Health interventions in crisis-affected communities of Nepal

Mission report

October 2006 Olga Bornemisza (Olga.Bornemisza@lshtm.ac.uk)

Francesco Checchi (Francesco.Checchi@lshtm.ac.uk)

Upon request of the:

Emergency and Humanitarian Action programme

World Health Organization, Kathmandu

Conflict and Health Programme

Department of Public Health and Policy

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Executive summary WHO-EHA Nepal commissioned the Conflict and Health Programme at the London School of Hygiene and Tropical Medicine (LSHTM) to assist it with the orientation of its current and future programming. The overall objective of LSHTM’s participation in the WHO CAP programme was to provide conceptual input into field-based humanitarian public health research and Health as a Bridge for Peace Programming. The stated mission objectives were as follows: 1) contribute to the establishment of an applicable and appropriate humanitarian public health monitoring system in Nepal; and 2) propose a conceptual framework for 'Health as a Bridge for Peace' in Nepal and contribute to developing a related programme and advocacy strategy. LSHTM was also asked to review evidence and data sources relevant to crisis detection and monitoring in Nepal, and assist with further intervention design and priority-setting within the scope of the WHO-EHA 2006 CAP programme. The consultants visited Nepal from August 24 to September 3, 2006. While in Nepal, they conducted numerous interviews with key stakeholders related to the objectives of the mission, and reviewed numerous surveys and other data sources. Public health monitoring systems and surveys were assessed and were found to be lacking. The health information management system of Nepal is very sophisticated, but there are credible concerns about the validity of incoming data. The nutrition and health surveys that were assessed were found to be problematic in terms of methods, and too few and far between to serve purposes of crisis evaluation and monitoring. As a result, information about key crisis indicators, such as acute malnutrition and mortality, are largely missing in Nepal. This has led to disagreements between the humanitarian and development communities as to whether there is a humanitarian crisis, and what the response should be. In addition, the possible impacts of the conflict on the Nepali health system were explored, as well as proposed systems to measure this. From existing data, it is impossible to deduct with any certainty what the role of the conflict has been on the health system, and proposals to measure this have been dropped due to difficulties in attribution and changing health sector priorities. WHO-EHA’s current and planned activities with regards to natural disaster preparedness, response and mitigation were assessed. WHO-EHA has built up substantial expertise in natural disaster preparedness and response training over the last few years, and should continue to pursue this as a primary activity. It should expand its training, possibly by taking a national partnership approach, however pragmatic considerations may limit it to a small number of districts. It could also play a role in strengthening the rapid health assessments that are done by various actors by working with the government and the Nepal Red Cross when conducting these types of assessments. Finally, a preliminary investigation of the role of health as a bridge for peace programming in Nepal was conducted. LSHTM concluded that more information needs to be sought about the nature of the conflict, and the ways in which the health sector plays a role in the conflict. This will inform at what level HBP workshops should be held, for instance with district health personnel or with senior Ministry of Health policy makers. It is important to consider whether health sector reform can play a role in peace-building, and to what extent district health officials will benefit from HBP training. To conclude, WHO-EHA should assume increasing responsibility for nationwide, effective coordination of humanitarian health issues in both the natural disaster and complex emergency domains. It should also stimulate a systematic approach, and promote methodologically rigorous methods for the collection of data for crisis detection and monitoring nationwide, if necessary filling in gaps. Finally, it should continue and reinforce activities in the area of natural disaster preparedness.

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Acknowledgments This mission was carried out within the framework of the WHO EHA 2006 Consolidated Appeals Process programme, thanks to funding from the Swedish International Development Cooperation Agency (SIDA). The authors are very indebted to Erik Kjaergaard (Programme Manager, WHO Emergency and Humanitarian Action, Nepal) and Dr Kan Tun (WHO Representative to Nepal) for supporting and facilitating our mission. We are also grateful to the many governmental and other agency staff who gave freely of their time and provided us with much-appreciated information. Most of all, we wish to thank the entire WHO-EHA team (Damodar Adhikari, Prahlad Dahal, Erik Kjaergaard, Saku Mapa, Dr Sara Ritchie, Sunita Sharma, and Budi Bahadur Tamang), as well as its dedicated drivers (Surya Sapkota, Ram Shrestha) for their touching hospitality, professional spirit and extremely generous help. We hope that this report will make a concrete contribution to the team’s immensely important activities in Nepal, and that future months and years will bring about a strengthened mandate and greater resource availability for WHO-EHA’s life-saving work.

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Table of contents

Executive summary................................................................................................................................................ ii Acknowledgments .................................................................................................................................................iii Table of contents ................................................................................................................................................... iv List of abbreviations ............................................................................................................................................. vi 1 Background and objectives .......................................................................................................................... 1 1.1 Overview of potential humanitarian issues in Nepal 1 1.2 The WHO EHA Nepal programme 2 1.3 The LSHTM-EHA collaboration 3 1.4 Objectives of mission 4 1.5 Method of work 4 2 Sources of data for crisis detection and monitoring .............................................................................. 5 2.1 A framework of data sources 5 2.2 Numerator data 6 2.2.1 Data on health system functionality 6 2.2.2 Data on disease cases 7 2.2.3 Data on disaster and conflict events 8 2.3 Denominator data 9 2.3.1 Census figures 9 2.3.2 Catchment populations 9 2.3.3 Crisis-affected populations 9 2.4 Sample surveys 10 2.5 Rapid assessments 11 3 Evidence on the effects of conflict on health in Nepal.......................................................................... 12 3.1 General consequences of armed conflict on health 12 3.2 Forced displacement 12 3.3 Food insecurity and malnutrition 13 3.4 Disruption of health services 14 3.5 Impoverishment 15 3.6 Isolation of civilian populations 15 3.7 Is there a humanitarian emergency? 15 3.7.1 What is the profile of Nepal’s conflict? 15 3.7.2 The bottom line: excess mortality 16 3.8 Scope for “Health as a Bridge for Peace” initiatives 17 4 Natural disaster preparedness and response........................................................................................ 19 4.1 Health sector capacity 19 4.2 WHO-EHA interventions 19 4.3 Partnership with other agencies 21

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5 Discussion and recommendations.......................................................................................................... 22 5.1 Humanitarian versus development approaches in Nepal 22 5.2 General orientation of the WHO-EHA programme 22 5.3 Nationwide coordination of stakeholders 22 5.4 Detection and monitoring of crises 23 5.5 Natural disaster-related activities 25 5.6 Health as a bridge for peace 26 5.7 Future funding for WHO-EHA activities 26 References............................................................................................................................................................. 28 6 Annexes .................................................................................................................................................... 30 6.1 Annex 1: List of stakeholders consulted 30 6.2 Annex 2: Proposed algorithm to detect and monitor crises in Nepal 31

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List of abbreviations ACF Action Contre la Faim CAP Consolidated Appeals Process CPN-Maoist Communist Party of Nepal – Maoist DHS Demographic and Health Survey DHWG Disaster Health Working Group EDCD Epidemiology and Disease Control Division EHA Emergency and Humanitarian Action programme EHNWG Emergency Health and Nutrition Working Group EWARS Early Warning and Reporting System GAM Global Acute Malnutrition HMIS Health Management Information System IFRC International Federation of the Red Cross/Red Crescent INSEC Informal Sector Services Centre IPD Programme for Immunization Preventable Diseases LSHTM London School of Hygiene and Tropical Medicine MCM Mass Casualty Management MSF Médecins Sans Frontières NGO Non-governmental organisation NRCS Nepal Red Cross Society OCHA United Nations Office for the Coordination of Humanitarian Affairs RRT Rapid Response Team SAM Severe Acute Malnutrition UN United Nations UNICEF United Nations Children’s Fund VAM Vulnerability Assessment Mapping VDC Village Development Committee WFP United Nations World Food Programme WHO World Health Organization WHO-EHA World Health Organization, Emergency and Humanitarian Action Programme

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1 Background and objectives 1.1 Overview of potential humanitarian issues in Nepal

Nepal, a land-locked country of 26 million, is a country of great concern to health agencies with a humanitarian mandate, due to several factors which expose its population to the risk of both slow- and sudden-onset emergencies. Since 1996, the country has been progressively affected by armed conflict between central government forces and rebels of the Community Party of Nepal – Maoist (CPN-Maoist). Data gathered by the Informal Sector Services Centre (INSEC), a Nepali non-governmental organisation (NGO), suggest that the conflict, initially centred in mid-western regions, and causing yearly death tolls in the hundreds until 2001, experienced a significant surge in activity starting in 2002, eventually leaving no district untouched and resulting in thousands of deaths every year. The conflict has culminated in a tenuous ceasefire in place since April 2006, which has left Nepal largely divided into (mostly rural) areas where the CPN-Maoist has substituted itself for the government, and (mostly urban) areas where government institutions are still in place. The total reported death toll stands at 13 000 (see http://www.inseconline.org/hrvdata.php), but may be considerably higher due to possible under-reporting of victims, and because it does not include excess mortality indirectly due to war and its consequences on public health. Severe human rights abuses are also a prominent feature of this conflict1-3. Currently, difficult negotiations between the CPN-Maoist and the recently reinstated multi-party democratic government are taking place. While there is great hope that the war may be over, a return to active fighting cannot be ruled out, and combatants continue to exert military pressure on civilian populations under their control. A CPN-Maoist splinter group is also active in the east of the country. The conflict’s likely consequences on Nepali health are reviewed in Section 0. The Nepalese territory is also markedly prone to natural disasters, the likely consequences of which are briefly reviewed in Table 1. Floods and landslides were by far the main reported natural hazard of concern between 1998 and 2002, with yearly a death toll ranging from 173 in 2000 to 441 in 2002, and affecting between 7901 families in 2001 and 38 859 in 20024. Widespread, monsoon-related flooding in low-lying districts in August-September 2006 confirmed this trend. This ranking, however, masks the potentially much more deadly threat of a major earthquake. As shown in Figure 1, most of Nepal including the Kathmandu Valley (around 1.5 to 2 million inhabitants) is at seismic risk, and a major earthquake is predicted in the near term, with potentially devastating consequences (Nepal’s National Society for Earthquake Technology assumes a scenario of 40 000 deaths and 95 000 injuries in the Kathmandu Valley alone, with more than 60% of buildings destroyed; see http://www.nset.org.np).

Figure 1. Seismic risk geographical stratification in Nepal, as of 1994. Source: Un Nepal information platform (http://www.un.org.np/resources/disastermanagement.php). Grey and dark grey areas marked as Z=1.1 and Z=1.0 indicate the highest seismic risk.

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Table 1. Main health problems and hazards commonly associated with natural disasters likely to occur in Nepal.

