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D R F A T O U F R A N C E S C A M B O W , S A V E T H E C H I L D R E N 2 6 . 1 1 . 1 3
HUMANITARIAN HEALTH ASSESSMENT IN DIFFA REGION
ASSESSMENT TEAM
• Dr Fatou Francesca Mbow, Save the Children WCA Regional Humanitarian Health Adviser
+221 777406701
Dakar-Niamey-Dakar: 18-27 Nov. 13
Niamey-Diffa-Niamey: 21-26 Nov.13
• Anda Oumarou, Save the Children Health and Nutrition Program Manager , Diffa
Excused -sick leave -(Diffa): Aicha Taybi (UNHCR)
METHODOLOGY
1. Literature review
2. Face-to-face discussions with key informants: Ministry of Health (Direction Régionale de la Santé, Health Facilities’ staff), Diffa Health District Head, Diffa Urban Health Centre Head, Mental Health Co. Diffa Regional Hospital*, NGOs (Save the Children, IRC) UN agencies (UNHCR), patients in health facilities *phone conversation
3. Direct observation: Bosso health centre, Kablewa health centre, Diffa’s regional hospital (paediatric ward including CRENI), Maine Soroa district hospital (paediatric ward and CRENI), Maine Soroa health center Limitations: -MoH and Save the Children staff very engaged in “Journées Nationales de Vaccination” - SAM/MAM Save the Children program not evaluated quantitatively
• 6 departments
• 3 health
districts
DIFFA REGION
Niger
17 million
Diffa
600,000 http://www.stat-
niger.org/statistique/file/rgph2
012.pdf
Diffa
48% below
age 15 http://www.snis.cermes.net/downl
oad/Annuaire_%20statistique_2
011.pdf
Maine Soroa:
216,600
people
15,000 km²
1 District
Hospi.
20 CSI
43 cases de
santé
Diffa REGION
600,000 people 157,000 km² 50 CSI 127 cases de santé N’Guigmi:
83,100 people
135,000 km²
1 District Hospi.
12 CSI
27 cases de
santé
Diffa:
224,000 people
7,000 km²
1 regional hospital
17 CSI
57 cases de santé
CARTE SANITAIRE DIFFA REGION AND DEPARTMENTS
HUMANITARIAN CHALLENGES IN DIFFA
OVERVIEW
http://reliefweb.int/report/niger/sahel-operation-diffa-situation-niger-november-2013
TRANS-BORDER MOVEMENTS DIFFA HEALTH DISTRICTS:
37,000 PEOPLE, ¼ NIGERIAN (UNHCR) HEALTH DISTRICT HEALTH FACILITY SITE NAME # MOBILE POP.
# NIGERIA
%NIGERIA
Diffa
Health Centre (urban) BOSSO 10913 1863 17%
MAMOURI 1582 277 18%
GARIN AMADOU 1294 420 32%
BOULAGANA 991 164 17%
GAMGARA 1 250 250 100%
GAMGARA 2 644 27 4%
BOULABRINE 162 162 100%
ABADAM 2218 1117 50%
TCHOUKOUJANI 1936 588 30%
Health Centre (rural) BAROUA 1247 381 31%
NGUELKOLO 1252 117 9%
Health Centre (urban) DIFFA 4638 963 21%
Health Centre (rural) TOUMOUR 837 47 6%
TOTAL Diffa 27964 6376 23%
N'Guigmi
Health Centre (rural) KABLEWA 5225 790 15%
TOTAL N'Guigmi 5225 790 15%
Maine Soroa
Health Centre (urban) MAINE-SOROA 2890 1013 35%
ABASSARI 304 47 15%
YABAL 58 75 129%
Health Centre (rural) TAM 443 68 15%
ABOUNGA 24 16 67%
TOTAL Maine Soroa 3719 1219 33%
TOTAL Diffa Region 36908 8385 23%
http://reliefweb.int/report/niger/flash-update-no1-du-15-novembre-2013-inondations-diffa-suite-la-crue-de-la-komadougou
