Response International

Azad Jammu and Kashmir
Kashmir has been the key to the dispute between Pakistan and India since their independence from the British in 1947. Each country claims Kashmir, and conflict has raged intermittently for over fifty years. The area is divided by a Line-of-Control, to the east of which is land occupied by India and to the west lies Azad Jammu and Kashmir (AJK). AJK is divided into eight districts, with a total population of 3.27 million, almost exclusively Muslim and speaking either Urdu or Kashmiri. It is a mountainous region, but with fertile agricultural plains due to the sub-tropical climate and high rainfall. The majority of the largely rural population depend on forestry, livestock and crops (maize, wheat, rice and vegetables) for subsistence, but there is high unemployment (approaching 50%, and rising because of the number of refugees, displaced from their homes during the conflict and living in camps and scattered settlements) and widespread poverty.

A legacy of the conflict is a ravaged environment, heavily contaminated with unexploded mortar shells and landmines displaced by the erosion caused by rain/snowfall induced landslides. More than 100,000 have died in AJK during the conflict, but a recent ceasefire finally brought real hope of a lasting peace.
Then on 8th October 2005 an earthquake measuring 7.6 on the Richter scale hit Pakistan, primarily affecting five districts in North West Frontier Province (NWFP) and three in AJK (Muzaffarabad, Bagh and Poonch). In addition to the estimated 80,000 deaths, several hundred thousand were injured and over three million left homeless. The health system and infrastructure were badly affected and the majority of health facilities were destroyed in affected areas.

This led to the total disruption of primary and secondary health care service provision in the affected districts. The needs of the health sector for the short to medium term were substantial and an emergency response involving multiple partners including the Ministry & Departments of Health, Pakistan Army, United Nations agencies, NGOs and local people is still ongoing. Health care is being provided by emergency primary health care teams and through the establishment of field hospitals with international and local support. In addition, preventive health interventions have been initiated including immunization, vector control, vitamin A supplementation, health education, and disease surveillance. However, more coordinated efforts will be required for the reconstruction and rehabilitation of the health system in the affected districts in order to prevent further misery, disease and loss of life.

Organization of Health Care in AJK
As elsewhere in Pakistan the Federal Ministry and Provincial Departments of Health are envisaged as policy and strategic leaders, whereas the actual implementation and delivery of health services takes place at the district level. The 3-tiered structure is based on the union/tehsil/district levels of administrative hierarchy, with the union council being the first level of contact in this organization, rising to district council. A District Coordination Officer (DCO) supervises the work of twelve line departments, including health, headed by Executive District Officers (EDO). The EDO for health looks after both the preventive and curative aspects of health in the entire district.

The district level health care system is organized in several tiers that link the community and the First Level Care Facilities (FLCF) with district level hospitals. They are grouped as follows:

Health Houses: At the community level where basic health services are delivered by Lady Health Workers (LHW) from their homes, which in effect function as health houses serving a catchment population of around 1,000. LHWs offer a standard primary health care package of promotive, preventive and limited curative services in the area of child and maternal health care and nutrition. Their main focus is on reproductive health, treatment of common illnesses and conditions in children and adults, and in supporting disease control interventions designed for the grass-root level.

Basic Health Units: BHUs provide basic health services in every union council, and cater for an average population of 10,000 – 15,000. The services offered include: antenatal and postpartum care; family planning; routine immunizations; nutrition promotion and education through growth monitoring; management of childhood diseases; management of simple malaria cases and TB-DOTS; and provision of essential drugs for common ailments. BHUs provide outpatient care till 2 p.m. only, and the two labour beds present in all of them are seldom utilized.

Rural Health Centres: RHCs cover a larger catchment population of 50,000 - 100,000 people and offer a wider range of services in the morning hours in addition to minor emergency services round the clock, and have inpatient facilities.

Tehsil Hospitals: Tehsil hospitals are first-referral or sub-district hospitals located in most tehsil headquarters, having the capacity to provide most services including surgery, X-rays, and comprehensive emergency obstetric care. These hospitals provide a wider range of essential drugs and laboratory services and are staffed by doctors, dental surgeons and by a number of professional nurses and paramedics.

District Headquarter Hospitals: The district headquarter hospitals are located in the main city of the district and serve as referral centres for the tehsil hospitals, offering a comprehensive package of specialist services for the whole district, including emergency medical, surgical and obstetric care round the clock.

