WHO Health brief on Southern Africa-August 2002
World Health Organization
Health Brief on
Southern Africa Humanitarian Crisis
August 2002
Department of Emergency and Humanitarian Action
WHO Health brief on Southern Africa-July 2002
TABLE OF CONTENT
1- Southern Africa: Health dimension of the humanitarian crisis…………... 3
2- Regional activities……………………………………………………….. 7
3- Financial overview of the Country Appeals……………………………… 8
4- Extracts from Country specific appeals: Health situation analysis and WHO
projects for:
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Swaziland…………………………………………………………
Lesotho…………………………………………………………….
Malawi…………………………………………………………….
Zimbabwe………………………………………………………….
Zambia……………………………………………………………..
Mozambique……………………………………………………….
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10
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33
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WHO Health brief on Southern Africa-July 2002
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1- SOUTHERN AFRICA: HEALTH DIMENSION OF THE
HUMANITARIAN CRISIS
Background
The countries of Southern Africa, mainly Malawi, Zambia, Lesotho, Zimbabwe,
Swaziland and Mozambique are currently facing an acute and large-scale humanitarian
crisis. Drought, floods, economic degradation, increased poverty and political instability
in Zimbabwe combined with a large burden of communicable diseases and outbreaks,
faltering health systems, malnutrition and the highest HIV/AIDS loads in Africa, have led
to increased mortality and wide suffering among at least 10 million people.
Unusually dry conditions together with erratic rainfalls (sometimes flooding) have led to
crop failures and limited production, which combined with poor policies for ensuring
adequate stocks, resulted in serious food shortages. Governments in Malawi, Lesotho,
Zimbabwe and Zambia have declared national disasters. WFP and FAO estimate that the
needs will rise more after the harvests of July and August. Adding to the food shortage,
the decreasing government budgets to health, the shortage of drugs, the epidemics of
cholera (the worst in Malawi for this year with more than 30,000 cases and 900 deaths),
the high burden of malaria, malnutrition, diarrheal diseases and respiratory infections,
and with the majority of the population (estimated at 70% in general) living with less
than a dollar per day, all these make the ingredients for complicated humanitarian
situation.
The past history of drought and famine in the regions especially looking back at the
1992-1993 and the 1995-1996 droughts, reminds us that these are recurring problems,
that have deep rooted causes ranging from poverty and cutting across land management
and governance issues. The humanitarian community usually responds quickly to such
emergencies and has in the past averted many humanitarian crises. However the adequate
management of these crises cannot be averted by addressing the food situation alone. As
mentioned in a WFP information paper to its executive board in February 2002,
" In many of the large scale life threatening natural disasters…. , it was lack of water, poor
sanitation and the risk of epidemics that correspondents highlighted in early dispatches… The
nutritional impact of food aid is significantly reduced when other root causes of malnutrition are
not addressed, such as inadequate health care and practices, lack of education and poor
sanitation and water supplies".
Goal:
In the countries mostly affected by the current humanitarian crisis, WHO will work with
the Ministries of Health (MOH) and the partners from the health sectors and from the
other sectors, to reduce the avoidable loss of life and the burden of disease in this crisis.
To achieve this, WHO through its country offices and the regional inter-country team in
Harare will at the regional level and specifically in the countries mostly affected, will
work on ensuring a Public Health approach for optimal and immediate impact.
Assessment:
The assessments undertaken by WHO and partners in Malawi and Zimbabwe, the hardest
hit countries, demonstrated that the crisis is a humanitarian one not just a food shortage
issue. People are dying, and not in the health facilities but in their homes (community
survey in Malawi revealed a Crude Mortality Rate CMR, of 1.9/10,000). The assessment
in Malawi showed that while the number of deliveries at health facilities have decreased
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WHO Health brief on Southern Africa-July 2002
by 7% as a symptom of the deterioration in economic accessibility, maternal mortality
rates recorded in these health facilities increased by 71%, due to malnutrition and poor
health status, lack of prenatal care and the weak capacity of the health system. Lack of
food weakens the population, their immune system, already challenged by endemic
diseases, cannot fight infections. This is reflected, in Malawi, by the severity of the
cholera epidemic and the increased number of deaths encountered.
The economic degradation, that results from crop failures leads to further weakening of
the purchasing power. The number of meals are decreased, the quality of the food eaten
becomes questionable. With the lack of water, poor hygienic conditions and sanitation
problems abound, setting the stage for diarrheal and other diseases. More so, in health
facilities, there are no medicines, and also no food, patients if they can reach a health
facility are not admitted, and they go home and die. In Zimbabwe, mortality rates in the
assessed districts have increased over the past year among the top ten priority diseases,
while outpatient attendance has been going down.
The HIV/AIDS pandemic, which has affected the Southern African countries (for
instance Malawi has sero-prevalence rates as high as 15% and Zimbabwe as high as
34%) has further complicated the situation with its resulting impact on households, and
on productivity. This has led to a vicious circle where malnutrition and disease take the
centre stage and where the food shortage, poverty, the drug shortage and the weak
surveillance system are the driving forces.
Source: UNAIDS Epidemiological Fact sheets 2002
The strategy to respond to the situation in the Southern Africa region should incorporate
an integrated approach for response. People are either dying or are sick and suffer from
malnutrition. Reports from surveys conducted from Save the Children UK and UNICEF
in Malawi report very high incidences of severe malnutrition on exacerbated by a
situation of chronic malnutrition. Besides ensuring food or any other form of
assistance(rations, food for work, etc.), there is a need to prevent further deaths, follow
up on the diseases and outbreaks, and address the health problems of the most vulnerable
(young children, pregnant women and mothers, aged persons). WHO will ensure that the
quality and the contents of the food basket are according to standards, especially for
essential micronutrients. Addressing malnutrition requires an integrated approach to
household food security, health and care." Meeting food needs in these situations is
essential, but also important is protecting people from illness and ensuring that young
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WHO Health brief on Southern Africa-July 2002
children and other vulnerable groups receive good care." (The silent emergency, The
State of the World's Children 1998- UNICEF).
Strategy:
WHO's strategy is a two- pronged:


Build on a regional team that is based in Harare as part of an inter-country support
team to support activities in Zimbabwe and in the region and
Focus intensively on Malawi, which is the hardest hit among the countries of the
region.
As a first step, WHO will recruit 2 epidemiologists and 2 nutritionist to reinforce and
ensure the quality of surveillance as well as increase capacity through training.
WHO will also increase its advocacy efforts to ensure that the donors give adequate
attention and support to the need to invest and support agencies involved in providing
health services and interventions.
WHO is coordinating with UNICEF both at regional and at country level regarding the
delivery of the key Survival components of the appeal, especially health and nutrition
issues (the support needed to nutrition and disease surveillance, monitoring the nutrition
situation and assessing impact and progress of interventions, and water sanitation
interventions, information sharing and dissemination).
Approach:
1. Strengthen the capacity of WHO to support the Ministries of Health (MOH) and
health concerned partners to identify priority health and nutrition related issues and to
ensure that they are properly addressed in an integrated primary health care approach
that preserves and strengthens the local system.
2. Strengthen health and nutrition surveillance systems (including HIV/AIDS
surveillance) to enable monitoring of any changes, early warning of deterioration and
immediate life-saving approach through outbreak response and technically sound
nutrition interventions.
3. Advocate for the delivery of basic preventive and curative care including essential
drugs and vaccines for all, giving priority to the most vulnerable areas
4. Ensure that the lessons learnt in a crisis are used to improve the health sector
preparedness for future crises and disaster reduction.
Activities
For this, WHO will be starting in Malawi and in Zimbabwe, and then extending after
assessment of needs in the other countries with the following:
1. Recruitment of an epidemiologist to strengthen the Country office and support MOH
and partners in surveillance, training and building capacity as well as early warning
for epidemics, including HIV/AIDS
2. Recruitement of a nutritionist to support the Country office, the MOH and partners in
assessing the problem of malnutrition and devising adequate programs to respond to
the needs.
3. Ensure a stock of essential drugs and supplies for responding to outbreaks and also
supplies for safe blood transfusion (HIV/AIDS screening)
4. Strengthen and support Reproductive health programs and Integrated management of
childhood illnesses (IMCI), which would ensure that diarrheal diseases and Acute
respiratory infections, the main causes of infant morbidity and mortality are
addressed.
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WHO Health brief on Southern Africa-July 2002
The team in Zimbabwe will support the region for epidemiological surveillance and
nutrition issues.
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WHO Health brief on Southern Africa-July 2002
2- REGIONAL ACTIVITIES
WHO is planning to reinforce the inter-country team in Harare in order to support the
concerned countries in the Southern African humanitarian crisis for the following :
- epidemiological surveillance, outbreak response and Nutrition surveillance through
the collection, analysis, compilation and dissemination of sub-regional
epidemiological Health situation
- liaising with the regional information management in Johannesburg and providing
a regional picture
- ensuring that complementary approaches between the countries and cross-border
activities are coordinated (including surveillance)
- monitor Crude Mortality Rates (CMR) and one or two major indicators for
Nutrition.(MUAC)
- providing surge and field technical support if needed especially that with the start
of the rainy season in November and December, all the ingredients are there for a
cholera outbreak.
