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HEALTH SECTOR ASSESSMENT

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HEALTH SECTOR ASSESSMENT

    Health Situation Report

    developed in conjunction with

    United Nations Resource Centre in Ambon

    July 30 August 14

    David A. Bradt

    WHO\EHA--Indonesia

    18 August 2000

WHO \ Ambon Health Situation Report page 1

I. PUBLIC HEALTH INDICATORS

    A. Population at Risk

    1. Census

Maluku Province total and IDP population estimates are presented in Table 1.

    Table 1

    Total and IDP Population Estimates in Maluku Province

    Source--Provincial Health Authorities

    1 August 2000

     + District Baseline IDPs Interval % ChangeIDPs * Population 04/0008/00 Change IDPs

    Ambon Municipality 312,135 49,860 143,384 95,324 +190%

    Central Maluku 568,034 61,690 63,338 1,648 +2.7%

    Buru Island 115,082 25,662 10,347 (15,315) -60%

    Southeast Maluku 176,640 41,375 33,642 (7,733) -19%

    West Southeast Maluku 139,674 12,831 10,317 (2,514) -20%

    Total 1,311,565 191,418 261,028 69,610 +36%

     * census data of 4/00 + (interval change / IDP population April estimate) x100

    The extent to which IDP flows have altered district populations remains unclear. The April census data show a decrease in Ambon Municipality population from 321,000 reported 11/99. Nevertheless, Provincial Health authorities are convinced the total population of Ambon Island and Ambon Municipality has increased by IDPslargely immigrating from Buru and Central Maluku Districts.

    Ambon Island subsumes 2 subdistricts of Central Maluku District as well as 3 subdistricts of Ambon Municipality. SATKORLAK estimates 149,834 IDPs inhabit Ambon Island equivalent to 57% of the total IDP population. Changes in total provincial population are speculative.

    IDPs reside in a variety of sites including governmental and military buildings, dedicated camps, host families, and improvised shelter. The total number of settlement sites is unclear though surpasses 200 on Ambon Island alone. Existing registrations are commonly initiated by IDPs for secondary gainsuch as

    health cards enabling free health care at Ambon Municipal health facilities. Refugee site population sizes remain largely speculative.

    2. Population Movements

    IDP locations and movements are tracked by SATKORLAK. Interval changes from April-August reveal a 190% increase in IDP population in Ambon. The most substantial IDP movement of the past month on Ambon Island occurred from the village of Waai. Waai, a coastal Christian village situated between two Moslem villages in northeast Ambon Island, was attacked the night of July 31-August 1. This attack, the second on Waai in a month, reportedly left 29 persons dead and displaced 3,776 persons to the neighboring village of Passo. There, a factory there now houses approximately 5,500 IDPs. SATKORLAK itemized IDP movements for the province are presented in Annex 1.

    B. Disease Surveillance Reporting

    There are no comprehensive periodic disease surveillance reports issued by Maluku authorities. Dinas Kesehatan, through its Chief of Communicable Disease Control (CDC), takes responsibility for disease surveillance of the general population. However, disease surveillance is acknowledged to be the weakest

WHO \ Ambon Health Situation Report page 2

    of four major functions of the CDC unit. Moreover, Kanwil and Dinas Kesehatan have not clearly delineated administrative responsibility for summarizing the health situation of IDPs. In general, provincial health authorities defer to SATKORLAK on denominator estimates of IDP population size.

    Periodic disease surveillance data sets exist only for Ambon Municipality. There, the Chief of the Ambon Municipal Health Office provides health center staff salary upon submission of health center monthly surveillance reports. Real time compliance with reporting requirements approaches 100%. Data sets are fragmentary from other districts in the province. Even within Ambon Municipality, there are no reliable periodic disease surveillance data for IDPs. While occasional camp-specific reports emerge of IDP illnesses and deaths, there is no functional IDP camp surveillance system, district-wide aggregate profiles, much less trend analyses. The Chief of the Ambon Municipal Health Office reports neither international nor local NGOs working in Ambon have submitted surveillance reports to her office in four months.

    Death data are incomplete. Officially recognized death reports originate in hospitals and health centers. Morbidity and mortality data follow a pathway prescribed by hospital type. The provincial hospital reports to the Ambon Municipal Health office. Military hospitals report to the Central Military Hospital in Jakarta, and those figures are routinely not provided to the Municipal Health Office. Private hospitals are generally non-reporting. The Al Fatah Hospital acknowledges non-participation in morbidity and mortality reporting. The limitations in collection and reporting of epidemiological data from the various health structures are characterized in previous WHO\EHA reports.

