FPHC Begins Reconstruction in Flood Areas

Sorry for the delay in communicating with you. We have been really overburdened and it continues. even now. The staff is working longer hours than routine, even the office staff..

Because our geographical area is prone to emergencies and we have needed to respond quickly in the past to earthquakes, floods and massive IDP migration, this past January, we opened a special bank account to create an emergency response fund. This also has helped us to track the emergency funds we received better. We had a small amount in this account when the floods hit that allowed us to jump right into relief services at the end of July, 2010 when the floods hit.

The need for medicine and supplies, even at the beginning, however was very big as whole families and communities had run from their flooded homes with only the clothes on their back. So we were very glad that you were able to raise and send funds to us so quickly.

Our early and effective emergency response was acknowledged by the government authorities, who put us on their official list. This helped as we then received some local donations from philanthropists and organizations. International groups such as UNICEF, WHO and UNHCR also came forward to assist us with supplies. In addition, we had realized some unspent funding in ongoing projects in the tribal areas and got approval from UNICEF for utilization of those savings in flood affected areas.

Along with the donations sent by Society of Rural Physicians of Canada, Hillman Medical Education Fund and Rose Charities we have been able to continue actively in our work since the floods began.

Recently we have been chosen by UNHCR for an emergency grant to set up two static health care centres in government health facilities in Nowshera and Charsadda districts for the flood-affected people. Each of the static centers supports six mobile teams. The static centre consists of 1 LHV, 1 MCH Assistant and 1 Male Social Mobiliser. Each of the six mobile teams supporting the static centre consists of 2 Medical Doctors, 1 Medical Technician, 1 Laboratory Technician, 2 LHVs, 2 MCH Assistants, 2 EPI Technicians and support staff. So this totals more than 50 additional staff members as well as the necessary medical and non-medical equipment, rented vehicles and medicine. As part of this UNHCR project we are also rehabilitating 12 health facilities, including several FPHC centers, that have been affected by the heavy rains and floods.

We expect to hear shortly from UNICEF regarding a possible six month Nutrition Project for flood affected people that is planned to start middle of October. Under this project FPHC will be providing Nutrition Services (specifically provision of ready to use micronutrients and nutritional information) to women and children in at least 10 Union Councils . A Union Council is an administrative unit like a big village.

In recognition of our activities, FPHC is now an established part of the the Nutrition Cluster at Country level and coordinate regularly with UN Office for the Coordination of Humanitarian Affairs (UNOCHA) and National Disaster Management Authorities. Thank you to all our generous donors for helping not only flood-affected people here in Pakistan but also for assisting Frontier Primary Health Care to build capacity in responding to these humanitarian emergencies.

from Dr. Emel Khan and FPHC.

Photos: Flood relief 2010

FPHC Contine Pakistan Flood Relief

Since late July, 2010 more than 10 million children have been affected by the Pakistan floods, including 2.8 million under five-year-olds. 1.2 million people still live in 6300 camps all across the country many in KPK.

Although progress is being made, many flood-affected families still have limited access to health facilities. In some areas, service delivery has been totally disrupted as up to 80% of the homes and facilities were affected. With

more than 200 health units destroyed completely or only partially functional, attention has now turned to repairing them.

The majority of private sector health providers in the area have also been disrupted by the floods. Luckily, most of Frontier Primary Health Care health units remained functional so they have been able to assist in areas where facilities have been destroyed.

Surveillance information from the affected flood areas of Pakistan is available on the WHO site. http://www.who.int/hac/crises/pak/en/index.html

In summary in the four districts of KPK, Punjab, Sindh and Baluchistan a total of 80 health facilities were affrected, almost half (38) of them in KPK (Northwest Frontier Province). WHO has 20 health partners assisting in the flood relief in KPK including Frontier Primary Health Care, which is active in both nutrition and health in flood affected areas in Mardan district and a refugee camp.