Immediate aftermath Post-acute phase

Type of disaster

Main type of health problems

Number of casualties Main health hazards

Risk of health hazard

Long-term

health system damage

Earthquake Physical trauma, post-crushing renal failure, mental trauma

Many Waterborne diseases: cholera, shigella, hepatitis, typhoid (after 1-2 weeks) Measles, meningitis in case of overcrowded displacement camps (after 1 week)

Low Severe

Flooding Trauma, aspiration pneumonia

Few As above, plus: Vector-borne diseases: malaria, dengue, Japanese encephalitis (after 3-4 weeks) Zoonoses: leptospirosis (after 1 week)

Moderate Limited (mostly non-structural damage)

Landslide Physical trauma

Few No major hazards Very low Limited

Drought n/a n/a Increased incidence and severity of infectious diseases (especially measles, diarrhoea, ARI), provided that a nutritional crisis occcurs

High if nutritional crisis

n/a

Both conflict-related complex emergencies and natural disasters such as flooding and drought may increase the risk of infectious disease epidemics (by facilitating person to person transmission, favouring vector breeding, and increasing host vulnerability). In Nepal, current large-scale epidemic threats mainly consist of diarrhoeal diseases (especially cholera and epidemic shigellosis), Japanese encephalitis, and P. falciparum malaria, although avian, human-pathogenic influenza is increasingly viewed as a concern, as elsewhere. The threat of both natural and man-made disasters, and related epidemics, exists against a backdrop of poverty and insufficient health care availability. Any relief intervention plans must also cope with formidable logistical obstacles, mainly due to the very limited road network, and the hilly or mountainous terrain where about half of the population resides. 1.2 The WHO EHA Nepal programme

The Emergency and Humanitarian Action (EHA) Programme of WHO-Nepal has been an active partner in the health sector emergency planning process since 1999. Over time, WHO-EHA has built up a strong coordination function within the government, and acknowledged expertise in disaster preparedness and response. Its main areas of activities have included national level emergency planning, mass casualty

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management (MCM) training and preparedness, seismic vulnerability assessments of hospitals country-wide, and the development of over a dozen public health guidelines and manuals, including the ‘Best Public Health Practices in Emergencies for District Health Workers’ and the ‘Health Sector Emergency Preparedness and Disaster Response Plan Nepal’, both produced in collaboration with the with the Epidemiology and Disease Control Division (EDCD) of the Ministry of Health. To strengthen disaster response implementation, it has conducted disaster management trainings with Rapid Response Teams (RRTs) and field staff on the best public health response in emergencies and how to do rapid health assessments. During the democratic movement in April 2006, WHO-EHA, together with UNICEF and UNFPA, conducted a country-wide assessment of 33 hospitals' mass casualty management capacity, and assessed their ability to respond to any emergency. This experience led WHO-EHA and UNICEF to establish an Emergency Health and Nutrition Working Group (EHNWG) to strengthen intra-sectoral collaboration between operational agencies, and resulted in the revitalization of the disaster health working group (DHWG), consisting of members from all major health-related institutions including hospitals, UN agencies, NGOs and donors, and chaired by the Director General from the Department of Health Services. The Swedish Agency for International Development (SIDA) funded WHO-EHA through the 2006 Consolidated Appeals Process (CAP) to further develop its programming, and to expand the human resources of WHO-EHA. The team has been increased to nine people with the aid of this funding, and activities will be implemented by the end of December 2006, with a possible no-cost extension to the end of March 2007. The bulk of the implementation of the new CAP project is to take place in conflict-affected districts, and is aimed at strengthening the emergency-related health sector response capacity and coordination. The expected products are:

1) Risk reduction and mitigation measures initiated at strategic health facilities. 2) Mass casualty management and triage system in place. 3) Mechanisms for health sector coordination related to emergencies in place. 4) Humanitarian monitoring and rapid health assessment of public health priorities conceptualized

and field tested. 5) Functional rapid response teams in place ready to respond to humanitarian and public health

challenges. 6) Best public health practice in emergencies identified and a pool of trainers ready to disseminate

findings 7) Minimum standing readiness to respond to emergencies created and technical support to facilitate

programme implementation provided 1.3 The LSHTM-EHA collaboration

WHO-EHA commissioned the Conflict and Health Programme at the London School of Hygiene and Tropical Medicine (LSHTM) to assist with various elements of WHO-EHA’s 2006 CAP Programme. The Conflict and Health Programme has expertise in various areas, including the evaluation of humanitarian aid, and the relationships between health and peace. The overall objective of LSHTM’s participation in the WHO CAP programme is to provide conceptual input into field based humanitarian public health research and Health as a Bridge for Peace Programming.

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1.4 Objectives of mission

The stated mission objectives were as follows: Contribute to the establishment of an applicable and appropriate humanitarian public health

monitoring system in Nepal; and Propose a conceptual framework for 'Health as a Bridge for Peace' in Nepal and contribute to

developing a related programme and advocacy strategy. More generally, the LSHTM consultants were also asked to review evidence and data sources relevant to crisis detection and monitoring in Nepal, and assist with further intervention design and priority-setting within the scope of the WHO-EHA 2006 CAP programme. 1.5 Method of work

Two consultants from the Conflict and Health Programme, Department of Public Health Policy, LSHTM (Olga Bornemisza, Conflict and Health specialist, and Francesco Checchi, epidemiologist) travelled to Nepal between 26 August and 3 September 2006. Due to the time constraints (six days in country), the mission took place almost entirely in Kathmandu, with the exception of a one day visit to nearby Sindhupalchok district. Work mainly consisted of interviewing representatives of key stakeholder agencies, as well as reviewing available documents (project proposals; narrative reports; study reports; media articles; outputs of surveillance systems; programmatic guidelines; data collection tools; etc.) relating to emergencies in Nepal, the effect of the conflict on Nepali health status, health system functionality, crisis detection and monitoring, epidemic surveillance, and the general humanitarian context. Due to the short time-frame of the visit, no attempt was made to contact an exhaustive list of stakeholders (i.e. all NGOs involved in health care delivery or disaster response; all bilateral and multinational donors; etc.). Instead, key informants were selected based on the types of information sought. A list of persons consulted is provided in Annex 1. The mission concluded with a briefing workshop, attended by the entire WHO-EHA team, to discuss preliminary findings and brainstorm future steps.

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2 Sources of data for crisis detection and monitoring 2.1 A framework of data sources

In Figure 2 we attempt to map the possible sources of useful data for health crisis-related activities in Nepal. Most such sources can only yield meaningful indicators if both the numerator (cases, services provided, events) and the denominator (population within which these cases/services/events took place) are known. For example, the true incidence rate of a disease can only be known if all cases in the community are counted, and if the population at risk is known. Properly designed sample surveys are an alternative where collecting exhaustive information would be too costly, and where the population denominator is not known reliably enough: surveys yield estimates of the true values, with an associated confidence interval. Rapid health assessments can include both exhaustive counts (ex. of affected households or reported deaths), or elements of representative sampling.

Figure 2. Schematic of different sources of data for health crisis-related purposes in Nepal.

Numerators Services provided Available capacity (i.e. “Health system functionality”) Disease cases Conflict/ disaster events

Denominators Population in catchment area Population at risk Population affected

Indicators derived from

surveillance or health facility

reporting

Indicators estimated from representative

sampling (with confidence

interval)

Indicators Disease rates Service coverage Malnutrition prevalence Mortality rates Crisis definition and benchmarking thresholds Conflict intensity Severity of disasters Epidemic onset and evolution

Health facility reporting systems Ad hoc data collection exercises Disease surveillance systems Databases of conflict/ disasters Media/agency reports

Census and demographic projections Disaster and epidemic risk profiling studies Ad hoc studies

Sample surveys Demographic and health surveys Living standard surveys Nutritional surveys Mortality surveys Outbreak investigations Others

Rapid health assessments

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Below we discuss some of the key potential sources of crisis-relevant data in Nepal that EHA and other humanitarian agencies could tap into. We proceed according to the framework outlined in Figure 2. 2.2 Numerator data

2.2.1 Data on health system functionality For crisis-related purposes, data on actual health services provided, and of available capacity in terms of staff, supplies, drugs and emergency provisions, are (i) crucial to predict likely gaps in the medical response to future natural disasters, and (ii) can potentially be used to assess the effect of conflict on health services provision. In Nepal, most such data are generated by the Health Management Information System (HMIS). Developed by the Ministry of Health in 1994-1995 to replace several vertical data collection systems utilising more than 100 different forms and tools, the HMIS has managed to integrate data flow on all aspects of health care delivery into 33 recording and 4 reporting forms and registers, present at all levels of health care. Data are centralised at the HMIS headquarters within the Ministry of Health and entered into an advanced computer database tool, which automatically generates monitoring indicators, standardised reports, trend analyses, and detects possible inconsistencies or gaps in the data received through a number of well-controlled error checks. As a tool, the HMIS seems extremely impressive and technically sound, and holds enormous potential for informing national health policy. HMIS data are used by development-oriented actors in Nepal to document trends in health sector reform, and chart progress towards Millennium Development Goals (MDGs)5. However, stakeholders we spoke to cautioned against over-reliance on HMIS figures, especially for crisis planning and response. There were consistent reports of discrepancies between HMIS figures and survey-based estimates or on the ground observations. For example, all government health facilities in Rukum and Kalikot districts were reported to be non-functional at the time of writing, despite reporting activity through the HMIS; and vaccination coverage survey estimates conflict with HMIS reports in 6 terai districts where both are available (a formal data audit has revealed considerable problems with registers kept at the village level and with the transmission of data up to the health post level). All stakeholders we spoke to mentioned that data recording and transmission at the periphery was likely to be a considerable weak point of the HMIS. Nevertheless, data from the HMIS and related MoH components (the Logistic Management Information System and the Human Resource Development Information System) were used prominently to compile district demographic and health profiles, produced by the Nepal Public Health Association, EDCD and WHO-EHA with DfID support in 20056. In light of likely problems with HMIS data reliability, at least in terms of actual service output, such district baseline profile information should be used mostly as a very user-friendly catalogue of health infrastructure theoretically available in a given district (for example, the number and location of sub-health posts), and of the main demographic characteristics of the district. Even though information on actual services provided may not be very accurate, HMIS and district profile data can help to plan relief interventions (for example, in the event of a major disaster, one could more strategically decide where and by how much to strengthen bed capacity, from which fixed posts to stage outreach clinics, etc.). We identified at least two major efforts to use independent (i.e. non-HMIS) data on health system functionality. First, DfID commissioned the United Mission to Nepal (UMN) to design a system to