For these activities WHO will adopt an integrated approach by using the regular budget
and the external funds for reducing mortality, morbidity due to humanitarian situation
and within a sub-regional framework support the country offices as needed ensuring the
link to development. WHO actions will strive to be sustainable and implemented with
local human resources.
WHO inter-country team in Harare will support the ongoing collection of information
related to epidemic prone diseases and will support any necessary response. WHO and
UNICEF will collaborate to ensure ongoing nutritional surveillance in order to monitor
the impact and progress of relief assistance.
OCHA is proposing the creation of the Southern Africa Humanitarian Information
Management Service (SAHIMS), an inter-agency information and data clearing house, be
established within the Regional Support Office (RSO). SAHIMS will liase with and
support existing information systems such as FEWS and those of SADC and other
technical bodies in the region. UNICEF and WHO will support this facility in order to
achieve a more coherent approach to information management and advocacy in their
areas of expertise, particularly in the area of nutrition surveillance and health information
dissemination.
Summary Table of Funding Requirements for Regional Activities:
Sector/Activity
Coordination
Drugs and
vaccines
Information
Management
Assessments
Total
OCHA
550,000
WFP
3,445,153
UNDP
180,000
WHO
300,000
UNICEF
500,000
Total
4,975,153
1,000,000
1,000,000
430,000
100,000
530,000
980,000
250,000
1,650,000
250,000
6,755,153
3,445,153
180,000
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500,000
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WHO Health brief on Southern Africa-July 2002
3- FINANCIAL OVERVIEW OF THE COUNTRY APPEALS
Country - Swaziland
Population at risk
Total Appeal Figure
Health, nutrition & Watsan
WHO Appeal
144,000
US$ 19,028,760
US$ 2,339,939
US$ 543,939
WHO Projects:
 Preparedness and response to cholera
Country - Lesotho
Population at risk
Total Appeal Figure
Health,nutrition & Watsan
WHO Appeal
500,000
US$ 41,033,465
US$ 4,072,000
US$ 1,272,000
WHO Projects:
 Control of malnutrition and related diseases in under fives US$ 816,200
 Provision of safe water and proper sanitation US$ 455,800
Country - Malawi
Population at risk
Total Appeal Figure
Health, nutrition & Watsan
WHO Appeal
3.2 millions
US$ 144,341,111
US$ 6,037,243
US$ 2,931,143
WHO Projects:
 To reduce malnutrition US$ 206,700
 Strengthening disease surveillance US$ 635,152
 Strengthening of cholera epidemic response US$ 605,366
 Reproductive health services US$ 442,263
 Improving response to disease outbreaks US$ 691,862
 Health coordination US$ 349,800
Country - Zimbabwe
Population at risk
Total Appeal Figure
Health, nutrition & Watsan
WHO Appeal
*
3 millions
US$ 285,112,870
US$ 27,499,625
US$ 13,208,395*
Two UNICEF/WHO joint projects adding up to US$ 2,968,000 where separate budgets not available
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WHO Health brief on Southern Africa-July 2002
WHO Projects:
 Building health sector partnerships US$ 378,420
 Disease surveillance US$ 593,600
 Strengthening health service delivery US$ 21,200
 Procurement of drugs and supplies US$ 7,763 ,175
 Cholera epidemic response US$ 1,113,000 (UNICEF/WHO joint project)
 Malaria epidemic response US$ 1,855,000 (UNICEF/WHO joint project)
 Reducing maternal mortality US$ 1,484,000
Country - Zambia
Population at risk
Total Appeal Figure
Health, nutrition & Watsan
WHO Appeal
2 millions including 400,000 children and 440,000
women
US$ 71,396,209
US$ 5,200,000
US$ 1,805,000
WHO Projects:
 Disease surveillance prevention and control
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WHO Health brief on Southern Africa-July 2002
4- EXTRACTS FROM COUNTRY SPECIFIC APPEALS: HEALTH
SITUATION ANALYSIS AND WHO PROJECTS
Swaziland
Priorities
In this appeal, the most vulnerable and/or socially marginalized groups will be targeted.
This population usually bear much of the disease burden in harsh conditions such as
those associated with food shortages. They include people with less access to safe water
and proper sanitation, pregnant women, children under five years of age, and people
living with HIV/AIDS. In this context, priority interventions are: diarrheal diseases
(cholera) / water and sanitation, reproductive health, EPI, and HIV/AIDS.
Objectives
To reduce the number of avoidable deaths and the suffering among the affected
population through:
 Cholera prevention and control
 To empower people at risk for cholera to prevent and manage infection with
vibrio cholerae.
 To assess water quality in affected districts and ensure provision of safe water
 To increase health facilities’ capacity to quickly detect and respond to cholera
epidemics.
 Integrated Management of Childhood Illnesses
 To strengthen the capacity of health services to reach the most vulnerable
communities with information and basic medicines for management of childhood
diarrhea, ARI, malaria, and skin diseases.
 Reproductive health
 To alleviate the negative impact of the food crisis on reproductive health
Analysis of need
According to the 1999 Health Statistics Report, the top four major causes of outpatient
consultations were respiratory diseases, skin disorders, diarrheal diseases, and genital
disorders. The five top major causes of inpatient mortality in the same year were
pulmonary tuberculosis, diarrheal diseases, AIDS, pneumonia, and malaria. These data
indicate that diarrheal diseases are amongst the most common causes of morbidity and
mortality in Swaziland. Before 2000, cholera epidemics occur every 10 years but now
cholera has become more frequent and its severity has increased. When people are
desperate for food, hygiene practices and preventive measures against food and waterborne diseases, such as cholera, are no longer a priority. Since 2000, the health sector has
struggled to establish a functional disease surveillance for early detection of cholera
epidemics and timely action. Health facilities in mostly affected areas are not well
prepared for rapid response to cholera epidemics and coordination mechanisms for
cholera prevention and control are not functioning.
The economic stress on families due to food shortages also affects families abilities to
access health services. Even though fees for primary health care services have recently
been lifted, the costs of transport and time to access services in the health facilities
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WHO Health brief on Southern Africa-July 2002
remain too high for those most affected by the emergency, at the very time when
nutritional stress increases the vulnerability especially of young children. Emergency
support will seek to enhance the outreach capacity of the health services for delivery of
immunization services, and to provide supervision for the initiation of growth monitoring
and enhanced care by community volunteers, targeting especially the orphans and
vulnerable children.
Statistics demonstrate that in times of crisis, reproductive health problems also increase.
Normal social patterns are disrupted, there is an increase in sexual violence, promiscuity,
and risky behaviors all of which lead to an increase of STI/ HIV transmission. Family
planning activities are threatened.
Operational Objectives
 Provide anti-cholera kits (including water jugs, disinfectants, chloramines, oral
rehydration salts) to 60 communities with limited access to safe water and proper
sanitation in drought-stricken areas between July and December 2002.
 Provide 15 peripheral health facilities around drought stricken areas with
emergency health kits between July and December 2002.
 Assist Regional Health Management Teams (RHMT) to develop regional cholera
epidemic preparedness and response (EPR) plans between July and August 2002.
 Train health staff on basic epidemiology and disease surveillance between July
2002 and August 2002.
 Reduce the likelihood of cross-infection of communicable diseases through
provision of protective equipment to community health care workers.
 Provide support for community outreach and supervision visits by health workers,
and training and equipment for community cadres to carry out growth monitoring
activities for children under five years.
 Increase access to reproductive services through training and upgrading voluntary
counseling and testing.
 Reduce maternal mortality by providing emergency reproductive health kits for
clinics.
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WHO Health brief on Southern Africa-July 2002
Swaziland-Project
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted beneficiaries
Implementing partners
Project duration
Funds requested
World Health Organization
Preparedness and Response to Cholera
SWA-02/H01
Health
Preparedness and contingency planning.
Information management.
Prevent cholera and prepare adequate
response to cholera epidemic in droughtstricken areas between July and December
2002
60 communities and 15 health facilities
around drought-stricken areas
WHO, MOH, NGOs, CBOs
July 2002-June 2003
US$ 543,939
Summary
In recent years, cholera has become endemic in most areas which are currently affected
by the food crisis. Decreased access to water and mainly safe water, together with the
weak health system at the rural level, coupled with severe economic constraints and the
food shortage contributed to exacerbation and frequent recurrence of epidemics of
diarrheal diseases and mainly cholera. The situation is likely to worsen if preventive
measures are not put in place and if the health system’s capacity to detect and respond to
cholera epidemics is not strengthened. This project contributes to the overall CAP
strategy to alleviate the suffering of those affected and to increase the capacity of the
health system for ensuring that the affected population receive proper public health
services, with preventive and curative activities. It aims also at monitoring the health
situation, documenting the impact of the food shortage and collecting information needed
to detect epidemics and respond to them in a timely and appropriate manner.
Project strategy & complementarity
WHO proposes to assist drought-stricken communities in a two pronged approach:
Supporting and empowering the communities to prevent infection with vibrio cholerae
and strengthening the health system’s capacity to plan and prepare for an adequate
response to cholera epidemics. The need exists to strengthen the outreach capacity of the
health services through the training and use of community volunteers to deliver care
when needed, monitor situation, identify epidemic prone diseases, monitor growth and
disseminate health education messages. The health workers in the affected peripheral
health services will receive appropriate training and will develop cholera epidemic
preparedness and response plans. This intervention will build on the previous activities
already undertaken when the first cholera outbreak was declared in 2001, and when UN
agencies, EU, Italian Cooperation, Chinese Embassy assisted the Ministry of Health and
Social Welfare to mitigate the impact of the outbreak. WHO has continued to provide
technical and financial support to the Ministry of Health and Social Welfare, UNICEF is
supporting training on participatory methods (PHAST), EU is running a water and
sanitation project in one of the most affected areas. Additional assistance in water and
sanitation is being provided by DFID and Japanese Cooperation.