FLOODS
FOOD INSECURITY
http://www.fews.net/pages/country.aspx?gb=ne
HUMANITARIAN HEALTH CHALLENGES IN DIFFA
OVERVIEW
SAM PREVALENCE THE HIGHEST IN THE COUNTRY AND INCREASING SINCE 2011
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
2007 2008 2009 2010 2011 2012 2013
Axi
s Ti
tle
Prevalence of SAM per Niger Region, SMART 2007-2013
Agadez
Diffa
Dosso
Maradi
Tahoua
Tillabery
Zinder
Niamey
Niger
GAM PREVALENCE DECREASING
HIV PREVALENCE POSSIBLY THE HIGHEST IN THE COUNTRY DHS 2006*
*HAVE NOT BEEN ABLE TO GET SENTINEL SURVEILLANCE DATA BUT IT APPARENTLY EXISTS
AND CONFIRMS THE ABOVE
• DHS 2006
http://www.measuredhs.com/pubs/pdf/HF16/Niger_HIV_FactSheet.pdf
ENQUÊTE SOCIO COMPORTEMENTALE ET DE PRÉVALENCE DES IST ET DU
VIH/SIDA DANS LE BASSIN DU LAC TCHAD A DIFFA AU NIGER, JUL. 2011
Hommes Femmes Ensemble
HIV-1
Intervalle de confiance à 95% Effectif HIV-1
Intervalle de confiance à 95% Effectif HIV-1
Intervalle de confiance à 95% Effectif
Inf Sup Inf Sup Inf Sup
Milieu de résidence
Urbain 0,0% 0,0% 1,5% 321 3,00% 1,3% 6,3% 236 1,3% 0,5% 2,7% 560
Rural 2,00% 0,7% 4,8% 254 3,70% 1,6% 7,8% 189 2,7% 1,5% 4,8% 447
Age
15 - 19 0,0% 0,0% 6,7% 68 0% 0,0% 4,5% 103 0,0% 0,0% 2,7% 171
20 - 24 0,0% 0,0% 5,3% 87 5,70% 2,1% 13,5% 87 2,9% 1,1% 6,9% 174
25 - 29 1,1% 0,1% 6,9% 90 1,10% 0,1% 7,1% 88 1,1% 0,2% 4,4% 178
30 - 34 2,2% 0,4% 8,4% 92 3,70% 0,6% 13,8% 54 2,7% 0,9% 7,3% 146
35 - 39 0,0% 0,0% 5,8% 79 6,80% 1,8% 19,7% 44 2,4% 0,6% 7,5% 123
40 - 44 2,8% 0,5% 10,7% 71 8,10% 2,1% 23,0% 37 4,6% 1,7% 11,0% 108
45 -49 0,0% 0,0% 10,9% 40 0,0% 0,0% 30,1% 12 0,0% 0,0% 8,6% 52
50 - 54 0,0% 0,0% 14,6% 29 - - - - 0,0% 0,0% 14,6% 29
55 - 59 0,0% 0,0% 20,9% 19 - - - - 0,0% 0,0% 20,9% 19
ND - - - - 0,0% 0,0% 43,9% 7
Niveau d’instruction
Aucun 3,10% 1,2% 7,6% 159 4,70% 2,4% 8,7% 214 4,0% 2,4% 6,7% 373
Primaire 0,0% 0,0% 5,1% 90 2,90% 0,2% 16,6% 35 0,8% 0,0% 5,0% 125
Secondaire 1er cycle 0,0% 0,0% 5,3% 86 1,60% 0,1% 9,5% 64 0,7% 0,0% 4,2% 150
Secondaire 2nd cycle 0,0% 0,0% 9,1% 49 9,10% 0,5% 42,9% 11 1,7% 0,1% 10,3% 60
Supérieur 0,0% 0,0% 32,1% 11 0,0% 69,0% 3 0,0% 0,0% 26,8% 14
Autres 0,0% 0,0% 2,6% 180 1,00% 0,1% 6,4% 98 0,4% 0,0% 2,3% 278
ND 0,0% 0,0% 43,9% 7
HIV IN DIFFA REGION
Diffa Regional Hospital
caseload 2008-2013 • 2013: 198 on ART, 11 of them
children (Diffa regional
hospital is the only ART site in
the region)
• We don’t know how many on
ART are lost to follow-up since Northern Nigeria crisis
• Assoc. of PLWHA: at least 300
people in Diffa Health District
(>50% from Nigeria)
• HIV+ in SAM seems to be overlooked issue
0
50
100
150
200
250
300
350
400
450
500
2008 2009 2010 2011 2012 2013
HIV+
ART
MENTAL HEALTH IN DIFFA REGION
• 323 mental health patients in Diffa’s regional hospital Jan.-Nov. 2013 (no data trends*). This is the only health facility with mental health capacity (1 “licencie en sante mentale”)in the Diffa region.
