Final Report of Talhatta Clinic Handover Project
December 31, 2011
Jonathan White and Dr. Rubina Mumtaz
RMF-Google Primary Healthcare Project Talhatta
Union Council Talhatta & Shohal Muizullah, Tehsil Balakot, District Mansehra, KPK, Pakistan
The October 8th, 2005 earthquake destroyed large portions of the NWFP and Kashmir (AJK) regions. Widespread death and devastation affected an area of approximately 30,000 square kilometers, home to more than 3 million people living in hamlets spread in Himalayan slopes and valleys. This disaster was described as the world’s third deadliest natural disaster in the last 25 years: it killed more than 80,000 people, injured more than a 100,000 and made 3 million homeless in the highest mountain ranges in the world (Brennan RJ and Waldman RJ, New England Journal of Medicine, April 2006).
Thousands of people were left injured. Most of them suffered even more as they were subjected to extremely harsh living conditions in the aftermath.
In October 2005, Hashoo Foundation (HF) established a medical relief camp in Jabri (UC Shohal Moizullah, District Mansehra) where 10 to 15 doctors volunteered to help alleviate the sufferings of the residents coming from remote villages located in the mountains surrounding Balakot. The medical camp ran for more than three months. During that period, patients were treated for crush injuries, infected wounds, orthopedic problems, post operative care and acute illnesses sustained as a result of the earthquake; others underwent treatment for chronic diseases which had gone untreated for years due to the remoteness of the region. As the Basic Health Unit (BHU) established by the government had been completely destroyed, the need for sustained health care for the residents of the area was felt strongly.
The RMF-HF Health Care Project resulted from a partnership between Real Medicine Foundation USA and Hashoo Foundation in mid-January 2006. A formalized RMF-HF Health Care Unit was established in Shohal Moizullah in February 2006. This Health Unit employed a full time MBBS doctor, a medicaltechnician, two LHVs and a dispenser. In December 2006, considering the catchments area size, the Health Unit was shifted from Jabri, Shohal Moizullah to UC Talhatta where a larger population could be served. For the next 5 years, RMF and HF funded and managed the clinic in Talhatta as a primary health clinic hub for this severely underserved and remote area of Pakistan.
RMF – Google Collaboration
Through Tides Foundation, on the recommendation of the Google Inc. Charitable Giving Fund, RMF received a grant of USD $25,000 in June of 2011 directed towards the RMF-HF Primary Healthcare Clinic in Talhatta. RMF had originally partnered with Tides Foundation/Google Inc. Charitable Giving Fund during the devastating floods of 2010 during which, with funding from Google Inc., 12 outreach medical camps were conducted over 8 weeks and 20,304 men, women and children benefited from free quality healthcare services.
The success of this intervention enhanced with the transparent, timely reporting led to issuance of a second grant of $25,000 which funded the transition and exit strategy for the RMF-HF Primary Healthcare Clinic in Balakot.
After 6 years of operating clinics in the Balakot region of Pakistan, Real Medicine Foundation had decided to hand back the management of the health clinic to a newly created Pakistani government health initiative. The funding Google provided enabled RMF to continue supporting the clinic through the 6-month wind down of medicine and staff support and ensured a smooth transition for the community. A successful exit strategy and handover also highlights our project’s unique 6 year success story.
Preparing to Exit
By Dr Rubina Mumtaz, RMF Country Director, Pakistan
RMF initially set up office in Pakistan in response to the 2005 earthquake. It was a time of great tragedy and uncertainty. The germ of the idea of providing relief in the most affected areas was born among RMF volunteers who at that time were students at the MPH program at the Harvard School of Public Health. It was followed up immediately by a team of RMF volunteers/MPH students hopping onto the first plane to Islamabad and a long bumpy ride up to the remote mountains of Balakot in freezing mid-winter. From that first 2-week long medical camp began a story that culminated in its 6 year milestone at the end of 2011.
