHSW to provide coordinated emergency response in affected areas.
4. To provide community based nutrition education through PHAST
5. To reduce morbidity and mortality due to malnutrition and related infections among children under five years of age
Targeted beneficiaries 20,000 children under five years of age in the affected areas
Implementing partners NGOs, Ministry of Health and Social Welfare, UNICEF, Ireland Aid, WHO
Project Duration June 2002 - June 2003 (12 months)
Funds requested (US$) 816,200

Summary

The situation analysis of the MOHSW and WHO conducted concurrently with the Inter-agency assessment due to the current food crisis revealed that there is high prevalence of malnutrition among children below the age of five years. A high prevalence of diseases such as: respiratory infections, diarrhoeal diseases, skin infections, ear infections and intestinal parasites have also been identified. Despite this revelation it is clear that there are weakness in data collection, analysis, utilization and record keeping by the health facilities. The capacity to report to the next level and to utilize the data is weakened by lack of communication facilities such as faxes, e-mails etc. and lack of appropriate training. These limitations affect timely transfer of information to the next level. In view of these finding, the project aims to initiate disease and nutrition surveillance system, which also strengthens the early warning system of the Disaster Management Authority (DMA).

Activities

  • Train health personnel in integrated disease surveillance, this will encompass nutrition, Disease Surveillance, care and management of malnourished children under five years of age, IMCI, record keeping, development of immediate emergency response strategies.

  • To strengthen the capacity of health facilities by provision of human resources in the form of consultants, engagement of more nurses to complement the low staffing situation.

  • To procure and distribute communication equipment to strengthen the early warning system at district level or (HSAs) for timely detection and reporting.

  • Procurement and distribution of IEC materials (including HIV/AIDS).

  • Community education sessions applying PHAST approach.
FINANCIAL SUMMARY

Requirements (US$)
Basic health equipment and essential drugs
250,000
Provision of technical assistance (short term consultancy of 3 work months and long term technical assistance of 12 work months)
100,000
Training in rapid detection and management of diseases
50,000
Procurement and distribution of IEC materials
20,000
Training in IDS including nutrition surveillance, IMCI, record keeping and response strategies
250,000
Integrate health and nutrition issues into the SADC Early Warning System
100,000
Programme Support Cost 6%
46,200
TOTAL
816,200

LESOTHO-PROJECT 2

Appealing Agency World Health Organization
Project Title Provision of safe water and proper sanitation
Project Code
Sector Water and Sanitation
Theme Provision of Water Supply and Sanitation
Objective 1. To provide safe water supply to 30% of rural communities
2. To provide sanitary facilities for 20% of rural communities during the disaster period up to July 2003
Targeted beneficiaries 4,000 households and 40 schools for sanitary facilities
2,000 households and 20 schools for water supply
Implementing partners Ministry of Health and Social Welfare, Local Government, Natural Resources, NGOs, and UN Agencies
Project Duration June 2002 - June 2003 (12 months)
Funds requested (US$) 455,800

Summary

Interagency assessment of water and sanitation in May 2002 in four districts revealed that some communities use unprotected water sources. The national coverage for safe water supply is 77.1 per cent (89.5 per cent and 74.1 per cent in urban and rural areas respectively) while that for sanitation is 53.6 per cent (88 per cent and 45.1 per cent for urban and rural areas respectively). The remaining proportion (32.9 per cent for safe water and 46.4 per cent for sanitation) is at risk of outbreaks of water and sanitation related disease, which are already being experienced in districts like Mohale's Hoek, Quthing, Berea, Mafeteng and Thaba Tseka. There is, therefore, need for urgent assistance to provide potable water supply and proper sanitary facilities to this population including schools in the affected areas. Partners participating in water supply are Ministries of Natural Resource (Dept of Rural Water Supply, WASA, Dept. of Water Affairs) Health and Social Welfare (water quality surveillance), Ireland Aid, NGOs. The different partners are coordinated through the Steering Committee for Water and Sanitation based in the Ministry of Development Planning.

Activities

  • Protection of water sources
  • Distribution of safe water by tankers to villages and schools
  • Purification of water from unprotected sources
  • Application of Participatory Hygiene and Sanitation Transformation (PHAST) methodologies at community level
  • Intensify water quality surveillance
  • Procurement of construction materials
  • Training of extension workers and communities in water quality surveillance and protection of water supply sources
FINANCIAL SUMMARY

Activity
Requirements (US$)
Provide water purification chemicals and Laboratory supplies and reagents
50,000
Logistical support and distribution of water
80,000
Training of extension workers and communities in PHAST methodologies
100,000
Recruitment of a Public Health Coordinator for 12 months
100,000
Water and Sanitation construction materials (VIP latrines and water protection)
100,000
Programme Support Cost 6%
25,800
Total
455,800

Malawi

The Nutritional, Health and Other Dimensions of the Crisis

The nutritional situation for children under five is extremely precarious. The Demographic and Health Survey of 2000 reflects a chronic malnutrition rate of 49 percent and a global1 acute (both moderate and severe) malnutrition rate of approximately 7 percent, excluding children with oedema, percentage which could rise in some instances to 12 percent. Based on these rates, it is estimated that approximately 86,000 children are at risk for global acute malnutrition and will need supplementary feeding, while 22,000 children under five will require life-saving interventions (therapeutic feeding) to redress their health status due to severe acute malnutrition.

During 2002, a number of NGOs carried out several nutritional surveys in some of the worst affected areas of the country. In January, SCF-UK carried out a survey in Salima. It reported a global malnutrition rate of 6.6 percent and a severe malnutrition rate of 1.9 percent. The survey was repeated in March 2002, illustrating an alarming increase in global malnutrition of 19 percent and severe malnutrition of 6.6 percent. In Mchinji, SCF-UK noted a similar increase. During the same period, the global malnutrition rate rose from 10.2 percent in January to 17.5 percent in March 2002, while acute malnutrition rate rose from 1.9 percent to 6 percent respectively. In another survey in Mulanje and Thyolo, Oxfam found malnutrition rates of 3.4 percent and 5.1 percent respectively.

Following the various assessments of the food security situation, and taking into account seasonal variations, it is likely that at the peak of the predicted "hungry season" (December 2002 to April 2003), the rate of severe acute malnutrition will increase from 1.2 to 3 percent. This implies that 54,000 children will be in severe distress, and in need of therapeutic feeding.

The severity of the 2001/2002 food security crisis was first widely reported when its impact began to be evident in terms of severe malnutrition (and even anecdotal reports of deaths in some instances). Apart from this, there were signals that the cholera outbreak during the reference period was more pervasive, and had greater case fatality ratios, than in previous years.

Given these reports, as part of the UNCT's response to the Government's appeal for assistance, it was decided to conduct sectoral and thematic assessments of the non-food dimensions of the crisis. This sub-section summarizes the findings of these thematic assessments, which formed the basis for the subsequent design of the non-food components of this Consolidated Appeal Response (CAR).

