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.

Floods Wreck Havoc in Mardan & Swabi

Frontier Primary Health Care has been called again to respond quickly to a humanitarian crisis, this time even closer to home as the recent devastating floods in Mardan and Swabi districts have played havoc in their own communities of Ismailia as well as Kagan and Baghica Afghan refugee camps. This most recent disaster comes just weeks after the Internally Displaced Refugees in camps around Mardan had been repatriated to Swat and the camps officially closed. For several weeks following the closure of the Sheikh Yaseem town camp, where FPHC had been providing 24-7 medical coverage, FPHC staff continued to provide nutritional services to other camps as well as some medical clinics in the camps until all were closed and the services no longer required.

On August 16th a heavy deluge of rain resulted in massive damage throughout Swabi and Mardan districts. Approximately 50% of the mud homes in the Kagan refugee camp were fully destroyed and the rest remain in dangerous condition. Ismailia Health Center was also badly hit with flood waters filling the clinic rooms and hall ways with mud and debris. The home of several staff members were also affected including FPHC's hardworking, stalwart administrator, Said Zaman. Luckily he and his family all escaped unscathed.

Homes in the refugee camps were especially badly affected, as they are made of mud and wattle. Many of the injuries and deaths that occurred were a result of collapse of the homes which happened suddenly and catastrophically.
As many as 27 people died in the flash floods with many more injured and thousands now without homes. Most of the deaths were reportedly due to collapse of the mud-walled houses. The Emergency Maternity Center (EMOC) in Ismailia as well as the Health Centre there, both of which have been extremely busy and active clinical sites suffered serious damage with loss of both medical and non-medical supplies as flood water tore through the buildings.

FPHC vehicles and staff assisted in Kagan with the evacuation of people from the worst of the flooded area. Hot meals were provided for those displaced. The health center at Ismailia and the emergency medical team provided emergency medical care to those injured.
Staff and community are busy rebuilding their homes, cleaning up and shifting the debris and mud that has been left behind. There remain ongoing concerns about the spread of cholera and typoid in the area.Everyone is busy now cleaning up the damage and attempting to put things right.

Photos: Kagan & Baghica Refugee camps and Ismailia.

FPHC continues Work in IDP Camp

Frontier Primary Health Care continue to be in the epicenter of one of the most massive movements of internally displaced persons on the globe as the number of people who have fled Swat, Bajaur, Lower Dir and Buner, just north of them, reaches 3 million.
As the disaster unfolded in May, FPHC was among the first to response, providing emergency and maternal care at their 14 health units. Frontier now has a formal agreement with UNICEF for provision of health and nutrition services in the Sheikh Yasin town camp, at 12,000 people the largest in Mardan district. The provincial health department has provided an ambulance and driver for use. Local and international organizations wanting to assist are asked by the government to coordinate their services thru FPHC, including specialist physicians from the large government hospitals from outside the area such as Punjab.

To continue their 24/7 coverage, FPHC have hired 90 temporary staff members including physicians, dispensers, lady health visitors (LHVs), assistant LHVs, EPI technicians and nutrition assistants. Until a formal agreement was in place, FPHC was providing care with their own staff who number only 120. In addition to emergencies staff provide general OPD care, MCH care, immunization, TB control and diarrhoeal disease control.

FPHC have also established nutrition services in six IDP camps that are screening children and pregnant women, providing nutritional supplements and sharing information about preparing healthy balanced diets. Prior to establishing nutritional services, three staff members, including Dr. Wagma received seven days of training on UNICEF’s emergency approach to nutritional support.

Frontier’s response to this humanitarian crisis have been truly extraordinary. The agreement with UNICEF does not include medical supplies so FPHC could use assistance in this regard. Tax deductible donations can be made on line thru Rose Charities Canada here.

Photo: FPHC staff respond to Mardan floods

Responding to IDPs in Northwest Frontier Province

While war wages around them, Frontier Primary Health Care (FPHC) struggles to assist in mitigating the impact of the disaster on women and children.

Frontier Primary Health Care is a small Pakistani NGO, working with 200,000 people at 14 separate sites in four districts in Northwest Frontier Province of Pakistan. They are well known to the Hillman Medical Education Fund having recently received a small grant for training and supervising traditional birth attendants. FPHC works in ten Afghan refugee camps and the surrounding Pakistani communities providing the full range of primary health care at the cost of $2 per person per year. FPHC have also had some experience in responding to disasters with the recent quakes and floods in the region.

