Microsoft word - jabri proposal _rmf_.doc
Proposal: A primary healthcare project for Union Council Shawal Moizullah
The earthquake measuring 7.6 on the Richter scale which struck North West Pakistan on 8 October, 2005
caused widespread devastation. With more than 73,000 dead and over 128,000 injured, the earthquake
displaced more than 2.8 million people from North West Frontier Province and Azad Jammu and Kashmir. 1
The injured were initially rushed to hospitals in neighboring cities and then taken as far away as Islamabad,
Lahore and Karachi. However, a number of affected regions being very remote and inaccessible, some of the
wounded could not have access to medical help of any sort. Although relief agencies, including the
Government of Pakistan and local and international NGOs have set up camps in and around the earthquake
affected areas, the most inaccessible areas still remain unaddressed. With the advent of winter which is
especially harsh in these regions, the conditions of these people are worsening. Living in the open air with
little or no shelter from the rain and the cold, the survivors are threatened with the outbreak of new diseases.
These conditions are also worsening old diseases among survivors who had never received any medical help.
Union Council Shawal Moizullah in Balakot, a remote and inaccessible mountainous area lying on the
opposite side of Balakot town is an example of these conditions. According to a door-to-door survey
conducted by HOAP between October and December, 2005, there are 34 villages and hamlets in UC Shawal
Moizullah with 2,526 households and a total population of 20,654. According to data tabulated so far for 326
households, there were 121 mortalities, out of which 75 are children. 90 people were injured or disabled, out
of which 38 were children. Unfortunately, most of the hamlets and villages where these people live are
situated high up on the mountain top, on altitudes between 5,500-7000 feet above sea level. Landslides have
virtually destroyed all pathways leading to these hamlets, increasing inaccessibility to medical aid for the
HOAP has been working in UC Shawal Moizullah to provide relief services to the earthquake survivors.
Along with undertaking relief services with its own resources, HOAP is working with the United Nations
World Food Programme (UNWFP) and Church World Services to provide relief food, shelter kits and winter
kits including blankets to the affectees. To date, HOAP has assisted 1766 households (14,440 individuals) in
30 villages of UC Shawal Moizullah based on a needs assessment conducted by a survey of affected
households in Shawal Moizullah. HOAP is taking an integrated approach and focuses its activities on UC
Shawal and the adjoining area of UC Talhata. HOAP has developed close linkages with the communities of
these areas based on its experience of working with mountain communities in the Northern Areas.
HOAP also provides medical assistance to the earthquake affectees of UC Shawal Moizullah from its
operational camp in Jabri. Strong networks of volunteer doctors have helped HOAP in providing quality
health services to the affected areas as well as linkages to hospitals across Pakistan. Consequently, HOAP
was able to attract donations as well as more volunteers from across the country and maintained a team of
15-20 doctors in the field at a time. In addition to providing medications from its own funds, HOAP’s
Earthquake Relief Operation (HERO) has received donations of medicines (ranging from antibiotics to cough
syrups and analgesics etc.) worth lakhs of rupees from private donors and organizations like the Real
Medicine Foundation of the United States. In December, a team of neurologists from the US worked with the
HOAP team in its Jabri camp and examined patients with spinal injuries. As a result, HOAP has arranged for
paraplegic patients in Shawal Moizullah to be moved to the Paraplegic Center in Peshawar and donated 500
injections and drips for care of paraplegics at the Melody Center in Islamabad.
HOAP’s medical camp in Jabri, UC Shawal Moizullah, dealt with general out-patient cases, orthopedic
cases, crushed injuries cases, infected wounds and post operative cases on a daily basis at the beginning of
the crisis. Some people have been harboring diseases for very long periods of time but have not had the
chance to seek medical care due to the inaccessibility of these regions. It is these groups of people who are
most vulnerable in the current difficult conditions. Recently, a group of doctors and public health
professionals affiliated with Harvard University and the Real Medicine Foundation conducted a medical
needs assessment of Shawal Moizullah to develop strategies for continuing medical help in the area during
the winter and beyond. Current situation and needs assessment
Presently, HOAP has a paramedic and a medical technician/dispenser operating on a volunteer basis at the
Jabri camp. HOAP has also trained a Lady Health Worker (LHW) who is stationed at Alari, an area above
the snowline. She is a local of Alari and works on a volunteer basis for the community. She mostly deals
with female and child patients and reports to the Jabri camp. HOAP also employs one full time doctor who
coordinates and works with teams of international doctors.
Currently, the HOAP medical setup at Jabri serves approximately 50 patients daily on an outpatient basis.