• 1 in 10 patients is displaced from Nigeria (no data stratified by age nor sex*)
• “majority” suffers from depression linked to husbands, children, other family members brutally killed (beheaded) in front of patient prior to fleeing Northern Nigeria.
• No info. on treatment*
*very short phone conversation
HEALTH IN DIFFA
L I TERATURE REVIEW
DHS 2012 PRELIMINARY REPORT: DIFFA
• Vaccination:
12-23 months who received all vaccines: Diffa lowest (42%) after Zinder (41%). Country is 52%
• Monitoring and evaluation: Data on ARTI, fever and diarrhoea treatment for Diffa is incomplete
• SAM and under-nutrition -3ET weight/height: Diffa 21% (Niger 6.2%) – worst of all regions. Similarly worst of all regions for -3ET weight for age and height for age
• HIV
Men knowledge on condoms’ protection against HIV is the worst in the country
DHS 2012 PRELIMINARY REPORT: NIGER
• Fertility index 7.6 children/woman (rural 8.1, urban 5.6) has increased since 2006. Adolescents contribute 15% to fertility index in rural areas.>80% women want another child “soon” or “later” regardless of number of living children already had. 86% women no contraception (usage has increased from 11% to 14% since 2006)
• 83% ANC but then only 30% delivery in health facility/assisted by health professional (Anthropo. Study French Red Cross 2012: no knowledge of danger signs/symptoms – neither health staff nor pregnant women)
• 6 months exclusive breastfeeding: 13% (with water added, 52%)
• 60% households owns an insecticide treated bed net yet ¾ children do not sleep under one
• 73% anaemia in children (43% severe), 46% anaemia in women (1/3 mild)
• U5MR declined since 2006 from 198 to 127 per 1,000 live births
ANNUAIRE STATISTIQUE 2011: DIFFA
• Diffa worst region for:
o% assisted deliveries (12% versus country 24.75%)
o% maternal deaths (0.66% versus country 0.13%)
o% Diffa regional hospital higher number of
consultancies compared with all other regional
hospitals (including Niamey)
• Transfusion not in hospitals but in “centres régionaux
de transfusion sanguine” in Diffa, Tahoua, Dosso,
Niamey
HEALTH IN DIFFA
DATA FROM HEALTH FACIL I T IES
UNEVEN DISTRIBUTION OF HEALTH FACILITIES AND STAFFS
ALTHOUGH SPHERE STANDARDS BROADLY RESPECTED
Health Staff Diffa
Region Public Private
# Drs 18 (13 urbain)
4 (3 urbain)
# Nurses 213 (109 urbain)
33 (26 urbain)
# Midwives 32 (24 urbain)
5 (4 urbain)
Effectif total du personnel
263 42
Ce
ntre
Hos
p.