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monitor the health system, as well assess the impact of the conflict on the health system. This system was to supplement HMIS data with data from various UN agencies and NGOs. Due to difficulties in attributing health system changes to the conflict via the use of indicators, DfID now plans to go ahead with only the first component, which is to strengthen the government’s ability to monitor the health system. DfID technical advisors within the MoH have been charged with this task. The degree to which this system will, in the end, use supplementary NGO and UN data is uncertain. Second, WHO-EHA itself is carrying out a data collection exercise on district health system functionality. It purposively sampled eight districts and collected data on health system functionality from the district hospital, primary health care centres, health posts and sub health posts, plus male and female community health workers. Aspects examined included: staffing levels, health facility capacity (equipment and supplies, laboratory capabilities, drug supplies, water supply), outbreaks of infectious diseases, child health, and disaster response capability. Information about other districts is being collected via questionnaires on an ad hoc basis (for example, district health officers at brought together at the training in Pokhara were interviewed about the conditions in their district; this information will be supplemented by NGOs who work in these districts). The results of this district assessment study are currently being written up, and will be presented to stakeholders at various forums. 2.2.2 Data on disease cases HMIS data. As part of the HMIS, diseases are reported according to the International Classification of Diseases, version 10 (ICD-10: see http://www.who.int/classifications/icd/en/ ). These include diarrhoeal and vector-borne diseases that could pose a threat in the aftermath of natural disasters. However, because the HMIS is not designed to detect outbreaks, but rather relies on progressive flow of information from the periphery to central level, which takes about one month to complete, HMIS data on disease occurrence are not likely to be very useful for crisis-related purposes, and a faster data reporting and analysis system needs to be sought. HMIS are also used to calculate acute malnutrition rates, but these should be disregarded, as they are not a classical point prevalence and are based simply on children who visit health facilities. The EWARS. The Epidemiology and Disease Control Division (EDCD)’s Early Warning and Reporting System (EWARS) has been operating for the last decade, and has progressively expanded into a surveillance system covering 28 sentinel hospital sites, and representing about 45% of Nepal’s territory, at least in terms of theoretical hospital catchment areas. EWARS calls for weekly passive reporting (including zero caseloads) of six priority diseases (malaria, Japanese encephalitis, visceral leishmaniasis, acute flaccid paralysis-suspected polio, neonatal tetanus, and measles) based on clear, standardised definitions and a mandatory schedule of reporting, with active tracing of defaulter facilities. Influenza like illness is due to be added in 2006. EWARS reporting is not linked to the HMIS. EWARS is also a vehicle for Rapid Response Teams countrywide to report outbreaks, including due to aetiologic agents (notably diarrhoeal diseases) not in the EWARS list. EWARS guidelines7 specify under which circumstances RRTs and district health officers should investigate and report such outbreaks, and recommend epidemic thresholds. EWARS surveillance bulletins appear weekly, and detailed period analyses are carried out. We could not evaluate the effectiveness of RRTs in detecting, investigating and reporting outbreaks; their potential role in the aftermath of certain epidemic-prone natural disasters is discussed below. The WHO-IPD. WHO’s Programme for Immunization Preventable Diseases (IPD) operates a very advanced and resourceful active weekly surveillance system focusing on AFP-suspected polio, measles, neonatal tetanus, Japanese encephalitis, and Haemophilus influenzae type B meningitis. It has a larger coverage and greater degree of decentralisation than the EWARS: 10 regional Surveillance Medical

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Officers oversee data reporting in 115 hospitals and 465 public health centres, representing 72% of the inpatient facilities country-wide (Dr Margarita Ronderos, WHO, pers. comm.), though mountain areas, as with EWARS, are least covered. It does not cover other diseases and is unlikely to consider adding more to its list. The IPD system relies on very clear case definitions and reporting lines. In 6 terai districts (Jhapa, Dhanusha, Mahottari, Nawalparasi, Bardiya, Dang), it is supplemented by a community surveillance system based on Female Community Health Volunteers, operated by the CORE group of NGOs. To our knowledge the comparative performance of EWARS, IPD and HMIS for diseases covered by all three has not been evaluated, and was also beyond the scope of our mission. Additional vertical surveillance systems exist for malaria, tuberculosis, HIV/AIDS and visceral leishmaniasis. Laboratory confirmation of suspected epidemic pathogens is available in Nepal, with the exception of virology. In general, surveillance guidelines and standards in Nepal seem very clear and well-developed. The degree to which health catchment areas in the more remote or conflict-affected areas benefit from training and on-site capacity to detect and respond to outbreaks is not clear. It should be emphasized that all of the above surveillance systems rely mainly on health facility-based reporting, which, in turn, is only as efficient as health care access and utilisation in the community. Considering diseases normally associated with natural disasters, especially water- and vector-borne diseases, a gap in outbreak detection capacity may exist in regions of Nepal not covered by the EWARS system (Japanese encephalitis is probably an exception since it is part of the IPD system). In addition, two possible types of high-impact, disaster-associated, epidemic-prone pathogens may, given the present set-up, risk being overlooked in the event of a disaster in a remote area: Water-borne diseases, notably diarrhoea, epidemic shigellosis and typhoid: although all district health

offices are instructed to report any such suspected outbreaks within 24 hours, these diseases are not part of routine reporting in any system but the HMIS;

Dengue fever is reported to be on the rise throughout the South-East Asia region; Nepal is conspicuous for being the sole country in the region to consistently report 0 cases (see http://w3.whosea.org/en/Section10/Section332_7490.htm), despite severe epidemics in India and Bhutan; a recent seroprevalence survey in Nepal (see http://www.who.int/hac/crises/npl/sitreps/2005/Nepal_Health_Action_Issue_III.pdf) demonstrated a high prevalence of dengue antibodies, suggesting that a significant caseload may be occurring, but going undetected.

2.2.3 Data on disaster and conflict events The Nepal Red Cross Society (NRCS) appears to be a major source of information about natural disaster events, and fairly credible records of numbers of deaths and casualties as a result of natural disasters are readily available from various sources, including the EDCD, WHO, the UN Office for the Coordination of Humanitarian Affairs (OCHA), and the NRCS. Bi-weekly summaries and maps of conflict-related events (killings; military confrontations; abductions; etc.) are prepared and published by OCHA (see www.un.org.np). The main source of conflict event information is INSEC, which relies on a network of grassroots organisations and observers in each district. While the organisation offers precise figures on killings, abductions and disappearances, by district, year and suspected perpetrator, it is possible, as is the rule in all armed conflicts, that a proportion of victims is left unreported. We could not find any means of verifying the exhaustiveness of INSEC data. It should be noted that only direct death tolls are reported; there has been, to our knowledge, no attempt to estimate the number of indirect conflict deaths (due to the deleterious consequences of the conflict on

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human health – see Section 3.1). This is a major gap in the evidence on the Nepal conflict’s true impact (see also Section 3.7.2). 2.3 Denominator data

2.3.1 Census figures Reliable data on denominators (i.e. populations living in a given area or affected by a given crisis) are important to create indicators on the basis of routine surveillance and reporting (for example: antenatal visit coverage; health facility-based incidence of infectious diseases), and to project findings from sample surveys to the populations the surveys are representative of (for example: applying a maternal mortality ratio to the overall population of pregnant women in a given district to compute the expected number of maternal deaths). The last census in Nepal dates from 2001, and covered about nine tenths of the country, the remainder being inaccessible to enumerator teams due to the insurgency. Since then, significant population movement has occurred away from mountain communities towards urban centres, the Kathmandu valley, and neighbouring India (see below). Until the next census (2011), population figures for local planning are forward-projected using demographic methods (i.e. assuming a function for population growth rate). The projection is made centrally, and communicated on a regular basis to District health offices through the HMIS. Districts then use population planning figures to calculate indicators for HMIS reporting. 2.3.2 Catchment populations A major challenge for developing reliable health indicators based on health facility data is defining the catchment populations of individual facilities, ex. a district hospital. In practice, these may not reflect the actual population of a given district or group of VDCs which the facility is designed to serve, since the facility could attract patients from neighbouring districts, or vice versa. This is likely to be a relatively minor problem at district level, but may lead to skewed health indicators at the level of each facility. WHO and others reported to us that, for example, HMIS-based vaccination rates often exceed 100%, suggesting a problem with denominators. 2.3.3 Crisis-affected populations In many countries affected by crisis, the UN system or the host government develops working definitions of ‘affected populations’. For example, in Darfur the UN considers as its theoretical population of humanitarian concern all IDPs, all refugees to Chad, and civilians living in towns hosting large numbers of displaced. While the resulting estimate of affected populations may be rough, it does provide an idea of the magnitude of the crisis, and a denominator for measuring the approximate coverage of relief interventions. In Nepal, such a definition, though partly developed in the official government IDP policy8, seems to be missing in practice, at least in the context of the now subsided armed conflict (this is discussed further below). As regards natural disasters, some procedures are in place through Rapid Response Team guidelines to collect information on the number of people affected, in the immediate aftermath of any such event. Due to time and resource constraints, we could not evaluate the extent to which quality denominator data have been collected in past natural disasters. At the time of writing, a major relief operation was ongoing to assist victims of floods. The NRCS appeared to be the major source of objective data on affected persons in this context, and UN OCHA played an impressive role in consolidating this information (see for an example Figure 3). Nepal also has a very vibrant media community that itself plays a role (though possibly sometimes not very objective) in highlighting crises and affected communities.

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Figure 3. Map of flood and landslide affected communities in Nepal. UN OCHA, September 2006 (from http://www.un.org.np ).

2.4 Sample surveys

The vast majority of sampling-based health surveys in Nepal are conducted with a development perspective, and mainly to monitor nation- or region-wide trends over a timeframe of decades. They are not initiated as a tool for crisis detection and monitoring, and they usually undergo a considerably delay from the time of data collection to release of the findings. The most recent Demographic and Health Survey (DHS) was published in 20019, the previous such effort dating from 1996 (Nepal Family Health Survey). Conflict affected data collection, precluding interviewing in several communities. The survey provides a range of useful baseline estimates from the period before the intensification of the conflict; some of these are reviewed below to assess evidence for a humanitarian emergency in Nepal (see Sections 3.3 and 3.7.2). A new DHS has recently been completed, and is due to be published in April 2007 (no information was gathered on any conflict-related constraints to data collection in the new DHS). The other national survey with a health component is the Nepal Living Standards Survey, most recently conducted in 2003/200410; encouragingly, vaccination coverage estimates from this survey and the DHS seem roughly similar, though both lower than HMIS figures. Other surveys we reviewed concerned a variety of health topics, and were usually meant to evaluate vertical programmes, such as Vitamin A distribution and deworming11, training of FCHVs in community