    C. Epidemiology

    Ambon Municipal Health Office reports the following July data acquired from 15 of 15 municipal health centers:

    1. Municipal Mortality

     IDP camps 2 (1 TB, 1 old age unspecified)

     Non camps 32

     Neonatal 3

     Infant 1

     Others 28

     Total deaths 34

    2. Municipal Morbidity

     ARI 6,684

     Malaria clinical 447

     Diarrhea simple 215

     LRI 50 (40 pneumonia)

     Measles 3

     Total visits 25,157

    Crude mortality rates, proportional mortality, and incidence rates cannot be calculated. Overall, available data does not suggest excess medical mortality for Ambon municipality.

    Ambon Municipal Health Office does not compile conflict-associated statistics for the Municipality. Provincial health authorities provide conflict-associated morbidity and mortality data for specific riots. These data are based upon verified reports from health facilities. These data are tabulated in official health summaries written after serial riots. The reports, therefore, encompass varying time intervals. Riot-specific reporting intervals with attendant morbidity and mortality are presented in Table 2 below.

WHO \ Ambon Health Situation Report page 3

    Table 2

    Riot-associated Morbidity and Mortality

    Source--Provincial Health Authorities

    Riot Dates Injured Survivors Deaths

    Mildly Injured Severely Injured

    1 Jan Jun 1999 658 958 250

    2 Jul 25 Dec 1999

    3 26 Dec 1999 10 Jan 64 80 85

    00

    4 11 Jan 00 present N/A N/A N/A

    Data from the Governor’s office, by contrast, reveal 918 deaths and 2,256 persons injured from conflict during the period Jan 99 Jan 16, 2000.

    From February 2000 present, aggregate data on district or province-wide conflict-associated violence remain unavailable from provincial authorities. Monthly data on trauma incidence in this period exist for Haulussy General Hospital (Table 3).

    Table 3

    Riot-associated Morbidity and Mortality at Haulussy General Hospital

    Source--Provincial Health Authorities

    Month Outpatients Inpatients Deaths

    January 1 29 4

    February 2 14 4

    March 0 9 0

    April 6 11 2

    May 2 30 2

    June 79 70 20

    July 24 27 9

    Total 114 190 41

    Anecdotally, provincial health authorities describe an evolution in trauma pathology during the conflict from edged weapons to high velocity firearms. Provincial health authorities suggest that official death reports are underestimates, that conflict is escalating, and that conflict-associated deaths in 2000 will surpass those in 1999. While rates are speculative, excess traumatic mortality clearly exists at a level consistent with a low intensity conflict.

    3. Epidemics and Epidemic Potential

    The Ambon Municipal Health Office reported no epidemics for July. Of the three measles cases reported in Ambon Municipality, one occurred in Latuhera Camp and two occurred in Passo village. All three cases were reportedly confirmed, and considered imported by IDPs from Buru and Southeast Maluku Districts. Public health response entailed camp-specific targeted measles immunization. Of diseases with epidemic potential, there were no reports of dehydrating diarrhea, dysentery, acute flaccid paralysis, suspected meningitis or hepatitis.

    The Provincial Chief of Communicable Disease Control (CDC) expressed epidemic concern in two areas of the province. Masohi village, Central Maluku District, on Seram Island reported 1013 cases of clinical malaria over the past 6 months. While comparative baseline figures were not provided, Chief of Provincial CDC characterized these data as an outbreak.

WHO \ Ambon Health Situation Report page 4

    Furthermore, MSF-B, working in Larike village, Leihitu Subdistrict, Central Maluku District, on Ambon Island, reported 5 cases of suspected measles among IDPs over the past two months. CDC has been unable to confirm. Nevertheless, these suspected cases have highlighted concerns over weakening EPI coverage, IDP population movements, and pockets of increasing population density. MSF-B, with concurrence of provincial health authorities, is planning a measles immunization and vitamin A campaign this month for Central Maluku subdistricts of Ambon Island. The Ministry of Health, with support of UNICEF and WHO, is planning a measles, vitamin A, and polio immunization campaign September - October for the entire Maluku Province.