The assessments carried out by WHO covered the 10 most affected districts. From the survey responses covering the period October 2001 to March 2002, the assessment estimated a crude mortality rate (CMR) of 1.9 per 10,000 population per day. Daily CMR is one of the best indicators of the existence of a humanitarian crisis. A CMR value greater than 1.0 indicates that a humanitarian crisis exists. The assessment concluded that this rather high CMR could be explained by a combination of factors. These are: severe malnutrition, compounded (in some cases) by the pre-existence of HIV/AIDS, as well as a documented outbreak of cholera (which hit 26 of the 27 districts).

The assessment concluded that there was an acute shortage of staff and basic equipment in most health facilities; maternal mortality in most health care centers rose significantly during the reference period; and, the existing epidemiological surveillance system was incapable of providing timely information to national and international stakeholders regarding epidemics, disease burden and mortality. Box 2 summarizes how health interventions in emergencies differ from regular programmes under normal situations.

WHO, in close collaboration with UNICEF, WFP and UNFPA, is proposing complementary interventions on: epidemiological surveillance, disease control, health coordination, reproductive health, nutrition and cholera control.

The objectives of these projects are to:

1- Strengthen the affected districts' emergency response capacities by training health personnel, NGOs involved in health and other relevant health related actors as well as provide basic equipment and drug (WHO emergency kits). Cholera epidemic control and maternal mortality will be tackled in particular projects. These projects will have a direct impact on reducing mortality and morbidity.

2-Build/strengthen a coordination mechanism among health partners/actors in order to harmonise emergency health interventions in accordance with respect for humanitarian standards and exchange of relevant information for action. This project will enable WHO to provide information to health partners on the overall picture on health situation and give the needed technical support to the field actors.

3- Strengthen the health information system for early epidemic detection, monitor health emergency indicators, and evaluate humanitarian health performances. The epidemiological surveillance will give a clear picture of what is happening and where the health problem are situated.

4- Support 89 Nutritional Rehabilitation Units to provide adequate and appropriate care to acutely malnourished children.

WHO Health Assessment was conducted in collaboration with UNICEF, UNFPA, MSF Greece, Save the Children UK, Care International and Red Cross National Society.

Malawi Project 1-STRENGTHENING DISEASE SURVEILLANCE

The absolute key to the prevention and control of extra disease prevalence in emergencies is good and timely information. A situation analysis conducted by WHO in ten districts most affected by the recent food crisis in Malawi revealed that there are major weaknesses in data collection, analysis and utilization and record keeping by the health facilities. Inter alia, the assessment found that there was a far higher mortality rate within the communities than that recorded by the health facilities.

Six district hospitals out of ten could not provide adequate records on deaths that occurred during the period under study. Lack of communication facilities like faxes, e-mail, reliable telephone lines in some health facilities affected timeliness of transfer of data to the national level or other project coordination centres.

Consistent with these findings, the project aims to strengthen the ability of the health system at national, district, health centre and community levels to achieve earlier detection of epidemics and proper assessment of the health impact of emergency situations. It is envisaged that this will enable adequate resource mobilization for prompt and effective response.

The following are the key activities to be undertaken in order to achieve the objective of the emergency intervention:

  • Training in integrated disease surveillance.
  • Record keeping.
  • Development of immediate response strategies.
  • Provision of human resources in the form of consultants for technical support.
  • Procurement and distribution of communications equipment and transport at national, district and health centre levels for timely reporting.

The tables below give a synopsis of the project and financial resources being sought.

Table WHO 1a: Summary Details for the Period June 2002 to May 2003

Project Title Strengthening Disease Surveillance for Emergency Response in Malawi
Appealing agency World Health Organization
Sector Health and information
Theme Health Epidemic Surveillance and Response
Objectives To improve and strengthen the surveillance of major diseases occurring in areas affected by food shortage.
Targeted Beneficiaries 3,188,337
Implementing Partners NGO, MoHP, UN agencies
Project Duration 1 July 2002 - 30 June 2003
Funds Requested US$ 635 152

Table WHO1b: Financial summary for the Period June 2002 to May 2003 (Disease surveillance)

BUDGET ITEMS
AMOUNT (US$)
Training in integrated disease surveillance, record keeping and development of immediate response strategies
300 000
Provision of human resource in the form of consultants for technical support at district level
60 000
Procure and distribute communication equipment and transport at national, district and health centre levels for timely reporting
200 000
Monitoring and evaluation
39 200
Programme support costs
35 952
TOTAL
635 152

Malawi Project 2- CHOLERA EPIDEMIC RESPONSE AND PREVENTION:

Cholera is preventable and treatable. Malawi has just gone through one of its worst-ever cholera epidemics this year. By 14 April, 2002, 33,150 cases and 981 deaths had been reported, giving an absolutely unacceptable average case fatality rate (CFR) of 2.96%. Out of 27 districts only one district in Northern Region was spared during the last outbreak.

The proposed project is targeted to cover ten cholera endemic districts: Lilongwe, Blantyre, Chikwawa, Nsanje, Mangochi, Zomba, Machinga, Balaka, Salima, and Karonga. The activities will cover cross-border activities, especially in the Malawi-Mozambique border areas). On an emergency footing, the project will address the priority objectives of the Malawi National Health Plan by strengthening surveillance (i.e. case detection, investigation, response, reporting and feedback), epidemic preparedness and response. It will aim to ensure proper disease control and low case fatality. Rapid improvement of health workers' capacity will go a long way to achieving this objective.

Training for case management, epidemic control and water quality will be organized jointly by WHO and UNICEF. MSF Greece will be facilitators in these training courses.

In the months before the next 'cholera season' the project will seek to fulfil the following objectives:

1. Increase public awareness about cholera transmission prevention and control

2. Build capacity for cholera control activities

3. Strengthen disease surveillance, early detection and rapid response for control and management

4. Strengthen coordination mechanisms for cholera control activities

5. Support activities to thoroughly investigate the causes of cholera outbreaks in the country

A detailed project proposal has been developed by WHO Malawi and is available for scrutiny. The tables below give an overview of the project and finances required for its implementation.