So far it has proved difficult to track activities of FPHC on the WHO website, which better captures activities of the large international organizations likely due to their better access to the internet. It was not possible, for example, to identify any of the FPHC health centers on the WHO maps which detailed health facilitiy status following the flood nor was FPHC mentioned as a partner in earlier WHO documents despite the fact that their daily medical contacts exceed that of many of the other organizations that are mentioned and despite the fact that they were in the field earlier than most of the other partner organizations.

However, in early Sept, 14 staff from the Frontier Primary Health Care (FPHC) mobile health teams were trained on the WHO Disease Early Warning System so hopefully their activities will be better tracked now.

The efforts of FPHC continue in assisting provision of emergency health assistance including high impact, critical life-saving services for men, women and children in communities of flood-affected areas of Mardan, Khyber Pakhtunkhwa through strengthening, providing and maintaining essential health services.

We have managed to send more than $8000 in flood relief to FPHC to date through Rose Charities. As many other organizations are now finding, direct contributions to effective local groups with a known, trusted reputation in the field appear one of the most cost-effective ways to assist.

Several large international organizations such as Hesperian, the distributors of Where There is No Doctor and Grassroots International are also recommending this approach. A wonderful side effect of this process is that local know-how and expertise in responding to such crises also increases.

It appears that Astarte, a grassroots organization linked to John Snow International at Johns Hopkins University is also raising funds for FPHC as is a Malaysian NGO called Campioning Sara.

A very big thank you to all our generous contributors and hard working volunteers, who make this kind of support possible.

Photos: FPHC Flood relief 2010

FPHC Responding to the 2010 Pakistani Floods

Frontier Primary Health Care is a small, effective Pakistani NGO operating for more than 20 years in the Khyber Pukhtoonkhwa (KPK) region, formerly called Northwest Frontier Province. They provide primary health care to more than 250,000 Afghan refugees and local Pakistanis in 4 rural districts and one of the federally administered tribal areas near the Afghanistan border.

They provide the complete range of PHC at a cost of less than $2 USD per person annually. While minimal in terms of cost, this PHC has increased the health status of the populations they serve enormously, with many of the parameters in their communities much higher than elsewhere in the region. They have accomplished this remarkable achievement by using an army of both male and female local volunteers and a committed group of staff paid local wages.

Over the past five years they have also responded to four humanitarian crises in their region. The earthquakes on the Kashmiri border; the deluge of Internally Displaced People (IDPs) as a result of violence in Northern Pakistan and floods in Mardan in 2009 and now a Pakistan-wide flood of 2010. Their expertise and efforts have been recognized by UNICEF and they have in the past been contracted to provide medical care and nutrition feeding centers.

In the current crisis more than 20 million people, almost 1/5 of the population of Pakistan, have been displaced and in the area where Frontier Primary Health Care operates, flood waters more than 20 feet deep flow over the roads, destroy homes and inundate the fields.

Nowsherra and Charsadda districts have been among those worst hit.FPHC is providing assistance to the flood-affected at their health units in those districts. Additionally Frontier has been deploying two mobile medical teams consisting of medical doctors, medical technicians, Lady Health Visitors, social mobilisers, EPI technicians and support staff equipped with ambulance, medicine and equipment daily. The mobile teams focus mainly on emergency services and MCH services. The major diseases reported are water related such as skin infections, diarrhoea and also respiratory infections.

The mobile teams are also distributing food and clothing donated locally; micronutrients and vaccines supplied by UNICEF and occasionally cooked food and utensils. Each morning the mobile teams report to the District Health Officer to be sent to the hardest hit areas. As the need is so great and the resources few, the teams rarely return to the same area. The threat of cholera and dysentery, because of the difficulty in obtaining drinkable water, increases daily with nutrition of the many displaced children and pregnant women an ongoing need.

FPHC has been in contact with UNICEF and UNHCR but so far international organizations have been experiencing difficulty in moving supplies and people in place in the rural areas. I notice that several of the humanitarian sites such as Hesperian and Grassroots International are suggesting donations be sent to appropriate, reliable local Pakistani NGOs to circumnavigate the difficulties the larger international NGOs are experiencing, in the same way SRPC is doing.