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WHO Health brief on Southern Africa-July 2002
Main activities
 Mobilise human resources for coordinating emergency health activities and
ensuring follow-up
 Assess water quality in most affected districts
 Provide anti-cholera kits to 60 communities in drought-stricken areas
 Provide emergency health kits to 15 health facilities around drought-stricken
areas.
 Develop cholera epidemic preparedness and response (EPR) plans
 Train 20 health staff on basic epidemiology and disease surveillance
Major outputs
 Emergency health coordinator posted
 Water quality assessed in the affected districts
 60 communities provided with anti-cholera kits
 15 peripheral health facilities provided with emergency health kits
 Cholera EPR plans available in Lubombo and Shiselweni regions
 20 health staff trained on data management, analysis, and reporting
FINANCIAL SUMMARY
BUDGET ITEMS
Human resources for coordination, training and water testing
Water testing , purification supplies and equipment
Anti-cholera kits
Identification of households, distribution and training on anti-cholera
kits
Emergency health kits
Training and distribution
Training of Regional Health Motivators to develop cholera plans
Training health staff in drought areas
Monitoring, reporting and visibility
Project support cost (6%)
TOTAL
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US$
120,000
30,000
180,000
6,500
125,000
2,000
1,000
2,000
46,650
30,789
543,939
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WHO Health brief on Southern Africa-July 2002
Lesotho
Analysis of need
The health status of Basotho, especially of women and children has declined
significantly in the last decade. The combination of the increased levels of poverty,
the declining access to quality health services and the impact of HIV/AIDS have
adversely affected the health and nutrition situation of traditionally the most
vulnerably population groups, women and children. The rates for infant and child
mortality have not improved substantially, and the maternal mortality rate has never
been so high with 738/100,000 (1997), with the 15-19 years olds and women above
35 years of age groups at highest risk, although this data was collected in 3 districts
only.
The major cause of child mortality and morbidity are still vaccine preventable diseases,
diarrhea, acute respiratory infections and malnutrition. Micronutrient deficiencies are still
prevalent. With lack of green leafy vegetables in the diet and the low vitamin A
supplementation coverage of 17 per cent (EMICS, 2002) vitamin A deficiency is
estimated to still be a public health problem. Although, substantial gains have been made
in the battle against iodine deficiency disorders, with 69 per cent of household using
adequately iodised salt (EMICS, 2002), the challenge is to remain at this level, in the
present situation that households have no money to buy iodised salt. The 1996 Multiple
Cluster Indicator Survey reports that 67 per cent of children under the age of 1 year were
fully immunized, which is a decline compared to the 1993 coverage of 71 per cent. As of
end 2001 the overall routine immunisation coverage was 62.4 per cent. The fundamental
underlying cause for the decline in health and nutrition status, especially of women and
children, is the increased poverty.
The major problems encountered by the health system are the persistent shortages of
staff, poor incentives for community health workers, equipment shortages, as well as
shortages of drug supplies. These problems have undermined the sustainability and
quality of health service delivery and the capacity of the health system to respond to the
current emergency. Health workers are also demoralised and/or highly de-motivated
because of the problems and especially the community health workers because they work
on a voluntary basis. The impact of HIV/AIDS will further exacerbate the situation,
particularly with increased demand for services. An additional problem, which heavily
affects the implementation of the projects and programmes within the health system, is
availability of quality routine data on childhood illness, malnutrition, and immunization.
The present emergency situation has increased need of the population, especially
women and children for access to and quality health services. However, the health
system is not able to cope with this increased need, and is already having problems to
cope with the increase number and care for HIV/AIDS related cases. The situation
calls for immediate measures to ensure that the health and nutrition status children and
pregnant and lactating women is not deteriorating any further to avoid the need for
facility-based care. As part of the emergency relief operation there is a need for an
integrated approach to provide essential basic health and nutrition services to the most
vulnerable at community level, in combination with a health and nutrition surveillance
system to adequately and timely respond on changing situations.
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WHO Health brief on Southern Africa-July 2002
Objective
Provision of essential quality basic health and nutrition services to children under five
and pregnant and lactating women with appropriate and timely monitoring and
evaluation in order to adequately respond on emerging issues.
Proposed action
 Accelerate an integrated approach to provide the basic nutrition and health
services to children under five at community level, including the supplementary
food, immunization, growth-promotion, early identification and referral, and
follow-up after hospitalisation, through ECD centres, NGO’s and faith-based
organizations.
 Strengthen the capacity and skills of the ante-natal care programmes to assess the
nutritional status of pregnant women, identify women at risks and provide early
referral, at community level.
 Support the provision of therapeutic feeding and essential drugs to the most
vulnerable groups and implement the Integrated Management of Childhood Illness
(IMCI) concept to improve early recognition and effective case management of the
major childhood illnesses.
 Strengthen the skills and capacity of the health workers, the NGO’s, Peace Corps
and Community-based organizations to implement an effective nutrition and health
surveillance system.
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WHO Health brief on Southern Africa-July 2002
LESOTHO-PROJECT 1
Appealing Agency
Project Title
Project Code
Sector
Theme
Objective
Targeted
beneficiaries
Implementing
partners
Project Duration
Funds requested
World Health Organization
Control of malnutrition and related diseases in children under 5
LES-02/H01
Health and Nutrition
Control of malnutrition and related diseases
1. To control malnutrition among children under-five through
training of health workers including community health workers
and initiation of nutrition surveillance system by December
2002
2. To control communicable diseases including diarrhoeal
diseases, TB and ARI
3. To strengthen the capacity of the MOHSW to provide
coordinated emergency response in affected areas.
4. To provide community based nutrition education through
PHAST
5. To reduce morbidity and mortality due to malnutrition and
related infections among children under five
20,000 children under five in the affected areas
NGOs, Ministry of Health and Social Welfare, UNICEF,
Ireland Aid, WHO
June 2002 – June 2003
US$ 816,200
Summary
The situation analysis of the MOHSW and WHO conducted concurrently with the
Inter-agency assessment due to the current food crisis revealed that there is high
prevalence of malnutrition among children below the age of five years. A high
prevalence of diseases such as: respiratory infections, diarrhoeal diseases, skin
infections, ear infections and intestinal parasites have also been identified. Despite
this revelation it is clear that there are weakness in data collection, analysis, utilization
and record keeping by the health facilities. The capacity to report to the next level
and to utilize the data is weakened by lack of communication facilities such as faxes,
e-mails etc. and lack of appropriate training. These limitations affect timely transfer
of information to the next level. In view of these finding, the project aims to initiate
disease and nutrition surveillance system, which also strengthens the early warning
system of the Disaster Management Authority (DMA).
Activities
 Train health personnel in integrated disease surveillance, this will encompass
nutrition, Disease Surveillance, care and management of malnourished children
under five years of age, IMCI, record keeping, development of immediate
emergency response strategies.
 To strengthen the capacity of health facilities by provision of human resources in the
form of consultants, engagement of more nurses to complement the low staffing
situation.
 To procure and distribute communication equipment to strengthen the early warning
system at district level or (HSAs) for timely detection and reporting.
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WHO Health brief on Southern Africa-July 2002


Procurement and distribution of IEC materials (including HIV/AIDS).
Community education sessions applying PHAST approach.
FINANCIAL SUMMARY
Basic health equipment and essential drugs
Provision of technical assistance (short term consultancy of 3
work months and long term technical assistance of 12 work
months)
Training in rapid detection and management of diseases
Procurement and distribution of IEC materials
Training in IDS including nutrition surveillance, IMCI, record
keeping and response strategies
Integrate health and nutrition issues into the SADC Early Warning
System
Programme Support Cost 6%
TOTAL
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Requirements
(US$)
250,000
100,000
50,000
20,000
250,000
100,000
46,200
816,200
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WHO Health brief on Southern Africa-July 2002
LESOTHO-PROJECT 2
Appealing Agency
Project Title
Project Code
Sector
Theme
Objective
Targeted
beneficiaries
Implementing
partners
Project Duration
Funds requested
World Health Organization
Provision of safe water and proper sanitation
LES-02/WS01
Water and Sanitation
Water supply, sanitation
1. To provide safe water supply to 30% of rural communities
2. To provide sanitary facilities for 20% of rural communities
during the disaster period up to July 2003
4,000 households and 40 schools for sanitary facilities
2,000 households and 20 schools for water supply
Ministry of Health and Social Welfare, Local Government,
Natural Resources, NGOs, and UN Agencies
June 2002 – June 2003
US$ 455,800
Summary
Interagency assessment of water and sanitation in May 2002 in four districts revealed
that some communities use unprotected water sources. The national coverage for safe
water supply is 77.1 per cent (89.5 per cent and 74.1 per cent in urban and rural areas
respectively) while that for sanitation is 53.6 per cent (88 per cent and 45.1 per cent
for urban and rural areas respectively). The remaining proportion (32.9 per cent for
safe water and 46.4 per cent for sanitation) is at risk of outbreaks of water and
sanitation related disease, which are already being experienced in districts like
Mohale’s Hoek, Quthing, Berea, Mafeteng and Thaba Tseka. There is, therefore,
need for urgent assistance to provide potable water supply and proper sanitary
facilities to this population including schools in the affected areas. Partners
participating in water supply are Ministries of Natural Resource (Dept of Rural Water
Supply, WASA, Dept. of Water Affairs) Health and Social Welfare (water quality
surveillance), Ireland Aid, NGOs. The different partners are coordinated through the
Steering Committee for Water and Sanitation based in the Ministry of Development
Planning.