Health Status in AJK
The limited access to health services, clean drinking water/sanitation and education, and high levels of poverty and malnutrition all contribute to the poor health status of the population of AJK, as per Pakistan as a whole. Nationally this is characterised by a high infant and child mortality rate, high maternal mortality ratio and a high burden of communicable diseases (all figures from WHO, 2006):

Infant Mortality Rate (IMR)                          77 per 1,000 live births
Under 5 Mortality Rate                                103 per 1,000 live births
Maternal mortality ratio (MMR)                     350 per 100,000 live births
Only 30% of births are attended by a skilled birth attendant

Incidence of tuberculosis                177 cases per 100,000 population annually
Incidence of malaria                      2-5 cases per 1,000 population annually

According to the UNDP's Human Development Index (HDI), these indicators contribute to Pakistan's position amongst the lowest ranking countries worldwide.

Malaria (in all areas less than an altitude of 2,000 metres), tuberculosis and leishmaniasis are all endemic in AJK. Vaccine-preventable diseases still cause considerable morbidity and mortality, although a well supported Expanded Programme on Immunisations (EPI) is beginning to improve vaccine coverage and reduce the impact of such diseases (polio in particular).

Although severe malnutrition is not immediately apparent in the region, there are significant numbers of underweight children. This high prevalence of mild to moderate malnutrition makes a huge contribution to childhood diseases and death. Several types of micronutrient malnutrition are also of great concern, particularly Vitamin A deficiency and nutritional iron-deficiency anaemia.

Bagh and Poonch Districts
Poonch has a total population of 633,712 (Ministry of Health/WHO estimate, 2006) and is divided into three tehsils (sub-districts): Rawalakot; Hajira; and Abbaspur. Bagh has a total population of 452,532 (Ministry of Health/WHO estimate, 2006) and is also divided into three tehsils: Bagh; Dhir Kot and Haveli.

The impact of the earthquake on health care provision in the Bagh and Poonch districts was highlighted by the WHO led Health Cluster in Islamabad, and confirmed by our field assessment and discussions with the EDO for health and WHO team in each district. Our early health response (rapidly deployed mobile clinics using existing in-country resources within days of the earthquake) in these districts gave us valuable information as to the extent and location of greatest need, and this initial response has since expanded into a major primary health care support programme covering over 50,000 beneficiaries (see Annex 1 for a project summary).

Earthquake damage to health care facilities in the two districts is summarised in the table below, with both hospital and primary health care facilities devastated:

* Includes First Aid Posts, Maternal-Child Health Centres and TB Centres

Vulnerable groups, mainly women and children, made up a large share of the earthquake victims. Along with general health services, maternal and neonatal health services were particularly badly affected. The availability of emergency maternal and neonatal health care is a critical determinant for the survival of mothers and newborns, and a rise in both the IMR and MMR is expected. The health sector also faces the additional burden of treating the new vulnerable population sub-groups, including the disabled, widows and orphans, who require specialized care and services. Because of poor environmental conditions, the spread of communicable and vector borne diseases (including measles, meningitis, leishmaniasis, pneumonia, diarrhoea, typhoid, hepatitis and cholera etc) is likely.

Not only have the centralized primary health care and hospital facilities been disrupted, but community based services have also been devastated. All but a handful of the LHW health houses in both districts have been partially or completely damaged. As a result, families have been deprived of village-level primary health care services including family planning, growth monitoring, immunization, pregnancy monitoring, treatment of minor infections/ailments and basic first aid.

A relatively small number of health workers in both districts suffered serious injury or death, but many have lost immediate or close family members and their homes. Most of them are weak and grieving, both physically and mentally unprepared to deliver health care, but gradually they are returning for duty.

“Reuters/photographer’s name, courtesy www.alertnet.org”

Both district health offices have been badly damaged, with the EDOs for health and their staff operating from tented facilities. Health facility equipment has also been badly damaged or destroyed; along with reconstruction work, there will be a need to fully equip health facilities, together with the provision of at least one year of all consumable supplies (including medicines).

Key objectives for the health sector in Bagh and Poonch districts are thus the same as those outlined in the Earthquake Reconstruction and Rehabilitation Authority (ERRA) “Health Sector Reconstruction and Rehabilitation Development Plan: Build Back Better”:

To restore health care infrastructure through rationalized reconstruction/rehabilitation of seismically safe and user friendly health facilities;
To ensure availability of an integrated and essential services package at different levels of the health care delivery system covering preventive and curative services, including a rehabilitation programme with improved access for the disabled;
To strengthen the management and organizational system to revive and sustain health services; and
To devise an institutional mechanism in the health sector to operationalize a rapid effective emergency and disaster response whenever required.