The Society of Rural Physicians of Canada has partnered with Frontier Primary Health Care for more than four years. During that time we have worked with FPHC to improve the management of sexually transmitted diseases, trained traditional birth attendants and are currently developing participatory research, conflict resolution and training projects. Money sent to FPHC will be appropriately and well spent. Along with the Hillman Medical Education Fund and Rose Charities Canada, Society of Rural Physicians proudly supports their work and have found secure reliable ways to send funds. Your generous donations have allowed us to send $6000 to date. Rose Charities is a volunteer-based organization with low overhead.

You can donate online at the rose Charities Canada website.

https://www.canadahelps.org/DonationDetails.aspx?cookieCheck=true

Click on Donate Now button.

On the Fund Destination list scroll down to Pakistan Flood Relief.

Tax Deductible receipts are provided for donations over $20. Every bit helps. We can make a difference.

Photos: FPHC in 2010 flood.

Scenes from NW Pakistan: FPHC Relief

Frontier Primary Health Care is supported by the Rose Charities Canada 'Hillman Fund' Rose Charities flood relief support is being carried out through them and through close partners AMDA Canada / AMDA International. If you wish to donate please see www.rosecharities.info/donate.htm

Images from Jan 2010 ETAT Training Couse Kenya

Training of Traditional Birth Attendants, Pakistan

Traditional birth attendant training Pakistan: Swabi and Wadaga Districts.

(click on pages below to enlarge)

TBAs Trained in Nowsherra Refugee Camps

Supported by a grant of $6000 from The Hillman Medical Education Fund, Frontier Primary Health Care recently completed training for an additional 45 Female Health Workers (FHW) in maternal and newborn health. In addition to usual traditional birth attendant activities, the FHW assist in general health education and immunization in the remote, rural region of North Western frontier Province in Pakistan. The women are carefully selected by the community. For many of them it is the first training of any kind they have received. They are proving to be ardent and committed communicators and change agents in their own communities as the following story illustrates.

Mero’s sister-in-law was due to deliver shortly after she completed her training with Frontier Primary Health Care as a Female Health Worker. Most of the deliveries in the refugee camp where she lived, were done in rooms set aside for animals or for bathing. This made the cleaning up afterwards easier. Mero had seen how careful the nurses were about hygiene in the labour rooms. Mero had been impressed by the importance her trainers placed on having a delivery done in clean surrounding.

So Mero shared this new information with her sister-in-law and together they began to prepare a room for the delivery and arranged clean clothes, pads, soap and basins. While Mero and her sister-in-law were preparing the room, other women in the camp were watching them and learning. They admired Mero’s efforts. They were glad Mero would be able to assist them to have healthy deliveries.

The baby was born safe and healthy in hygienic conditions with Mero using her new Clean Delivery Kit. Things were already starting to change in the camp .

45 new TBAs were trained in Akora and Kairabad Refugee Camps in Nowsherra district of Northwestern Frontier Province in Oct and Dec, 2009. Training of these female health workers will ensure women in this remote area of Pakistan have ready access to accessible skilled maternal and newborn care. 32 in Akora and 13 in Khairabad.

A comprehensive community selection process ensures that the female health workers are trusted and respected individuals in their own community who will be allowed to visit women and care for them in their homes. The TBAs are provided with three weeks of interactive training in primary health care with an emphasis on maternal and newborn care. They are coached in to recognize and refer pregnancy complications early and to provide health promotion over the three weeks of their training. More than 15 days is spent in health center labour rooms and first level EmOC facilities of Frontier Primary Health Care.Improvements have already been noticed in Ankora within the first three months since the training was done. New registrations of mothers has increased 25% from 88 in Oct to 101 in Dec. while babies weighed within the 72 hours has increase from 92 to 131 in the same periods. The number of women delivered by skilled workers also increased 30%, from 98 to 127.

Photos from FPHC, TBA training in Akora and Khairabhad

Successful TBA Training in the Midst of War

Almost 60-70% of women and their families in the isolated communities of Wardaga and Ismailia prefer and use traditional birth attendants. Over the past ten years, due to illness, old age, insecurity and relocation, the number of Traditional Birth Attendants in Wardaga and Ismailia village in Northwestern Frontier Province has decreased drastically. As the area is conservative and rigorous purdah practiced, women rarely venture outside their own homes. In these areas linking pregnant women up to women within their own community who are knowledgeable about pregnancy and child birth is crucial to reducing deaths from child birth.