    Overall, outside of Ambon Municipality, provincial health authorities anecdotally characterize epidemic preparedness as inadequate.

    D. Health Personnel

    Attrition of health staff is a major issue for provincial health authorities. Provincial health authorities report the following data on physician staff in their health facilities (Tables 4 and 5). Data for nursing staff remain unavailable.

    Table 4

    Physicians Staff in District Health Centers

    Source--Provincial Health Authorities

    February 2000

    Location # Health Physicians Dentists

    Centers Working Unmet Need Working Unmet Need

    Ambon 15 8 7 3 5

    Municipality

    Central Maluku 49 13 41 1 20

    Buru Island 10 4 7 0 3

    Southeast Maluku 19 9 12 1 2

    West Southeast 17 3 17 1 4

     Maluku

    37 86 6 34 Total 110

    Table 5

    Physician Staff in Selected District Civil Hospitals

    Source--Provincial Health Authorities

    June 2000

    Hospitals Specialist Physicians General Practitioners

    Working Unmet Need Working Unmet Need

    Dr. Haulussy Provincial 6 6 6 2

     Hospital (Ambon)

    Al Fatah (Ambon) 4 5 2 2

    Masohi Hospital (Central 0 4 4 2

     Maluku)

    Much of the physician shortage is attributed to security deterioration. People have fled Maluku. Hiring and reassigning local physicians in response to local needs is precluded by bureaucratic regulation. Only the MoH reportedly has authority to contract and assign health staff. Temporary remedies have emerged from military medical teams seconded through the MoH to provincial health facilities. Nevertheless, Tables 4 and 5 reveal significant gaps remain in physician availability--particularly for health centers.

WHO \ Ambon Health Situation Report page 5

    Moreover, physician secondments last 6 months with the some teams now due for replacement. Provincial health authorities believe that additional funding at ministry level could ameliorate physician staff shortages.

    E. Essential Drugs and Supplies

    Provincial health authorities report deficiencies in essential drugs and supplies. Site visits to hospitals and health centers confirm. Major reasons for these deficits include:

    1. Marginal baseline provisioning of health centers

    Yearly provincial budget for procurement of health center drugs and supplies is 5.4 b Rp. Provincial health authorities report 60% comes from provincial financial allocation (impress obat), 30 % comes from direct MoH distribution, and 10% comes from donations (typically international donors). The sources are considered marginally adequate without unforeseen circumstances.

    2. Material destruction of warehouse stocks

    The most recent example was complete destruction by arson of a Central Maluku district warehouse at Galala last month. This warehouse contained one year’s stock of essential drugs and supplies valued at 1.6 b Rp (20% of provincial procurement budget). While Central Maluku stock redistribution has restored 50% of the losses, government replacement of the remainder is considered unlikely. This deficit represents 10% of the province’s yearly supply. Specific items are listed in Annex 2 (electronic version not available).

    3. Altered epidemiology with increased resource consumption

    All major Ambon hospitals interviewed report increased trauma caseloads. Government decree stipulates that victims of riots receive free care at provincial government civil and military hospitals. These hospitals would ostensibly receive provincial government reimbursement for increased medical resource consumption. Local hospital authorities assert such reimbursement is not forthcoming. Moreover, private hospitals providing surgical procedures, such as Al Fatah, report receiving reimbursement inferior to that given government hospitals. Consequently, marked deficits have accumulated in resources needed for hospital-based trauma care. These deficits are detailed in Annex 3 (electronic version not available).

    4. Interrupted distribution chain

    Medical logistics remains impaired by security incidents (refer to Section IIA). Consequently, provisioning to provincial health centers is irregular and delayed. Moreover, lack of trucks and drivers complicates medical logistics even during periods of relative calm.

II. SECTORAL ISSUES

    A. Security

    The security situation in Ambon is unpredictable and dangerous. From July 31-August 13, mission team members witnessed, heard, or obtained firsthand reports of the following events:

; village ambush Waai Village; August 1

    ; arson Ambon Municipalityold market; August 1

    ; grenade explosions Ambon Municipality; recurring

    ; extrajudicial execution by hanging Ambon MunicipalityAl Fatah; August 8

    ; snipers Ambon MunicipalityAir Mata; recurring

    ; urban transportation choke points Ambon Municipality--Jl. Dr. Tamaela; recurring ; hate speechLaskar Jihad threats Siwalima Newspaper, August 7, 8

     against Christian villages; Governor’s

     response

The state of civil emergency is evidenced by:

WHO \ Ambon Health Situation Report page 6

; curfew from 22:00 to 06:00;

    ; TNI checkpoints at corners of the Governor’s civil administration building, major intersections in

    Ambon, roads from Ambon, and the airport;

    ; TNI patrols in public streets;

    ; helicopter gunship making multiple landings to discharge soldiers before the Governor’s civil

    administration building;

    ; disrupted public servicesgarbage uncollected for months on city streets; electrical blackouts

    frequent.