Activities
 Protection of water sources
 Distribution of safe water by tankers to villages and schools
 Purification of water from unprotected sources
 Application of Participatory Hygiene and Sanitation Transformation (PHAST)
methodologies at community level
 Intensify water quality surveillance
 Procurement of construction materials
 Training of extension workers and communities in water quality surveillance and
protection of water supply sources
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WHO Health brief on Southern Africa-July 2002
FINANCIAL SUMMARY
Activity
Provide water purification chemicals and
Laboratory supplies and reagents
Logistical support and distribution of water
Training of extension workers and
communities in PHAST methodologies
Recruitment of a Public Health Coordinator
for 12 months
Water and Sanitation construction materials
(VIP latrines and water protection)
Programme Support Cost 6%
Total
- -
Requirements (US$)
50,000
80,000
100,000
100,000
100,000
25,800
455,800
19
WHO Health brief on Southern Africa-July 2002
Malawi
The Nutritional, Health and Other Dimensions of the Crisis
The nutritional situation for children under five is extremely precarious. The
Demographic and Health Survey of 2000 reflects a chronic malnutrition rate of 49% and
a global1 acute (both moderate and severe) malnutrition rate of approximately 7%,
excluding children with oedema, percentage which could rise in some instances to 12%.
Based on these rates, it is estimated that approximately 86,000 children are at risk for
global acute malnutrition and will need supplementary feeding, while 22,000 children
under five will require life-saving interventions (therapeutic feeding) to redress their
health status due to severe acute malnutrition.
During 2002, a number of NGOs carried out several nutritional surveys in some of the
worst affected areas of the country. In January, SCF-UK carried out a survey in Salima. It
reported a global malnutrition rate of 6.6% and a severe malnutrition rate of 1.9%. The
survey was repeated in March 2002, illustrating an alarming increase in global
malnutrition of 19% and severe malnutrition of 6.6%. In Mchinji, SCF-UK noted a
similar increase. During the same period, the global malnutrition rate rose from 10.2% in
January to 17.5% in March 2002, while acute malnutrition rate rose from 1.9% to 6%
respectively. In another survey in Mulanje and Thyolo, Oxfam found malnutrition rates
of 3.4% and 5.1% respectively.
Following the various assessments of the food security situation, and taking into account
seasonal variations, it is likely that at the peak of the predicted "hungry season"
(December 2002 to April 2003), the rate of severe acute malnutrition will increase from
1.2 to 3%. This implies that 54,000 children will be in severe distress, and in need of
therapeutic feeding.
The severity of the 2001/2002 food security crisis was first widely reported when its
impact began to be evident in terms of severe malnutrition (and even anecdotal reports of
deaths in some instances). Apart from this, there were signals that the cholera outbreak
during the reference period was more pervasive, and had greater case fatality ratios, than
in previous years.
Given these reports, as part of the UNCT's response to the Government's appeal for
assistance, it was decided to conduct sectoral and thematic assessments of the non-food
dimensions of the crisis. This sub-section summarizes the findings of these thematic
assessments, which formed the basis for the subsequent design of the non-food
components of this Consolidated Appeal Response (CAR).
The assessments carried out by WHO covered the 10 most affected districts. From the
survey responses covering the period October 2001 to March 2002, the assessment
estimated a crude mortality rate (CMR) of 1.9 per 10,000 population per day. Daily CMR
is one of the best indicators of the existence of a humanitarian crisis. A CMR value
greater than 1.0 indicates that a humanitarian crisis exists. The assessment concluded that
this rather high CMR could be explained by a combination of factors. These are: severe
malnutrition, compounded (in some cases) by the pre-existence of HIV/AIDS, as well as
a documented outbreak of cholera (which hit 26 of the 27 districts).
1
Global acute malnutrition relates to children who are between 75-85% of their weight-for-height.
- -
20
WHO Health brief on Southern Africa-July 2002
The assessment concluded that there was an acute shortage of staff and basic equipment
in most health facilities; maternal mortality in most health care centers rose significantly
during the reference period; and, the existing epidemiological surveillance system was
incapable of providing timely information to national and international stakeholders
regarding epidemics, disease burden and mortality. Box 2 summarizes how health
interventions in emergencies differ from regular programmes under normal situations.
WHO, in close collaboration with UNICEF, WFP and UNFPA, is proposing
complementary interventions on: epidemiological surveillance, disease control, health
coordination, reproductive health, nutrition and cholera control.
The objectives of these projects are to:
1) Strengthen the affected districts' emergency response capacities by training health
personnel, NGOs involved in health and other relevant health related actors as
well as provide basic equipment and drug (WHO emergency kits). Cholera
epidemic control and maternal mortality will be tackled in particular projects.
These projects will have a direct impact on reducing mortality and morbidity.
2) Build/strengthen a coordination mechanism among health partners/actors in order
to harmonise emergency health interventions in accordance with respect for
humanitarian standards and exchange of relevant information for action. This
project will enable WHO to provide information to health partners on the overall
picture on health situation and give the needed technical support to the field
actors.
3) Strengthen the health information system for early epidemic detection, monitor
health emergency indicators, and evaluate humanitarian health performances. The
epidemiological surveillance will give a clear picture of what is happening and
where the health problem are situated.
4) Support 89 Nutritional Rehabilitation Units to provide adequate and appropriate
care to acutely malnourished children.
WHO Health Assessment was conducted in collaboration with UNICEF, UNFPA, MSF
Greece, Save the Children UK, Care International and Red Cross National Society.
- -
21
WHO Health brief on Southern Africa-July 2002
MALAWI - PROJECT 1
Appealing Agencies
Lead Agency
Project Title
Project Code
Themes
Objective
Target Beneficiaries
Implementing
Partners
Project Duration
Funds Requested
United Nations Children’s Fund and World Health
Organization
UNICEF
Emergency Nutrition
MAL-02/H01A-B
Nutrition Rehabilitation Programmes
To reduce the prevalence of global acute malnutrition in
drought-affected
Communities to less than 10% and acute malnutrition
rates
to less than 2% over the course of the year.
For supplementary feeding programmes an average
40,000 a month
moderately malnourished patients and 40,000 a month
vulnerable
pregnant/lactating women in 25 Districts. For monthly
therapeutic
feeding of average 4,000 severely malnourished children.
GoM, WFP, EU, Donors and NGOs
July – December 2002
US$ 2,138,700
Summary
Malawi has a chronic food insecurity problem which has worsened in recent years as
illustrated by the high global chronic malnutrition rate of 49% (DHS2000). The situation
has been complicated and compounded by last year’s events as demonstrated clearly by
several nutritional surveys in some of the most vulnerable districts. Furthermore,
attendance rates among the 89 nutritional units in the country are known to have
increased dramatically in the first quarter of 2002. It is anticipated that there will be
considerable problems of access to food for a significant proportion of the population.
These problems in access are in turn expected to lead to substantial increases in levels of
moderate and severe acute malnutrition at the end of this year and the beginning of the
next.
In collaboration with the Government and NGOs, UNICEF assessed the status of
therapeutic feeding interventions in Malawi. Several problems were identified, including
outdated and non-standardised protocols being used in the centres throughout the
country, which meant that patient care and treatment are poor, and in some cases even
detrimental to the patient.
One of the major resource constraints has been the irregular delivery of specialist foods,
such as dried skimmed milk, sugar, oil and likuni phala. Another major obstacle is lack
of adequately trained staff to provide an acceptable level of care. This reflects the poor
attention paid to the treatment of malnutrition within the health system. Finally, the poor
reporting structure means that countrywide estimates of caseload (used to design health
delivery plans) do not reflect the accurate situation. This leads to incorrect allocation
proportions and quantities in the health centres.
- -
22
WHO Health brief on Southern Africa-July 2002
To address the problem of acute malnutrition, UNICEF proposes to provide support to
the NRU infrastructure, which at its present level is unable to deliver a satisfactory
service. The support will include provision of technical support, training of personnel and
provision of many elements of a comprehensive medically supervised therapeutic feeding
to some 4,000 children in the middle of 2002 increasing to 6,000 in the beginning of
2003. The provision of other resource elements will be coordinated with MoHP, WFP
and INGOs. The programme will be supported in tandem with the provision of technical
support and assistance to the supplementary feeding programme in close collaboration
with WFP and finally communities will be assisted to ensure that preventative activities
are considered.
Key to the successful implementation of therapeutic feeding on such a scale will be the
collation and analysis of data from the centres. The establishment of an information and
monitoring system will be used to monitor and evaluate interventions. The same data
coupled with anthropometric data will be used to develop a nutrition surveillance system
integrated into the wider surveillance and assessment system being developed by
partners. This system will be supported at MoH level by WHO. The latter will ensure that
the MoHP have the capacity to collate, analyse and report on nutritional centre and
surveillance data from other sources.
