Draft

Health Coordination

Ambon, Maluku Province, Indonesia

10 October 2000 – 9 January 2001

Assignment Report

Robyn McDermott

Short –Term Professional

EHA/SEARO

World Health Organization

Purpose of Assignment

Terms of Reference[1]

  1. Provide technical assistance for the health sector in the Malukus, based in Ambon
  1. Take steps to improve the supply of drugs in both health centres and hospitals, including working to obtain critical medical supplies and drugs to supplement available stocks.
  1. Take steps to improve the availability of health personnel.
  1. Ensure minimum standards for displaced persons, particularly shelter, sanitation, water and food supply.
  1. Disease surveillance for displaced persons. Take steps to improve disease surveillance and epidemic preparedness in the Malukus, particularly around Ambon, including the distribution of technical guidelines, improving communication of health information and the compilation and analysis of data. Activities will be undertaken to strengthen local capacity for outbreak investigation and epidemic management.

Existing situation and the main problems faced

Security situation

At the beginning of the assignment, the Malukus were still in Security Phase 4 (UN program suspension), so travel to Ambon from Jakarta was delayed until 23 November, 2000. Currently, Ambon is operating under a provisional security plan which has placed restrictions on travel. Disturbances, battles and isolated riots in the city area on November 23, 29, December 6 and 30 further disrupted normal activities for those days. In addition, both Christian and Muslim holidays around Christmas, Idul Fitri and New Year reduced the number of days in which effective work could be undertaken with Ministry of Health and other Government programs. The UN Security Plan for Ambon required that international staff not be present in Ambon over the potentially volatile period of Christmas and Idul Fitri, so the WHO and UNICEF staff spent that period (18 – 28 December) in Maluku Tengarra (South-east District, including the Kei island group). The combined effect was to reduce the time when WHO work could take place in Ambon to just over 4 weeks. On the positive side, international staff are currently welcomed in the Malukus and are not targets of violence.

Internally Displaced People (IDP) situation

Registered IDP population in Maluku Province as of end September 2000

District / Families / Persons

Ambon Municipality

/ 16,756 / 83,686
Central Maluku / 16,025 / 77,711
Buru Island / 2,680 / 10,317
South-west Maluku / 1,680 / 8,402
South-east Maluku / 6,804 / 34,945
TOTAL / 43,901 / 215,061

Source: SATKORLAK PB, Ambon.

Less than one third of these families are living in IDP camps. Most are staying with friends or relatives. The largest IDP camps are in Ambon Municipality, at Passo (approx. 6,500 people) and Halong (approx. 8,300) and have water and sanitation facilities provided by MSF. In South-east Maluku (49,000 registered IDPs as of 26 December 2000) the largest camps are in Tual (145 Muslim families, about 600 people) and Langgur (2 camps of 209 and 315 people, Christian). The remainder are spread around the islands among villages, including in 3 new villages on the west coast of Kei Besar. WHO visited these larger camps and collected information according to the emergency rapid needs assessment (UNDP) protocol. Overall there was significant crowding, adequate water (20 litres per person per day or more) and inadequate sanitation facilities. The food supply was adequate and camps were within 2km of a Puskesmas or hospital. Most children were enrolled in local schools or had alternative education provided in the camps.

A recent needs assessment conducted by MSF in Buru Island and Central Maluku (where clashes in December 2000 have produced several thousand IDPs) identified significant shortages of emergency and other drug supplies, as well as health staff displacements in these areas. This report will be available in mid-January, 2001.

Health problems of IDPs

Staff interviewed in Puskesmas and hospitals serving IDPs reported that the health problems of IDPs were similar to those of the general population. Primary care consultations reported by MSF mobile clinics to IDP camps were mainly for diarrhoea (5%), URTI (29%), LRTI (2%), suspected malaria (6%), skin infections (9%), family planning (1.4%) and injury (0.9%)[2]. According to MoH, Puskesmas data are unreliable or unavailable. There is anecdotal evidence of significant emotional distress among IDPs arising from the violence, but there is no supporting documentation of mental health problems. Apart from measles cases in Central Maluku in mid-2000 (in a general population with very low prior immunisation coverage), no diseases with epidemic potential have been reported amongst IDPs in the last 2 years. The last reported case of cholera in the Malukus was in 1995. A single case of dengue haemorrhagic fever was reported in August 2000 in Kota Ambon. Water-borne illness is uncommon, possibly due to the almost universal practice of boiling drinking water.

