Republic of Tajikistan: Relief, Health and Capacity Building Situation Report No. 2

With excellent funding and despite a difficult environment, the programme continues to be implemented successfully. Major improvements were achieved, particularly in the supplementary food distribution to the beneficiaries in West Tajikistan and the effective response to floods and landslides in northern Tajikistan. Progress has been achieved in the strengthening of the National Society, but continued support to the Federation and the Red Crescent Society of Tajikistan (RCST) humanitarian programmes will be needed in 2000-2001.
appeal no. 01.46/99
period covered: 1 July 1999 - 20 December 1999

The context

The 1992 civil war took an appalling toll, both in the number of human casualties and in the destruction of medical structures, education facilities, and other essential services. The collapse of the medical infrastructure has caused the reappearance of diseases such as TB and hepatitis. Preventable diseases are on the increase, including typhoid fever, diarrhoea, respiratory tract infections, sexually transmitted diseases and malaria. There are serious shortages of general basic medical supplies and equipment.

A large number of families in Tajikistan continue to face poverty. According to the UN, 80% of the country's population lives below the poverty line and almost 50% are unemployed. Compared to other former Soviet Union countries, Tajikistan has a high birth rate (26.7 per 1,000), a high child mortality rate (30.9 per 1,000), the lowest GNP per capita (USD 350), the highest population per physician (430:1), and the lowest percentage of the population with access to safe water (25-49 percent). Since the start of its operation in Tajikistan in 1994, the Federation, together with the Red Crescent Society of Tajikistan (RCST), has been providing humanitarian assistance to the most vulnerable individuals and communities. This includes emergency relief supplies consisting of food, medical and other relief assistance, as well as support to the RCST with Disaster Preparedness (DP) and training programmes, thus strengthening its capacities.

To respond to the humanitarian situation, the Federation and RCST established the following objectives:

Relief:

• Supplementary food rations to 76,500 most vulnerable beneficiaries in West Tajikistan, including free food distribution to 63,400 beneficiaries, food to 1,100 patients at psychiatric institutions in Dushanbe, Khatlon and the Rayons of Republican Subordination (RRS), and food for food security programmes to 12,000 beneficiaries;
• Food to patients in 29 hospitals and psychiatric institutions in Gorno-Badakshan Autonomous Oblast (GBAO);
• Support to fifteen RCST-run public canteens, providing 6,000 beneficiaries with a daily meal;
• 1,200 MT of coal and 120 heaters for heating of twenty-nine medical institutions in GBAO;

Health:

• Medical distribution to 50 Rural (SUBs), 22 District (CRHs), and 7 Specialised hospitals, and 645 Ambulatory Health Posts (FAPs) and Dispensaries (SVAs) in Kurgan-Tube and Kulyab rayons;
• Medical distribution to 105 Ambulatory Health Posts (FAPs) in the RRS;
• Public Health Education Campaign;
• Water and Sanitation activities in rural areas of Khatlon Oblast;

Social Welfare:

• Support to RCST Street Children and Shoe-Making programmes;
• Disaster preparedness:
• Through several simultaneous DP activities (training on all levels, provision of DP stocks, etc), strengthening the capacities of the RCST, thus enabling it to respond to future disasters;

Capacity Building:

• Strengthening of capacities of the RCST in the areas of management of human, material and financial resources;
• Community-Based First Aid (CBFA) programmes with the RCST.

Latest events

The implementation of the peace process in Tajikistan, agreed on in the 1997 Peace Accord, achieved considerable progress during the second half of 1999. A number of United Tajik Opposition (UTO) members were appointed to various positions in the cabinet, including Mirzo Ziyoev, one of the key UTO commanders, who was appointed as Minister of the State Committee on Emergencies (SEC). A national referendum was held in September 1999, deciding on key constitutional amendments, including the length of term of the presidency and the legitimacy of political parties based on ethnic or religious groupings. The Supreme Court of Tajikistan lifted a ban in August on activities of four UTO parties which had been banned in 1993. The RCST, together with the Federation Delegation, demonstrated a high disaster response capacity, in a rapid reaction to assist the victims of the floods and landslides which hit Asht Rayon in Leninabad Oblast in July 1999.

