DIRE HEALTH AND HUMANITARIAN CONDITIONS OF IDPS IN THE PAKISTAN’S NORTH WEST FRONTIER PROVINCE
Interview with Dr. Khalif Bile Mohamud1, WHO Representative, Pakistan
What is the humanitarian and health
situation of the approximately two
million people displaced by violence
in the North West Frontier Province?
The situation is dire for the majority of the people who have been forced to flee their homes. This is mainly because their displacement has overwhelmed health services in areas where they have fled to. Of all the people displaced by the conflict in the Swat Valley and Malakand district, 90% have been living mostly in five districts of the North West Frontier Province. This has increased the population in these five districts to more than ten million people, pushing available health facilities to the brink. The remaining number of displaced people are living in more than twenty camps.
There is a continued concern, therefore, about the health situation of the displaced, especially children, pregnant women (approximately 63,000), the chronically ill and elderly who are living within host communities where the coping capacities of health services are near exhaustion.
The major health concerns facing the internally displaced persons (IDPs) in northwest Pakistan are diarrhoea, acute respiratory infections, measles, medical and surgical emergencies, acute child and maternal care, and mental health and psychosocial support. Their exposure to extreme weather conditions, such as searing heat and monsoonal rainfall, adds further misery to the lives of the displaced and exacerbates health risks that they are already confronted by.
Other major factors compound these health concerns include:
- Continued displacement: IDP numbers are around 2 million and with military operations spreading to South Waziristan the numbers of displaced may increase. Access to newly displaced in Dera Ismail Khan and Tank is complicated by security issues, and, therefore, provision of healthcare to IDPs could be compromised.
- Returnees and the population trapped in the conflict zones have access to limited health supplies in their home areas. There has been damage and destruction sustained by approx 60% of health facilities in the Swat Valley and other areas of conflict. Private health providers, who were responsible for 60–70% of health-care services in some areas, have stopped and may not re-launch their services back any time soon.
- We have insufficient numbers of health staff, particularly female health workers, available to deliver health care. The gap, in the immediate term, the healthcare services provision at the point of return will fall on the public sector and the humanitarian community.
- The harsh weather conditions, whether it be the high temperatures or monsoonal rainfall. Heavy rains increase the risk of outbreaks of communicable diseases, particularly in crowded camps, where poor hygienic and sanitation conditions and waterborne diseases’ control will become real challenges facing the health system.
- Insecurity is another major factor, which limits the level of humanitarian care that can be provided to the displaced. Insecurity is a major factor that discourages female health practitioners including doctors and lady health workers to serve in these localities and provide care to female IDPs in this culturally-sensitive area. The government has made some efforts to address this gap, but much more is needed.
You have been head of the WHO
country office in Pakistan for several
years. Can you tell us what is the role
of WHO as Health Cluster lead and
how the Health Cluster partnership
has made the health response more
In my time in Pakistan, I have led WHO’s operations during several large-scale emergencies, including the 2005 earthquake. During these events, WHO and the health sector has learned a lot and improved its response, particularly in terms of coordination. This has all been done via the cluster approach.
What the cluster partnership has done is bring together all those involved in providing healthcare in humanitarian settings. In our regular cluster meetings, and through the sharing of information, we learn what needs exist and can assess our collective operational capabilities. It also allows us to know what each cluster partner can offer and where they have to lend support to respond to the health needs of the displaced people and their hosting communities.
The Cluster approach has made the humanitarian health response better organized, more effective and more resourceful by converging the skills and capacities of a large number of partners. The government’s role as the lead of this whole process must be commended as they have continuously offered all the necessary facilitation and partnership throughout the course of this operation.
A matrix has been developed on “Who does what where?” This is a vital tool for effective coordination. It helps us respond to immediate needs and plans for the future. The cluster partnership helps avoid parallel coordination structures and duplication of activities.
All cluster partners also share responsibility for the timely identification of disease out-breaks. They report all cases that are clinically compatible with any of the 11 notifiable diseases outlined by the WHO-designed Disease Early Warning System (DEWS) of disease surveillance and epidemic control.
Each notified case is labeled as an “alert” and once notified comprehensively investigated and diagnosed. If a potential disease outbreak is confirmed, a response action is put in place until the risk of outbreak is fully averted. Although WHO is oordinating the technical dimensions of the DEWS operation, the organization of this disease surveillance network would not have been possible without the active participation of all cluster partners. The DEWS is the flagship programme that determines the effectiveness of any humanitarian health operation. A weekly DEWS report is produced and shared with all cluster partners and OCHA.
The Health Cluster also works closely with other clusters, particularly in water and sanitation, nutrition and logistics, to ensure coordination among a wider group of humanitarian actors across different, yet related, sectors.
Throughout all of this, WHO has led the way. As the lead agency of the Health Cluster, WHO works tirelessly to bring the partners together, to facilitate information and resource sharing and to more effectively plan interventions. By knowing where the needs are, WHO is able to help fill such needs by supplying medicines, and providing the technical norms and standards for the delivery of promotive, preventive, curative and rehabilitative care to the IDPs and their hosting communities. These standards are shared with all cluster partners to attain their endorsement and commitment for application and practice.
What are the most urgent health
needs as of today?