MoH situation (staffing, surveillance, drug supplies)

Staffing: Hospitals in Ambon Municipality have lost more than 50% of the medical staff and now rely on a 6-monthly rotating system of locum specialist teams from Jakarta. With the division of the city into Muslim and Christian areas, this shortage is particularly severe in the Muslim side. Likewise the Puskesmas in Kota Ambon have lost doctors, and MSF (B) now provides mobile medical clinics to five Puskesmas in the Municipal area, and a further 9 in Hitu (northern part of Ambon island, in Central Maluku District). The situation in other Districts is less clear, but MSF report a severe shortage of trained nurses and doctors in Buru and Seram (Central Maluku). The Provincial MoH is unable to provide details of staffing in the Puskesmas outside of Kota Ambon.

Disease Surveillance and control: A review of current surveillance systems was undertaken (Annex 2) which identified major shortcomings in case definition, reporting, communications, data management and analysis and CDC responsiveness.

Drug Supplies: Looting and destruction of warehouse drug stocks in 1999 and 2000 coupled with disruption of the drug supply system has resulted in severe shortages of standard list drugs and emergency drug supplies. 49 out of 112 Puskesmas are affected and 20 of these have been prioritised for WHO assistance. MSF has contributed to hospital emergency drug and equipment stock in Kota Ambon and Central Maluku Districts.

Health Activities of NGOs and others in Ambon

Medecins sans Frontieres (Belgium) have provided water and sanitation services in the larger IDP camps in Kota Ambon and South-east Maluku. MSF run garbage collection services around the city from selected sites. They have supplied emergency drugs and equipment to the hospitals in Kota Ambon and Central Maluku for the treatment of clash victims and IDPs. They are also providing primary health care services to Puskesmas serving IDPs where there are shortages of doctors. MSF was a major implementing partner in the measles immunisation campaign on Ambon Island in September 2000.

ICRC established an office in Ambon (Mutiara Hotel) in November 2000. They are supporting the Indonesian Red Cross (PMI) to establish first aid posts and commence first aid training in the city. PMI has also been active in emergency aid to IDPs in Kota Ambon and has developed proposals to restore and improve blood transfusion services in Kota Ambon and Central Maluku.

UNICEF is commencing a garbage collection service for Ambon city in January 2001, with two garbage trucks (one each for the Muslim and Christian sides of the city) in collaboration with local NGOs. Funding is for 6 months with the expectation that local authorities will resume responsibility for these services later in 2001. UNICEF has also provided Vitadelli food supplements for distribution to children of IDPs in Ambon and Central Maluku.

Activities Undertaken

Technical assistance to the health sector
  • WHO visited hospitals in Ambon Municipality and prepared the medical section of the Ambon Security Plan.
  • WHO has distributed guidelines for the management of diseases with epidemic potential to MoH (Dinas) and MSF.
  • WHO Emergency Library will be located in the UNRC Office in Ambon for use by all local health service providers.
  • Epi-Info V6.2 software was installed on UNRC and UNICEF PCs for use, initially to create a database for the Puskesmas survey, (see below) and for distribution to health workers (MSF and MoH) as required.
Drugs and Medical Supplies

Warehouse stocks of medical supplies in Kota Ambon and Central Maluku are very low, due to looting in August 1999 and burning of a warehouse in July 2000. MoH has identified 49 Puskesmas (out of a total of 112 in the Province) which require additional medical supplies and which are serving significant numbers of IDPs. Of these, 20 have been prioritised; in Central Maluku, Buru and South-east Maluku. WHO has prepared an APW with MoH to provide emergency drug supplies (for 3 months) in January 2001 to these 20 priority centres (see Annex 1, Agreement for the Performance of Work). This exercise will be combined with a survey of Puskesmas to clarify logistical, communications, staffing, training, power and water supply needs (see survey form, Annex 1) of Puskesmas. Management of the drug distribution and ordering system also needs support.

