Health Assessment North Malukus Province

JE, WHO – Indonesia (May 2001)

Health Assessment North Malukus Province

13 – 19 May 2001

EHA

WHO INDONESIA

INDEX SUMMARY

v  Introduction and Background

v  Demography and Population

v  IDPs Current Situation

v  Survey Area

v  Security and Reconciliation

v  Health NGOs in North Malukus Province

v  Health Sector in North Malukus Province

¨  Health Facilities

¨  Health Staff

¨  Immunization Activities

¨  Disease Surveillance System

¨  Other Epidemiological and Public Health Indicators

¨  Malaria

¨  Medical Logistics

v  Recommendations

v  Recommendations Specific to W.H.O.

v  Annexes

INTRODUCTION AND BACKGROUND

The outbreak of sectarian violence in North Malukus Province is reported to have started in October 1999 when people from Kao sub district, Muslim and Christian together, attacked the sub district of Malifut, Muslim majority, due to a land property problem. There were violent clashes and the whole sub district was reportedly destroyed and the people fled to Makian Island and Ternate.

The conflict became a religious conflict between Muslim and Christian communities. In November, Clashes in Tidore and Ternate islands and in the sub districts of Kao, Galela, Tobelo and Jailolo forced the arrival of a large number of IDPs all along North Malukus and Central Halmahera District as well as to Ternate, Tidore, Makian and Bacan islands. See annex No 1

In order to know the after conflict health situation and to identify potential areas to support the local health system (Kanwil at provincial level and Dinas at district level), a WHO Health Situation Assessment was carried out on North Malukus Province from the 13th to the 19th of May. The WHO team consisted of Dr. Jota Echevarria, Dr. Emil Ibrahim and Dr. Asri Mohamed

DEMOGRAPHY AND POPULATION [1]*

·  In October 1999 the former Province of Malukus was divided in two provinces, namely Malukus and North Malukus provinces.

·  The new Province of North Malukus consists of 2 districts of North Malukus and Central Halmahera and the Municipality of Ternate. There are 27 sub districts and 716 villages or desas.

·  Ternate is the capital of the province and is also functioning as the capital of the district of North Malukus. The headquarters of the second district, Central Halmahera, are located in the island of Tidore.

·  The total population of the province is around 880.000 of which about 72% are Muslims and 24% are Christians. See annex No 2

IDPs CURRENT SITUATION *

·  The number of IDPs in the province is variable depending on the source.

·  According to Satkorlak office in Ternate, the total number of IDPs in the province is 197.327, but almost 40% of this total are not real IDPs but returnees. That means people who fled during the conflict time and now they have returned to their home places finding their houses and villages destroyed.

·  From the total of 197.327, around 39% are located in North Malukus district, around 50 % in Ternate Island and only 11% in Central Halmahera district.

See annex No 3.

·  These returnees still need aid to reinitiate their lives and that is why they are included in the IDPs list.

·  After assessment, FAO will dedicate around USD 3 millions to aid IDPs from Malukus and North Malukus provinces in their coming back (livestock, seeds, building material, tools, etc.) Also Danish, USA and Italy governments have promised funds for the same aid issue.

·  An Education Program for IDPs to build and rehabilitate schools, will be supported with 20 millions of yens (USD 89.000) by Japanese government,

·  Central GoI is providing shelters (barracks in wood) to IDPs (mainly for returnees).

·  Following the Program for IDPs Returning Home (?), GoI will provide 400 gr. of rice and 1.500 Rp (p.p./day) to all 197.322 IDPs and for a first phase period of 4 months (the Program is scheduled for a year). This represents around 10.000 metric tones of rice and around 36 billions of rupees (USD 3,5 millions )

SURVEY AREA

·  The survey area is the new Province of North Malukus.

·  The WHO team visited the islands of Ternate and Tidore and the sub district of Jailolo, Makian, Kao, Tobelo and Galela, all of them in the district of North Malukus. See annex No 4.

·  During the survey, 12 health facilities were visited and 32 persons were contacted. See annexes No 5 and 6

SECURITY AND RECONCILIATION

·  Security situation appears to be safe and calm.

·  No clashes, riots or any other fighting reported since June 2000

·  People from both Muslim and Christian communities are going back to their home places and living mixed and peacefully again in some areas like Tobelo,Jailolo, Kao and Galela.