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acute respiratory infection (ARI) management (USAID, unpublished), effectiveness of community-based integrated management of childhood illness12, etc. Most of these surveys are of no specific relevance to crisis detection and monitoring, but contain some information about the health context in communities they are representative of. Unfortunately, all of these surveys, for different reasons, sample only from a few districts of Nepal, apparently chosen purposefully, or based on accessibility criteria. Hill and mountain districts, especially if far from Kathmandu Valley, are consistently excluded from such survey exercises; however, findings are often quoted with a national perspective. Surveys specifically conducted to assess suspected emergency conditions are conspicuously rare, though in most other crises they are the mainstay of needs evaluation and evidence-based humanitarian planning. A striking lack of recent estimates of two key crisis indicators - population mortality and malnutrition prevalence - is apparent throughout Nepal, including regions where conflict has hit hardest, and where various reports suggest significant impact of the conflict on health access and food security. Because the country does not have a reliable birth and death registration system, any estimates of mortality must come from either ad hoc community surveillance systems, or retrospective surveys (these are particularly useful since they do not require a denominator, i.e. a list of VDCs and their updated population). The only recent estimate of mortality we found is contained in an Action Contre la Faim survey13 from Humla and Mugu districts; however, the survey appeared to only collect mortality data from households with living children under 5 (a common mistake in mortality studies nested within nutritional surveys), leading to a probable under-estimate. The same survey also provided one of the only malnutrition prevalence estimates, along with surveys by WFP14 and UNICEF (as yet unpublished) from 2005 and early 2006, reviewed in Section 3.3. The 2006 DHS will provide fresh estimates of global acute malnutrition (GAM) and severe acute malnutrition (SAM), broken down by region. However, it must be stressed that nutritional crises, real or suspected, must be monitored regularly using standardised anthropometric surveys as well as other food security assessments that target affected communities. DHS surveys are not a tool to monitor humanitarian crises of any sort, mainly because (i) they are done too infrequently and (ii) they do not provide sufficient geographic resolution. 2.5 Rapid assessments

Due to time constraints, we did not review humanitarian agencies’ practices in rapid health assessment during suspected crises. WHO-EHA and EDCD attempted to introduce a standardised rapid health assessment form in 2003, for use by RRTs, and an IDP monitoring system in 2005. However, the latter system was discontinued due to low reporting rates and lack of an operational ‘case definition’ of IDPs in the Nepal context. The few NGO rapid assessment reports we reviewed were generally very unstructured, containing mostly qualitative narratives, or quantitative data derived from very small convenience samples. Such reports may at best serve to sound alerts about a possible crisis, but are not very useful to plan for a response. The need for more standardised rapid assessment tools is discussed in Section 5.4.

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3 Evidence on the effects of conflict on health in Nepal 3.1 General consequences of armed conflict on health

Armed conflict-related crises generally have profoundly adverse effects on health status through essentially two pathways: an increase in disease incidence (through increased transmission and host susceptibility) and an increase in case-fatality ratios (through decreased host immune response and poorer access to treatment). These effects are ultimately quantifiable as an increase in mortality. Young children are usually the most affected: accordingly, infant and under 5 years mortality are sensitive emergency indicators. Apart from its direct consequences (i.e. trauma victims), armed conflict increases disease incidence and case-fatality ratios in several indirect ways, among which the following are perhaps most important: Conflict results in forced displacement. Displaced persons often congregate in camps, where

overcrowding and poor water and sanitation conditions favour disease transmission. Conflict contributes to food insecurity and thus to malnutrition. In turn, acute malnutrition (low

weight for height, or wasting) as well as select micronutrient deficiencies exist in a vicious cycle relationship with many infectious diseases, increasing both their incidence and their case-fatality: malnutrition thus exacerbates mortality, mainly in children unless conditions reach the (rare) generalised famine stage, when adults are also affected. The vast majority of deaths among severely malnourished children occur because of an underlying infection, not because of ‘starving to death’.

Conflict results in a disruption of both preventive and curative health activities: for example, vaccination and disease control programmes are interrupted; health facilities experience drug, supply and staffing shortages.

Conflict impoverishes civilian populations, hence decreasing their access to health care, aggravating medical conditions and thus increasing case-fatality.

Conflict also isolates civilians, which equally decreases access to health care and preventive interventions like vector control and vaccination.

Based on the limited available evidence we found, we speculate below on the likely extent of the above effects in Nepal. 3.2 Forced displacement

Forced displacement is a common feature of many armed conflicts. In Nepal, large-scale, acute waves of internal displacement have not been noted in recent years. With minor exceptions, internally displaced persons (IDPs) have not assembled in camps, and have not been registered systematically. IDPs living in camps, or those who have been registered, are easily identified as crisis-affected populations; the formation of camps facilitates delivery of relief, but also increases the risk of infectious disease transmission. By contrast, IDPs who integrate in the community or swell the ranks of urban slum dwellers are far harder to track and assist, and published evidence on the health status of these ‘invisible’ IDPs is largely missing. Another largely silent phenomenon is migration, which may be prompted in part by conflict or fear of persecution, as documented by the UN World Food programme (WFP)15. Many sources report very significant migratory movements in Nepal over the past few years, especially from mountain districts to the Kathmandu valley or neighbouring Indian states16. WFP estimated that 46% of rural

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households had lost one or more member due to migration14. A correlation between conflict intensity and rate of migration seems apparent, and many migrants may have sought occupations entailing high health hazards, such as sex trade16. A UN Inter-Agency mission to the Eastern region reported insightfully about the different typologies of displacement, and noted that only a minority of effective IDPs are perceived and counted as such, suggesting serious underestimation of official IDP figures17. Recent reports from Caritas16 and OCHA 18highlight the difficulty in enumerating IDPs in Nepal, and cite a commonly accepted range of 100 000 to 200 000. It is evident that governmental policy on IDPs is not well established in Nepal. On the other hand, significant movement of IDPs back to their areas of origin has been noted in the post-ceasefire period18. 3.3 Food insecurity and malnutrition

Food security assessments serve to detect communities in which nutritional emergencies may be already happening or will soon emerge. The best indicator of a nutritional emergency is the prevalence of acute malnutrition (wasting or low weight for height). Perhaps the best available evidence that conflict directly impacted on food security comes from a WFP-commissioned 2002 qualitative study19 from Dailekh, Jumla, Dadeldhura and Kailali districts, showing declines in food surpluses, and attributing increased food insecurity to hampered transport and market trade, combatant looting of surpluses, and migration of labourers as a result of the military pressure. A WFP nation-wide Vulnerability Assessment Mapping (VAM) exercise in late 200514 provides a quantitative baseline against which to monitor future trends in food security in Nepal, but may not be repeated soon. Interestingly, the VAM survey showed an 18% prevalence of global acute malnutrition (GAM) among children under 5 years in the terai, namely above international crisis thresholds (15%). The previous estimate for the terai, from the 2001 DHS9, was 13%, possibly suggesting a deterioration in food security (however, GAM prevalence is known to have seasonal fluctuations, and surveys should be repeated in comparable seasons). A subsequent winter drought prompted rapid assessments by WFP, and the launch of an emergency operation which aims to feed 225 000 beneficiaries in 70 VDCs of ten western mountain and hill districts, where 50-100% of the winter crop is estimated to have failed (see http://www.un.org.np/reports/WFP/2006/2006-6-21-WFP-EMOP-Fact-Figures_Final.pdf). In Rajhena IDP camp, Banke district, 16% GAM was found by the NGO Terre des Hommes among children under 3 years, but the assessment relied on unorthodox sampling13. UNICEF has conducted anthropometric surveys in several districts of Nepal over the past 12 months (at the time of writing, only the main findings were available, and no final report could be shared). GAM findings were not alarming in Sankhuwasabha and Baitadi districts in January-February 2006, exceeded 10% in Surkhet (March 2006) and reached 21% in Kanchanpur District in March 2006, up from 17% in June 2005 (UNICEF, unpublished observations). Surprisingly, only one of the UNICEF surveys was conducted in a district targeted for food relief by WFP: in Jumla (August 2006), GAM was 14%, with a low proportion of severe acute malnutrition (SAM). A rapid assessment (UNICEF, unpublished observations) was also conducted in Bajura, served by WFP, showing SAM of 6% and GAM of 21% (consistent with a very severe nutritional crisis); however, the sampling design (consisting of two clusters only) seemed invalid. To our knowledge, the only other recent survey-based nutritional data come from the NGO Action Contre la Faim (ACF) in Humla and Mugu districts (mountain region), who found GAM and SAM levels of 12%

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and 3% respectively (indeed, this is the only nutritional survey for which we could confirm the methodology’s validity)13. Other agencies reported high malnutrition in specific communities, such as Rukum district, but have not conducted quantitative assessments. In general, there appears to be a severe deficiency in implementation, reporting and coordination of nutritional surveys in Nepal, especially in areas where food insecurity is suspected. There does not seem to be a consistent strategy for nutritional surveillance. It is almost impossible to evaluate the extent of malnutrition, and its likely impact on health, given the available findings. Nonetheless, there is certain cause for alarm: GAM levels >15% (a broadly shared international emergency threshold) are a common finding, suggesting a possible breakdown in food security coping mechanisms in selected communities of Nepal (note that national surveys up to 2001 had consistently showed GAM<15%13). Underlying causes such as social marginalisation and poor feeding practices may exist, as well as seasonal ‘hunger gap’ effects; while these may require responses other than the classical ‘food first’ approach, they should probably not be dismissed as mere developmental issues. 3.4 Disruption of health services

Evidence on the conflict’s effect on health services functionality is limited and contradictory. The high reported coverage of vitamin A11, as well as the relatively low incidence of measles as detected by IPD surveillance, may be reasonably good proxies showing that the conflict has not had a major impact on key preventive, vertical child survival interventions, such as vaccination. Indeed, this impression was confirmed by agencies we spoke to. The situation with horizontal curative services may be strikingly different, though any conflict-related effects are hard to discern against a background of very poor pre-war health infrastructure and given the probable unreliability of many data on health system functionality communicated to the HMIS. HMIS data show a clear improvement in various indicators over the years 2000 to 2004, just as the conflict gathered pace. For example, full vaccination coverage against Diphtheria-Pertussis-Tetanus (DPT-3) rose from 80% in 2000-2001 to 90% in 2003-2004; the proportion of deliveries attended by health workers rose from 7% to 18%; the proportion of pregnant women attending a first antenatal visit from 41% to 66%; and the number of health facilities rose slightly5. Humanitarian agencies we spoke to suggested a drastically different scenario, with government health service delivery nearly at a standstill in some of the most conflict-affected districts. Indeed, during the same period government health expenditure decreased from Rs 39 billion to Rs 28 billion. A 2003 World Bank-supported qualitative and semi-quantitative study20 in six districts (Banke, Bardia, Nuwakot, Rasuwa, Dolakha and Bhaktapur) showed that local health systems met a fraction (usually less than half) of the planned targets in staffing and delivery of certain essential services, such as oral rehydration and vaccination. While the above does not in itself implicate the conflict, the report also details a variety of instances in which health staff were harassed and prevented from fulfilling their regular activities. Similarly, a United States Agency for International Development (USAID) report21 from 2002, while relying on secondary sources and noting the lack of objective data, presents an impressive collection of instances including “destruction of sub-health posts, increased absence of health care providers at peripheral health facilities, blockades of essential drugs and other health commodities into certain health facilities, difficulties in conducting supervision and monitoring visits by regional and district-level health officers, disruption of the cold chain due to lack of fuel in places where electricity is no longer available,

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and destruction of telephone towers and roads with the subsequent isolation of districts and their health facilities”. Data gathered in 2006 by WHO-EHA in seven districts (see Section 2.2.1; WHO-EHA, unpublished findings), while again not itself proof of the conflict’s impact, confirm a general impression of severely under-resourced health services. 3.5 Impoverishment

During the 1990s, there were declines in the levels of poverty due to good economic growth. Poverty levels decreased by 11 percentage points from 42% in 1996 to 31% in 2004. However, economic growth has declined in the last few years, from 3.3% in 2003/04 to 2% in 2004/05, which could result in a slow-down of these trends. Income inequalities between castes, ethnic groups, men and women are growing. There are also strong rural-urban discrepancies, with rural poverty at 35% compared to 10% in urban areas, and 3% in the Kathmandu Valley. The agricultural sector provides a livelihood for 80% of Nepal’s population, and remittances from abroad are playing an increasingly major role as a source of income for many households. Labour migration to either foreign countries or to urban areas of Nepal are important coping mechanisms, especially for households that are food-insecure. Despite the decline in poverty levels, stunting (low height for age), a sign of chronic food intake deficiency, has reduced little between 1975 and 2001, from 69.4% to 54.7%22. 3.6 Isolation of civilian populations

Several stakeholders we interviewed believe that, in Nepal, those worst affected by the conflict are the populations cut off from essential services like transport and health care, because of the segregation of the country between CPN(Maoist) and government-held areas. Two agencies mentioned widespread instances of civilians been prevented from accessing health facilities by the CPN(Maoist). 3.7 Is there a humanitarian emergency?