Table WHO 2a: Summary Details for the Period August 2002 to July 2003

Project Title Rapid strengthening of Cholera epidemic response
Appealing Agency WHO, UNICEF
Sector Health
Themes Cholera surveillance, management, response
Objectives To control cholera epidemic by organising prompt intervention at community level, to stop the transmission and reducing related mortality by better case management of the disease.
Target Beneficiaries 10 most regularly affected districts
Implementing
Partners
Ministry of Health and Population, NGOs
Project Duration 1 July 2002 - June 30 2003
Funds Requested by WHO US 605,366 out of US$ 825,866

Table WHO 2b: Financial Summary for the Period August 2002 to July 2003
Rapid strengthening of cholera response

BUDGET ITEMS
AMOUNT (US$) WHO
AMOUNT (US$) UNICEF
Development, production and dissemination of necessary IEC materials
100,000
Conduct training for health workers and village health committees on IEC, early detection, community/EI and case management
160,000
Provision of equipment and supplies for cholera control (drugs, tents, water testing kits etc)
200,000
Procure computer, software, telephone, radio equipment, internet connection, vehicle for cholera units at all levels
150,000
Support the establishment of a Rapid Response Team at Health Centres/District level
100,000
Support the establishment of multi-sectoral cholera task forces at different levels and formulation of their terms of reference
10,000
Conduct water quality surveillance activities
10,000
Monitoring and evaluation
51,100
Programme support cost
34,266
10,500
TOTAL
605,366
220,500

Malawi Project 3- EMERGENCY ACTION FOR REPRODUCTIVE HEALTH

A situation analysis conducted in ten districts mostly affected by food crisis in Malawi revealed a high maternal mortality during the period 2001-2002 as compared to the year 2000-2001. In 8 district hospitals for which mortality data were available, maternal deaths had increased by 72 percent, even though the number of deliveries had declined by 7,6 percent during the same period. The diminishing number of women gaining access to hospitals, combined with increased mortality of those who do, is an ominous development. The unacceptably high maternal mortality can be directly attributed to the food shortage aggravating already high anemia rates in pregnant women and cultural practices that require mothers to eat last in the family.

It is apparent from the high and increased maternal mortality that the health facilities lack capacity to handle emergency obstetric care. It is proposed to effect a reversal of this trend in the shortest possible time by acting immediately on two fronts: I) training in emergency and essential obstetric care, and ii) supply of reproductive health kits to improve obstetric service response.

Table WHO 3a: Summary for the Period August 2002 to July 2003

Project Title Reproductive health services for vulnerable communities in Emergency situations
Appealing agency World Health Organization
Sector Health
Themes Reproductive health, essential emergency obstetric care
Objectives To ensure the provision of essential and emergency obstetric care
Target Beneficiaries 76,520
Implementing Partners MoHP, UNFPA, UNICEF, Min of Gender & community Services, NGOs
Project Duration 1 July 2002 - 30 June 2003
Funds Requested US$ 442,263

Table WHO 3b: Financial Summary for the Period August 2002 to July 2003 (Cholera)

BUDGET ITEMS
AMOUNT (US $)
Training of Trainers
60,800
Training of Health workers
50,600
Procurement and distribution of Reproductive health kits (1 for each district)
98,685
Procurement of VCT testing kits
90,800
Procurement of STD reagents
58,900
Procurement of Nevirapine
45,912
End of project evaluation
11,532
Programme support costs (6%)
25,034
TOTAL COST
442,263

Malawi Project 4- IMPROVING RESPONSE TO DISEASE OUTBREAKS IN EMERGENCY SITUATIONS

Extra-ordinarily high levels of malnutrition in the recent food crisis period, particularly among children under 5 years, has increased susceptibility to various diseases such as diarrhea, malaria, ARI and skin diseases. The areas most severely affected in 2001/2002 will remain highly vulnerable in 2002/2003. The WHO and UNICEF health assessments indicated that there was limited capacity in the affected districts to cope with the crisis. The common problems identified included, shortage of staff at all levels, drug stock-outs during the peak period of the crisis and usually very old equipment.

There was high mortality at community level during the crisis compared to the information obtained from health facilities. Therefore the objective of this project is to strengthen capacity of affected districts for responding to priority diseases in the country.

In view of the above situation, WHO and UNICEF will provide technical support to front line teams and structures. WHO will also link closely with epidemiological surveillance for immediate response as well as intensive collaboration with NGOs following their capacities and presence in the field. Project information and financial requirements for the successful implementation of the programme component are given in the tables below.

Table WHO 4a: Summary for the Period August 2002 to July 2003

Project Title Improving response to disease outbreaks in emergency situations
Appealing Agencies WHO AND UNICEF
Sector Health
Themes Health, Capacity building
Objectives To strengthen capacity of affected districts for response to priority diseases, particularly those prone to epidemic
Target Beneficiaries 318,833
Implementing Partners Ministry of Health and Population, NGOs, Local Government
Project Duration 1 July 2002 - 30 June 2003
Funds Requested US$ 1,260,262

Table WHO 4b: Financial Summary for the Period August 2002 to July 2003

BUDGET ITEMS
UNICEF (US$)
WHO (US$)
Train district and health centres focal persons and frontline workers on emergency detection and response
120,000
Ensure that frontline health teams are provided with basic health kits and adequate transport.
90,000
Procure and distribute educational materials and guidelines for epidemic response
20,000
Provide technical support for disease control especially those of epidemic potential
80,000
Provide emergency health kits and basic equipment for frontline structures to facilitate rapid response of most killer diseases.
300,000
Insecticide treated bed nets for vulnerable groups
490,000
Monitoring and evaluation
49,000
42,700
Project Support cost
29,400
39,162
TOTAL
568,400
691862
TOTAL FUNDING REQUESTED BY UNICEF AND WHO
US$ 1,260,262

Malawi- Project 5 IMPROVEMENT OF EMERGENCY HEALTH COORDINATION

During the recent humanitarian crisis a large number of partners (more than 23 NGOs and UN agencies) were working in the Health sector and several other partners were also working in Nutrition, and Water and Sanitation areas. It was clear that they collectively needed an improved and shared approach to health information in an emergency: case definitions of disease and control strategies were different from one NGO to another; partners could not take the best-informed decisions; and there was a perceived lack of leadership at this crucial time.

There is a need to recruit a Public Health Focal Point in WHO Malawi specialized in emergencies, a subject currently beyond the capacities of the regular WHO staff. As the technical agency for health coordination, WHO will issue regular statements on epidemiological trends and related matters. The WHO Focal Point will be the Emergency Health Coordinator in the UN Emergency Response Coordination Unit (ERCU). WHO will also consider different approaches with all partners and obtain consensus on emergency disease control strategies according to existing resources. When the Ministry of Health and Population or Local Government are taking the lead for coordination, WHO will provide technical support to the Government structure.

Table WHO 5a. gives an overview of the proposed project. A more detailed version of the project proposal can be obtained from WHO. The budget to undertake the above planned activities is given in Table WHO 5b.