Northwest Frontier Province has been swamped with more than 2 million internally displaced people (IDP), according to the UN. It is one of the most extensive migrations of IDPs on the planet as people take flight from intensive US and Pakistani bombing, drone attacks and fires in Swat, Bajaur, Lower Dir and Buner districts. Fleeing their homes, they are quite literally running for their lives. 80% of the refugees have arrived in Mardan and Charsadda, the target area of Frontier Primary Health Care.

As the disaster has unfolded, FPHC has been providing free medical and maternity services at all 14 of their health centers including the Ahmed Shah Abdali Hospital in Mardan. On May 7^th, 2009 Frontier Primary Health Care arranged for emergency health care services for IDPs in one camp and was planning how they could assist with emergency health care and nutrition rehabilitation services in four other camps.

In discussions with UNICEF, FPHC indicated that although they have limited resources, their staff is eager to assist. By May 10th, staff had been deputed and health posts established in two IDP camps . Community labour rooms in Mardan and Nowsherra were also taking on deliveries of the IDPs.

In a recent email, Dr. Emel Khan, executive director of FPHC, said,"The security situation is frightening. Though there is no specific threat to FPHC or its outlets, every one in our target area is at risk and scared. Noone knows when and where something wrong will happen."

Some IDPs are able to go to the homes of relatives but most look for shelter, food and health care where they can find it. The people, especially the pregnant mothers and children, have been arriving in miserable condition as the unrest and violence in their homes has been ongoing for many months. Many women and children have nutritional deficiencies. Civil society groups,government and common people are doing their best to provide relief.

Four main camps have now been established in Mardan district, Jalala, Sheikh Shehzad town, Mazdoorabad and Sheikh Yasin town. Emergency and comprehensive health care at the IDP camp at Sheikh Yasin town was officially delegated to FPHC. FPHC staff have continued to provide round the clock services with their own resources assisted by donations from friends and staff. Working in their regular health centers during the day, many staff take on additional evening and night duties at the IDP camps,extending their working days to 18 hours.

FPHC have been using their own meagre drug supplies as supplies have been slow to arrive and 700- 800 patients daily present at the clinics with diarrhea, dysentery, respiratory infections and skin conditions in addition to the pregnant women who present for delivery.

FPHC urgently need funds to continue to provide medical supplies and nutritional support to mothers and children. Check here to find out more about the Hillman Medical Education Fund and Rose Charities. Rose Charities Canada is able to accept and send donations directly to Frontier Primary Health Care and provide tax receipts for Canadians. For a USA tax receipt donate through Rose Charities US

Photos: FPHC responds to Earthquake; Lady doctors hold MCH clinic during emergency; FPHC hold emergency clinics during Floods.

2009 Recipients of the Hillman Awards in Kenya

Letter from Grace Irimu of the Kenya Pediatric Association to Prof Elizabeth Hillman

Sent: Friday, May 15, 2009 1:41 PM
Subject: FW:
Dear Prof Hillman ,

We had very successful Kenya Paediatric Association Annual Scientific Conference which was held from 22nd April to 25th April in Mombasa.

Thanks a lot for the Hillman Leadership Award. You sent funds to sponsor one person; but we were able to use the funds to sponsor 2 people- they shared a double room in the hotel and they were given money to travel by bus. Finally they added their cash and were able to take a flight to Mombasa. The two postgraduate students were:

Dr Jalemba Aluvaala - the postgraduate student who have contributed most to training of ETAT+ in the Dept and at the National level.
Dr John Ngugi- he is the outgoing Chief Resident and has demonstrated outstanding leadership within the Dept and outside the Dept.

Attached please find their picture posing with the Chairman of the Dept Prof Dorothy Mbori-Ngacha.

During the award & certificate presentation “The Hillmans and the Hillman Medical Education Fund” were introduced to the audience and people really were really touched and appreciated what Prof Hillman is doing for the medical education in Kenya.

We are in the process of developing an objective criteria for selecting the postgraduate student with the most outstanding leadership skills. A draft has been circulated to the members of staff and the postgraduate students. Once it is discussed at the Dept level then we shall forward it to you.

Prof we missed you in the Conference and we hope that you shall join us in our next year conference and meet the paediatricians from all over the country.

Grace