During the week of Jan 7 to Jan 13, 2006, 147 children under 5 years of age and 185 cases over the age of 5
years were examined. 2 of the patients over 5 years were referred to the Field Hospital at Gari Habibullah for
spinal injury complications and advanced pneumonia respectively. Proportional morbidity data for the
patients who visited the HOAP camp at Jabri during the week of Jan 7 to Jan 13, 2006 is summarized below:
Fig 1 Proportional Morbidity am ong
Fig 2 Proportional Morbidity among
population age <5 years
population age >5 years
As can be seen, cases of acute respiratory infections (ARIs), particularly among children less than 5 years of
age, are very high and have been on the rise since the advent of winter. There was one mortality -a 3 month
old- from acute respiratory infection in UC Shawal Moizullah on Jan 2, 2006. Cases of diarrhea are also high
and rising. For neonates, some cases of diarrhea were found to be related to improper breast feeding.
Anecdotal information also suggests that children from these remote villages have not received basic
immunizations, rendering them particularly vulnerable to disease, particularly measles given the high
incidence of pneumonia. Among patients above 5 years of age, the main problems are ARIs, scabies and
urinary tract infections (UTIs) which have all increased.
The medications needed to meet the urgent medical needs at Jabri with projected amounts based on
consumption in the week of Jan 7-Jan 13, 2006 are tabulated in the appendix. Goal
With the advancing winter, it is not possible to continue medical operations in Union Council Shawal
Moizullah from a temporary medical camp and with volunteer staff. At the same time, the rising burden of
disease threatens the lives of the most vulnerable: children and neonates. HOAP proposes to initiate a
primary healthcare project to serve an area of 20,000 people in Shawal Moizullah, Balakot to meet their
urgent medical needs for the winter and beyond. This project will entail revitalization of the Basic Health
Unit (BHU) at Jabri which will serve as the staging ground for health promotion initiatives throughout
• To revitalize the Basic Health Unit at Jabri with appropriate staff and materials for the next 6 months
• To provide a standard package of primary health care in UC Shawal Moizullah incorporating disease
prevention, health promotion and health education
• To improve a) the coverage and utilization of services by remote village populations; b) access to
healthcare for girls and women; c) the standard of care
• To involve the government and local communities in the health care system and build their capacity to
take ownership of the system after 6 months
• To involve and train government health workers who wish to work in Shawal Moizullah. Components
• Revitalizing the Basic Health Unit at Jabri
(a) Reconstruction of the building
The Basic Health Unit (BHU) at Jabri that was destroyed by the October 8 earthquake will be rebuilt by WHO using a prefabricated structure by mid February, 2006.2 At that time, HOAP will operate from the reconstructed BHU. In the interim, HOAP will provide services at its camp situated in Jabri. Jabri is the best site for the project because it is the nearest point for accessing all the communities /hamlets scattered over Shawal Moizullah. HOAP currently contributes a tent for the residence of a physician and visiting doctors. WHO will provide one or more large winterized tents to accommodate a male and female OPD, a doctor’s office, a small dressing room/pharmacy, and a small ward for 2 beds.3 In addition, HOAP/Real Medicine is seeking the help of OXFAM in constructing sanitary toilet at its Jabri camp.
(b) Staff and clinical services
HOAP/Real Medicine will hire a doctor who will be a general practitioner on contract basis for 6 months. The doctor will reside at the Jabri camp. 3 local female nurses/LHVs will also be hired by HOAP/Real Medicine. One local nurse/Lady Health Visitor(LHV) will work with the doctor at Jabri and will be responsible for keeping family health folders and patient records for Shawal Moizullah as well as reporting alerts and weekly surveillance data to WHO. One local nurse/LHV will be stationed at Alari and will be responsible for visitations, surveillance and vaccination in the Alari zone. Similarly, the third nurse will be responsible for and stationed in the Kaleesh zone. The nurses will report to the doctor at Jabri and will be responsible for providing data, including follow-up data, from their respective zones. The current volunteer technician and paramedic at Jabri will be responsible for initial training and supervision of the nurses. The government dispenser will work closely with the HOAP staff and under supervision of the doctor. In addition, HOAP has decided to engage the services of a health consultant who is working with the Aga Khan Health Services to monitor and improve the system. Support staff consisting of a cleaner, a cook and 2 watchmen will also be hired. The medical setup will provide basic clinical services and primary health care to UC Shawal Moizullah. All complicated cases and surgeries will be referred to the Field Hospital at Gari Habibullah or the Tehsil HQ Balakot City Hospital.
A list of the medicines required is appended below. WHO and Merck has agreed to provide some medicines.3,4 The remaining cost for the medicines will be borne by HOAP/Real Medicine.
2 As indicated by WHO during a meeting between representatives of WHO and HOAP/Real Medicine at Balakot city on Jan 9, 2006.
3 Per informal agreement between WHO and HOAP/Real Medicine. A contractual agreement is pending.
4 Per informal agreement with Merck and Dohme
A list of the medical equipment required for the BHU is appended below. Real Medicine Foundation will provide funds to purchase the equipment.