On 22 September a Memorandum of Understanding (MOU) and seven programme agreements were signed between the Federation and the RCST, covering projects in relief, health, water and sanitation, and institutional development. In addition, there are three current agreements between the Regional Delegation (RD) Almaty, and the RCST covering the Population Movement programme, information activities and CBFA.

The 1998/1999 ECHO funded supplementary food distribution in Tajikistan, Medical Relief Distribution in Khatlon Oblast and the RRS Water and Sanitation programme in rural areas of Khatlon Oblast, and a country-wide DP programme were completed between July and October 1999.

Simultaneously the implementation of the 1999/2000 programmes funded by ECHO began in June. Currently, the Tajikistan Delegation is staffed by nine delegates, supported by 91 locally recruited staff. Delegates are: Head of Delegation, Relief Co-ordinator and Relief Administrator, Health Co-ordinator and Health Delegate, Water/Sanitation Delegate, Logistics Co-ordinator, Finance/Administrative Delegate and Reporting Delegate. The Delegation is currently seeking to recruit a DP Delegate and a Field Delegate for Khorog. A new Development Delegate is expected to arrive in January 2000.

Red Cross/Red Crescent action

Relief

Supplementary Food Distribution in West Tajikistan

The distribution of food commodities under the 1998/1999 ECHO funded programme was completed in August. Following negotiations with the ECHO office in Dushanbe, Disaster Preparedness commodities were procured, planned to be used for emergency response in the event of an influx of Afghan refugees into Tajikistan. Alternatively, should no such influx occur, this emergency stock will be used to respond to beneficiary needs in future natural disasters. The implementation of the programme was completed by the end of October 1999.

The 1999/2000 ECHO-funded programme started in June 1999. A total of 76,500 beneficiaries are planned to be assisted under this programme. The overall food element of the relief programme consists of three main components: free food distribution, food security and food to psychiatric institutions. Under the first component, a total of 63,400 beneficiaries will be provided with two supplementary food baskets, each consisting of 25 kg of wheat flour, 5 litres of vegetable oil, 10 kg of rice and 1 kg of iodised salt. Under the food security component seeds and fertilisers, along with food rations, will be provided to 12,000 beneficiaries. Finally, a total of 1,100 patients in the psychiatric institutions will be provided with supplementary food.

Under this current ECHO contract, a series of improvements were made, resulting in more effective implementation. This included the introduction of a completely new registration system, involving more than nine hundred selection committees from makhalas - the grass-root level in the structure of authority in Tajikistan. The main advantage of the new system is the improvement in beneficiary targeting, as the communities became very closely involved in the selection. Beneficiaries were selected using the following criteria: isolated elderly, families without breadwinners, beneficiaries with insufficient or no income, widows, multi-children families, disabled persons and patients in psychiatric institutions. As a result of improved training of the RCST and the new registration system, the monitoring of beneficiary lists and the implementation phase of the programme are expected to improve significantly.

The procurement of rice, wheat flour and vegetable oil for this programme was undertaken by the British Red Cross on behalf of the Federation. The food arrived in Tajikistan during October 1999, in good time for the start of the first distribution round. Iodised salt was procured locally by the Federation Logistics department in Dushanbe. Wheat seeds and fertilisers for the food security component have been procured by the Regional Logistics Unit in Almaty.

The second week of November saw the start of the first round distribution of supplementary food rations. The distribution of commodities is implemented by the RCST relief staff and volunteers. Under the food security component, seeds and fertilisers were distributed to 12,000 beneficiaries, in addition to distribution of food rations. A total of 1,100 beneficiaries received their food rations in psychiatric institutions in Dushanbe, Khatlon and Rayons of Republican Subordination (RRS), together with second-hand clothing and dried milk. A total of approximately 30,000 beneficiaries collected their rations during the reporting period.

