Pakistan

Goal
To improve the health and well-being of those affected by the October 2005 earthquake, with a focus on the 120,000 persons in five Union Councils of Tehsil Balakot.

Project Objectives:

• To provide a standard package of primary health care 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 health care

•  To involve the government and local communities in the health care system and build their capacity to take ownership of the system after completion of the project.
• To involve and train government health workers who wish to work in this area.

Consolidated Morbidity Report from April to July 2011

From April 1st 2011 to July 31st 2011: 2,985 patients were diagnosed and treated at the RMF-HF Health Unit Talhatta. During the 4 months under review, the figures show that the patients visiting the unit consist of 38% males and 62 % females. 16% of the overall patients were children.

During these 4 months, 99 women came for antenatal visits, 135 women visited the health unit for Gynecological Problems, and 46 women visited the RMF-HF health unit for Family Planning.

Most of the diseases diagnosed and treated result from the weather and living conditions of the patients:

• Acute Respiratory Infections (ARI): 33.2 %
• Diarrhea: 14 %
• Dyspepsia:10.5 %
• Scabies 3.2 %,
• General body aches and weaknesses: 2.4 %
• Urinary Tract Infections: 4.5 %
• Hypertension : 5.8 %

Cases of suspected meningitis (6), acute abdomen (14), burns (7), acute appendicitis (12) and acute jaundice syndrome (14) were less frequent. These cases were subsequently referred to secondary and tertiary care hospitals for further treatment.

10 to 15 patients are benefiting from home consultations each month.

The health unit has generated Quarterly Morbidity Reports (QMR), which were shared with the Ministry of Health (MOH) and the World Health Organization (WHO).

Special report:

RMf-Hashoo Clinic in Talhatta reached its 5-year mark at the end of 2010. Since 2008, RMF was the only NGO still present in ground. All other organizations had wrapped up their activities and moved out the area without formulating a planned exit strategy.

The 5-year milestone meant that the way forward had to be explored to exit the area but ensure the healthcare facility is self sustainable. The reality on the ground was that the government based BHU was still lying vacant, neglected by the provincial health department despite several attempts to bring their attention to revitalize this primary health care facility. The mission of RMF is to provide healthcare to vulnerable populations until the government can revitalize their basic healthcare infrastructure to take over. Unfortunately in Talhatta, the government still does not have the resources to take over many of its healthcare facilities that were damaged five years ago in the earthquake.

Faced with this situation, RMF’s philosophy dictates that we cannot leave the community unattended. The way forward decided was to implement a community based micro-insurance health scheme to make the current facility sustainable. The first step was to share this idea with the community leaders which manifested in several meetings first led by the doctor and later by our National Health Coordinator with the community key leaders, which were conducted over 3 months. The main theme of this interaction was to determine the community’s willingness to participate in implementing a micro-insurance or cooperative health scheme. The main conclusion of this interaction included the following points:

• The community Leaders (CLs) discussed the problem of sensitization and registration issues of the members. Transportation to distant mountain pockets of the region was categorized as a major issue. Sensitization of the people to the foreign idea of micro-insurance was voted to be the second main issue
• The community is living below poverty line and is based in remote mountainous area and many of them have lost land/livelihood during the earthquake. Hence there is limited hope of receiving regular insurance money from the community.  The CLs said that it is difficult for the community members/community team to collect the fees for RMF/HF. They were however willing to guide and help to mobilize people but it will be RMF out-reach team (Community mobilizers) who will be collecting the fee from community. The community expressed their reluctance towards regular availability for this program.
  • They also feared that registration of persons could start off but not be able to meet the target number to achieve the basic monthly running costs of the clinic. In such a situation, what would be the strategy to address the registered patients’ health needs?

Our desk review of other such models implemented in Pakistan revealed that the insurance model in other parts of the country cannot be compared as the there are very few common denominators in the demographics or geography served. Each part of the country has its own unique culture and varying levels of education and resources.

The insurance models in other parts of the country are either urban, small organizational based (like Naya Jeeven) or rural but with implementing organizations that draw on very large resources e.g. like Aga Khan Health Service (AKHS) in Hunza and Gilgit. For such models to be implemented effectively, sensitization of the community cannot be ignored as the community in Gilgit is highly educated and sensitized. Secondly since the community in Gilgit and Hunza are mostly Ismailis (followers of the Aga Khan), and thus a close knit community, it is considered a communal duty to obey and participate in programs conducted by the Aga Khan Foundation. Such a situation is impossible to create in Balakot where people live by ethnic lines and “Baradari” foundations, hence lacks the close knit fabric of the Ismaili community.

The conclusions of this exercise were discussed extensively and the final decision reached was to transform the current health care clinic into a residual clinic with the following changes:
1. To introduce a small OPD fees of Rs 10/- per patient
2. To provide high quality medicine at subsidized rates of 50% off the market rate
3. To reduce the medical staff to a skeletal staff of a medical doctor, one LHV, one Medical Technician and a guard.

After sharing this decision with Hashoo Foundation and then with the community leaders and having sought their approval, the residual clinic is scheduled to be become operative by August 2011.