    In Ambon Municipality, activities of daily living continue. Street traffic is orderly. Pedestrians walk leisurely. Pedestrian fear is not evident. The Governor’s administration building which houses the UN Resource Center is reportedly considered neutral. Work at the building was precluded only once over two weeks by security concerns.

    However, snipers and choke points have markedly altered patterns of daily activity. One violence-prone area curtails traffic on Jl. Dr. Tamaela. Closure of this road divides Ambon Municipality and precludes vehicular access to the major military hospital and provincial hospital. Overall access is recurrently impaired to lifelines of markets, hospitals, and schools. Utilities have been under attack, and administrative work at the Governor’s administration building was impaired 25% of the time by electrical blackouts.

    Outside Ambon Municipality, field work is complicated by needs to negotiate corridors of access in response to an evolving security situation. Burned villages are common. Many streets have makeshift barricades. UN drivers expressed fear of driving through villages of different religion without police escort.

    International aid workers have not been expressly targeted. Indeed, UN agency affiliation confers locally acknowledged privileges of movement and access. MSF-B reports that flag mounted vehicles attract the least interference.

    B. Environmental Health

    The most recent IDP movement to Passo led to makeshift housing in local factory buildings which fail to meet minimum standards in water quantity, sanitation facilities, and shelter space. Moreover, the largest existing IDP camp at Halong, with approximately 10,000 persons, also fails to meet minimum standards in water quantity and sanitation facilities. MSF-B is presently working to address these deficiencies. Nevertheless, breaches of environmental health standards in the largest as well as the most recent camp augur poorly for local capacity to manage future IDP flows.

    Moreover, in Ambon Municipality, garbage piles tens of meters in length accumulate in numerous parts of the city. Public Works reportedly lacks vehicles and operating funds for garbage removal. While environmental health appears as yet uncomplicated by epidemic disease, it clearly emerges as a major risk factor in future excess medical morbidity and mortality for the entire population.

    C. Coordination of External Assistance

The Vice Governor’s coordination meeting occurs weekly on Wednesdays at 11:00. Health coordination

    meetings between Provincial Health Authorities and MSF occur biweekly on Fridays at 10:00. A component summary of humanitarian health assistance on Ambon Island, compiled by WHO, is presented in Annex 4.

WHO \ Ambon Health Situation Report page 7

III. RECOMMENDATIONS

    A. Health Sector of Ambon Island

1. Complete measles immunization campaign on Ambon Island.

    2. Deliver minimum standards of water supply to Passo and Halong Camps.

    3. Construct minimum standards of sanitation facilities in Passo and Halong Camps. 4. Clear the garbage from streets of Ambon Municipality.

    5. Replace 800,000,000 Rp of destroyed essential drugs at Galala warehouse.

    6. Investigate adequacy of provincial medical logisticsparticularly for drug and supply

    distributions to hospitals and health centers.

    7. Establish agreements with Al Fatah and Haulussy Hospitals on needs prioritization in

    anticipation of equal, pre-announced, publicized, concurrent, and transparent distributions of

    health commodities.

    8. Print and distribute health cards enabling health care access by IDPs.

    9. Recruit 10 physicians for Ambon Health Centers by salary support to MoH.

    10. Provide qualified health professional to support disease surveillance at the Ambon Municipal

    Health Office and Provincial Communicable Disease Control. Equip this professional to provide

    technical assistance in epidemic preparedness, outbreak investigation, and disease control. 11. Disseminate clinical case definitions and treatment protocols including IMCI guidelines to the

    Health Centers and health NGOs.

    12. Initiate IDP camp sentinel surveillance to include Halong and Passo camps.

    13. Develop contingency plan for further IDP flows. Urgently prepare two reception facilities

    capable of receiving 3,000 persons each. Consider structural rehabilitation of local university

    and former Moslem market.