·  Health staff in the main health facilities (hospital of Ternate, hospital of Tobelo, some of the health centres in Ternate town, Kao and Galela) are Muslim and Christian mixed and they are working without problems.

·  Reconciliation Ceremonies are taken place along the Province with the support from the main religious and political leaders.

HEALTH NGOs in NORTH MALUKUS PROVINCE

1.  IMC (International Medical Corps)

·  Presents in the Province since July 2000

·  Staff and resources: 7 national doctors, 1 boat, 1 ambulance

·  The IMC doctors are performing health support activities in the public hospital of Tobelo and health centres of Kao, Galela, Daruba and Berebere (last two ones in Morotai Island).

·  One IMC international surgeon was performing surgery operations in Bethesda Hospital in Tobelo along the month of April.

·  The IMC teams are also carrying out mobile clinics to the IDPs sites in the area.

2.  ICRC (International Committee of the Red Cross)

·  Staff and resources: 1 delegate, 1 health delegate, and 1 boat.

·  Implementing relief and health activities jointly with Indonesian red Cross

·  Relief activities: Distribution of 17.000 family packets among the IDPs in isolated areas from east of Central Halmahera District and south of North Malukus District. Relief activities were over last month.

·  Health activities: Supporting some health centres and health post in isolated areas making a logistic bridge with Kanwill in Ternate.

·  A project to rehabilitate IDPs houses in the sub-districts of Gane Barat, Gane Timur and Patani Gebe, is in process.

3.  MDM (Medecins Du Monde)

·  Staff and resources: 3 international (1 doctor), 1 national doctor, 1 boat.

·  Implementing health activities (mobile clinics) in IDPs camps in Makian Island, Ternate City, and Sau and Ibu sub-districts.

·  Rehabilitation, Water & Sanitation works and training staff in the health centres

4.  ACF (Action Contre la Faim)

·  Staff: 5 international

·  Implementing food distribution activities in Ternate Island, Bacan Island and Sau, Jailolo,. Loloda and Gane Timur sub-districts for a total of 65.000 beneficiaries.

·  The regularly food distribution activities are over. ACF is making assessment in Gai Timur sub-district looking to move their activities into the agriculture and watsan.

5.  WVI (World Vision International)

·  Food distribution activities in Ternate Islan, Tobelo Galela, Rau and Daruba

·  Last distribution beginning of May. WV finished the food distribution activities

·  Programme to rehabilitate IDPs houses in Wasile sub-district will continue one year more.

·  Carrying out monthly nutritional surveys in IDPs camps in Ternate, Tobelo, Kao and Galela. No major nutritional problems found.

6.  MSF-F (Medecins Sans Frontieres – France)

·  Measles immunization campaign, 74.000 people vaccinated

·  Permanent clinic in Bacan Island to attend IDPs from the camps

·  Mobile clinics in Loloda sub-district

·  Watsan and rehabilitation works in some health centres

·  Capacity building to health staff in Bacan and Loloda

HEALTH SECTOR IN NORTH MALUKUS

Health Facilities[2]

·  There are a total of 1514 health facilities in the Province. Distribution by categories is following:

Ø  4 Public Hospitals + Private Bethesda Hospital in Tobelo

Ø  46 Health Centres

Ø  213 Sub-Health Centres

Ø  326 Polindes

Ø  981 Posyandu

·  Around 87% of the Health Centres, 84% of the Sub-health Centres and 72% of the Polindes are functioning. No information about the Posyandu.

·  Hospital in Ternate is a public General Hospital with 160 beds (bed occupation rate in 2000 was 60%) providing specialist care to inpatients and outpatients, invasive surgical procedures, labor and delivery and laboratory and radiological services

·  Hospital in Tobelo is a public hospital seriously damaged during the conflict. At present the hospital can only provide outpatients care. Rehabilitation works are being carrying out and financing by Halmahera Mineral Company.

·  Bethesda Hospital in Tobelo, private hospital with 50 beds, providing inpatient and outpatient medical care, minor surgery and laboratory and radiological services.

·  Hospitals and health centres staff are mixed (Muslim and Christian) and there is not discrimination with patients from different religion.