Coordination will be through the MoH and specifically the Task Force Sub-group on
nutrition chaired by the Ministry and whose membership is made up of NGOs, donors
and other UN agencies. This technical working group has already prepared protocols for
supplementary and therapeutic feeding and agreed on the need to develop new training
and survey protocols. UNICEF will facilitate the development of short, medium and
long-term nutrition rehabilitation strategy in line with the PRSP, the national health
programme and the essential health package and the safety net mechanism and
UNICEF’s commitment to community based preventative activities.
The programme strategy will be developed around a four-tier system. Referral from
community-based programmes will lead through supplementary feeding in health centres
on to therapeutic feeding in NRUs. The NRUs will be further divided into a group of 20
to 30 hospital-based centres addressing the most severe and complicated cases with
medical and nutritional support. The remaining 60 to 70 “simple” therapeutic feeding
centres will address the less complicated cases with nutritional care. Once cured, the
system will work in reverse ensuring an adequate follow-up of patients as they return step
by step into the community, thereby reducing the levels of re-admissions. Interventions at
each level will strengthen linkages and lends itself to a human rights- based approach
with all the duty bearers playing their part.
Support to training will initially begin in 20 centres targeting the most severely affected
areas identified by centre records and through the analysis of food security issues,
coordinated by WFP. These centres will then serve as training ground for the remaining
centres. Training of NRU and SFC personnel using the new protocols will be coordinated
with NGOs and the WFP. The training will be based on the new national protocols for
feeding programmes. In addition, WHO will ensure the training of health staff and
community based staff and volunteers such as Health Service Assistants (HSAs) in the
identification, community-based treatment, referral and follow up of malnutrition.
In coordination with WFP, UNICEF will also ensure the supply of adequate and
appropriate food to the centres. In addition, UNICEF will ensure the supply of specialist
foodstuffs such as F75 milk, ReSoMal and CMV. In coordination with NGOs and the
- -
23
WHO Health brief on Southern Africa-July 2002
MoHP, UNICEF will ensure supplies of special medicines, measuring equipment and
papers for the centres. Other essential items required include blankets, soap and other
utensils for the preparation and distribution of food will be provided to the centres. Toys
will be provided in line with the need for malnourished children to be intellectually and
emotionally stimulated. The close collaboration between WFP and UNICEF will be set
out in a country-level MoU, describing each agency’s responsibilities for each aspect of
the nutrition rehabilitation programme.
FINANCIAL SUMMARY
Budget items
Supplies and equipment
Technical assistance
Logistical support
Information collection and data
analysis
Training
Monitoring and evaluation
Activity total
Project and direct support costs
TOTAL
GRAND TOTAL
UNICEF (US$)
630,000
210,000
90,000
200,000
WHO (US$)
400,000
80,000
1,610,000
322,000
1,932,000
165,000
30,000
195,000
11,700
206,700
2,138,700
- -
24
WHO Health brief on Southern Africa-July 2002
MALAWI - PROJECT 2
Appealing Agency
Project Title
Project Code
Sector
Theme
Objectives
Targeted Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization
Strengthening Disease Surveillance for
Emergency Response in Malawi
MAL-02/H02
Health and information
Health Epidemic Surveillance and
Response
To improve and strengthen the
surveillance of major diseases occurring
in areas affected by food shortage.
3,188,337
NGOs, MoHP, UN agencies
July 2002 - June 2003
US$ 635,152
Summary
The absolute key to the prevention and control of extra disease prevalence in emergencies
is good and timely information. A situation analysis conducted by WHO in ten districts
most affected by the recent food crisis in Malawi revealed that there are major
weaknesses in data collection, analysis and utilization and record keeping by the health
facilities. Inter alia, the assessment found that there was a far higher mortality rate within
the communities than that recorded by the health facilities.
Six district hospitals out of ten could not provide adequate records on deaths that
occurred during the period under study. Lack of communication facilities like faxes, email, reliable telephone lines in some health facilities affected timeliness of transfer of
data to the national level or other project coordination centres.
Consistent with these findings, the project aims to strengthen the ability of the health
system at national, district, health centre and community levels to achieve earlier
detection of epidemics and proper assessment of the health impact of emergency
situations. It is envisaged that this will enable adequate resource mobilization for prompt
and effective response.
The following are the key activities to be undertaken in order to achieve the objective of
the emergency intervention:





Training in integrated disease surveillance.
Record keeping.
Development of immediate response strategies.
Provision of human resources in the form of consultants for technical support.
Procurement and distribution of communications equipment and transport at national,
district and health centre levels for timely reporting.
The tables below give a synopsis of the project and financial resources being sought.
- -
25
WHO Health brief on Southern Africa-July 2002
FIANCIAL SUMMARY
Budget items
Amount
(US$)
Training in integrated disease surveillance, record keeping and 300 000
development of immediate response strategies
Provision of human resource in the form of consultants for technical 60 000
support at district level
Procure and distribute communication equipment and transport at 200 000
national, district and health centre levels for timely reporting
Monitoring and evaluation
39 200
Programme support costs
35 952
TOTAL
635,152
- -
26
WHO Health brief on Southern Africa-July 2002
MALAWI - PROJECT 3
Appealing Agencies
Project Title
Project Code
Sector
Themes
Objectives
Target Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization/United Nations Children’s
Fund
Rapid Strengthening of Cholera Epidemic Response
MAL-02/H03A-B
Health
Cholera surveillance, management, response
To control cholera epidemic by organising prompt
intervention at
community level, to stop the transmission and
reducing related
mortality by better case management of the disease.
10 most regularly affected districts
Ministry of Health and Population, NGOs
July 2002 – June 2003
US$ 825,866
Summary
Cholera is preventable and treatable. Malawi has just gone through one of its worst-ever
cholera epidemics this year. By 14 April, 2002, 33,150 cases and 981 deaths had been
reported, giving an absolutely unacceptable average case fatality rate (CFR) of 2.96%.
Out of 27 districts only one district in Northern Region was spared during the last
outbreak.
The proposed project is targeted to cover ten cholera endemic districts: Lilongwe,
Blantyre, Chikwawa, Nsanje, Mangochi, Zomba, Machinga, Balaka, Salima, and
Karonga. The activities will cover cross-border activities, especially in the MalawiMozambique border areas). On an emergency footing, the project will address the
priority objectives of the Malawi National Health Plan by strengthening surveillance (i.e.
case detection, investigation, response, reporting and feedback), epidemic preparedness
and response. It will aim to ensure proper disease control and low case fatality. Rapid
improvement of health workers’ capacity will go a long way to achieving this objective.
Training for case management, epidemic control and water quality will be organized
jointly by WHO and UNICEF. MSF Greece will be facilitators in these training courses.
In the months before the next ‘cholera season’ the project will seek to fulfil the following
objectives:
1. Increase public awareness about cholera transmission prevention and control
2. Build capacity for cholera control activities
3. Strengthen disease surveillance, early detection and rapid response for control and
management
4. Strengthen coordination mechanisms for cholera control activities
5. Support activities to thoroughly investigate the causes of cholera outbreaks in the
country
A detailed project proposal has been developed by WHO Malawi and is available for
scrutiny. The tables below give an overview of the project and finances required for its
implementation.
- -
27
WHO Health brief on Southern Africa-July 2002
FINANCIAL SUMMARY
Budget items
Development, production and dissemination of necessary
IEC materials
Conduct training for health workers and village health
committees on IEC, early detection, community/EI and
case management
Provision of equipment and supplies for cholera control
(drugs, tents, water testing kits etc)
Procure computer, software, telephone, radio equipment,
internet connection, vehicle for cholera units at all levels
Support the establishment of a Rapid Response Team at
Health Centres/District level
Support the establishment of multi-sectoral cholera task
forces at different levels and formulation of their terms of
reference
Conduct water quality surveillance activities
Monitoring and evaluation
Programme support cost
TOTAL
GRAN TOTAL
- -
Amount
(US$)
WHO
100,000
Amount
(US$)
UNICEF
160,000
200,000
150,000
100,000
10,000
10,000
51,100
34,266
10,500
605,366
220,500
825,866
28
WHO Health brief on Southern Africa-July 2002
MALAWI - PROJECT 4
World Health Organization
Reproductive health services for vulnerable communities in
Emergency situations
MAL-02/H04
Project code
Health
Sector
Reproductive health, essential emergency obstetric care
Themes
To ensure the provision of essential and emergency obstetric
Objectives
care
Target Beneficiaries 76,520
MoHP, UNFPA, UNICEF, Min of Gender & community
Implementing
Services, NGOs
Partners
1 July 2002 - 30 June 2003
Project Duration
Funds Requested
US$ 442,263
Appealing agency
Project Title
Summary
A situation analysis conducted in ten districts mostly affected by food crisis in Malawi
revealed a high maternal mortality during the period 2001-2002 as compared to the year
2000-2001. In 8 district hospitals for which mortality data were available, maternal
deaths had increased by 72%, even though the number of deliveries had declined by 7,6%
during the same period. The diminishing number of women gaining access to hospitals,
combined with increased mortality of those who do, is an ominous development. The
unacceptably high maternal mortality can be directly attributed to the food shortage
aggravating already high anemia rates in pregnant women and cultural practices that
require mothers to eat last in the family.