    14. Hire 50 community aid workers through the UN Resource Center. Disseminate health promotion

    information on survival in low intensity conflicts through contacts established by UNDP

    community development activities.

    B. Precursors to Effective Humanitarian Health Assistance on Ambon Island

    1. Saturate local media and information outlets with UN Resource Center mission statement, goals,

    and activities.

    2. Establish military duty posts at chokepoints to Al Fatah Hospital and Dr. M. Haulussy General

    Hospital. Specifically open and ensure traffic through Jl. Dr. Tamaela.

    3. Extirpate snipers from Air Mata and other inner city areas.

    4. Report security incidents and maintain spot maps of security incidents at UN Resource Center in

    cooperation with regional Police Chief Firman Gani.

    5. Declare humanitarian corridors to IDP sites, major markets, and hospitals in Ambon

    Municipality.

    6. Condemn hate speech in print and broadcast media.

    7. Support UN Resource Center with 2 satellite phones, one vehicle and driver-translator per

    international staff member, and US $100,000 in unallocated funds.

    8. Hire 2 water trucks, 2 cargo trucks, 2 garbage trucks, and four international drivers. 9. Staff the UN Resource Center with an international security officer to establish UN civil-military

    liaison. Provide salary support to Bakornas to hire one Indonesian disaster management officer

    for the UN Resource center.

    10. Prepare UN Resource Center staff withdrawal plan from Ambon Municipality to rural village

    safe house, and staff evacuation plan from Ambon Island.

WHO \ Ambon Health Situation Report page 8

    Annex 1

Updated IDP Numbers and Location: Provided by SATKORLAK on Request, Dated August 1, 2000.

     Location Number of IDPs Island

    Satkorlak notes that this is not to

    be taken as a comprehensive list,

    recognizing that there are IDPs

    who have not yet registered.

    AcF had a count of 1,631 IDPs

    on Haruku Island (between

    Ambon and Seram) in April

    2000. A current update is not

    readily available. The situation

    in the Kei islands is also

    confused at this time.

    IDPs seeking refuge before January 25, 2000

    Kab. Maluku Tengah 25,490

    Kab. Maluku Tenggara 33,642

    Kab. Kota Ambon 49,054

    IDPs seeking refuge since January 25, 2000

    Tantui, Galala, Waai 32,500 Ambon

    Benteng, Kuda Mati, 26,150 Ambon

    Air Salobar

    Kusu-Kusu 7,530 Ambon

    Ema, Kilang, Naku 28,150 Ambon

    Alang, Lilibooy, Hattu, 6,450 Ambon

    Laha, Watusori,

    Wailawa, Hative Besar

    Saumlaki 10,317 Tanimbar

    Namlea, Leksula, and 10,347 Buru

    nearby locations

    Masohi, Waipia, and 31,398 Seram

    nearby locations

    Total Ambon Island 149,834

    Grand Total 261,028

    WHO \ Ambon Health Situation Report page 9

    Annex 4

    Humanitarian Health Assistance Component Summary

     Components of Assistance Milestones and Benchmarks Status Priority Lead/Contact

    Rapid Epidemiological Assessment

    Security stabilization Access Negotiable Governor Beneficiary identification Site mapping Not done

     Registration Not done Communication Radio handset provision Variable Rapid epidemiological assessment Template None Assessment priorities Crude mortality rates Not available

    Environmental Health Services

    Water supply Minimum standards Unmet PU, MSF-B Food supply Minimum standards Met intermittently AcF Sanitation Minimum standards Unmet PU, MSF-B Shelter Minimum standards Unmet Vector control Service delivery Inadequate PHA

    Public Health and Clinical Services

    Primary prevention Measles immunization campaign In process PHA, MSF-B

     Vitamin A distribution In process PHA, MSF-B Health services delivery Complete camp allocation Not done Standardized case management Clinical case definitions NGO specific MSF-B

     Treatment protocols NGO specific MSF-B

     Essential drug list NGO specific MSF-B

     Referral guidelines Not done

     Secondary prevention measures Not done Epidemic preparedness

     Communicable diseases of epidemic potential Clinical case definitions Not disseminated PHA

     Case management guidelines Not disseminated PHA

     Outbreak management protocol Staff to investigate Assigned PHA

     Specimens to collect Assigned PHA

     Reference lab to identify Assigned PHA

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