Table WHO 5a: Summary for Emergency Health Coordination - Period August 2002 to July 2003

Project Title Strengthening Emergency Health Coordination among partners
Appealing Agency World Health Organization
Sector Health
Themes Health coordination
Objectives Coordination of health interventions in order to increase efficiency in the allocation of the resources, provide technical back up for acceptable health quality services and information sharing
Target Beneficiaries Vulnerable communities in the whole country
Implementing Partners UN agencies, NGOs, MoHP, CBOs
Project Duration July 2002 - June 2003
Funds Requested US$ 349,800

Table WHO 5b: Financial Summary for the Period August 2002 to July 2003

BUDGET ITEMS
AMOUNT (US$)
Providing technical support for coordination and guideline, good practices and monitor health quality services
150,000
Conduct joint assessments and information sharing with partners
120,000
Logistic support
60,000
Project Support Costs ( 6%)
19,800
TOTAL
349,800

Zimbabwe

HEALTH SECTORAL PLAN

Zimbabwe is under an economic and humanitarian crisis characterized by foreign currency shortages and a fall in budgetary allocation that have caused a deterioration of social services, including the delivery of health services. The effects of the economic downturn, increased poverty and the HIV/AIDS pandemic have had adverse impact on human resource base and thus impacting negatively on the health delivery system. It has also eroded the post-independence gains achieved in areas such as reproductive health. Inadequate health service delivery has adversely affected the health of the vulnerable population groups, i.e. in the communal lands, new and peri-urban settlements. The effects of the natural phenomena such as El Nino, Cyclone Eline and year 2000 floods, coupled with successive droughts, have further exacerbated the plight of the vulnerable populations.

The various UN agencies in partnership with some government departments under the Humanitarian Action and Response Plan (HARP) conducted rapid assessments to provide evidence and quantify this humanitarian crisis. The health needs assessment came out with the following major findings:

  • The mortality rates in the assessed districts have been increasing over the past year among the top ten priority diseases, e.g mean rates for TB have increased from 25.47 in 1998 to 41.87 in 2001 per 100,000 population; that of acute respiratory infections (ARI) increased from 19.35 in 1998 to 36.15 in 2001 and that for HIV/AIDS has increased from 18.29 in 1998 to 34.14 in 2001.

  • Outpatient attendances at health institutions have been going down. This shows decreasing access to health facilities by the population, which may be a result poverty and a known lack of service and supplies.

  • The vital essential drugs stocks are critically low nationally as found during the assessment but the situation is more critical at peripheral health institutions. This has been due to shortage of foreign currency to import the vital drugs and inadequate distribution system.

  • There is an acute shortage of vital health personnel especially in the peripheral health institutions due to high attrition of professional staff from the public service in search of new employment opportunities and the HIV/AIDS pandemic.

  • Outreach services have been drastically scaled down or suspended in a number of districts due to lack of financial, logistical support and inadequate human resources.

  • The ability of the Ministry of Health and Child Welfare (MoHCW) to respond to epidemic prone diseases has been weakened by lack of resources including finance and logistics.

  • There are gaps in the coordination mechanism between MoHCW and other health stakeholders, e.g. NGOs, leading to duplication of efforts.

  • An estimated 1,430,817 people will require reproductive health assistance between June 2002 and July 2003 - of that number, 500 000 require critical emergency assistance.

Goal

Reduce number of avoidable deaths and suffering of vulnerable populations

Objectives

i) Improve accessibility of health services to the identified vulnerable population groups regardless of their location.

ii) Increase availability of vital drugs and medical supplies including drugs for reproductive health and HIV/AIDS opportunistic infections in health institutions.

iii) Monitor epidemic prone disease, strengthen prevention, and response to epidemics

iv) Improve access to crisis-related critical emergency reproductive health services to the most vulnerable groups/communities

v) Support Ministries, Parastatals and NGOs to reduce maternal morbidity and mortality due to pregnancy and childbirth compounded by the crisis.

Vulnerability Criteria and Caseload

The assessment revealed that the vulnerable populations in this sector include approximately 1,000,000 excluding approximately 100,000 people in peri-urban settlements. Within this population there are subgroups such as under-fives (15.44%), pregnant women (20%), the poor (+60%) and the elderly (10%) who are highly vulnerable. Some of the population groups are located far from health facilities and considering the current state of outreach services these populations have been exposed to higher risk. During 2002, interventions will focus on the most acute areas such as those that were identified by HARP 1 assessment conducted in May 2002 and it is estimated that the various health sector stakeholders will reach a population of approximately 1,100,000. In terms of reproductive health support, target groups are adolescents, youths, women, pregnant women, nursing mothers and other "at risk" groups, including commercial sex workers and mobile/transient groups.

Strategies:

  • Mobilize adequate funding to procure vital drugs and medical supplies.

  • Improve planning, stock control and procurement and distribution of vital drugs and medical supplies at all levels.

  • Engage in policy dialogue for policies that will attract and retain professional health personnel.

  • Training of health workers to improve the ability of the health sector to prevent and control diseases including responding to disease epidemics.

  • Improve communication systems and logistical support for disease surveillance, prevention and control.

  • Improve outreach services in the areas where it had been scaled down, resuscitate where it had been suspended and establish outreach services in areas where they do not exist in order to serve the identified vulnerable population groups.

  • Training of community workers to improve the ability of the health sector to serve the vulnerable population.

  • Community education to raise community awareness in order to be able to actively participate in prevention and control diseases including responding to disease epidemics.

  • Strengthening reproductive health interventions, advocacy and coordinating access to emergency services for vulnerable populations affected by the crisis.

Activities

To meet the objectives in this sector, humanitarian agencies (health sector stakeholders) will:

  • Procure and distribute vital drugs and medical supplies.

  • Train health workers in disease control, surveillance and epidemic preparedness and response.

  • Provide radio communications equipment to peripheral health centres and resuscitate radio communications at affected district and rural health centres in order to respond to disease epidemics on time.

  • Establish and/or resuscitate outreach services in the vulnerable areas.

  • Provide transport to extension workers for the outreach programmes focusing on community education, home based care under the HIV/AIDS pandemic, EPI, etc and disease surveillance, prevention and control and quick response to epidemics in the vulnerable areas.

  • Conduct community information and education campaigns.

  • Train community-based extension workers to respond to the evolving crisis.

  • Provide support for quality reproductive health service provision to vulnerable groups, including facilitating procurement of RH drugs, kits and supplies and provision of support for development of materials for use in advocacy towards behaviour change

Indicators

Programme monitoring will be based on the following indicators:

  • Stock levels of vital drugs and medical supplies

  • Number and category of health workers trained to serve the vulnerable populations

  • Number of identified health centres with adequate communication systems and logistics to respond to the emergency

  • Population reached or covered by education campaigns and proportion involved in disease prevention and control activities

  • Number of outreach visits conducted for the vulnerable population groups by extension workers.

  • Population covered by outreach services.

  • Numbers of community level extension workers trained and functional within the affected areas

  • Widened access and increaesd numbers of RH emergency assistance beneficiaries, disaggregated by gender and age.