$4000 was provided by the Hillman Medical Education Fund and Society of Rural Physician donors to train 30 TBAs. A lengthy consultation with the two communities ensured they were supportive of the plan to improve maternal health services; were willing to have their wives and mothers trained as TBAs and/or visited by the TBAs in their homes and had agreed upon a minimal fee for provision of birth kits and TTBA care. Discussion of the qualities needed for being a TBA lead to development of a set of criteria and identification of suitable candidates for each community. At the end of the process the communities had identified a total of 38 women were needed.

Wardaga’s population is 12,000 while Ismailia’s is 30,000. It was recognized that these female health workers as the only ones in their community would also be important conduits of health information on diarrheal diseases, immunization and nutrition as well as pregnancy and newborn care. Wardaga has a day labour room staffed by two nurses and 3 dais while Ismailia has a basic emergency obstetrical center (EmOC) providing 24 hour coverage with 3 nurses, 1 assistant nurse and 4 dais. So skilled TBAs were an important adjunct to getting services to women and women into the health centers for delivery when needed.

The need for skilled female health workers in the community resulted in the extending the training from four weeks to six weeks. This 50% increase in enrolment and training period were accomplished with cost efficiencies within the original budget with $4000 training 38 TBAs, or approximately $105 per TBA trained. This cost included provision of a supply of individual birth kits containing rubber gloves, soap, razor and tie. The individual kits form a rotating supply that will be sold to pregnant women at cost plus a small amount for the TBA which is agreed in advance by the community, approximately $0.50. In addition each newly trained TBA received a TBA kit with rubber sheet, nail brush, towels, gloves, soap, plastic apron, containers and a supply of oral rehydration packets.

The project did not include an evaluation component and information is available for only 4-6 months following the training but data from the health units show a real impact. Ismailia Health Center, where 38 TBAs were trained, reported an increase of more than thirty percent of women, from 240 to 320 women attending ANC in the first four months following training of the TBAs and a >200% increase, from 30 to 68 in the number of women delivering at the Health Center. Prior to training. almost half of the women admitted to the obstetric unit did not proceed to delivery prior to training while six months following training less than 10% of the pregnant women who initially admitted were discharged without delivering.

Health Center, where nine new TBAs were trained, ANC attendance doubled from 51-106 within six months and the number of women receiving at least two doses of tetanus toxoid rose from 36-51 in three months.

While the follow-up period is short and the data preliminary, these figures suggest that not only do trained TBAs refer more pregnant women to ANC and for delivery in this region but they appear to be appropriate and effective in their referrals. The Hillman Medical Education Fund is proud to be assisting to develop skilled Trained Traditional Birth Attendants in Northwestern Frontier Province who are reaching women in their homes and linking them to appropriate delivery and antenatal care. The pride and dedication of these TBAs to improve the care of pregnant women is humbling.

Photos: TBAs in class; TBAs using models; TBA with certificates

ETAT (Emergency Triage Assessment and Treatment ) Course

Annual ETAT+ Instructors day held 21 Jan. in the seminar room at the KEMRI/WT centre. Sponsored by Hillman Fund


Half of the day was dedicated to a review of changes in the science literature behind the guidelines and the research going on around the implementation of the training and materials. The rest of the day was spent in discussions of the directions ETAT+ will go, funding and discussions of educational topics.
In the photos first is Robin Achoki talking on the science (or lack of clear guidance in the evidence) behind treating hypoglycemia.
In the second photo are four of the graduates of the UoN M.Med programme in Paediatrics. All were trained in the GIC course utilising monies from HMEF. From left to right are Bernard Awuonda posted to Voi District Hospital, Eric Ngetich at MTRH (who will be the lead person in bringing ETAT+ to be a part of Moi University), James Gitau posted at Garissa and behind them is Nyawira Githinji posted at Kerugoya DH.