·  More than 84% of the health facilities in the Province are physically able to function but in some of them (around 20%) the health staff is not present.

·  Table: Population and Health facilities by District

Health Staff 2

·  Before the conflict the total health staff in the Province was around 2000 people, (all services included). From the total, 20% are Christians and 80% Muslims.

·  Around 25% of the total staff, left their working place due to the conflict and most of them fled to Ternate and Manado in November and December 1999.

·  At the end of year 2000 the total number of health staff in North Malukus Province was 1605. From the total, 15% are Christians and 85% Muslims.

·  130 people (36 of them, doctors) from the health staff who fled to Sulawesi are located in North Sulawesi District, around Manado. They want to go back to North Malukus but need support to pay transport.

·  Table: Health Staff by Categories and District

Immunization Activities [3]

·  The Head of Provincial Health Department (Kanwil) asserted that with the support of some NGOs, EPI immunization coverage is 90%

·  MSF-F carried out a mass measles immunization campaign among IDPs. Around 74.000 people were vaccinated.

·  In the north of North Malukus District, the immunization programme is only maintained in Kao, Tobelo and Morotai Island, but supplies are estimated to last only until April and the programme is dependent on the government to supplies vaccines every six months.

Disease Surveillance System

·  The Districts Health Office request monthly disease surveillance reports from the health facilities. Whether health staff does not report they do not receive the salary (?)

·  Each of the functioning health centres has a staff person to assume responsibility for routine collection and monthly reporting to the District (Dinas) who is responsible for copy the data to the Provincial (Kanwil)

·  After the conflict, several health centres have been without doctors or any other person responsible, and some NGOs have been providing mobile medical services. It is not known how this data are incorporated into the Dinas system.

·  Systematic case definitions are not standardized and not available.

·  Reporting from health post and health centres are been affected by loss of staff who were replaced in several facilities by new staff with no training about disease surveillance system.

·  Lacks of supervision and appropriate analysis of data at Dinas and Provincial level. Limited staff able to perform collection, reporting and epidemiological analysis. Inadequate data management at Dinas and Provincial level

·  Actually it was not possible to have an updated monthly disease surveillance report. Morbidity and mortality figures were not available at Provincial Health Office.

Other Epidemiological and Public Health Indicators

·  CMR (Crude Mortality Rate) between IDPs in Central Halmahera District by year 2000 was 0,55 (10.000/day).

·  Nutritional status is adequate.

·  According the Provincial Health Office the global malnutrition reached 51% in some field areas and 31,1% in Ternate City (MUAC methodology)

·  Regular nutritional surveys and screening carried out for MSF, MDM, WVI, ICRC and ACF (age/weight methodology) showed a global malnutrition no superior than 1%.

·  According to the head of Kanwil, 2.6% of the IDPs suffer psychological traumas.

·  Morbidity data fragmentary from NGOs and Ternate Municipality but no evidence of epidemics or immediate concern of potential epidemic in the Province.

·  At present there is not surgery services available in the north of North Malukus District (Christian area)

·  Table: Eleven Most Frequent Diseases Recorded (January – March, 2001) ***

·  A regular Health Coordination Meting is chairing by PMI (Indonesian Red Cross). Health Coordination among all parts involved in health activities in North malukus (Kanwil, Dinas, PMI and NGOs) appears to be weak and inefficient.

Malaria

·  Endemic in North Malukus. In some areas the prevalence is 80.35%

·  CFR in Ternate hospital was 12.08% or 20 deaths among 142 severe malaria cases by year 2000

·  Only 11 health centres are able to perform laboratory confirmation

·  There was reported in 1966, that Anopheles Farauti and Anopheles Functulatus are the main vector in Central Halmahera

·  Entomological survey is not regularly carried out. There are not reports about mosquito or larval density.

·  Lack of skills and experience of the health staff

·  Case definition and treatment protocol is not standardized.

Medical Logistics

·  Kanwil runs the Central Pharmacy in Ternate and has a distribution system to provide, on a biyearly basis, a six months supply to all health centres.

·  Health centres have to distribute the supplies to the sub-health centres and health post in their area.

·  Last distribution started in April but some of very isolated areas, mainly in Christian areas, have not received yet the supply.