Zimbabwe Project Summaries
Appealing Agency: World Health Organisation (WHO)
Project Title: Building/Strengthening Health Sector Partnership (Stakeholders)
Project Code:
Sector: Health
Themes: Health Sector Coordination
Objective: Coordinate health sector interventions in order to increase efficiency in resource allocation and distribution and provide technical back up for acceptable quality health services and information sharing.
Targeted Beneficiaries: All health sector partners
Implementing Partners: MOHCW, UN Agencies and NGOs
Project Duration: July 2002 to June 2003.
Funds Requested: US$378,420

Summary

During the previous (Cyclone Eline and floods) and current humanitarian crisis, it was noted that there is a large number of health sector stakeholders (60 Local Authorities - RDCs/Urban Councils, 20 NGOs/Church related organisations, private sector and UN Agencies) working in the health sector and a lot of other partners working in the various sectors. In the health sector these partners use various disease case definitions and disease control strategies. This gives different pictures and figures on assessed situations making unclear background for partners to take appropriate decisions. There is lack of leadership and direction resulting in overlaps and duplication of services.

The MoHCW in conjunction with WHO, a technical body for coordination will on regular basis issue a statement to inform partners on the epidemiological trends and other relevant information. MoHCW in conjunction with WHO will also consider different approaches, discuss with all partners, and obtain consensus on disease control strategies according to the existing resources. The Health Coordinator-HARP in WHO will assist with the day-to-day coordination of the sector.

Relationship to CHAP strategic and short-term goals and sector objectives

This project is in line with the overall CHAP short-term objectives of laying the foundations for recovery programming in health services preventing, containing and addressing the outbreak of disease, including HIV/AIDS. It also supports the overall health sector plan in the CHAP, specifically the objectives on (a) preventing and controlling disease epidemics timeously and (b) improving accessibility of health services to the most vulnerable population groups

Expected outcome

The main expected outcome will be improved health service delivery to the target population and improved response to disease prevention, control and epidemics.

Activities

  • Organize and prepare in collaboration with partners coordination meetings from national down to district level.

  • Strengthen health information exchange by regular dissemination of epidemiological information and distribution of health guidelines and manuals.

  • Monitor quality of health services

  • Conduct joint field assessment missions.

Financial Summary
Budget Item
US$
Providing technical support for coordination and guideline, good practices and monitor health quality services
150,000
Conduct joint assessment and information sharing with partners
130,000
Logistical support
60,000
Contingency
17,000
Program support costs(6%)
21,420
Grand Total
378,420
Appealing Agency: World Health Organization (WHO)
Project Title: Disease Surveillance
Project Code:
Sector: Health
Themes: Data collection and appropriate use
Objective: Improve the ability of health personnel to utilise health information for decision-making and prompt detection and control of epidemics.
Targeted Beneficiaries: 10 most vulnerable districts.
Implementing Partners: MOHCW, UN Agencies and NGOs
Project Duration: July 2002 to June 2003.
Funds Requested: US$593,600

Summary

One of the critical areas assessed for the HARP was that of disease surveillance. The rapid assessment revealed that surveillance was weak at all levels. Although the timeliness and completeness of data collection was reported as 86% and 96% respectively, analysis and use of surveillance data at health facility level was minimal. Response to epidemics and disease outbreaks was therefore delayed. A large number of health workers interviewed had not received any training in disease surveillance. Case definitions were available for EPI diseases at 74% of health facilities, but less than 5% of health facilities had case definitions for other priority diseases like AIDS, malaria and cholera. Twenty-one per cent (21%) of the health facilities did not have standard case definitions for any priority diseases. Supervision was minimal - only 4% of rural health facilities had received any supervisory visits in the last 6 months.

According to Ministry of Health projections in 1998, it was estimated that people suffering from HIV/AIDS related illnesses occupy 70% of all hospital beds. The assessment revealed that HIV/AIDS was among the top five causes of mortality, however it did not feature in the top causes of morbidity, although health workers generally agree that the bulk of the morbidity that they see in Outpatients services is HIV related.

A large proportion of diseases were classified in non-descript categories such as "symptoms and ill defined conditions, viral conditions or diseases of the central nervous system." Such classifications do not help in defining the burden of disease in a population. Age distribution of data is limited to two main age groups, under fives and five and above. There is no information by more specific age groups or gender. It is therefore very difficult to identify particularly at risk groups for certain conditions. Humanitarian assistance may thus not be targeted at the appropriate groups.

Expected Outcome

This project therefore aims at strengthening disease surveillance so as to be able to detect and respond promptly to epidemics. It also aims at strengthening the health information system so as to be able to accurately assess the disease burden and the particular populations at risk and how it is affected by this emergency situation.

Activities

  • Training in basic epidemiology and surveillance and outbreak response
  • Review the case definition for HIV/AIDS and improve diagnosis and recording of HIV related illnesses
  • Review of data health information tools so as to capture narrower age groups and gender
  • Support and supervision
  • Programme management

Financial Summary
Budget Item
US$
Train district and rural health centre staff on disease surveillance - action thresholds, epidemic preparedness, disease detection and response.
150 000
Review/redesign, produce and distribute health information tools
50 000
Develop/reproduce and distribute disease case definitions and community level IEC materials
100 000
Communication equipment - procurement and/or repair and installation
(See Outreach budget)
Provide emergency kits for epidemic prone diseases
200 000
Monitoring and support
60,000
Program support costs (6%)
33,600
TOTAL
593, 600
Appealing Agency: World Health Organization (WHO)
Project Title: Policy on professional health staff to strengthen health service delivery
Project Code:
Sector: Health
Themes: Policy dialogue on Staff Retention
Objective: Advocate for policies that will attract and retain professional health personnel.
Targeted Beneficiaries: Vulnerable populations: 1,100,000
Children: 169,840 Women: 307,230
Implementing Partners: MOHCW, UN Agencies and NGOs
Project Duration: July 2002 to June 2003.
Funds Requested: US$21,200

Summary

In the recent rapid health needs assessment it was established that the country is facing a critical shortage of professional staff especially at district and sub-district levels. The public health sector has lost 7% of its personnel since January 2000 and approximately +40% posts remain vacant. This picture is based on the old staff establishment, however, the MoHCW is currently going through a restructuring exercise which attempts to rationalize staffing levels to suit the public health sector needs and when this exercise is completed it is expected to reflect an even worse staffing situation. The non-availability of key professional staff in the health delivery system adversely affects the quality care provided.

The WHO in conjunction with other stakeholders needs to engage government (MoHCW) to urgently review policies or develop a policy that would attract and retain professionals.

Relationship to CHAP strategic and short-term goals and sector objectives

This project is in line with the overall CHAP short-term objectives of laying the foundations for recovery programming in health services preventing, containing and addressing the outbreak of disease, including HIV/AIDS. It also supports the overall health sector plan in the CHAP, specifically the objectives on (a) preventing and controlling disease epidemics timeously and (b) improving accessibility of health services to the identified vulnerable population groups regardless of their location.