Food to institutions in GBAO

The aim of this programme is to provide food to patients in hospitals and psychiatric institution in Gorno-Badakshan Autonomous Oblast (GBAO). It is essentially a continuation of last year's programme. Due to difficulties experienced in obtaining funding for the purchase of food commodities, an agreement was reached between the Federation, WFP and Mercy Corps International (MCI), under which MCI agreed to provide 55 mt of wheat flour, 33 mt of rice and 7.6 mt of vegetable oil. The Federation undertook to transport the rice and vegetable oil from MCI warehouse in Dushanbe directly to 29 medical institutions situated in six rayons of GBAO - Khorog, Shugnan, Roshtkala, Vanch, Darvaz, Rushan, Ishkashim and Murgab. WFP delivered the wheat flour from Osh in Kyrgyzstan to Central Rayon Hospitals. The distribution of food commodities between the Central Rayon Hospitals and medical institutions in each rayon will be arranged by the Khorog branch of the Red Crescent Society of Tajikistan. According to the agreement, MCI will reimburse the wheat flour to WFP warehouses in Kolkhozabad. The number of beneficiaries is not known at this stage, as it will depend on the hospitals' occupancy rates. This provision of food commodities, as well as coal (please refer to Heating and Refurbishment of hospitals in GBAO), will keep the hospitals open during 2000, and will enable them to provide health services to the regional population, especially during the harsh winter period.

Public Canteens

In October 1995, in close co-operation with the RCST, the Federation started the first public canteen in a district of Dushanbe. Since then, the programme has expanded and is now entirely managed by the National Society. Today, there are fifteen canteens, supported by the Swedish RC: six in Dushanbe, three in Khodjent/Chikalovsk, and one in Kofarnihon, Leninsky, Kulyab, Kurgan-Tube, Gissar and Tursunzade. The initial target group was established with the help of the social welfare department of the district authority (khukumat). From these lists the beneficiaries were chosen from among people with no income or with only a very low state pension. The project provides a total of 6,000 beneficiaries with one hot meal a day, six days a week, on a weekly rotation basis. On average two times a week, each beneficiary is entitled to a hot meal at the public canteen. The menus were created in close co-operation with qualified nurses, thus meeting the nutritional needs of the elderly. The types of meals served varies daily. The Federation is concerned to secure continual donor support for this programme.

Heating and Refurbishment of hospitals in GBAO

As a result of the deteriorating economy of Tajikistan, and a lack of government support to public institutions, many public facilities are unable to carry out their normal services. One of the most serious problems experienced by hospitals is the lack of heating. This is of particular concern in GBAO, where in winter the temperatures often fall to 40 degrees below zero Celsius.

During the second half of the year, intensive efforts were made in order to secure funding for this programme for the winter 1999/2000. This resulted in a prompt response from several PNS donors - the British RC, Finnish RC, Norwegian RC, Swedish RC and the Swiss RC. Thanks to this support, the programme was initiated before the onset of winter. As a result, during October and November a total of 1,200 mt of coal intended for hospitals in GBAO was procured at the Alai Mine (Kyrgyzstan) and distributed to the target institutions according to a priority list agreed with the Ministry of Health.

Some problems were experienced with the mine's excavator breaking down on several occasions. Furthermore, there were difficulties in securing the fuel required for the transport of the coal, due to the shortage caused by changes in prices within the region. In addition to coal, a total of 120 electric heaters were procured in Osh and distributed to target institutions.

Additional funding was received in November from the Norwegian RC for heating and refurbishment in GBAO. Due to the lack of a delegate in Khorog (the GBAO capital), an assessment mission is planned to be conducted by the Reporting Delegate during January 2000. It is anticipated that the programme for the year 2000 will focus on refurbishment of a selected number of health institutions, exploration of alternative energy sources, and coal briquette making.