It is apparent from the high and increased maternal mortality that the health facilities lack
capacity to handle emergency obstetric care. It is proposed to effect a reversal of this
trend in the shortest possible time by acting immediately on two fronts: I) training in
emergency and essential obstetric care, and ii) supply of reproductive health kits to
improve obstetric service response.
FINANCIAL SUMMARY
Budget items
Training of Trainers
Training of Health workers
Procurement and distribution of
Reproductive health kits (1 for each district)
Procurement of VCT testing kits
Procurement of STD reagents
Procurement of Nevirapine
End of project evaluation
Programme support costs (6%)
TOTAL
Amount (US $)
60,800
50,600
98,685
90,800
58,900
45,912
11,532
25,034
442,263
- -
29
WHO Health brief on Southern Africa-July 2002
MALAWI - PROJECT 5
Appealing Agencies
Project Title
Project code
Sector
Themes
Objectives
Target Beneficiaries
Implementing
Partners
Project Duration
Funds Requested
World Health Organization and United Nations Children’s
Fund
Improving response to disease outbreaks in emergency
situations
MAL-02/H05A-B
Health
Health, Capacity building
To strengthen capacity of affected districts for response to
priority diseases, particularly those prone to epidemic
318,833
Ministry of Health and Population, NGOs, Local Government
1 July 2002 - 30 June 2003
US$ 1,260,262
Summary
Extra-ordinarily high levels of malnutrition in the recent food crisis period, particularly
among children under 5 years, has increased susceptibility to various diseases such as
diarrhea, malaria, ARI and skin diseases. The areas most severely affected in 2001/2002
will remain highly vulnerable in 2002/2003. The WHO and UNICEF health assessments
indicated that there was limited capacity in the affected districts to cope with the crisis.
The common problems identified included, shortage of staff at all levels, drug stock-outs
during the peak period of the crisis and usually very old equipment.
There was high mortality at community level during the crisis compared to the
information obtained from health facilities. Therefore the objective of this project is to
strengthen capacity of affected districts for responding to priority diseases in the country.
In view of the above situation, WHO and UNICEF will provide technical support to front
line teams and structures. WHO will also link closely with epidemiological surveillance
for immediate response as well as intensive collaboration with NGOs following their
capacities and presence in the field. Project information and financial requirements for
the successful implementation of the programme component are given in the tables
below.
FINACIAL SUMMARY
Budget items
UNICEF
(US$)
Train district and health centres focal persons and frontline
workers on emergency detection and response
Ensure that frontline health teams are provided with basic
health kits and adequate transport.
Procure and distribute educational materials and guidelines
for epidemic response
Provide technical support for disease control especially those
of epidemic potential
Provide emergency health kits and basic equipment for
- -
WHO
(US$)
120,000
90,000
20,000
80,000
300,000
30
WHO Health brief on Southern Africa-July 2002
frontline structures to facilitate rapid response of most killer
diseases.
Insecticide treated bed nets for vulnerable groups
Monitoring and evaluation
Project Support cost
TOTAL
GRAN TOTAL
- -
490,000
49,000
42,700
29,400
39,162
568,400
691862
US$ 1,260,262
31
WHO Health brief on Southern Africa-July 2002
MALAWI - PROJECT 6
Appealing Agency
Project Title
Project code
Sector
Themes
Objectives
Target
Beneficiaries
Implementing
Partners
Project Duration
Funds Requested
World Health Organization
Strengthening Emergency Health Coordination among partners
MAL-02/H06
Health
Health coordination
Coordination of health interventions in order to increase
efficiency in the allocation of the resources, provide technical
back up for acceptable health quality services and information
sharing
Vulnerable communities in the whole country
UN agencies, NGOs, MoHP, CBOs
July 2002 - June 2003
US$ 349,800
Summary
During the recent humanitarian crisis a large number of partners (more than 23 NGOs
and UN agencies) were working in the Health sector and several other partners were also
working in Nutrition, and Water and Sanitation areas. It was clear that they collectively
needed an improved and shared approach to health information in an emergency: case
definitions of disease and control strategies were different from one NGO to another;
partners could not take the best-informed decisions; and there was a perceived lack of
leadership at this crucial time.
There is a need to recruit a Public Health Focal Point in WHO Malawi specialized in
emergencies, a subject currently beyond the capacities of the regular WHO staff. As the
technical agency for health coordination, WHO will issue regular statements on
epidemiological trends and related matters. The WHO Focal Point will be the
Emergency Health Coordinator in the UN Emergency Response Coordination Unit
(ERCU). WHO will also consider different approaches with all partners and obtain
consensus on emergency disease control strategies according to existing resources. When
the Ministry of Health and Population or Local Government are taking the lead for
coordination, WHO will provide technical support to the Government structure.
FINANCIAL SUMMARY
Budget items
Providing technical support for coordination and guideline, good
practices and monitor health quality services
Conduct joint assessments and information sharing with partners
Logistic support
Project Support Costs ( 6%)
TOTAL
- -
Amount (US$)
150,000
120,000
60,000
19,800
349,800
32
WHO Health brief on Southern Africa-July 2002
Zimbabwe
Health Sector Plan
Zimbabwe is under an economic and humanitarian crisis characterized by foreign
currency shortages and a fall in budgetary allocation that have caused a deterioration of
social services, including the delivery of health services. The effects of the economic
downturn, increased poverty and the HIV/AIDS pandemic have had adverse impact on
human resource base and thus impacting negatively on the health delivery system. It has
also eroded the post-independence gains achieved in areas such as reproductive health.
Inadequate health service delivery has adversely affected the health of the vulnerable
population groups, i.e. in the communal lands, new and peri-urban settlements. The
effects of the natural phenomena such as El Nino, Cyclone Eline and year 2000 floods,
coupled with successive droughts, have further exacerbated the plight of the vulnerable
populations.
The various UN agencies in partnership with some government departments under the
Humanitarian Action and Response Plan (HARP) conducted rapid assessments to provide
evidence and quantify this humanitarian crisis. The health needs assessment came out
with the following major findings:
 The mortality rates in the assessed districts have been increasing over the past
year among the top ten priority diseases, e.g mean rates for TB have increased
from 25.47 in 1998 to 41.87 in 2001 per 100,000 population; that of acute
respiratory infections (ARI) increased from 19.35 in 1998 to 36.15 in 2001 and
that for HIV/AIDS has increased from 18.29 in 1998 to 34.14 in 2001.
 Outpatient attendances at health institutions have been going down. This shows
decreasing access to health facilities by the population, which may be a result
poverty and a known lack of service and supplies.
 The vital essential drugs stocks are critically low nationally as found during the
assessment but the situation is more critical at peripheral health institutions. This
has been due to shortage of foreign currency to import the vital drugs and
inadequate distribution system.
 There is an acute shortage of vital health personnel especially in the peripheral
health institutions due to high attrition of professional staff from the public
service in search of new employment opportunities and the HIV/AIDS pandemic.
 Outreach services have been drastically scaled down or suspended in a number of
districts due to lack of financial, logistical support and inadequate human
resources.
 The ability of the Ministry of Health and Child Welfare (MoHCW) to respond to
epidemic prone diseases has been weakened by lack of resources including
finance and logistics.
 There are gaps in the coordination mechanism between MoHCW and other health
stakeholders, e.g. NGOs, leading to duplication of efforts.
 An estimated 1,430,817 people will require reproductive health assistance
between June 2002 and July 2003 - of that number, 500 000 require critical
emergency assistance.
Goal
Reduce number of avoidable deaths and suffering of vulnerable populations
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33
WHO Health brief on Southern Africa-July 2002
Objectives
i)
Improve accessibility of health services to the identified vulnerable population
groups regardless of their location.
ii)
Increase availability of vital drugs and medical supplies including drugs for
reproductive health and HIV/AIDS opportunistic infections in health institutions.
iii)
Monitor epidemic prone disease, strengthen prevention, and response to
epidemics
iv)
Improve access to crisis-related critical emergency reproductive health services to
the most vulnerable groups/communities
v)
Support Ministries, Parastatals and NGOs to reduce maternal morbidity and
mortality due to pregnancy and childbirth compounded by the crisis.
Vulnerability Criteria and Caseload
The assessment revealed that the vulnerable populations in this sector include
approximately 1,000,000 excluding approximately 100,000 people in peri-urban
settlements. Within this population there are subgroups such as under-fives (15.44%),
pregnant women (20%), the poor (+60%) and the elderly (10%) who are highly
vulnerable. Some of the population groups are located far from health facilities and
considering the current state of outreach services these populations have been exposed to
higher risk. During 2002, interventions will focus on the most acute areas such as those
that were identified by HARP 1 assessment conducted in May 2002 and it is estimated
that the various health sector stakeholders will reach a population of approximately
1,100,000. In terms of reproductive health support, target groups are adolescents,
youths, women, pregnant women, nursing mothers and other "at risk" groups, including
commercial sex workers and mobile/transient groups.
Strategies:
 Mobilize adequate funding to procure vital drugs and medical supplies.
 Improve planning, stock control and procurement and distribution of vital drugs and
medical supplies at all levels.
 Engage in policy dialogue for policies that will attract and retain professional health
personnel.
 Training of health workers to improve the ability of the health sector to prevent and
control diseases including responding to disease epidemics.