Expected outcome

The main expected outcome would be improved staff retention and thus improved access to health services by the vulnerable populations.

Activities

  • Conduct high-level discussions with policy makers
  • Development of draft policy
  • Monitor implementation of the policy
Financial Summary

Budget Item
US$
Meetings
10,000
Monitoring assessment and information sharing with partners
10,000
Program support costs(6%)
1,200
Total
21,200
Appealing Agency: World Health Organization (WHO)
Project Title: Procurement of vital drugs and medical supplies
Project Code:
Sector: Health
Themes: Vital drugs and medical supplies
Objective: Increase availability of vital drugs and medical supplies including drugs for HIV/AIDS opportunistic infections in health institutions.
Targeted Beneficiaries: Vulnerable populations: 1,100,000
Children: 169,840 Women: 307,230
Implementing Partners: MOHCW, UN Agencies and NGOs
Project Duration: July 2002 to June 2003.
Funds Requested: US$7,683675

Summary

In a recent rapid health needs assessment it was established that the country is facing a critical drug shortage of vital drugs and the missions and rural health centres are the worst affected. These peripheral health facilities had less than 30% of their average drugs stocks, which shows that they had a month's cover, or less. Drug distribution was found to be unsatisfactory with some institutions having more than their requirements in certain drug categories.

The WHO in conjunction with MoHCW and other major stakeholders will urgently procure and ensure prompt distribution of the vital drugs and medical supplies. The WHO in conjunction with MoHCW and other partners will carry out periodic drug assessments and all efforts to prevent stock outs of the vital drugs and medical supplies that have been experienced over the last year will be minimised.

Relationship to CHAP strategic and short-term goals and sector objectives

This project is in line with the overall CHAP short-term objectives of laying the foundations for recovery programming in health services preventing, containing and addressing the outbreak of disease, including HIV/AIDS. It also supports the overall health sector plan in the CHAP, specifically the objectives on (a) increasing availability of vital drugs and medical supplies including drugs for HIV/AIDS opportunistic infections in health institutions and (b) preventing and controlling disease epidemics timeously.

Expected outcome

The main expected outcome will be improved availability of vital drugs and medical supplies and improved access to health services to the vulnerable populations.

Activities

  • Procure and distribute drugs to the identified areas.
  • Monitor drug and medical supply stocks and quality of health services

Financial Summary
Budget Item
US$
Procurement of drugs and medical supplies to the health services providing for the vulnerable populations
6,900,000
Logistics support
60,000
Monitoring assessment and information sharing with partners
15,000
Contingency
348,750
Program support costs(6%)
439,425
Grand Total
7,763,175
Appealing Agency: World Health Organization (WHO)/UNICEF
Project Title: Strengthening of Cholera Epidemic Response
Project Code:
Sector: Health
Themes: Cholera Prevention, Surveillance, Management, Response
Objective: To prevent cholera epidemic by improving water and sanitation to the epidemic prone communities, To decrease transmission and reduce mortality through organizing prompt action at community and health center level.
Targeted Beneficiaries: 3 Regularly affected Provinces.
Implementing Partners: MOHCW, UN Agencies and NGOs
Project Duration: July 2002 to June 2003.
Funds Requested: US$1,113,000

Summary

Zimbabwe is experiencing one of its worst cholera epidemics this year. The epidemic has affected three provinces namely, Manicaland, Mashonaland East and Masvingo. Sporadic cases have occurred in some Cities and other provinces. Zimbabwe has reported 2,484 cases and 242 deaths giving a high mortality rate of 9.7%. The institutional case fatality is 3.1%. The most affected province is Manicaland where cases are still being reported. The epidemic has affected those districts with poor water and sanitation coverage. The surveillance system has been found wanting and the response to the epidemic by health staff less than optimal.

The projects target those districts with poor water and sanitation coverage that have been affected by the current cholera outbreak. It aims to improve access to safe water through protection of family and communal wells and supply of commodities for Improved Ventilated latrines for families. The project will also improve community awareness on identifying cholera cases and management before referral to health centres.

At health center level, the project aims to strengthen surveillance (i.e. case detection, investigation, response, reporting and feedback) through training of health workers and proving the commodities that enhance epidemic preparedness.

Relationship to CHAP strategic and short-term goals and sector objectives

This project is in line with the overall CHAP short-term objectives of laying the foundations for recovery programming in health services preventing, containing and addressing the outbreak of disease, including cholera. It also supports the overall health sector plan in the CHAP, specifically the objectives on (a) preventing and controlling disease epidemics timeously and (b) improving accessibility of health services to the most vulnerable population groups

Expected outcome

The main expected outcome would be improved water and sanitation coverage. Strengthened cholera prevention methods and enhanced cholera preparedness.

Activities

  • Identification and protection of water facilities (Conduct water quality surveillance)
  • Supplying building materials for VIP latrines.
  • Develop, produce and disseminate IEC materials to the Community and Health Institutions.
  • Disseminate guidelines on cholera control.
  • Train health staff on early case detection, case management, and reporting and epidemic control in general.
  • Provision of drugs and supplies for cholera control and preparedness.
  • Strengthen communication through provision/repair of communication radios, telephones etc.
Financial Summary

Budget Item
US$
IEC material development and dissemination
150 000
Training of staff
200 000
Drugs and supplies for cholera
300 000
Community mobilisation activities
150 000
Communication equipment - procure/repair and install.
250 000
Program support costs(6%)
63000
Total
1 113000
Appealing Agency: World Health Organization (WHO)/UNICEF
Project Title: Strengthening of Malaria epidemic response
Project Code:
Sector: Health
Themes: Malaria prevention, Surveillance, Management, Response
Objective: To prevent malaria mortality and reduce morbidity and reduce social suffering due to malaria.
Targeted Beneficiaries: 10 districts mostly affected by malaria.
Implementing Partners: MOHCW, UN Agencies and NGOs
Project Duration: July 2002 to June 2003.
Funds Requested: US$1,855,000

Summary

Malaria remains one of the major causes of Outpatients clinics (OPD) attendances in Zimbabwe. Over 2 500 people die of malaria and over 3 million have at least one episode of malaria in a year. Resistance to chloroquine is increasing as evidenced by the drug sensitivity monitoring exercises currently being carried out in the country. Drug shortage particularly Sulphadoxine -Pyramethamine (S-P) which has been the second line treatment has been experienced in past years. This was mainly due to the declining foreign currency availability in Zimbabwe

The outreach services have been declining in the last few years due to the current humanitarian crisis. The Ministry has not managed to respond adequately to disease outbreaks due to staff shortages and other logistics. This has aggravated the plight of the vulnerable populations. This project seeks to strengthen malaria control interventions in the vulnerable areas through indoor residual spraying and provision of insecticide treated nets (ITN).