Health

Due to lack of resources, and consequently a lack of support to the health system by the Ministry of Health, the need for medical humanitarian assistance still remains. Since 1995, the Federation has provided basic medicines and medical supplies to four different levels of health service institutions in Tajikistan. The structure of health care in Tajikistan can be described as follows: the base of the system consists of FAPs (Feldshersky Akushersky Punkt - health posts) and SVAs (Selskaya Vrachebnaya Ambulatoria - rural dispensaries). The higher levels are SUBs (Selskaya Utsatskovaya Bolnitsa -rural hospitals), followed by CRHs (Central Rayona Bolnitsa - district hospitals), and specialised hospitals. The distribution of medicines and medical supplies by the Federation/RCST to medical institutions in Khatlon Oblast and parts of RRS is funded by ECHO through the Netherlands Red Cross.

Medical Distribution to Rural (SUBs), District (CRHs), Specialised Hospitals, Ambulatory Health Posts (FAPs) and Dispensaries (SVAs)

Post-monitoring on the utilisation of basic medicines and medical supplies distributed during the first half of 1999 to 50 SUBs, 22 CRHs and 7 specialised hospitals in Kurgan-Tube and Kulyab rayons, and 855 FAPs and SVAs in Khatlon Oblast and parts of RRS, was conducted throughout the second half of the year. This was carried out by twenty-eight monitoring teams of the National Society, each consisting of one physician and one other medical person.

The monitoring concluded that the registration of medicines, their storage and their use in the medical institutions was carried out in an appropriate way and that the medicines were dispensed to the patients free of charge. In some institutions, the monitoring discovered inadequate registration of medicines. In such cases, recommendations were made and follow-up visits conducted. In two visited places, the monitoring teams discovered that certain medicines provided under the Federation and RCST programme have been sold to patients - these institutions have been removed from the distribution list. Many hospitals experienced shortage of bedlinen, mattresses, disinfectants and reagents for laboratories. In some hospitals the nutrition of patients is a problem. Medical stocks in many hospitals have been nearly consumed. As a result, the number of beneficiaries treated in the hospitals decreased. At the same time, some hospitals still have large stocks of certain medicines (mainly ketamin), which is planned to be redistributed to other hospitals.

Preparations for the implementation of the new ECHO-funded project began. The medicines and the medical material required for the first round distribution have been procured by the Netherlands Red Cross. However, although they were ready in November, they have not yet been dispatched from the Netherlands to Tajikistan, as the documentation necessary for customs and import formalities is incomplete to-date. The Ministry of Health and the National Pharmaceutical Centre have been informed of the imminent arrival of the consignment. Meanwhile, preliminary distribution lists were prepared by the Federation delegation in Dushanbe, taking into account the needs of each institution, based on ongoing monitoring findings. It is expected that the medicines will arrive in Tajikistan at the end of December or in early January 2000. The distribution will follow shortly thereafter.

Distribution of locally purchased bedlinen sets, pillows, and washing powder in hospitals, washstands in FAPs and SVAs, and uniforms, bleach, soap and towels in all institutions was carried out. Together with Pharmaciens Sans Frontieres (PSF) and Medecines Sans Frontieres (MSF), prescription books which are being distributed to health facilities together with the medicines, were examined. Based on the information collected, and taking into consideration WHO guidelines, some changes will be introduced. All FAPs and SVAs monitors received two booklets on hygiene education, which were prepared by the local NGO Ecologia with support from UNICEF. These brochures were also distributed to CBFA volunteers. An article about the FAPs and SVAs programme was written for the WHO magazine 'All for Health'.

A number of training workshops were held for the RCST monitors of medical institutions, discussing a range of health issues and preventative measures. These included a seminar on clinical features of malaria and anaemia in children and in pregnant women, where a great deal of attention was given to information on prevention. The lectures were given by specialists from the local health system. Lectures were also given by malaria specialists from the NGO ACTED. In addition, a seminar was held on bronchitis and asthmatic diseases, issues surrounding family planning, the activities of PSF and the work of a joint pharmaceutical task force consisting of the Ministry of Health and WHO, as well as on sexually transmitted diseases (STDs) and AIDS and dental care. Work on preparing the monitoring workshop on STDs, use of obstetrical medicines and dental care, is currently ongoing.