There are several urgent health needs facing those displaced in Pakistan. Key among them is the delivery of wide range primary health care services, the control of communicable diseases, delivery of antenatal and postnatal care, provision of mental and psychosocial health services and conducting of childhood immunization campaigns. Ensuring peoples’ access to these essential services is vital.
Those affected by the conflict need robust health services, but the scale of the displacement and the damage to health facilities severely hampered the level of care available to these people.
Sixty percent of health facilities in the confl ict areas have been damaged or destroyed. The private sector, which was responsible for 60–70% of health care in these areas, has vanished. In areas where the displaced have fled to, too few female staff were available to treat the existing communities. Now the influx of displaced people has heaped further pressure on already fragile health staffing systems. This is particularly the case in terms of female health workers. There are too few available to treat the many females who have been displaced, which increases risks including pregnancy complications and other maternal and child health issues.
We see also patients with chronic non-communicable diseases, such as hypertension, chronic heart disease, diabetes mellitus, bronchial asthma and chronic pulmonary diseases and mental disorders. The majority of these patients cannot afford to buy the necessary medicines, increasing the risk of life threatening complications. WHO ensures the regular procurement and supply of essential medicines for such diseases and ensures their management as an integral part of the emergency health response.
In terms of funding, the health sector’s request for $37 million is roughly one-quarter funded. More resources are needed to meet the health needs of the displaced, especially in light of the harmful impacts of the monsoon season, and to the need to revitalize the damaged health sector in the conflict areas.
What are the health challenges to
be faced by health partners in the
The immediate and long term challenge is to fill this alarming widening gap between health needs and health service provision. This critical deficit of service provision must continue to be addressed. In the same vein, I would say that strengthening of health systems in this crisis implies not only urgently bridging resource and coverage deficits but also their appropriateness in terms of gender and cultural sensitivities.
Gender balance and sensitivity in service delivery have become serious considerations as a large proportion of the displaced people are women and children and, according to local cultural practices, women clearly have a strong preference for female doctors and health care workers are currently underrepresented.
The outbreak of communicable diseases surely remains one of the major threats we are facing. The monsoon season, and the health risks it brings with it, poses one of the key problems for the displaced people and the Health Cluster members who are striving to provide essential health care. Sanitation, hygiene and water quality will need rigorous and continuous monitoring and robust coordination with the WASH cluster.
Ensuring that health facilities and systems are repaired and working in the areas of return is also key, as sustainable healthcare is essential. Maintaining security is also critical. Renewed fighting may lead to further displacement and a continuation of the misery facing these people.
On behalf of Health Cluster partners,
what would you be appealing for?
The Health Cluster response needs continued support from the international community in terms of financial resources and medicines. We want to have guaranteed safe access to be able to deliver care to all vulnerable people. This will require an improvement in the security situation. There needs to be a clear understanding from all sides that health facilities, the staff who work in them and the people who use them are neutral and must be protected at all costs. Health services are essential for the survival of any community, particularly in times of crisis.
What message/s would you like to
give to UN country teams where cluster
implementation is either still in
transition or is likely to transpire in
The cluster approach is a fantastic means in which essential life-saving health care can be delivered in humanitarian settings. It helps maximize the life-saving potential that can be offered to people living at risk. Resources are becoming increasingly hard to attract, particularly in light of the global financial crisis. This underscores the value of coordination and team work which the cluster approach embodies. It is clear that no one entity can respond to all health needs in humanitarian crises, especially in developing countries. The cluster approach helps overcome this.
What roles can NGOs play in
strengthening cluster mechanism?
NGOs are vital in terms of cluster response. The cluster approach should not be seen as a UN-led effort. It requires the active participation of all humanitarian actors. NGOs’ involvement makes the cluster approach work. In many settings, it is nongovernmental organizations that are often the main providers of healthcare. The manpower, resources, expertise and reach that NGOs provide are vital for the Health Cluster’s success.
1 Born in 1945 in Somalia, Dr Khalif Bile Mohamud graduated in medicine from Sofia University, Bulgaria in 1971, obtained two post-graduate specializations from the University of Rome, Italy — one on Tropical & Sub-tropical Medicine and the second on Clinical Gastroenterology and Digestive Endoscopy. Subsequently, he secured his Ph.D. in the field of Epidemiology of Communicable Diseases from Karolinska Institute of Sweden. In Somalia, he first practiced clinical medicine, became a tertiary care hospital administrator and senior academician as a Professor of Medicine and ultimately Dean at the Medical College of the Somali National University from 1980–1985. He joined the World Health Organization from 1986–1989 in Somalia, and later from 1992 to 1998 as WHO Medical Officer Primary Health Care in Pakistan. Dr Bile was designated as WHO Country Representative first in Iran from 1999 to 2001 and in Pakistan since late 2001 and is currently based in Islamabad. Additionally, he officiated as UN Resident Coordinator and WHO Representative in Afghanistan during 2002– 2003. He has more than sixty publications in indexed international journals focusing on communicable diseases and health systems to his credit. Dr Bile was awarded a high civil award of Sitara-i-Quaid-i-Azam by the President of Pakistan in recognition of his outstanding services to the country. He is also the recipient of the honorary Fellowship of the College of Physicians and Surgeons of Pakistan. His principal public health interest is to forge unity between health systems and medical education, promote the critical role of social determinants of health and link them to the poverty reduction through community based integration development interventions.