Reg
Ho
p.
de
dist
rict
CSI
2
CSI
1
Cas
e
de
san
té
Tot
al
Diff
a
1 0 2 15 57 75
MS 0 1 2 18 43 64
NG 0 1 2 11 27 41
Tot
al
1 2 6 44 127 180
HEALTH STAFF MOBILITY AND RETENTION CHALLENGES
- Out of 17 CSI in Diffa Health District, 9 are staffed by 1 single person only –
a nurse. Diffa urban CSI has 30 health staffs (but no lab. Technician). Female health staff should “follow their husbands” so very hard to place them in rural settings.
- All health actors highlight very high turnaround of staff and long gaps for staff coverage (ex. Lab technician in Dosso health centre – 6 months’ gap). We recently lost our protection officer to IRC and have also experienced relatively high turnover of staff. Diffa is a very expensive city compared to other cities in Niger- 80,000 XOF rent for 1 room in Diffa town, salaries of our national officers around 300,000 XOF
- Female staff usually located in towns since policy is that “they follow their husbands”
DIFFA URBAN HEALTH CENTRE
# total pop. 36,000 (60% within 0-5km of the
health facility, none >15km)
# pregnant 3,200
# U5 7,000
0
50
100
jan
v.…
fév
r.-1
3
ma
rs…
avr.
-13
ma
i-1
3
juin
-13
juil.
-13
ao
ût-
…
sep
t.…
oc
t.-1
3
622 assisted deliveries
Jan.-Oct. 2013
# total
accouch
assistes
0
500
1000
1500
12,000 consul. 3 diseases
Jan.-Oct. 2013
GAM moins de 5 ans depistes
Total palu.
Diarrhees
Pneumonies
0
5000
10000
47,000 consult. (17,000 new)
2,200 references
Jan.-Oct. 2013
Nvelles consult Total consult
DIFFA URBAN HEALTH CENTRE MEASLES AND PENTA VACCI.
DIFFA URBAN HEALTH CENTER TETANOS AND BCG VACCI.
DIFFA HEALTH DISTRICT VACCINATION : YELLOW=50-80% COVERAGE, GREEN=>80% COVERAGE
DTP3, Sept. 2013 Polio, Sept 2013
MAINE SOROA URBAN HEALTH CENTRE
# total pop. 24,000
# pregnant 1,000
# U5 5,000
0
500
1000
1500
2000
11,300 consult. (10,100 new)
150 references
Jan.-Oct. 2013
Nvelles consult Total consult
0
10
20
30
40
50
1 2 3 4 5 6 7 8 9
268 assisted deliveries
Jan.-Oct 2013
# total
accouch
assistes 0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9
No
mb
re d
e c
as
3,900 consult. 3 diseases
Jan.-Oct 2013
GAM moins de 5
ans depistes
Total palu
Diarrhees
Pneumonies
KABLEWA HEALTH CENTRE
# total pop. 10,400 (2/3 live >15 km from
health facility)
# pregnant 510
# U5 2,200
0
200
400
600
800
1000
1200
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-13
Au
g-1
3
Se
p-1
3
Oc
t-1
3
6,800 consult. (6,300 new)
33 references
Jan.-Oct. 2013
Nvelles consult
Total consult
0
5
10
15
20
1 2 3 4 5 6 7 8 9 10 11
96 assisted deliveries Jan.-Oct 2013
(122 2013)
# total accouch
assistes
0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9
Axis
Title
2,812 consult. U5 3 diseases
GAM moins de 5
ans depistes
Total palu
Diarrhees
Pneumonies
GAM
33%
Malaria.