Public Health Campaign/Training of Monitoring Teams and Health Staff

One of the most important elements of the Federation/RCST Health programme is dissemination of public health information. This is being implemented by the Health Departments of both the Federation and the RCST, in close co-operation with the Ministry of Health, through training of the RCST monitoring teams, and of volunteers and physicians from the hospitals. Health materials, including posters and video clips are produced and used in schools, kindergartens, and health institutions, and for public broadcasts on radio and television.

Together with the national AIDS Centre and the Reproductive Health Centre, the RCST has been involved in a series of five radio programmes on STDs. A major seminar on STD and AIDS was conducted for 250 physicians and nurses in Khatlon Oblast hospitals. In addition, lectures on STDs and AIDS were held for the personnel of the public transportation system in Dushanbe, and for chief physicians of the city's hospitals. In co-operation with the Ministry of Health, posters and leaflets on STDs and AIDS were printed and distributed in all oblasts. This material was also provided to the AIDS Centre and the military health services. A meeting was held with the personnel of the State Emergency Committee on AIDS, and STDs.

In collaboration with a specialist of the Ministry of Health (MoH) and its Children Stomatology Department, posters on dental care were printed in the Tajik and Uzbek languages and distributed mainly in Kathlon Oblast and the RRS. Some posters were also provided to the RCST branch in GBAO.

Nine workshops on prevention of TB were held in Kathlon Oblast during October. A total of 350 physicians and nurses of the hospitals took part, and all workshops were also attended by the RCST monitoring teams. Tajikistan suffers from a large-scale TB problem, although the official 1999 Khatlon Oblast figures are lower than in 1998. Surprisingly, many of the participants did not know about the national TB programme or the Direct Observed Short Treatment course (DOTS), the WHO-recommended treatment of TB. Posters and calendars with information on the prevention of TB are currently being printed.

First contacts with the Ministry of Health and local experts have been made concerning seminars, posters and leaflets on nutrition. Brochures on typhoid prevention were distributed in Kulyab region, Kurgan-Tube, GBAO and Leninabad Oblast. RCST and Federation Public Health staff members attended a UNESCO seminar on health dissemination for journalists and writers. Some radio programmes on different health issues were recorded during this seminar. Public Health staff members of the RCST and the Federation attended several seminars during November: on hygiene and cleanliness organised by the local NGO 'Women and Earth'; on problems related to drug abuse organised by the Agency for Drug Control; and on AIDS organised by the AIDS Centre in Dushanbe.

Water and Sanitation

The overall aim of the programme is to provide technical assistance to improve the safety of the domestic water supply and provide support for health education in selected rural areas under the existing CBFA programme in Khatlon Oblast.

The main technical part of the programme concentrated the installation of eighty-eight driven boreholes in nine villages in Pyanj district, Kurgan-Tube rayon, assisting approximately 880 beneficiary families. This concluded the 1998/1999 ECHO-funded programme.

The current year's project is essentially a continuation of the 1998/1999 programme. So far, a total of eighteen bore-holes have been installed in Pyanj district under this new programme. In an effort to identify villages who could be additionally assisted by the current ECHO-funded programme,

Water/Sanitation team have, together with CBFA team, carried out assessments in Khojamaston, Kolkhozabad and Pyanj districts. As a result a number of villages were identified where driven boreholes will be installed in the coming months. In addition, first assessments on spring catchments in Dahana (Gozimalik) and in Varzob district were carried out. The springs which are difficult to access, seem to have enough yield and good water quality, which will be tested further.

An extensive evaluation of bore-holes installed by the Federation in Pyanj district was carried out. A total of 110 pumps were visited. Out of that number, twelve (11%) were no longer operational, due to one of the following reasons: broken handle connections, problems with bottom valves, handles removed by the local population, and worn out rubber seals.

Regular testing of driven-borehole water was carried out throughout the programme implementation. The analysis of water was conducted by the Sanitary Epidemiological Station (SES) in Pyanj, which tested the samples for the level of colibacteria, salmonella typhi and shigella. The total number of colibacteria detected in some samples was relatively high, although within the allowed limits. None of the tested samples showed the presence of shigella (the bacteria causing diphteria) or salmonella typhi.