 Improve communication systems and logistical support for disease surveillance,
prevention and control.
 Improve outreach services in the areas where it had been scaled down, resuscitate
where it had been suspended and establish outreach services in areas where they do
not exist in order to serve the identified vulnerable population groups.
 Training of community workers to improve the ability of the health sector to serve
the vulnerable population.
 Community education to raise community awareness in order to be able to actively
participate in prevention and control diseases including responding to disease
epidemics.
 Strengthening reproductive health interventions, advocacy and coordinating access to
emergency services for vulnerable populations affected by the crisis.
Activities
To meet the objectives in this sector, humanitarian agencies (health sector stakeholders)
will:
 Procure and distribute vital drugs and medical supplies.
- -
34
WHO Health brief on Southern Africa-July 2002







Train health workers in disease control, surveillance and epidemic preparedness and
response.
Provide radio communications equipment to peripheral health centres and resuscitate
radio communications at affected district and rural health centres in order to respond
to disease epidemics on time.
Establish and/or resuscitate outreach services in the vulnerable areas.
Provide transport to extension workers for the outreach programmes focusing on
community education, home based care under the HIV/AIDS pandemic, EPI, etc and
disease surveillance, prevention and control and quick response to epidemics in the
vulnerable areas.
Conduct community information and education campaigns.
Train community-based extension workers to respond to the evolving crisis.
Provide support for quality reproductive health service provision to vulnerable
groups, including facilitating procurement of RH drugs, kits and supplies and
provision of support for development of materials for use in advocacy towards
behaviour change
Indicators
Programme monitoring will be based on the following indicators:
 Stock levels of vital drugs and medical supplies
 Number and category of health workers trained to serve the vulnerable populations
 Number of identified health centres with adequate communication systems and
logistics to respond to the emergency
 Population reached or covered by education campaigns and proportion involved in
disease prevention and control activities
 Number of outreach visits conducted for the vulnerable population groups by
extension workers.
 Population covered by outreach services.
 Numbers of community level extension workers trained and functional within the
affected areas
 Widened access and increaesd numbers of RH emergency assistance beneficiaries,
disaggregated by gender and age.
- -
35
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 1
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization
Building/Strengthening Health Sector Partnership
(Stakeholders)
ZIM-02/H01
Health
Health Sector Coordination
Coordinate health sector interventions in order to increase
efficiency in resource allocation and distribution and
provide technical back up for acceptable quality health
services and information sharing.
All health sector partners
MOHCW, UN Agencies and NGOs
July 2002 - June 2003.
US$ 378,420
Summary
During the previous (Cyclone Eline and floods) and current humanitarian crisis, it was
noted that there is a large number of health sector stakeholders (60 Local Authorities –
RDCs/Urban Councils, 20 NGOs/Church related organisations, private sector and UN
Agencies) working in the health sector and a lot of other partners working in the various
sectors. In the health sector these partners use various disease case definitions and disease
control strategies. This gives different pictures and figures on assessed situations making
unclear background for partners to take appropriate decisions. There is lack of leadership
and direction resulting in overlaps and duplication of services.
The MoHCW in conjunction with WHO, a technical body for coordination will on
regular basis issue a statement to inform partners on the epidemiological trends and other
relevant information. MoHCW in conjunction with WHO will also consider different
approaches, discuss with all partners, and obtain consensus on disease control strategies
according to the existing resources. The Health Coordinator-HARP in WHO will assist
with the day-to-day coordination of the sector.
Relationship to CHAP strategic and short-term goals and sector objectives
This project is in line with the overall CHAP short-term objectives of laying the
foundations for recovery programming in health services preventing, containing and
addressing the outbreak of disease, including HIV/AIDS. It also supports the overall
health sector plan in the CHAP, specifically the objectives on (a) preventing and
controlling disease epidemics timeously and (b) improving accessibility of health
services to the most vulnerable population groups
Expected outcome
The main expected outcome will be improved health service delivery to the target
population and improved response to disease prevention, control and epidemics.
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36
WHO Health brief on Southern Africa-July 2002
Activities
 Organize and prepare in collaboration with partners coordination meetings from
national down to district level.
 Strengthen health information exchange by regular dissemination of epidemiological
information and distribution of health guidelines and manuals.
 Monitor quality of health services
 Conduct joint field assessment missions.
FINANCIAL SUMMARY
Budget Item
Providing technical support for coordination and guideline, good
practices and monitor health quality services
Conduct joint assessment and information sharing with partners
Logistical support
Contingency
Program support costs(6%)
TOTAL
- -
US$
150,000
130,000
60,000
17,000
21,420
378,420
37
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 2
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
World Health Organization
Disease Surveillance
ZIM-02/H02
Health
Data collection and appropriate use
Improve the ability of health personnel to utilise health
information for decision-making and prompt detection and
control of epidemics.
Targeted Beneficiaries 10 most vulnerable districts.
Implementing Partners MOHCW, UN Agencies and NGOs
Project Duration
July 2002 to June 2003.
Funds Requested
US$593,600
Summary
One of the critical areas assessed for the HARP was that of disease surveillance. The
rapid assessment revealed that surveillance was weak at all levels. Although the
timeliness and completeness of data collection was reported as 86% and 96%
respectively, analysis and use of surveillance data at health facility level was minimal.
Response to epidemics and disease outbreaks was therefore delayed. A large number of
health workers interviewed had not received any training in disease surveillance. Case
definitions were available for EPI diseases at 74% of health facilities, but less than 5% of
health facilities had case definitions for other priority diseases like AIDS, malaria and
cholera. Twenty-one per cent (21%) of the health facilities did not have standard case
definitions for any priority diseases. Supervision was minimal – only 4% of rural health
facilities had received any supervisory visits in the last 6 months.
According to Ministry of Health projections in 1998, it was estimated that people
suffering from HIV/AIDS related illnesses occupy 70% of all hospital beds. The
assessment revealed that HIV/AIDS was among the top five causes of mortality, however
it did not feature in the top causes of morbidity, although health workers generally agree
that the bulk of the morbidity that they see in Outpatients services is HIV related.
A large proportion of diseases were classified in non-descript categories such as “
symptoms and ill defined conditions, viral conditions or diseases of the central nervous
system.” Such classifications do not help in defining the burden of disease in a
population. Age distribution of data is limited to two main age groups, under fives and
five and above. There is no information by more specific age groups or gender. It is
therefore very difficult to identify particularly at risk groups for certain conditions.
Humanitarian assistance may thus not be targeted at the appropriate groups.
Expected Outcome
This project therefore aims at strengthening disease surveillance so as to be able to detect
and respond promptly to epidemics. It also aims at strengthening the health information
system so as to be able to accurately assess the disease burden and the particular
populations at risk and how it is affected by this emergency situation.
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38
WHO Health brief on Southern Africa-July 2002
Activities
 Training in basic epidemiology and surveillance and outbreak response
 Review the case definition for HIV/AIDS and improve diagnosis and recording of
HIV related illnesses
 Review of data health information tools so as to capture narrower age groups and
gender
 Support and supervision
 Programme management
FINANCIAL SUMMARY
Budget Item
Train district and rural health centre staff on disease surveillance –
action thresholds, epidemic preparedness, disease detection and
response.
Review/redesign, produce and distribute health information tools
Develop/reproduce and distribute disease case definitions and
community level IEC materials
Provide emergency kits for epidemic prone diseases
Monitoring and support
Program support costs (6%)
TOTAL
- -
US$
150 000
50 000
100 000
200 000
60,000
33,600
593, 600
39
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 3
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization
Policy on professional health staff to strengthen health
service delivery
ZIM-02/H03
Health
Policy dialogue on Staff Retention
Advocate for policies that will attract and retain
professional health personnel.
Vulnerable populations: 1,100,000
Children: 169,840 Women: 307,230
MOHCW, UN Agencies and NGOs
July 2002 - June 2003.
US$ 21,200
Summary
In the recent rapid health needs assessment it was established that the country is facing a
critical shortage of professional staff especially at district and sub-district levels. The
public health sector has lost 7% of its personnel since January 2000 and approximately
+40% posts remain vacant. This picture is based on the old staff establishment, however,
the MoHCW is currently going through a restructuring exercise which attempts to
rationalize staffing levels to suit the public health sector needs and when this exercise is
completed it is expected to reflect an even worse staffing situation. The non-availability
of key professional staff in the health delivery system adversely affects the quality care
provided.
The WHO in conjunction with other stakeholders needs to engage government
(MoHCW) to urgently review policies or develop a policy that would attract and retain
professionals.
Relationship to CHAP strategic and short-term goals and sector objectives
This project is in line with the overall CHAP short-term objectives of laying the
foundations for recovery programming in health services preventing, containing and
addressing the outbreak of disease, including HIV/AIDS. It also supports the overall
health sector plan in the CHAP, specifically the objectives on (a) preventing and
controlling disease epidemics timeously and (b) improving accessibility of health
services to the identified vulnerable population groups regardless of their location.
Expected outcome
The main expected outcome would be improved staff retention and thus improved access
to health services by the vulnerable populations.