These six years have been a long and successful journey of not only providing high quality healthcare services to the poor and vulnerable populations of nearly 150,000 people from Union Council Talhatta and its five neighboring Union Councils but also establishing RMF as a unique organization unlike other NGOs. Within 2-3 years post-earthquake, all relief and rehabilitation developmental agencies had wrapped up their activities and left the area without any planned exit strategy. RMF became the only NGO that stayed on despite funding running out on several occasions, a fact which did not deter us from our mission of complete and whole aid for communities devastated by a natural disaster. This fidelity earned us a tremendous goodwill in the community which proved to be extremely useful in protecting us during the years when the Taliban invasion of the northern part of Pakistan took place transforming Pakistan into one of the most dangerous countries in the world. Our special understanding of the culture and ensuring that we respect the traditions of the area further aided us in strengthening this foundation.
Our first healthcare clinic was based in Union Council Showal Muizullah and within a year of its operation, the BHU of this Union Council was revitalized with aid from UNICEF and WHO. Having achieved the target of providing healthcare until the government health machinery can take over RMF shifted its BHU down to the neighboring Union Council of Talhatta to become the only functional primary health care facility for a total of 6 Union Councils serving a total population of almost 150,000. Four years later, the government had still been unable to revitalize its original health care infrastructure, giving us no opportunity for a safe and ethical exit. Despite funding hurdles, RMF has stood fast for its philosophy of not abandoning the communities it has declared to serve. This would not have been possible without help from our implementing partners, Hashoo Foundation who endeavored to maintain to keep as trim a budget as possible and bridge financed in time of dire need without compromising on the high quality of health care we are so proud of. Hashoo Foundation’s cooperation with RMF’s determined stance to continue the project is an amazing, unparalleled feat.
The need for an exit strategy without abandoning the community was discussed extensively. The concluding suggestion accepted was to transform the free healthcare services into a community based micro-insurance health scheme. Funding for implementation of the exit strategy was eventually obtained by a grant of USD $25,000 from the Tides Foundation in June of 2011, on the recommendation of Google Inc. Charitable Giving Fund.
Exit Strategy Outlined
Our exit strategy was outlined as a two-phase process that was to take place in the six month period from June – December 2011. The first phase was the discussions with community key leaders to float the idea of piloting a community health micro-insurance scheme and garner the community response. This phase was conducted in a series of meetings and interviews by the RMF and Hashoo staff. Simultaneously the clinic operations were trimmed down slightly in terms of staffing, their RMF sponsored boarding and lodging, and charging a nominal OPD fee. The results of Phase I were disappointing in terms of the lack of community cooperation and cohesion with respect to the micro-insurance option, based on differing ethnic and social divides. Consultative review of the Phase I results between Hashoo Foundation, RMF and other key organizations led to developing the outline of Phase II of the exit strategy.
The conclusions of this consultative exercise to transform the current health care clinic into a residual clinic for 6 months with the following changes:
-To continue treatments with OPD fees of Rs 20/- per patient
-To provide high quality medicine at subsidized rates of 50% off the market rate
-To reduce the medical staff to a skeletal staff of a medical doctor, one LHV, one medical technician and a guard.
Simultaneously networking with the Ministry of Health of KPK and its district level health department was initiated in order to strategize for other means of handing over the clinic and its operations to the locals. The purpose of interaction with the local health officials was to chalk a way forward toward re-vitalizing the inoperative Basic Health Units in Talhatta thereby augmenting the government healthcare system and ensuring that the community is not left bereft of healthcare services. RMF’s aim was to nudge the local health department’s attention toward Talhatta’s primary healthcare services and be prepared to help them in the best way possible.
After sharing this decision with Hashoo Foundation and then with the community leaders and having sought their approval, the residual clinic become operative by August 2011 and continued into early 2012. The principle behind operating a residual clinic was two-fold; one was to seek funding to implement a pilot CBIC project and the other to act as a liaison with the local health authorities to revitalize the BHU of Talhatta so that the government can take over the stand alone health care services for this area.