The chemical quality of the water was good. However, it is important to point out that, although the beneficiaries were provided with considerably improved water sources, the water from driven boreholes is of medium quality. For that reason, beneficiaries were advised to always boil water prior to consumption.

Ongoing training of volunteers in hygiene education is conducted by the CBFA team, in close co-operation with the Water/Sanitation programme. A total of eight workshops took place, both for the CBFA monitoring teams and various elements of the community. Some of the seminars included training on malaria, immunisation and safe water, TB, ECHO visibility, hygiene practices, waterborne diseases and other health-related issues. Most seminars and events were attended by representatives of the local authorities - Sanitary Epidemiological Stations (SESs), Vodokanal (the water authority), khukhumats and jamoats, FAPs and other health structures, and kindergartens. In addition, a number of seminars included rural population, women and children in particular. It is hoped that most of these trained individuals will spread their knowledge further within the rural areas. In addition to seminars, training of village inhabitants was regularly carried out during visits to project villages. Tajik republican TV recorded a fifteen-minute programme on a health-related school performance in Khojimaston and installation of driven bore-holes in Pyanj. This was funded from the ICRC dissemination budget. A number of the National Society employees and representatives from the community were interviewed. The programme was broadcast on TV in two parts during November and December.

Social Welfare

Street Children

The Street Children programme continues to be implemented smoothly by the RCST, with financial and technical support from the Federation. During summer vacation, the RCST Street Children Centre in Dushanbe organised a health camp, provided various games for children, and organised walking tours and swimming. A number of events are organised on a regular basis, including music and dancing, as well as small workshops on the making of toys, artificial flowers for house decoration, and gardening. The centre is currently looking for funds to buy a computer.

Shoe-Making Project

The shoe-making programmes in Kulyab and Aini, funded by the Spanish RC, continued to be implemented by RCST. Currently, the programme has an underspend which the RCST proposes to utilise to continue the programme in Aini and Kulyab or to start a new income generating (IG) initiative. The National Society plans to submit a proposal to the Federation soon.

On 28 September the RCST branch in Gorno-Badakshan Autonomous Oblast (GBAO) finalised the purchase of a large compound in the oblast capital, Khorog, which will serve as its offices and also house a shoe-making workshop as part of the IG programme. Pending the refurbishment of the compound buildings, shoe-making is being carried out in rented premises in Khorog. At the rayon level, leather production and shoe-making are continuing, and will accelerate when pupils return to their schools in October. Progress will be monitored by the delegation's Reporting Delegate who will undertake a mission to the oblast in January 2000. The Aga Khan Foundation (AKF) have expressed their interest in purchasing four hundred pairs of manufactured shoes from the RCST programme.

Disaster Preparedness and Response

The overall goal of the programme is to assist the RCST in strengthening its disaster preparedness ability, hardware, and human resources, enabling it to play the central role in responding to future disasters.

The Red Crescent Society of Tajikistan recruited a new staff member in August, who will act as assistant to the Disaster Preparedness Co-ordinator. This new addition to the DP team of the National Society will further contribute towards strengthening its capacities. Joint RCST/Federation monitoring trips took place to Kurgan Tube, Kulyab and Aini Rayons in August. The monitoring team visited the National Society branches and DP stocks and provided some recommendation to the DP officers of both branches on better stock management and disaster response. A separate report on these trips was prepared by the Reporting Delegate who was a member of the team. The Health Co-ordinator and HoD checked the RCST and Federation DP stocks in GBAO. A team led by the RCST ID Co-ordinator visited GBAO during October to review development issues, including the impact of the DP workshops held earlier this year. The Relief Co-ordinator implemented a logistics workshop, as part of the effort to strengthen RCST warehousing procedures and stocks control.

One element of donor support for the programme, from USAID, was only approved in August 1999, although the proposal had been submitted in late 1998. Due to the lapse of time betw