Our assessment mainly reveals very large gaps in quantitative evidence on the health effects of Nepal’s conflict, despite a wealth of semi-quantitative and anecdotal evidence. With this in mind, cautious conclusions can be drawn. 3.7.1 What is the profile of Nepal’s conflict? The dynamics of this conflict are atypical: Forced displacement has occurred, but has not resulted in overcrowded camp conditions: IDPs and

“forced” migrants may thus not have faced an increased risk of disease transmission following their displacement, but the weakest and most economically fragile among them may well have entered a spiral of poverty, or experienced very limited access to curative health services;

There is no evidence of massive nutritional crises, but localised emergencies are likely to have occurred;

Insurgents’ presence, as well as army counter-measures, seem to apply a silent but constant pressure on an already fragile system of curative health services;

Certain key preventive health services, in particular vaccination, seem to have survived this pressure and continue to function well in spite of fighting;

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There is strong evidence that civilians have been prevented by combatants from accessing health services, and that medical staff have been restricted in their activities; the extent of such phenomena is not quantified.

3.7.2 The bottom line: excess mortality Ultimately, any physical health effects of the conflict must be measurable as an increase in population mortality rate, the most fundamental indicator of health status. On balance, we speculate that the above elements are indeed consistent with such an increase, though one of a relatively moderate extent. When benchmarking the scale of a humanitarian crisis based on mortality rates, two threshold-based approaches are currently used to classify a situation as an emergency: (i) if crude (all ages, unadjusted) mortality rate (CMR) exceeds 1 death per 10 000 persons per day, or if under 5 years mortality rate (U5MR) exceeds 2 deaths per 10 000 per day; (ii) if CMR or U5MR are more than double the local pre-crisis baseline (in our case, the best estimate of this baseline would be from the 2001 census, namely CMR 0.27 per 10 000 per day). The former approach is more globally equitable, but the latter is more sensitive for detecting alterations in settings with relatively low baseline mortality (i.e. outside of sub-Saharan Africa). In reality, mortality rate thresholds are overplayed when evaluating crises: what matters ultimately is the amount of excess mortality, that is to say, how many deaths occur as a result of the crisis, above and beyond the ‘background’ pre-crisis mortality – indeed, these are the deaths that one can hope to prevent through timely relief interventions. Excess mortality does not depend merely on the magnitude of the mortality rate, but also on the size of the population that is experiencing this elevated mortality. This is particularly relevant for Nepal, where any elevation in mortality rate as a result of the conflict may not have been very remarkable, but where, on the other hand, the population affected is far greater than in other current crises (for example, about 4 million in Darfur; 2 million in northern Uganda). Cautious parallels may be drawn with both Iraq and the Democratic Republic of Congo, where respective surveys23,24 demonstrated, on a nearly country-wide scale, relatively slight elevations in mortality rate during the conflict period, which nonetheless, when applied to the entire populations, implied a very significant death toll. In reality, the smaller the geographical resolution (ex. VDC level), the greater the degree of clustering in mortality rates: thus, a survey purposefully done in a small community (ex. a group of VDCs) known to have experienced very heavy fighting or an epidemic will probably yield a high mortality rate; a survey covering an entire district will yield a diluted, less severe death rate that reflects both localised crises and the experience of less affected communities. The previously cited Action Contre la Faim survey13 found a CMR of 0.67 per 10 000 per day (95% confidence interval 0.01 to 1.34) in areas of Humla and Mugu districts during the period October 2005-March 2006; although the confidence interval is wide, and the survey methodology almost certainly resulted in an under-estimation of the true rate, this would suggest a substantial elevation from baseline levels country-wide (0.27 per 10 000 per day – see above). According to census and DHS data, infant (0-1 years) and child mortality (1-4 years) have declined steeply in Nepal during the past decades: total under 5 mortality was 161 per 1000 live births in 1990, 118 in 1995, and 91 in 2001, when it was last measured. However, the 2001 DHS report states that its mortality measures are likely to be under-estimates, citing several reasons connected with interviewer consistency.9 Furthermore, the previous birth history questionnaire used in DHS surveys to estimate under 5 mortality is believed by some to under-estimate true mortality, as shown previously25,26, while more direct methods (past or current household census), used in emergency retrospective mortality surveys,

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may yield better estimates. Nevertheless, assuming the methodology and under-estimation biases in the various estimates have remained constant, a declining trend seems apparent, and the publication of DHS 2006 should provide a crucial update of progress, or alternatively demonstrate a reversal in the trend in the crucial post-2001 years when the insurgency took on national proportions. When DHS 2006 is released, it will be important to evaluate any under-estimation in its under 5 mortality estimates, as well as its geographical coverage (in the previous DHS, only a few survey clusters in the west could not be completed due to insecurity). Regions not covered by the DHS are likely to experience worse health indicators. Infant and child mortality are most likely to have been affected by the conflict, but there are plausible reasons why adult mortality might also have increased (for example, poorer access to emergency obstetric care; untreated tuberculosis or HIV/AIDS, as well as other chronic conditions). There are however no data by which to evaluate adult mortality trends in recent years, and existing estimates are merely extrapolations using indirect methods based on trend projections, which do not take into account any changes in living conditions as a result of the insurgency (see for example population projections by the Nepali Central Bureau of Statistics: http://www.cbs.gov.np). 3.8 Scope for “Health as a Bridge for Peace” initiatives

Due to the short mission, a thorough examination of “Health as a Bridge for Peace” (HBP) was delayed until the next visit by LSHTM. However, some preliminary impressions are presented here. LSHTM conducted research on the conceptual underpinnings of HBP and other similar initiatives in 2004-2005. WHO describes HBP as “a multidimensional policy and planning framework which supports health workers in delivering health programmes in conflict and post-conflict situations and at the same time contributes to peace-building”27. HBP as a concept was popular in the 1990s but the idea has slipped into decline for a variety of reasons, including the role of individuals driving the concept, the changing priorities of DfID (its main donor agency), and a lack of evidence for its effectiveness28. Recently there have been efforts to resurrect it at various conferences (such as Health as a Bridge for Peace (HBP) International seminar, Helsinki, September 6-7, 2005, and a preparatory conference in “Health as a Bridge for Peace” Conference of Specialists, February 10, 2005 in New York); however, there is no department or unit at WHO that specializes in these types of initiatives. As a result of its research, LSHTM has re-conceptualized HBP as containing two types of activities:

health through peace, and peace through health29. Health through peace (HtP) can be defined as peace and conflict mitigation activities that are primarily conducted in order to achieve positive health outcomes; in other words, public health is the primary concern, not peace. A humanitarian ceasefire, whereby a cessation of hostilities is agreed that allows for vaccinations or other health services to be carried out, is a good example of HtP. Peace through health (PtH) initiatives are those where peace is the primary concern, and health outcomes are a secondary objective. Efforts to reintegrate health personnel and health services factionalised by war in places like Bosnia-Herzegovina, Croatia, and Angola are good examples of widely promoted PtH interventions. Despite the WHO’s insistence that health should be the foremost objective of HBP, the majority of the WHO’s most highly touted HBP initiatives have been PtH projects. Given that the conflict in Nepal has been driven, in part, by poverty and inequality (which has an ethnic and caste dimension), there may be scope to do some HBP programming. Clarity needs to be sought, however, regarding its primary objectives (health or peace) and expected outcomes. Workshops can be done at the district level, where issues around human rights, conflict resolution, and international humanitarian law can be discussed with local actors, as has been done in previous WHO-EHA HBP

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workshops in Sri Lanka and elsewhere. Care must be taken to ‘do no harm’ as health workers in Nepal have been targeted during the conflict1,30 and HBP workshops may elicit considerable sensitivities (for example, doctors are not allowed to treat ‘rebels’ and may be punished for this by the government). HBP programming can also be directed towards senior policy-makers in the Ministry of Health, where issues around equity, non-segregation, professional ethics and human rights could be discussed as part of health sector reform; the rationale behind this is that if services are delivered in an equitable and professional manner, grievances due to inequitable service provision may be alleviated. Before HBP programming is taken forward, more thought is required as to causes of the conflict, the role of the health sector in the conflict, the most effective level at which to hold HBP workshops, and the possible sensitivities that could be raised.

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4 Natural disaster preparedness and response 4.1 Health sector capacity

Nepal’s health system is chronically weak because of numerous factors, including under-funding, weak management and supervision systems, and endemic corruption. Supply systems and access are difficult due to the mountainous terrain and lack of roads. This already fragile health system has been further weakened by the conflict in terms of displacement of medical stuff and disrupted drug supplies. The conflict, however, is hardly acknowledged by the government’s national health sector plan, which focuses primarily on various health sector reforms such as decentralization. In 2000, the Ministry of Health, the DHS and the EDCD established Rapid Response Teams (RRTs) at three levels (national, regional and district level) to manage epidemics. Their remit was subsequently expanded to emergency preparedness and response, dealing with the public health effects of any disaster. As the district RRTs are present locally, they are likely to be the first responders concerned with public health issues in emergencies. The teams include the district health officer, district public health officer, medical officer, health assistants and nurses, plus other district health staff. When a disaster occurs, RRTs coordinate with the District Disaster Relief Committee, which in turn reports to the Ministry of Home Affairs. Within the health sector, the recently institutionalised Disaster Health Working Group (DHWG) is the body responsible for coordination of emergency preparedness and disaster response at the national level. Various RRTs have received training from a variety of agencies at different times, but it is unclear how many RRTs have benefited from training, what level of training they have received, and the effectiveness of this training. In addition, a lack of adequate supplies and the weak underlying health system make it difficult for RRTs to act effectively, and needs to be addressed. 4.2 WHO-EHA interventions

WHO-EHA has not yet assumed a field leadership role in the response to natural disaster-related crises within Nepal. By contrast, it has initiated and supported numerous very important disaster preparedness activities, which cover many of the following aspects of what may be considered an essential package of interventions: Mitigating likely damage to critical health structures. For example, EHA (as part of its regular

non-CAP programme) has very recently funded seismic assessments of blood banks, as well as Hospital Preparedness for Emergencies (HOPE) training.