Official Project Exit and Ceremony
The Talhatta Health Clinic officially closed its doors on December 31, 2011 after having served the communities of UC Talhatta and the surrounding five Union Councils of Tehsil Balakot with high quality primary healthcare for a full six years following the 2005 earthquake that rocked this northern region of Pakistan. RMF-Hashoo Foundation’s exit strategy involved a gradual phasing out of provision of free health care over 6 months to a residual clinic offering the same high quality healthcare at a nominal OPD fee and provision of high standard medicines at a subsidized rate.
During the 6-month operations of the residual clinic, we collaborated on a continuous and sustained level with the District Health Office until they gave us the green signal that the Government was now in a position to take over the healthcare infrastructure via its People’s Primary Healthcare Initiative (PPHI) launched in District Mansehra in October 2011. The official handing over of the Talhatta Health Unit to the District Health Office took place in a closing ceremony on March 3, 2012 held in the Hashoo Foundation Office in Mansehra.
The Guest of Honor for the closing ceremony was Dr Shafqat Tanoli, representing the Executive Director Office (EDO) of Health. The participants included a large group of people hailing from the LSO (Local Support Organization) of UC Talhatta, different health based organizations working in this region, officials from the District Health office and the media. The opening statement by Mr Atif Quddus, the Regional Manager of the Mansehra Office, Hashoo Foundation introduced all key stakeholders and participants, highlighted the objective of the program and gave a brief outline of the exit strategy RMF-HF of the Talhatta Health Unit. This was followed by a presentation by RMF in which the history of the project from the time of the earthquake till the present and all the different achievements were presented.
The EDO representative Dr Shafqat Tanoli expressed his appreciation of the RMF-HF healthcare services for the region focusing specially on the longevity of the project. He introduced the PPHI to the participants, highlighting the success of this government venture in Punjab. Now with the PPHI launching in Districts Abbotabad, Mansehra, Lakki Marwat and Bannu, this was the most opportune time for the RMF-HF Health Unit to wind up activities since the communities of these Union Councils will continue receiving healthcare services without any disruption
The ceremony came to a close with the handing over of all the equipment and machinery of the Health Unit by RMF and HF to the District Health Department. 4 different newspapers from the local press also covered the exit ceremony, articles can be found here: http://www.realmedicinefoundation.org/news
6 Year Consolidated morbidity report for RMF-HF Health Units in Tehsil Balakot:
During the six years of operation, we saw a total of 107,121 patients of which 12% were children and 88% were adults. Among the adults the gender distribution was 35% male to 65% female. The breakdown is as follows.
During the first year at Jabri, the clinic saw 11,028 patients, a relatively low number in comparison to the following years but attributable to the remoteness of the area, hence it served only one Union Council with a population of 20,000. The most common presentation at the clinic was follow up visits of injuries and wounds sustained in the October 2005 earthquake (31%) followed by respiratory tract infections (29%) and gastrointestinal infections (16.1%). The Lady Health Visitor (LHV) component of care for MNCH related problems was 10.1%. In this first year of 2006 where the need for healthcare in the whole region was acute RMF-HF also conducted three outreach medical camps and treated 5,576 patients with free consultation and medicines.
Over the next five years at Talhatta, the most common presentation at the clinic was acute respiratory tract infections (ARI) for which a total of 31,838 cases were successfully treated. Our LHVs saw a total of 16,842 cases of antenatal visits, family planning and general gynecological/obstetric problems. Other cases commonly presented and successfully treated were bloody and non-bloody diarrhea (9,202), dyspepsia (8,005), scabies (6,443), urinary tract infections (5,141), hypertension (5,611) and body weakness and malaise (5,686). A total of 2,757 patients presented with cases of enteric fever, worm infections, unexplained fevers, snake bites, burns, mumps, measles, spinal cord injuries (SCI), severe jaundice and acute abdominal pain. Of these, a total of 4,568 cases were referred to secondary and tertiary level hospitals in nearby towns and cities.
In our community outreach program, the health clinic staff conducted home visits to patients who were unable to travel down to the clinic (usually spinal cord injury patients). About 10-15 visits on a monthly basis were carried out totaling to 196 visits over a three year span from mid-2007 to the 6-year end.