Health Personnel

Apart from a more than 50% reduction in the medical workforce in Kota Ambon (Municipality) in the hospital sector (temporarily addressed by a 6-monthly rotation of doctors from other parts of Indonesia), there is little information about staff shortages in the rural Puskesmas. To get a better information base upon which to plan interventions, MoH has agreed to undertake a survey of Puskesmas which includes information about staff shortages and training needs, including inviting suggestions from staff on ways to improve staff retention. The survey should be completed by March 2001. WHO should provide technical assistance in the analysis of these data.

Ensuring minimum standards for IDPs

WHO and UNICEF visited the five largest IDP camps in Kota Ambon and South-east Maluku Districts. Where services failed to reach SPHERE standards (water supply and sanitation in Halong, and sanitation in Tual), WHO raised these issues with the relevant providers (MSF in both cases). Detailed reports of these visits are contained in the UNDP IDP camp database.

Disease Surveillance

Because IDPs in the Malukus are mostly living with local families, rather than separately in IDP camps, and receive health services from existing Puskesmas and hospitals, it is not appropriate to develop a separate surveillance system for IDPs. Rather, the existing system needs to be rehabilitated and supported. The aim is to improve the capacity of the Provincial and District level health services to monitor and control communicable diseases.

WHO reviewed the existing system (see Annex 2) and provided a report to the Provincial MoH at a meeting on 12 December 2000, chaired by WHO. At this meeting, a Health Surveillance Working Group was formed, convened by WHO and including key members of Provincial and Dinas MoH, WHO and MSF. The working group was to prepare a plan of action to simplify and standardise the existing system, initially for Kota Ambon.

The working group met on 15 December to consider the scope of reporting (selection of reportable conditions) and case definitions. These were agreed (see Annex 3) and circulated to the other 4 Districts for comments.

A second meeting of the working group was held on 4 January 2001 to consider feedback from the Districts. The Districts endorsed the scope of reportable conditions and case definitions, and additionally raised issues of communications at the Puskesmas level, laboratory support, staff training and resources for outbreak control. On the basis of this work, WHO should prepare a draft plan of action for disease surveillance in Maluku Province for 2001, for consideration by the working group.

Health as a Bridge for Peace

This is a joint initiative of WHO and MoH, Indonesia. The first Workshop (Train the trainers) of this program was held in Yogyakarta from 16-21 October 2000. There were 30 participants from across Indonesia, particularly trouble spots (Maluku, Aceh, West Papua, Kalimantan). The aim of the workshop was to transfer knowledge and skills regarding the application by health professionals of humanitarian law and medical ethics to peace-building in conflict situations. The Workshop was evaluated and appropriate changes made to curriculum to incorporate local case studies. The University of Gadja Mada in Yogyakarta was contracted to adapt and translate the curriculum in preparation for a second workshop. This is scheduled for Ambon in late January.

Conclusions and Recommendations

  1. There is a need for ongoing technical assistance from WHO in the Maluku health sector in the areas of clinical guidelines and training, implementing a new disease surveillance system, communicable disease control and improving primary health care systems, including the management and distribution of drugs.
  1. WHO should provide continuity of staff in Ambon, to enable the effective implementation of the disease surveillance system, over at least a six month period.
  1. WHO should work with the Health Surveillance Working Group to develop a plan of action for Disease Surveillance and Control, and commence its implementation.
  1. WHO should follow up on the MSF needs assessment for Buru and Central Maluku Districts.
  1. WHO should work with the MoH to act on the findings of the Puskesmas survey, in the key areas of staff support, drug supply and communications.
  1. WHO should provide technical support for the data analysis of the Puskesmas survey.
  1. WHO provide support to implement the recommendations of the forthcoming “Health as a Bridge for Peace” workshop in Ambon.