Developing disaster plans and best practice guidelines. WHO-EHA has been integral to developing excellent in-country national guidelines regarding how to respond to disasters. In collaboration with the EDCD, a national plan has been produced (‘Health Sector Emergency Preparedness and Disaster Response Plan Nepal’) as well as guidelines for RRTs (‘Best Public Health Practices in Emergencies for District Health Workers’) and hospitals (‘Guidelines on Emergency Preparedness and Disaster Management for Hospitals’).

Training of health care providers on disaster response. WHO-EHA has implemented numerous disaster management training sessions, including earthquake mitigation, mass casualty management, and training of RRTs on how to prepare and respond to the health impacts of floods and drought. Most of this training has taken place in the Kathmandu Valley, and the team is now aiming to expand their training program outside the Valley. To this end, it conducted a disaster preparedness

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training session in September 2006 in Pokhara. The current plan is to target four districts based on the results of the district assessment study WHO-EHA has conducted in eight districts (See Section 2.2.1).

First aid supplies and inpatient trauma care supplies. Ad hoc donations have been made. Capacity for referral of emergencies from periphery to hospitals. Triage systems. Triage guidelines and materials, such as coloured tags, have been produced and

distributed to select hospitals, and were witnessed in use during April 2006 unrest in Kathmandu. Pre-positioning of drugs and supplies. Plans for this are being drawn up as part of the current CAP

programme. Ensuring inter-agency coordination. WHO-EHA has contributed to revitalising and currently co-

chairs the Disaster Health Working Group. Information on gaps in the above is partly gathered through the aforementioned district data collection exercise. The choice of natural disaster-related activities currently proposed or already underway, as well as the rationale for their geographical targeting, are not explicitly formulated in the current CAP programme. Suggestions for this are provided in Section 5.5. While various considerations (such as good collaboration with certain agencies or district authorities) may ultimately determine some of the programme’s focus, prioritisation of activities clearly needs to be informed by a prediction of where interventions are likely to make the most impact (essentially in terms of lives saved). Specifically, the following key issues need to be considered: Response to current disasters versus preparedness. As reviewed in Table 1, the most serious

recurrent type of disaster in Nepal is floods. The health consequences of flooding, beyond the initial days of search-and-rescue and trauma management, are relatively mild, and post-flooding epidemics infrequent. On the other hand, the occurrence of a major earthquake would have a far greater health impact. Directing the currently limited resources primarily towards preparedness for earthquakes seems amply justified.

Geographical focus. While scenarios and plans exist for the eventuality of an earthquake in the

Kathmandu Valley (see http://www.nset.org.np/nset_new/html/publications.html), less attention seems to have gone into quantifying the potential health effects of a similarly sized seismic event in non-urban areas of Nepal, and particularly the less accessible mountain and hill regions, which in several respects may present challenges for response similar to those of the communities affected by the 2005 Pakistan earthquake. On the other hand, the choice of geographical focus should clearly be guided by other parameters, such as the total population at risk, the coverage of health facilities, the presence of other agencies, etc.).

Local, intensive focus versus nationwide activities. An apparent pattern of international aid in

Nepal is incomplete national coverage. Many programmes seem to focus on a relatively small number of districts, usually in the Terai. WHO-EHA also currently plans to focus some of its disaster preparedness activities on four districts. The rationale as to why four districts should be targeted, as well as their selection criteria, is not entirely spelled out, and obvious questions of equity arise. Furthermore, the risk of missing a major disaster if one focuses activities in only four out 75 districts is very high. A decision clearly needs to be made on whether to continue to collect data in more districts with a view to prioritizing some for more intensive disaster preparedness and management

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training (as is currently planned for four districts), or to proceed with a more national approach, based on information already obtained. Accordingly, a choice could be taken to deliver all aspects of the preparedness package to a specific region, such as Kathmandu Valley, or focus on a few components of the package, such as triage and referral, on a more national scale.

First aid versus primary care versus secondary care. This choice very much depends on the

geographical setting. For example, in the event of an earthquake, a crucial life-saving intervention in an urban context might be to ensure that referral hospitals are protected from structural damage and thus remain functional. By contrast, in a rural mountainous context, a large number of lives could be saved by ensuring that remote communities know how to triage life-threatening casualties, stabilise them, and use stretchers to carry them to the nearest hospital.

Type of implementing agency. In addition to government and WHO-EHA, the choice could be taken

to fund and technically assist NGOs (local or international) or the NRCS to carry out activities. 4.3 Partnership with other agencies

The NRCS, supported by the International Federation of the Red Cross (IFRC), takes a leading role in disaster preparedness and response. There is a team in each of the 75 districts of Nepal who have received some training, and have limited supplies. However, information collected by WHO-EHA in eight relatively accessible districts indicate that training is irregular, most have very limited equipment (such as stretchers), none have a working ambulance, and most have no drug supplies, all of which restrict their ability to give immediate help. Strengthening these Red Cross teams with training and supplies could be one avenue for WHO-EHA to explore, given the excellent coverage of the NRCS. If a more national approach is chosen, UNDP suggested four possible partners that WHO-EHA could approach to do health-focused disaster management training. First, UNDP is currently conducting disaster management training (including first aid, search and rescue, disaster mitigation) with community based organizations in rural and urban settings in six districts that have been identified as more risky than other areas in terms of floods and landslides. UNDP stated that they are open to exploring with WHO-EHA the need for more health related training (such as disease outbreak response). Second, UNDP suggested that WHO-EHA should follow up with the focal points for Avian Flu in each of the districts, as these staff are currently being given technical support through the World Bank-led avian flu response on Nepal. Third, UNDP suggested engaging with the Ministry of Local Development, which is working with UNDP on strengthening civil servants at the district level regarding multi-sectoral development work. Finally, WHO-EHA could expand its training capacity beyond disaster management, and link to UNDP’s Rural Urban Partnership Program (RUPP), which examines migration issues in various settings, such as the impact of migration on the provision of social services, including health. As RUPP has already identified migrants, this would be an opportunity for WHO-EHA to assess their vulnerability, health statistics and access to quality health services.

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5 Discussion and recommendations 5.1 Humanitarian versus development approaches in Nepal

Nepal’s international aid community is complex in that both the development community and the humanitarian community are present. The development community has remained in the country despite the conflict, reflecting current thinking that there is a need to stay engaged in fragile states in order to help stabilize them31. The humanitarian community arrived starting in 2003 due to an upsurge in the conflict and presumably, reports of very poor health indicators. These two communities differ in how they conceptualize the current situation in Nepal, including how they perceive the effects of the conflict on the health of the population. For example, the development community believes the current rates of high malnutrition in some areas of the country are mostly due to chronic underdevelopment and takes a development approach to address them. The humanitarian community, on the other hand, takes a rapid, direct intervention approach, identifying communities affected and directly addressing their needs through food aid or other humanitarian mechanisms, often with little linkage to the existing health system. As has happened in other countries where this situation exists (for example in southern Africa during the drought response32), there is a need to bridge the gap between the two approaches in order to improve the effectiveness of international aid. WHO-EHA could possibly play this bridging role due to its dual mandate to strengthen the government’s capacity using a developmental approach, and to respond to humanitarian crises. 5.2 General orientation of the WHO-EHA programme

The work that WHO-EHA does is very important given Nepal’s high risk of natural disasters, and the on-going conflict situation. The CAP programme has given the WHO-EHA team the ability to expand its work on disaster preparedness at the national level, and to strengthen its coordination and technical advice activities within the humanitarian sector. WHO-EHA should play a leading role in crisis detection, assessment, and monitoring, and ensure an appropriate response by various national and humanitarian actors. Our overall recommendation for the current WHO-EHA CAP-funded programme, as well as its overall orientation, is to take a three-pronged approach:

i) Assume increasing responsibility for nationwide, effective coordination of humanitarian health issues in both the natural disaster and complex emergency domains;

ii) Stimulate a systematic approach, and promote methodologically rigorous methods for the collection of data for crisis detection and monitoring nationwide, if necessary filling in gaps;

iii) Continue and reinforce activities in the area of natural disaster preparedness. Specific recommendations for each of these three areas are outlined below. 5.3 Nationwide coordination of stakeholders

WHO-EHA should assume increasing responsibility for nationwide, effective coordination of stakeholders involved in humanitarian health issues in both the natural disaster and complex emergency

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domains. It should strengthen the Emergency Health and Nutrition Working Group and the Disaster Management Working Group and take the lead in terms of documenting gaps in knowledge and ways to fill them. While WHO-EHA’s role should be to provide technical advice and support to various partners, namely government and humanitarian partners, some operational field experience is warranted to give first-hand knowledge of the health sector outside the Kathmandu valley. Finding the appropriate balance between implementation at field level and technical support to implementing partners is a challenge for the WHO-EHA team. Recommendations for WHO-EHA: I. Continue to revitalise the Disaster Health Working Group and the Health and Nutritional Emergency Working Group, encouraging active participation from NGOs. II. Discuss the balance between implementation and technical advice in strategic planning meetings. Equity of response should also be discussed - i.e. the pros and cons of a national level response versus a more focused, district level response. An operational, district level response is only be justified if it is developed as a model (or “pilot programme”) that can then be put forward for nationwide scaling up; as such, feasible (costed) plans for such a scale-up should also be developed. III. Continue to publish the EHA bulletin, and expand it to systematically include any new health-related information (especially assessments, study reports and other hard data) relating to crisis-affected populations in Nepal. 5.4 Detection and monitoring of crises

A serious gap in quality data collection to objectively assess and benchmark suspected humanitarian emergencies exists, and must urgently be filled. All humanitarian agencies in Nepal should increasingly design and justify their programmes on the basis of objective crisis indicators, the most crucial being mortality rate and acute malnutrition prevalence. For humanitarian purposes, mortality data on a country-wide scale have limited operational utility. Instead, estimates for communities in Nepal which may be experiencing crises, derived from simple, short-lived community surveillance systems or, alternatively, statistically valid household surveys, are sorely needed so as to provide objective grounds for evaluating the scale of any emergency, and monitoring the effectiveness of humanitarian relief. Stand-alone retrospective mortality surveys are preferable33, but they may be combined with nutritional surveys.34 In Annex 2, we suggest an algorithm for collecting crisis-related data, by phase of data collection. The WHO-EHA team currently has most of the skills it requires, but could use more support in nutrition and epidemiology if it plans to initiate, support or evaluate epidemiological survey work. Recommendations for WHO-EHA: IV. Actively promote the need for on-going data collection to better detect and monitor crises using key crisis indicators (mortality and acute malnutrition), and promote existing best practice methods for how to do this. As a first step, WHO-EHA could present a synopsis of the information gap as outlined in the sections above, and make suggestions regarding what the humanitarian community could do to fill them.