34%
Diarrhea
10%
ARTI
23%
Diffa Urban Health Center
PROPORTIONAL MORBIDITY U5 3 DISEASES 3 HEALTH FACILITIES DIFFA REGION JAN.-OCT. 2013
GAM
22%
Malaria
19%
Diarrhea
23%
ARTI
36%
Maine Soroa Urban Health
Center
GAM
17%
Malaria
14%
Diarrhea
18%
ARTI
51%
Kablewa 1
3
4
7
5
Nguigmi
Diffa
Maine-Sorda
Diffa
0 50 100
Kilometers
Food economy zones
Zone de culture de rente de la rivière Komadougou et du Lac Tchad -7 -7
Zone pluvio-agricole55
Zone Agropastorale44
Zone Pastorale33
Desert1 Desert1
PMTCT BOSSO HEALTH CENTRE FEB.-AUG. 2013
Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13
ANC 114 214 179 460 424 477 640
HIV test 58 43 382 107 152 57
ANC HIV+ 0 2 2 4 2 2 0
CMX 2nd trimester 0 2 4 4 2 2 0
AZT 0 2 4 4 2 2 0
tritherapy 0 0 0 0 0 0 0
husband tested 0 0 0 1 0 0 0
husband HIV+ 0 0 0 0 0 0 0
total women tested in the maternity ward 19 9 31 21 17 7
HIV+ in maternity 2 2 0 1 2 0
delivered 42 35 20 33 43 54 51
HIV+ delivered 0 0 0 1 1 1 0
AZT and NVP durinf delivery 1 1 0
AZT and 3TC post-partum 1 1 1
newborn AZT+3TC+NP syrup 1 1 1
J4 to J15 taking AZT+3TC+NP syrup 1 0 1
born alive 1 1 1
• Data from Bosso health centre seems to be completely unreliable with very little compiled data apart from PMTCT data and some data from the lab. HIV test ruptures seem to have been frequent
• 13 Sept.-21 Nov., lab. data: 8 HIV+ out of 23 requests. Out of 13 TB+, 4 were also HIV+ coinfected.
EPI IN NIGER NOW TARGETING 0-23 (PNEUMO1,2 AND 3, ROTARIX 1AND 2)
AND 9 Y/O GIRLS RECEIVE HPV 1, 2 AND 3
H E A L T H ; H U G E G A P I N P R E S E N T H U M A N I T A R I A N R E S P O N S E I N D I F F A
HEALTH SUPPORT TO DIFFA
SC THE ONLY NGO CONSISTENTLY ACTIVE ON “HEALTH”
IN DIFFA THROUGH SAM AND MAM SUPPORT
• In Northern Nigeria healthcare is either not free or health facilities are not functional. SC supports health and nutrition activities in Northern Nigeria through HPI who themselves work via national consultants. No technical visit of those projects for the last 4 years due to insecurity.
• Populations from Niger and from Nigeria are used to using each others’ territories and services – and have family ties in both countries - this did not change during the March-April crisis, putting a strain on health services in areas of acute short term mobility.
• Save the Children started activities in Diffa in 2010 following HKI’s departure (HKI had supported SAM and MAM in Diffa region since 2005). It supports MAM and SAM in Diffa Region since 2010 (Maine Soroa and N’Guigmi) and since September 2013 Diffa district (Diffa urban health centre and Bosso). Cholera, measles and shigellosis’ response kits also donated to Diffa Region (Direction Régionale de la Santé) by Save the Children .
Health facilities in Diffa region
In red, supported by Save the Children (SAM and MAM)
Centre Hosp. Reg.
Hop. de district
CSI2 CSI1 Case de santé
Total
Diffa 1 0 2 (Diffa and Dosso)
15 57 75
Maine
Soroa
0 1 2 18 43 66
N’Guig
mi
0 1 2 11
(9)
27 46
HEALTH IN DIRE NEED FOR SUPPORT
• Health is presently not really supported except
punctually (MSF donated medicines, ICRC
supported surgical treatment of war casualties and
gave a steriliser to Bosso HC, Save gave
cholera/measles/shighella treatment kits to the
region etc.). Save the Children supports GAM
activities and through them health activities (mobile
clinics, drugs, staff) and is consistently identified as
“the NGO concretely supporting the MoH in Diffa”
QUALITY OF NUTRITION SERVICES NEEDS ASSESSMENT
• Quality of CRENAS nutrition activities is difficult to assess since
they occur daily and not weekly
• Kwash. seems to have unexpectedly high prevalence – needs
broad data review.