Relationship to CHAP strategic and short-term goals and sector objectives

This project is in line with the overall CHAP short-term objectives of laying the foundations for recovery programming in health services preventing, containing and addressing the outbreak of disease, including malaria. It also supports the overall health sector plan in the CHAP, specifically the objectives on (a) preventing and control disease epidemics timeously and (b) Improving accessibility of health services to the most vulnerable population groups

Expected outcome

The main expected outcome would be reduction in mortality and morbidity in malaria.

Activities

  • Train health staff on early case detection, case management, and reporting and epidemic control in general
  • Provision of adequate anti-malarial drugs
  • Training of communities to promote community based malaria control activities
  • Develop, produce and disseminate Information Education and Communication (IEC) materials to the Community and Health Institutions.
  • Increase indoor residual spraying coverage
  • Provision of impregnated bed nets( ITNs)
  • Monitoring and evaluation
Financial Summary

Budget Item
US$
Training of health workers
150 000
Provision of anti-malarials
200 000
Training of the community
100 000
IEC material development and dissemination
200 000
Provision of ITNs
600 000
Provision of transport
100 000
Community mobilisation activities
150 000
Monitoring and evaluation.
250 000
Program support costs (6%)
105,000
TOTAL
1,855,000
Appealing Agency: World Health Organization
Project Title: Reducing increasing maternal mortality in rural settings due to the humanitarian crises.
Project Code:
Sector: Health
Themes: Prompt referrals and emergency obstetric care
Objective: a) To reduce increasing maternal deaths
b) To improve methods of prompt referrals of pregnant women especially young girls at village/community level.
c) To ensure the provision of essential and emergency obstetric care.
Targeted Beneficiaries: Pregnant women identified in HARP 1 District Assessment.
Implementing Partners: MOH&CH, WHO,UNICEF, UNFPA, NGOs
Project Duration: July 2002 - June 2003
Funds Requested: US$1,484,000

Project Description

The current socio-economic crisis in Zimbabwe has worsened the plight of women, especially, vulnerable pregnant women. The Ministry of Health and Child Welfare Reproductive Health Care Assessment of 1999 highlighted the most common emergency obstetric complications, which were ante-partum haemorrhage, pre-eclampsia, malpresentation. The Herald newspaper of 19/06/02 highlighted increases in unsafe abortions by youths aged between 15-19 years compounded by rising HIV infections in the youth accounting for 30% of all infections. Health facilities able to manage emergency obstetric cases were found to be low. (MOH&CW Reproductive Health Rapid Assessment 1999). This picture is getting worse because of the high attrition rates of professional staff and increasing poverty levels - HARP Assessment Report.

Relation to CHAP Strategic and Short-term Goals and Sector Objectives

The project is in line with the overall CHAP short-term objectives of strengthening community and health sector response of preventing and containing the priority reproductive health problems exacerbated by HIV/AIDS pandemic and increasing poverty levels. The RH project supports the overall health sector plan in the CHAP specifically objective (b) improving accessibility of health services to the most vulnerable population groups.

Expected Outcome

The main expected outcome will be improved prompt referrals to access emergency obstetric care using appropriate rural transport, the 4 wheel scotch carts "Haka wagons", recognition of problems related to pregnancy by community early and vulnerable pregnant women especially pregnant young girls in rural areas. Creating awareness and strengthening diagnosis and critical interventions in the clinical areas through training of staff in health centres and district hospitals using the HARP Rapid Assessment report for selection.

Financial Summary

A total of US$1.4 million is being requested to accelerate and strengthen community education and develop partnership in RH for prompt health seeking behaviour during pregnancy, setting up a supportive system of prompt referrals at village level to the nearest health centre and training nurses/midwives and doctors in emergency obstetric and abortion care. Procuring transport for outreach work and ensuring availability of vital and essential drugs including medical supplies.


Financial Summary

Budget Item
US$
Training of community based workers/VHW in recognizing early problems
200,000
Training Health Professionals in emergency obstetric and abortion care
250,000
Procuring transport for outreach work
200,000
Fuel and mileage for outreach work
100,000
Community mobilisation
50,000
Procuring four wheeled scotch carts (Haka wagons) for prompt Referrals x 8 Districts
500,000
Monitoring and Evaluation
50,000
Project Management (Coordinator of project, travel costs etc)
50,000
Program support costs(6%)
84,000
TOTAL
1,484,000

Zambia

Health and Nutrition

Analysis of need

The health and nutrition status of Zambia's people has been in decline for at least two decades. Zambia is a poor country. Entrenched grinding poverty and the almost total failure of economic recovery efforts have undercut Government's struggle to provide basic drugs and services. HIV/AIDS, a new challenge, has ravaged the country and is now the leading killer in Zambia. As a consequence, life expectancy at birth has declined to a mere 37 years - the third lowest in the world. It should be noted, however, that even that grim figure fails to capture the reality for most Zambian's. In 1999, it is officially estimated that the prevalence of HIV/AIDS was 20%, but as in many southern African countries, this estimate may be low. Those who have the disease find themselves in a country where anti-retroviral drugs are still beyond their reach. For most, the drugs and healthcare they need to cope with Tuberculosis, cancers and the opportunistic infections they suffer are simply unavailable. The sick and dying seek shelter within the extended family and in so doing, undermine the capacity of those families to cope with the impending food and water crisis.

The downward spiral reaches every household and spares no age group. Estimates indicate that from 1990 to 1999, the infant mortality rate has increased from 108 to 122, and the under 5 mortality rate has increased from 191 to 202 per 1,000 live births. Amongst children under-5 malaria remains the number one direct cause of death. But the real cause is the inability of Zambia's people to access basic drugs and health care or to pay for bed nets to protect their children. Malaria may be the coup de grâce, but it is poverty and the dilapidation of the health system that sentence million of children in Zambia to an early death.

Health service delivery has been decentralized to the districts who are now responsible for planning management and implementation in the districts. While considerable effort and resources have gone into Zambia's health sector reform process, the capacity to deliver quality services varies considerably among districts. Throughout the country there is a shortage of qualified staff at all levels as well as insufficient stocks of essential drugs and equipment. This is particularly noticeable in rural areas, many of which are affected by the current food shortages.

Another indicator of the stress experienced by Zambia's children is the high prevalence of stunting. Among under-5's this has increased from 39% in 1992 to 53% in 1996 and is now estimated at 54%. While, admittedly, stunting is a trailing rather than a leading indicator of malnutrition, it makes clear that many children in Zambia have little reserves to carry them through an extended "hungry season" and they are therefore highly vulnerable in the current crisis.