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It could also present the preliminary findings of its district assessment study at various forums – including the Emergency Health and Nutrition Working Group, the Disaster and Health Working Group, and OCHA’s bimonthly humanitarian coordination meeting – as this type of health information, systematically presented, currently seems to be lacking in most forums. WHO-EHA should in time become a first point of reference for any agencies looking for guidance on appropriate data collection in crisis contexts within Nepal. V. Intervene early on in suspected crises, following the suggested algorithm (Annex 2), and with particular attention to filling gaps in data collection. ‘Filling gaps’ could refer to directly sourcing and managing staff and capacity to conduct data collection activities, such as the setting up of simple prospective surveillance for infectious diseases in the aftermath of a natural disaster, or the organisation of a nutritional survey in a region affected by food insecurity. It could also involve instigating and coordinating data collection by other agencies with expertise in field research, and/or monitoring and enforcing methodological standards. WHO-EHA could also collate any new survey data, conduct an objective epidemiological analysis of it, and then interpret it for both the humanitarian and development communities. VI. Hire staff with specific skills in nutrition and epidemiology if WHO-EHA initiates, supports or evaluates epidemiological survey work (see above recommendation). In addition, seek continued technical support from regional and HAC headquarters in Geneva, for instance in terms of piloting and finalizing the rapid health assessment protocol. VII. Create an informal network of key informants who can provide objective, real-time information on actual conditions in communities where crises might be occurring: these include NGOs, local journalists, locally posted UN staff, and local district health officials. VIII. Work closely with OCHA to ensure that its repository of assessments and reports concerning communities in crisis in Nepal is as complete as possible, especially as regards health. The UN website (www.un.org.np) is an excellent platform for storing and making accessible such information. IX. Develop and field-test a standardised Rapid Health Assessment tool, using as a template examples from other humanitarian agencies and contexts. A UN-wide initiative to standardise rapid assessment tools is currently underway. X. Work with government counterparts and/or the NRCS when doing rapid health assessments. This will help build capacity of government counterparts, and validate the assessment forms for different types of emergencies. XI. Strongly suggest to relevant agencies that the DHS 2006 data should be compared to the HMIS data to assess its validity over the last five years, based on comparison of indicators collected by both sources. Alternatively, this may be done within WHO provided sufficient time is set aside to collect and compare the necessary data.

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Recommendations for other agencies: XII. Work together to develop a clear definition of crisis-affected populations. XIII. Register any new and existing IDPs, especially if political conditions do not improve significantly over the next few months.. XIV. Invest in expert epidemiological and nutritional support to perform proper surveys or surveillance in communities for which a claim of humanitarian crisis is made.

5.5 Natural disaster-related activities

It was decided at a final briefing workshop on Sept 1, 2006 that the CAP Programme should focus on meeting the needs of complex emergencies, as well as building capacity to respond to natural disasters. As the regular WHO-EHA programme has focused on disaster preparedness plans and mitigation of earthquakes -- which is warranted and should be continued as outlined in Section 4.2 -- the CAP programme could focus more on floods and droughts. The WHO-EHA programme of response to natural disasters, however, should be conceptualised and presented as a seamless whole and should not be divided according to funding lines. Recommendations for WHO-EHA: XV. Continue to focus natural disaster-related activities on earthquake preparedness within the overall programme. XVI. In collaboration with key stakeholders, carry out an informal analysis aiming to identify (i) all the crucial opportunities for maximising access to care for earthquake trauma victims, by region of Nepal (mountain/hill; terai; Kathmandu Valley and other major urban centres), and (ii) which interventions are likely to feature the most favourable cost-benefit ratio (for example: procuring n stretchers per VDC in mountain and hill districts so as to transport emergencies, versus pre-positioning essential drugs and supplies in n district capitals). This analysis should include a consideration of number of people at potential risk; extent of vulnerability; likely profile of casualties; likely pathway of referral of medical emergencies, and hospitals likely to serve as major referral hubs. It should aim to build a decisional matrix in which all the different components of a disaster preparedness package are clearly spelled out and compared in terms of cost, feasibility, need, and of course potential impact. The very well-written publication ‘Health Sector Emergency Preparedness and Disaster Response Plan Nepal’ already contains the essential rationale and epidemiological framework on which to base such calculations. Obviously, many of the assumptions in such an analysis will have to be speculative (for example: what proportion of life-threatening injuries would be seen promptly with and without a triage system): the objective, however, should merely be to broadly identify the most cost-beneficial interventions, given reasonably conservative scenarios. In this respect, reviewing evidence from past disaster responses, especially the recent earthquake in Pakistan, could be extremely informative, and may warrant a study visit to Pakistan.

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XVI. In the event of a flood, focus efforts on rapid assessment, coordination of other health agencies, monitoring of water (quality and quantity) and sanitation coverage, and reinforcing disease surveillance in the community itself (and not just in health structures). XVII. Rationalise the choice of districts in which to provide disaster preparedness services directly. Focussing on only a few districts can hardly be justified as a viable strategy, unless it is a way to pilot a comprehensive package of disaster preparedness activities, and, based on the experience gained, stimulate and partner with key agencies who do hands-on work in other districts (such as the NRCS or key NGOs) to scale up the package nationwide. Selection of districts for prioritisation could be based on the following criteria: Support from district authorities (while this may seem arbitrary, it is in fact a useful pragmatic

consideration) Level of vulnerability (essentially to earthquakes; this could be determined based on the advice of

specialised agencies such as the Nepali Society for Earthquake Technology) Number of people at risk Extent of gaps in disaster preparedness, as revealed by objective data collection Presence of an NGO and/or a strong NRCS office that can carry the work forward after WHO-EHA’s

intervention Security.

XVIII. Continue to build strong partnerships with implementing NGOs and the NRCS in as many districts as possible, and involve them in disaster-related activities. 5.6 Health as a bridge for peace

Based upon discussions with the Technical Officer of WHO-EHA, it was decided that further follow-up was needed in terms of exploring the real need and possible effectiveness of health as a bridge for peace training in Nepal. Recommendations for WHO-EHA: XVIIII. The Technical Officer should discuss possible Health as a Bridge for Peace activities with various actors, including counterpart government officials and SEARO. The Technical Officer should also read the research papers on health and peace supplied by LSHTM, and explore the possibilities for procuring WHO-EHA trainers from either the regional SEARO or Geneva office. LSHTM is available in the meantime to provide advice, and a second mission to Nepal is planned to take this process forward. 5.7 Future funding for WHO-EHA activities

Given the importance of the work that WHO-EHA does, there is a need to procure continued funding for the WHO-EHA programme that will not only allow it to continue, but to expand and strengthen its programming. To this end, potential donors need to be approached.

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Recommendations for WHO-EHA: XX. The WHO-EHA team should start discussing with possible funding agencies plans to fill the funding gap from March-December 2007. As the team develops its implementation strategy for 2006, it should develop programming that is designed to lead to further activities that can be funded. XXI. WHO-EHA should approach ECHO and DfID with proposals including how to fill the health information gap in Nepal, and how to continue to work with the government to increase its disaster response and mitigation capacity. ECHO could be approached with a humanitarian focused proposal on, for example, improved crisis detection. DfID, which is a developmental donor in Nepal, could be approached with proposals regarding how best to continue to support the government in terms of its disaster planning and response. To this end, it may help if WHO-EHA gained a better understanding of present plans for health sector reform. For instance, the 2004-2009 Nepal Health Sector Implementation Plan mentions plans for disaster preparedness and response; WHO-EHA could write a proposal to support this, citing its comparative advantage in terms of its previous work, and its excellent relationships with relevant government departments. XXII. Other donors, including the World Bank, USAID and GTZ should also be approached. The World Bank funds state-building activities, so may be interested in activities that build the government’s capacity to prepare and respond to disasters. USAID and GTZ are both interested in investigating the impact of the conflict on the Nepali health system, and could be approached to further explore potential areas of collaboration. Overall, the work that WHO-EHA does in Nepal is of immense importance given the high risk to human health from natural disasters and conflict. Presently, its resources are limited and time-bound. We strongly urge all funding agencies, as well as WHO-HAC headquarters in Geneva and SEARO, to support WHO-EHA’s activities in Nepal. Such support will enable the programme to take the lead in both coordination and crisis detection and response in the humanitarian health sector, carry out crucial activities in the field of natural disaster preparedness, with a particular focus on earthquakes, and strengthen the overall health sector response in Nepal.

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References 1. Singh S, Arya N, Mills E, Holtz T, Westberg G. Free doctors and medical students detained in Nepal.

Lancet 2006;367(9524):1730. 2. Singh S, Bohler E, Dahal K, Mills E. The state of child health and human rights in Nepal. PLoS Med

2006;3(7):e203. 3. Singh S, Dahal K, Mills E. Nepal's war on human rights: a summit higher than Everest. Int J Equity

Health 2005;4:9. 4. Epidemiology and Disease Control Division MoH. Health sector emergency preparedness and disaster

response plan, Nepal: Ministry of Health, 2003. 5. World Health Organization. Nepal National Health System Profile (draft). Kathmandu: WHO, 2006. 6. Nepal Public Health Association MoH, World Health Organization,. Compilation and Collection of

District Profiles: Baseline Data through Secondary Source. Kathmandu: NPHA, 2005. 7. Epidemiology and Disease Control Division MoH. Early warning reporting system (EWARS)

guidelines. Kathmandu: Ministry of Health, 2006. 8. His Majesty's Government of Nepal. National Policy on Internally Displaced Persons, March 2006.

Kathmandu: Government of Nepal, 2006. 9. Ministry of Health NE, ORC Macro,. Nepal Demographic and Health Survey 2001. Kathmandu:

Ministry of Health, 2002. 10. Central Bureau of Statistics. Nepal Living Standards Survey. Kathmandu: Government of Nepal,

2004. 11. Nepali Technical Assistance Group. Mini Survey Report. Kathmandu: NTAG, 2005. 12. Solutions Consultant (P.) Ltd. Survey on assessing effectiveness of CB-IMCI programme - a

comparative study in Kaski and Tanahu districts. Kathmandu, 2004. 13. Action contre la Faim. Nutritional exploratory mission, Humla and Mugu districts, Nepal.