• Quality of CRENI activities needs urgent and serious technical
support. The strategy of “integration” with MoH shows its limits
here (staff recruitment and trainings, supervision etc.).
“Espaces amis enfants” needs clear ToR and on that basis,
evaluation.
• In-patients’ paediatric services share CRENI staff and
medicines but other than that seem to basically limit themselves to beds, mattresses and little more unless patients pay for their own medicines when stock ruptures occur.
UNIVERSAL PRECAUTIONS AND WASH ISSUES EVERYWHERE
Bosso Health Centre latrine Maine Soroa Health Centre
UNIVERSAL PRECAUTIONS AND PATIENTS/STAFFS’ SAFETY
Bosso health centre Bosso health centre
CHALLENGES IN REHABILITATING EQUIPPING HEALTH FACILITIES
Kablewa health centre
entrance door
Intensive Care Diffa
Regional Hospital
PROPOSED ACTION O N H U M A N I T A R I A N H E A L T H I N D I F F A
F O R S A V E T H E C H I L D R E N
TARGETED HEALTH FACILITIES
HEALTH DISTRICT HEALTH FACILITY SITE NAME # MOBILE POP. # NIGERIA %NIGERIA
Diffa
Health Centre (urban) BOSSO 10913 1863 17%
MAMOURI 1582 277 18%
GARIN AMADOU 1294 420 32%
BOULAGANA 991 164 17%
GAMGARA 1 250 250 100%
GAMGARA 2 644 27 4%
BOULABRINE 162 162 100%
ABADAM 2218 1117 50%
TCHOUKOUJANI 1936 588 30%
Health Centre (rural) BAROUA 1247 381 31%
NGUELKOLO 1252 117 9%
Health Centre (urban) DIFFA (+ LADA Case de Sante) 4638 963 21%
Health Centre (rural) TOUMOUR 837 47 6%
TOTAL Diffa 27964 6376 23%
N'Guigmi
Health Centre (rural) KABLEWA 5225 790 15%
TOTAL N'Guigmi 5225 790 15%
Maine Soroa
Health Centre (urban) MAINE-SOROA 2890 1013 35%
ABASSARI 304 47 15%
YABAL 58 75 129%
Health Centre (rural) TAM 443 68 15%
ABOUNGA 24 16 67%
TOTAL Maine Soroa 3719 1219 33%
TOTAL Diffa Region 36908 8385 23%
OBJECTIVE 1: IMPROVE ACCESS TO QUALITY PRIMARY HEALTH CARE PROGRAMMES INCLUDING THROUGH OUTREACH ACTIVITIES
- Free healthcare services for U5, pregnant and lactating
women, emergencies
- Universal precautions are met; essential quality
medicines are available; national clinical protocols are adhered
to and laboratories are
functioning and providing quality services; qualified staff are
trained and retained
- Strengthen PMTCT in all sites
- Condoms’ promotion and distribution
- WASH in health facilities is strengthened
OBJECTIVE 2: IMPROVE ACCESS TO SECONDARY HEALTHCARE SERVICES
- Referrals
- Paediatric ward in CRENI (maternity and emergencies also if funding allows)
Universal precautions are met; essential quality
medicines are available; national clinical protocols are adhered
to and laboratories are
functioning and providing quality services; qualified staff are
trained and retained
- Mental Health: support to be determined (staff and
medicines)
- HIV (tracing of PLWHA on ART lost to follow-up; sensitization to mobile populations and to health staff for enough supplies of
ART to be provided in relation to displacement)
OBJECTIVE 3: IMPROVE MONITORING AND EVALUATION
• Staff
• Data collection tools
• Dissemination of evaluation data