Acknowledgements

To the Government of the Netherlands for funding the program in the Malukus.

Thanks to Drs Umarello, Ristianto, Yopi, Fenno and Nona (MoH Ambon) for their co-operation and support on the Disease Surveillance Working Group.

Thanks to MTV and Bart van den Bergh (MSF, Ambon) for generously sharing information and assisting with CDC guidelines.

Thanks to UNRC and UNICEF staff in Ambon for administrative and logistical support and good company.

Annex 1

AGREEMENT FOR THE PERFORMANCE OF WORK

Between

WHO Indonesia and Dr Ristianto Sugeono, Dinas Kesehatan Propinsi Maluku

Address: Jl Dewi Sartika, Karang Panjang, Ambon, 97122.

Telephone:(0911) 345924

Fax:(0911) 345924

Bank Account Name:Proj. Peningkatan Palayanan Kesehatan Masyaraka (PPKM)

Bank:Bank Pembangunan Daenah, Maluku

Bank Account Number: 200-7148Branch: Ambon

Title of Project:

Emergency Medical Supplies to Maluku Puskesmas

and Puskesmas Audit, Maluku Province.

Background

Widespread destruction of property, large population displacements (including loss of health staff) in Maluku Province in the past 6 months have disrupted the normal medical supply and communications system to about half of the 112 Puskesmas in the Province.

Aims of this APW

This project aims to deliver 3 months of standard drugs (see list) to 20 of the worst affected centres which have large numbers of IDPs, and also to collect more detailed and current information from all Puskesmas with respect to facilities, previous and current staffing (including reasons for loss of staff), population served (including % of IDPs), drug and equipment supply, communications systems, functioning of the surveillance system and other relevant information needed to restore and improve community level health services (see Form).

Timeframe

3-6 months, commencing January 2001.

Budget:

Drugs for 20 Puskesmas (see list and prices attached)USD40,000

Packing and handling 5,000

Transport 8,000

Travelling allowance for MoH staff (project officer) 3,000

Completion of survey reports 2,000

Total USD 58,000

Deliverables

Statement of Expenditures with receipts

Completed survey forms from 112 Puskesmas in the Province, with location map.

Final payment due on receipt of the completed survey forms by agreed due date.

MALUKU PROVINCE PUSKESMAS SURVEY FORM (WHO / MoH)

Puskesmas………………………District……………………Sub District…………..

Address: …………………………………..Phone/Fax number ……………….(if applicable)

Date:…………… Person completing Survey…………………Designation…………………

Person providing information……………………… Designation……………………………..

Nearest phone……………Phone number ……….. Distance from Puskesmas……………

Other communications (eg SSB radio)……………….Functioning Y / N

Mains electricity Y / N If Yes, hours of electricity / day…….. Power generator Y / N, if yes, adequate fuel Y / N Vaccine Refrigerator Y / N, if yes, functioning Y / N

Total population served…………Number IDPs………

Main cultural group:Christian / Muslim / Mixed (circle one)

Staffing of PuskesmasNumberYears of training
Category / Normally / Now / Normally / Now
Doctor
Nurse
Midwife
Sanitarian
CDC control
Administration
Other (specify)

If staff have left, reasons why ……………………………………………………………. …………………………………………………………………………………………

Current stock of medical supplies (% of normal)…………Date of last supply……………

Source of current medical supplies: MoH / NGO / other (specify)……………

Location of nearest medical supply distribution point………………………

Distance from Puskesmas………….(km)

Access: Paved road / unsealed road / boat / walking track / other (specify)………….

Number of Pustus ………. Current staffing of Pustus (years of training)……………….

…………………………………………………………………

Number of Pusyandus…… Current staffing of Pusyandus (years of training)…………

…………………………………………………………………

Date of last monthly surveillance report from Puskesmas to Dinas…………………

If reporting system not functioning, reasons why……………………………………..

……………………………………………………………………………………………..

Suggestions for improving the staffing, surveillance and medical supply systems:

………………………………………………………………………………………………………………………………………………………………………………………………………………