Increased hunger will compound maternal health problems, including miscarriages, self-induced abortions and problematic labours. While fertility levels are likely to drop during severe food shortages family planning services and supplies should be ensured, including condoms. Zambia already has high maternal mortality and morbidity rates. Vulnerable people are more likely to engage in unsafe sexual practices, and considering the high prevalence of HIV, it is important that people have access to condoms.

Strategy

During the current emergency, the UN system proposes a strategic framework that will address both immediate and underlying problems. The first element will be to identify, target and feed the vulnerable and to provide on an emergent basis new water sources (boreholes and wells) for the Southern province. This work will be done in close collaboration with local NGOs and will build on already existing programmes of food and water assistance.

Weakness in the capacity of national and local authorities to monitor and analyze changes in the nutritional status of high risk groups mandates urgent intervention. While the timely acquisition of quality data for programme planning is an imperative, so too is the need for strengthening of local capacity, capability and commitment in nutrition surveillance. Competent external technical advisors will need to be mobilized to lead in the conduct of nutrition surveys and in efforts to train local workers. Funds and technical assistance will be provided for the Government to assume a coordinating role and enhance future capacity to prevent and mitigate the results of a food crisis.

An adequate surveillance system providing timely information on food, nutrition and health will help avert severe malnutrition and death. The cost of rehabilitating severely malnourished children is very high, and so is the mortality rate among the severely malnourished. All efforts will be made to avoid an increase in malnutrition rates. To the extent possible establishment of therapeutic feeding centres will be avoided, care will be home-based. Because the relief ration is largely maize, potential nutritional deficiencies will be addressed through the provision of multivitamin supplements.

Strengthening of the existing health system to provide basic services to women and children will be the main strategy for health service delivery. Local and international NGOs will fill identified gaps. Efforts will be made not only to address the immediate problems and save lives but also strengthen local capacity to detect, prevent and respond to disease outbreaks and other emergencies in the future. Cost effective interventions, proven to be effective in emergencies, such measles immunization, vitamin A and other micronutrient supplementation, malaria prevention and treatment will be core activities.

Objectives

The overall goal is to minimize the impact of the present food crisis on the health and nutritional status of vulnerable populations.

More specifically the objectives are to:

  • To prevent further worsening of the global malnutrition rates at the present level until the next harvest

  • To provide micronutrient supplements and reach a biannual coverage above 80% among children below 5 years of age in the affected districts

  • To provide therapeutic food for rehabilitation of 3,000 severely malnourished children

  • To train 75 health workers on management of severe malnutrition

  • To provide essential drugs and medical equipment for 100,000 people for one year

  • To immunize more than 90% of all children between 9 months and 15 years of age in the 10 worst affected districts

  • To provide insecticide treated bed nets to the most vulnerable 10% of the population in the affected districts

  • To train surveillance officers in the affected districts and strengthen the capacity of government to recognize and respond to disease outbreaks

  • To increase availability of condoms and other family planning services and provide information to prevent the spread of HIV/AIDS

  • To reduce the impact on maternal morbidity and mortality and increase the likelihood of positive birth outcomes

  • To decrease the prevalence STD infections by providing contraceptives including condoms and STD drugs

Proposed action
  • Establish a surveillance system to monitor change in the nutritional status of vulnerable populations and measure the impact of food and nutrition interventions and provide timely data for adapting programme interventions.

  • Support rehabilitation of severely malnourished children through training and capacity building in the management of severe malnutrition. Provision of therapeutic food (F75, F100 and Plumpy Nut) and technical assistance.

  • Strengthen the existing disease surveillance, recognition and response system. Provision of essential drugs and equipment and ensure adequate monitoring and response capacity for the management of cholera outbreaks.

  • Provision of micronutrient supplements to children and pregnant and lactating women.

  • Ensure provision of Vitamin A, Iron, Folic Acid

  • Support to malaria prevention and control through the distribution of impregnated bed nets and anti-malarial drugs

  • Ensure targeted measles vaccination of children under 15's in vulnerable areas. Strengthen existing

  • Maintain and increase EPI coverage through support to the cold chain and improving injection safety.

  • Ensure pregnant women if affected areas are identified and provided with ante-natal, birthing and post-natal care, including parasite control, nutritional supplementation, malaria prophylaxis, obstetric care and if necessary emergency obstetric care, family planning and STD treatment.

Health and Nutrition
Appealing Agency: WHO
Project Title: WHO: Disease surveillance, prevention and control
Project Code:
Sector: Health and Nutrition
Themes:
Objective: To strengthen disease surveillance and response
To strengthen disease prevention and control systems
To provide basic health services to people in the affected areas
To reduce morbidity and mortality from measles and malaria
Targeted Beneficiaries:
(total # & description)
The food crisis is assumed to affect 2 million people, incl.
Children: 400,000 Women: 440,000
Implementing Partners: Ministry of Health, Central Board of Health, District Health Management Teams, UNICEF
Project Duration: July 2002 - July 2003
Total Project Budget:
Funds Requested: 1,805,000

Summary

The overall aim of this project is to reduce morbidity and mortality among women and children in the affected area.

The project will strengthen the existing disease surveillance system, recognition and response system, and in particular the response capacity for the management of cholera outbreaks. Essential drugs for treatment of main diseases such as malaria, diarrhea and acute respiratory diseases will also be provided to health facilities in the affected districts together with basic medical equipment. To reduce death from measles and stop transmission in the worst affected areas, measles vaccination of all children 9 months -15 years of age will be carried out in selected geographical areas (contiguous zones). Emphasis will be place on both coverage and the quality of the campaign including injection safety and safe disposal of sharps. To ensure potent vaccine a limit amount of cold chain equipment will be provided.

Malaria is the main killer of children in Zambia where insecticide treated nets (ITNs) are sold by the private sector in urban areas at high cost and through health facilities in rural areas. Because the current crisis will greatly diminish the possibility of households to purchase nets and protect the members against malaria, subsidized ITNs will be provided to vulnerable households. Drugs will also be provided for treatment of malaria. To ensure proper use of the nets social mobilisation and training on malaria control will be supported.The Integrated Management of Childhood illnesses (IMCI) will be implemented in targeted localities, in order to ensure proper case management of the most common causes of mortality and morbidity among children.


Financial Summary

Activities
Requirements (US$)
Capacity building in integrated disease surveillance
100,000
Essential diagnostic supplies for surveillance and case management
100,000
Malaria drugs
200,000
Targeted IMCI
200,000
Disease surveillance/cholera outbreak control
50,000
Essential drugs and basic equipment
150,000
Measles immunization campaign
300,000
Malaria prevention and control
400,000
Monitoring and supervision
100,000
Programme support costs/technical assistance
170,000
Admin costs
35,000
Total
1,805,000

Footnote:

1 Global acute malnutrition relates to children who are between 75-85 percent of their weight-for-height.