3 mobile sets will be purchased for use by the staff and communication costs will be borne by HOAP/Real Medicine. A computer and printer will be purchased by HOAP/Real Medicine to keep records, inventories and prepare reports.
One 4x4 jeep or 4 wheel drive will be contracted on a monthly basis for 6 months by HOAP/Real Medicine. It will be used to transport the BHU staff to the villages and to transport patients as needed. HOAP will provide an ambulance that can transport patients from the base camp in Kotbala to the Field Hospital in Gari Habibullah, the Tehsil HQ Hospital in Balakot city or even hospitals in Islamabad.
A Honda Electric Power Generator will be purchased by HOAP/Real Medicine together with 4 electric heaters, electric lights and wiring, 4 emergency lights and gas cylinders for cooking.
• Disease prevention and health promotion initiatives
(a) Immunization for children:
The polio and MMR vaccination status of children in Shawal Moizullah will be ascertained through a house to house survey by HOAP volunteers. The survey will be completed by the end of February. The information will be cross-checked with the Microplans for immunization status available from WHO, UNICEF and the District Department of Health. The vaccination status will be reported to WHO, UNICEF and the EPI coordinator in the District Department of Health. Based on the need, an EPI center will be set up in Jabri with the help of UNICEF.5 Necessary immunizations will be carried out village to village by HOAP’s mobile medical team.
(b) Primary prevention and early warning signs for disease:
UNICEF will provide a 3 day training in PHAST, a behavioral change campaign targeting ARIs and diarrhea. HOAP will offer its current medical technicians and paramedic for training and these master trainers will train the nurses and LHVs who will work at the community level. WHO will also distribute health information leaflets based on the National Pakistani Plan for the prevention of ARIs, scabies and diarrhea and for the recognition of early warning signs for diseases.6
To stem the rising incidence of scabies and UTIs, HOAP will approach OXFAM to set up a water and sanitation project in Shawal Moizullah.7 This will involve the distribution of hygiene kits including basin, soap, towel, scissors as well as the construction of pit latrines in Shawal Moizullah. In addition, OXFAM will conduct a workshop on hygiene, ORS, solid waste management, latrine use and maintenance and water chain protection.8 HOAP will send its nurses, LHVs and volunteers to the workshop for training. These personnel will then train the local communities.
5 As indicated by UNICEF during a meeting between representatives of UNICEF and HOAP/Real Medicine at Balakot city on Jan 9, 2006.
6 As indicated by WHO during a meeting between representatives of WHO and HOAP/Real Medicine at Balakot city on Jan 9, 2006.
7 As discussed in a meeting with OXFAM and WHO/Real Medicine representatives.
8 OXFAM briefing during WHO cluster meeting in Balakot city on Jan 9, 2006.
(d) Family planning, prenatal, obstetrical, post-partum care and child care:
The female nurses/LHVs in the Alari, Kaleesh and Jabri zones will visit families in their respective zones to address reproductive health issues including family planning, obstetrical and post-partum care and the importance of proper breast feeding. In particular, pregnant women will be given micronutrient supplements such as vitamins, iron and iodine and will be advised on proper nutrition during pregnancy. Pamphlets with pictorial information from WHO will be distributed among these women. Mothers will also be educated on proper nutrition and care for their children and neonates with a particular emphasis on the prevention of ARI, diarrhea and dysentery. They will also be given information pamphlets and nutritional supplements such as multivitamin tablets and Ensure® for this purpose.
• Capacity building of the local community and government to take ownership
A Village Management Committee (VMC) has been formed which consists of represented from each village
in Shawal Moizullah. The VMCs will provide assistance on the implementation of the primary healthcare
project. Wherever possible, staff for the BHU will be hired from Shawal Moizullah for local capacity
building. In addition, HOAP will continue to play the role of building linkages with the relevant government
departments throughout the duration of the project. Implementation strategy
HOAP will have administrative control over the health facilities for 6 months. HOAP will enter into a
contract with District Department of Health and WHO to manage the primary healthcare project in Shawal
Moizullah. The contract will detail the responsibilities of each party. HOAP/Real Medicine will transfer
ownership of the health care system including supplies and medicines to the community and the government
after 6 months.
Monitoring and evaluation
HOAP will be responsible for monitoring and evaluation of the project against agreed performance
indicators. It will also frequently provide all required information to the various stakeholders in the project.
Fig. 1 List of essential medicines required at Jabri with projected figures based on consumption in the
week of Jan 7 to Jan 13, 2006
Fig. 2 List of medical equipment needed for the BHU at Jabri
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COLLABORATIVE LEARNING EXERCISE XXIII The Tracy Corporation has a machining facility specializing in jobs for the aircraft-components market. The previous job costing system had two direct- cost categories (direct materials and direct manufacturing labor) and a single indirect-cost pool (manufacturing overhead, allocated using direct manufacturing direct-labor hours). The indirect-cost