Kathmandu: ACF, 2006. 14. United Nations World Food Programme. Household Food and Security in Nepal. Kathmandu: WFP,

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Nations, 2006. 18. United Nations Office for the Coordination of Humanitarian Affairs. OCHA Thematic Report: The

Internally Displaced Persons - current Status. Kathmandu: UN OCHA, 2006. 19. National Labour Academy-Nepal. A study on conflict induced food insecurity in Nepal. Kathmandu:

NLA, 2003. 20. Devkota M. An assessment on impact of conflict on delivery of health services: Nepal Health Sector

Programme, 2005. 21. United States Agency for International Development. Primary health care services in Nepal - field

report. Kathmandu: USAID, 2002. 22. United Nations Development Programme. Meeting the Millennium Development Goals in Nepal.

Kathmandu: UNDP, 2005. 23. Coghlan B, Brennan RJ, Ngoy P, et al. Mortality in the Democratic Republic of Congo: a nationwide

survey. Lancet 2006;367(9504):44-51. 24. Roberts L, Lafta R, Garfield R, Khudhairi J, Burnham G. Mortality before and after the 2003 invasion

of Iraq: cluster sample survey. Lancet 2004;364(9448):1857-64.

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25. Becker SR, Diop F, Thornton JN. Infant and child mortality in two counties of Liberia: results of a survey in 1988 and trends since 1984. Int J Epidemiol 1993;22 Suppl 1:S56-63.

26. Taylor WR, Chahnazarian A, Weinman J, et al. Mortality and use of health services surveys in rural Zaire. Int J Epidemiol 1993;22 Suppl 1:S15-9.

27. World Health Organization. Training on "Health as a Bridge for Peace", Chateau de Penthes 24-28 June 2002. Geneva: WHO, 2002.

28. Rushton S, McInnes C. The UK, health and peace-building: the mysterious disappearance of Health as a Bridge for Peace. Med Confl Surviv 2006;22(2):94-109.

29. Bloom J BO, Sondorp E,. Rethinking Peace and Health Conceptual Frameworks. London: LSHTM internal report, 2005.

30. Sharma GK, Osti B, Sharma B. Physicians persecuted for ethical practice in Nepal. Lancet 2002;359(9316):1519.

31. Department for International Development. Why we need to work more effectively in fragile states. London: DfID, 2005.

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33. Checchi F, Roberts L. HPN Network Paper 52: Interpreting and using mortality data in humanitarian emergencies: a primer for non-epidemiologists. London: Overseas Development Institute, 2005.

34. Standardised Monitoring and Assessment of Relief and Transitions programme (SMART). SMART Methodology, version 1: SMART, 2005.

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6 Annexes 6.1 Annex 1: List of stakeholders consulted

Agency Name Position WHO: WHO-EHA Erik Kjaergaard Technical Officer Damodhar Adhikari National Operations Officer Prahlad Dahal Administrative Assistant Saku Mapa Information Officer Dr Sara Ritchie Public Health Field Coordinator Sunita Sharma National Field Coordinator WHO-IPD Dr Shahin Huseynov Operations Manager WHO Dr Kan Tun Country Representative Dr Margarita Ronderos Epidemiologist Dr Ilasa Nelwan Public Health Administrator Other UN agencies: OCHA Paul Handley Humanitarian Affairs Officer Catherine Lefebvre Information Management Officer Aditee Maskey National Coordination Officer UN Security Ujjwal Bickram Rana National Security Officer UNICEF Dr Birthe Locatelli-Rossi Chief, Health Section UNDP Rahul Sengupta Programme Officer Ministry of Health: EDCD Dr GD Thakur Acting Director DHS-Management Div. Dharanidhar Gautam Deputy Director, Chief of MIS Section District Health Office District Health Officer, Sindhupalchok Donors: DFiD Dr Jenny Amery Senior Regional Health Adviser for Asia Susan Clapham ECHO Peter Burgess Head of Office, Regional Support Office Dominique Feron Technical Assistant World Bank Sundararajan Gopalan Senior Health, Nutrition and Population

specialist NGOs: CORE Group Pradeep Adhikari Coordinator, Polio Eradication Initiative MSF-France Dr Duncan McLean Head of Mission Dr Christina Medical Coordinator MSF-Holland Mr Kostas Dombros Country Director United Mission to

Nepal Dr Beverly Booth

Dr Maureen Gariang

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6.2 Annex 2: Proposed algorithm to detect and monitor crises in Nepal

When detecting and responding to crises, sensitivity (i.e. the ability to recognise and assist communities truly in need) should be privileged over specificity (i.e. the ability to properly recognise communities that do not require humanitarian assistance): expressed bluntly, sensitivity saves lives, while specificity ‘only’ saves money. EHA and other humanitarian stakeholders should accept a priori that, on occasion, superfluous assistance will be provided to communities that are able to cope adequately without external support – all the more so given the confusing Nepali context. The following proposed algorithm of data collection phases, meant as a tentative proposal, intentionally contains a mix of quantitative and qualitative indicators, as it is recognised that hard data may not always be available at the alert stage. The algorithm is meant to ensure that (i) only credible alerts are followed up on by rapid health assessments, and that (ii) only emergencies of a significant magnitude or duration lead to further data collection efforts, thus economising resources. As discussed above, sensitivity is privileged over specificity among the criteria for moving to a more in-depth exercise of data collection, so as to minimise the risk that true emergencies will be overlooked. As shown in Figure 4 and Table 2, alert information must be collected on a ongoing basis, mostly on an informal and qualitative basis (this, however, requires building an effective network of key informants, for which regular disaster or health and nutrition emergency working group meetings can provide a platform).

Figure 4. Proposed algorithm for health crisis detection and monitoring in Nepal.

If the alerts received meet one or more of a given set of criteria of gravity (Table 3), a decision is taken to move to the rapid health assessment phase, which should take place as soon as possible and ideally within one week of the alert (Table 2), must feature a standardised rapid assessment tool, and may include other

Criteria to justify rapid

health assessment?

Alert information

Rapid health assessment

Crisis monitoring

Criteria to justify formal

health assessment?

Criteria to justify crisis monitoring?

stop

YES

NO

Formal health assessment

stop

stop

YES

YES NO

NO

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brief data collection exercises depending on the reported nature of the crisis. Rapid assessment findings must be disseminated immediately after collection. Based on other sets of criteria, one may move to a more formal set of health assessments (meaning well-planned and based on statistically sound survey methods). Findings of formal health assessments must however also be released very rapidly (within 1-2 weeks of data collection) if they are to have any bearing on field operations. Crisis monitoring activities would be initiated as soon as possible after a rapid assessment if this suggests a long-duration crisis, with a risk of disease outbreaks. Alternatively, they could be initiated after the results of more formal assessment reveal such conditions, assuming that the rapid health assessment didn’t. Table 2. Phases of data collection and corresponding types of data collection exercises.

Phase of data collection (timing)

Possible types of data collection exercise needed

Alert information (ongoing)

Routine contact with UN OCHA, NGOs, local agencies, ECDC, Red Cross Media monitoring

Rapid health assessment

Standard rapid health assessment exercise (always)

(within 1 week of alert)

Rapid malnutrition screening

Interviews with key community informants

Preliminary outbreak investigation Formal health assessment

Health service availability mapping exercise

(within 2-3 weeks of alert)

Retrospective mortality survey (not useful if excess deaths occurred within the scope of a few days, as in an earthquake)

Nutritional (anthropometric) and vaccination coverage survey (can be coupled with mortality survey)

Health access/coverage survey (can be coupled with other surveys) Formal outbreak investigation (as per RRT/ECDC/IPD guidelines) Crisis monitoring

Reinforced or ad hoc disease surveillance system, with active case finding if needed

(to start within 1-2 weeks of alert)

Community mortality surveillance system, with regular census of affected population figures

Repeat mortality and/or nutrition surveys

Note that this proposed system is in no way meant to replace existing RRT guidelines, which should be adhered to and encouraged. Rather, it is meant to guide WHO-EHA and other agencies with a humanitarian mandate to systematise and better target their data collection activities. A presentation of survey and surveillance methods for emergencies is beyond the scope of this proposal, but an excellent review is provided by Pavignani and Colombo (see http://www.who.int/hac/techguidance/tools/disrupted_sectors/en/index.html). Generally, specialist epidemiological support is required for most survey and surveillance-related work, other than rapid assessments.

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Table 3. Tentative list of criteria for deciding when to proceed to further data collection in the context of a given crisis (suspected or demonstrated).

Carry out ongoing surveillance for alert information

Proceed to a rapid health assessment if, based on available alert information, one or more of the following criteria is met: Conflict-related complex emergency alerts: Natural disaster alerts: Very significant battle taking place within a

village or town, with casualties reported Major destruction of housing and infrastructure

reported Low-level clashes for >1 month in the district Disruption to water sources as a result of

flooding reported

>200 households or >1000 people reported to have temporarily or permanently had to leave their home

>200 households or >1000 people reported to have temporarily or permanently had to leave their home

Drug, supply, staffing or bed capacity shortages reported by health facilities responding to the disaster

The disaster has resulted in the destruction of health facilities

NGO or local agency report of a conflict-related health crisis, which might include: (i) rise in malnutrition cases; (ii) major drug shortages or service interruptions in surrounding health facilities; (iii) isolation of communities and denial of patients’ access to health facilities as a result of fighting or combatant policy; (iv) an unusual rise in diarrhoea or febrile illness cases An unusual rise in diarrhoea or febrile illness

cases, provided this is reported >1 week after the onset of the disaster

Proceed to a formal health assessment if, based on the rapid health assessment, one or more of the following criteria is met: >1000 households or >5000 people are affected by the crisis Mortality rate appears elevated (>twice the assumed baseline country-wide of 0.27 per 10 000 per

day), or there are credible reports from NGOs or village heads about unusually elevated mortality among adults or children

Rapid nutritional screening (ex. by MUAC) suggests an alarming situation (>10% of children have a MUAC<125 mm), or a large number of severe malnutrition cases are noted in the community

The rapid health assessment suggests a very serious problem with access to health care among the affected population

The crisis will probably last for at least two more months (i.e. people are not likely to return to their homes; food shortages or crop failures are continuing; conflict is ongoing; etc.)

Initiate crisis monitoring if, based on rapid and/or formal health assessments, one or more of the following criteria is met: The crisis will probably last for at least two more months (i.e. people are not likely to return to their

homes; food shortages or crop failures are continuing; conflict is ongoing; etc.) Mortality rate or acute malnutrition prevalence exceed emergency thresholds (respectively, >double

the baseline mortality rate, and >15% Global Acute Malnutrition prevalence or >5% Severe Acute Malnutrition Prevalence)

The natural disaster has resulted in potential contamination of water supplies, disruption of the usual sanitation standards, overcrowding in shelters, or environmental changes (such a the creation of stagnant water pools) that may favour vector breeding