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

f.mbow@savethechildren.org.uk

+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