Activities
 Conduct high-level discussions with policy makers
 Development of draft policy
 Monitor implementation of the policy
- -
40
WHO Health brief on Southern Africa-July 2002
FINANCIAL SUMMARY
Budget Item
Meetings
Monitoring assessment and information sharing with partners
Program support costs(6%)
TOTAL
- -
US$
10,000
10,000
1,200
21,200
41
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 4
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
World Health Organization
Procurement of vital drugs and medical supplies
ZIM-02/H04
Health
Vital drugs and medical supplies
Increase availability of vital drugs and medical supplies
including drugs for HIV/AIDS opportunistic infections in
health institutions.
Targeted Beneficiaries Vulnerable populations: 1,100,000
Children: 169,840 Women: 307,230
Implementing Partners MOHCW, UN Agencies and NGOs
Project Duration
July 2002 to June 2003.
Funds Requested
US$ 7,763,175
Summary
In a recent rapid health needs assessment it was established that the country is facing a
critical drug shortage of vital drugs and the missions and rural health centres are the
worst affected. These peripheral health facilities had less than 30% of their average drugs
stocks, which shows that they had a month’s cover, or less. Drug distribution was found
to be unsatisfactory with some institutions having more than their requirements in certain
drug categories.
The WHO in conjunction with MoHCW and other major stakeholders will urgently
procure and ensure prompt distribution of the vital drugs and medical supplies. The
WHO in conjunction with MoHCW and other partners will carry out periodic drug
assessments and all efforts to prevent stock outs of the vital drugs and medical supplies
that have been experienced over the last year will be minimised.
Relationship to CHAP strategic and short-term goals and sector objectives
This project is in line with the overall CHAP short-term objectives of laying the
foundations for recovery programming in health services preventing, containing and
addressing the outbreak of disease, including HIV/AIDS. It also supports the overall
health sector plan in the CHAP, specifically the objectives on (a) increasing availability
of vital drugs and medical supplies including drugs for HIV/AIDS opportunistic
infections in health institutions and (b) preventing and controlling disease epidemics
timeously.
Expected outcome
The main expected outcome will be improved availability of vital drugs and medical
supplies and improved access to health services to the vulnerable populations.
Activities
 Procure and distribute drugs to the identified areas.
 Monitor drug and medical supply stocks and quality of health services
- -
42
WHO Health brief on Southern Africa-July 2002
FINANCIAL SUMMARY
Budget Item
Procurement of drugs and medical supplies to the health services
providing for the vulnerable populations
Logistics support
Monitoring assessment and information sharing with partners
Contingency
Program support costs(6%)
TOTAL
- -
US$
6,900,000
60,000
15,000
348,750
439,425
7,763,175
43
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 5
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization/United Nations Children’s Fund
Strengthening of Cholera Epidemic Response
ZIM-02/H05
Health
Cholera Prevention, Surveillance, Management, Response
To prevent cholera epidemic by improving water and sanitation
to the epidemic prone communities, To decrease transmission
and reduce mortality through organizing prompt action at
community and health center level.
3 Regularly affected Provinces.
MOHCW, UN Agencies and NGOs
July 2002 to June 2003.
US$ 1,113,000
Summary
Zimbabwe is experiencing one of its worst cholera epidemics this year. The epidemic has
affected three provinces namely, Manicaland, Mashonaland East and Masvingo. Sporadic
cases have occurred in some Cities and other provinces. Zimbabwe has reported 2,484
cases and 242 deaths giving a high mortality rate of 9.7%. The institutional case fatality
is 3.1%. The most affected province is Manicaland where cases are still being reported.
The epidemic has affected those districts with poor water and sanitation coverage. The
surveillance system has been found wanting and the response to the epidemic by health
staff less than optimal.
The projects target those districts with poor water and sanitation coverage that have been
affected by the current cholera outbreak. It aims to improve access to safe water through
protection of family and communal wells and supply of commodities for Improved
Ventilated latrines for families. The project will also improve community awareness on
identifying cholera cases and management before referral to health centres.
At health center level, the project aims to strengthen surveillance (i.e. case detection,
investigation, response, reporting and feedback) through training of health workers and
proving the commodities that enhance epidemic preparedness.
Relationship to CHAP strategic and short-term goals and sector objectives
This project is in line with the overall CHAP short-term objectives of laying the
foundations for recovery programming in health services preventing, containing and
addressing the outbreak of disease, including cholera. It also supports the overall health
sector plan in the CHAP, specifically the objectives on (a) preventing and controlling
disease epidemics timeously and (b) improving accessibility of health services to the
most vulnerable population groups
Expected outcome
The main expected outcome would be improved water and sanitation coverage.
Strengthened cholera prevention methods and enhanced cholera preparedness.
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44
WHO Health brief on Southern Africa-July 2002
Activities
 Identification and protection of water facilities (Conduct water quality surveillance)
 Supplying building materials for VIP latrines.
 Develop, produce and disseminate IEC materials to the Community and Health
Institutions.
 Disseminate guidelines on cholera control.
 Train health staff on early case detection, case management, and reporting and
epidemic control in general.
 Provision of drugs and supplies for cholera control and preparedness.
 Strengthen communication through provision/repair of communication radios,
telephones etc.
FINANCIAL SUMMARY
Budget Items
IEC material development and dissemination
Training of staff
Drugs and supplies for cholera
Community mobilisation activities
Communication equipment - procure/repair and install.
Program support costs(6%)
TOTAL
- -
US$
150 000
200 000
300 000
150 000
250 000
63000
1,113,000
45
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 6
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization/United Nations Children’s
Fund
Strengthening of Malaria epidemic response
ZIM-02H/H06
Health
Malaria prevention, Surveillance, Management, Response
To prevent malaria mortality and reduce morbidity and
reduce social suffering due to malaria.
10 districts mostly affected by malaria.
MOHCW, UN Agencies and NGOs
July 2002 to June 2003.
US$ 1,855,000
Summary
Malaria remains one of the major causes of Outpatients clinics (OPD) attendances in
Zimbabwe. Over 2 500 people die of malaria and over 3 million have at least one
episode of malaria in a year. Resistance to chloroquine is increasing as evidenced by the
drug sensitivity monitoring exercises currently being carried out in the country. Drug
shortage particularly Sulphadoxine –Pyramethamine (S-P) which has been the second
line treatment has been experienced in past years. This was mainly due to the declining
foreign currency availability in Zimbabwe
The outreach services have been declining in the last few years due to the current
humanitarian crisis. The Ministry has not managed to respond adequately to disease
outbreaks due to staff shortages and other logistics. This has aggravated the plight of the
vulnerable populations. This project seeks to strengthen malaria control interventions in
the vulnerable areas through indoor residual spraying and provision of insecticide treated
nets (ITN).
Relationship to CHAP strategic and short-term goals and sector objectives
This project is in line with the overall CHAP short-term objectives of laying the
foundations for recovery programming in health services preventing, containing and
addressing the outbreak of disease, including malaria. It also supports the overall health
sector plan in the CHAP, specifically the objectives on (a) preventing and control disease
epidemics timeously and (b) Improving accessibility of health services to the most
vulnerable population groups
Expected outcome
The main expected outcome would be reduction in mortality and morbidity in malaria.
Activities
 Train health staff on early case detection, case management, and reporting and
epidemic control in general
 Provision of adequate anti-malarial drugs
 Training of communities to promote community based malaria control activities
 Develop, produce and disseminate Information Education and Communication (IEC)
materials to the Community and Health Institutions.
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46
WHO Health brief on Southern Africa-July 2002



Increase indoor residual spraying coverage
Provision of impregnated bed nets( ITNs)
Monitoring and evaluation
FINANCIAL SUMMARY
Budget Items
Training of health workers
Provision of anti-malarials
Training of the community
IEC material development and dissemination
Provision of ITNs
Provision of transport
Community mobilisation activities
Monitoring and evaluation.
Program support costs (6%)
TOTAL
- -
US$
150 000
200 000
100 000
200 000
600 000
100 000
150 000
250 000
105,000
1 ,855, 000
47
WHO Health brief on Southern Africa-July 2002
ZIMBABWE – PROJECT 7
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted Beneficiaries
Implementing Partners
Project Duration
Funds Requested
World Health Organization
Reducing increasing maternal mortality in rural settings due to
the humanitarian crises.
ZIM-02/H09
Health
Prompt referrals and emergency obstetric care
a) To reduce increasing maternal deaths
b) To improve methods of prompt referrals of pregnant
women especially young girls at village/community
level.
c) To ensure the provision of essential and emergency
obstetric care.
Pregnant women identified in HARP 1 District Assessment.
MOH&CH, WHO,UNICEF, UNFPA, NGOs
July 2002 – June 2003
US$ 1,400,000
Summary
The current socio-economic crisis in Zimbabwe has worsened the plight of women,
especially, vulnerable pregnant women. The Ministry of Health and Child Welfare
Reproductive Health Care Assessment of 1999 highlighted the most common emergency
obstetric complications, which were ante-partum haemorrhage, pre-eclampsia,
malpresentation. The Herald newspaper of 19/06/02 highlighted increases in unsafe
abortions by youths aged between 15-19 years compounded by rising HIV infections in
the youth accounting for 30% of all infections. Health facilities able to manage
emergency obstetric cases were found to be low. (MOH&CW Reproductive Health
Rapid Assessment 1999). This picture is getting worse because of the high attrition rates
of professional staff and increasing poverty levels – HARP Assessment Report.
Relation to CHAP Strategic and Short-term Goals and Sector Objectives
The project is in line with the overall CHAP short-term objectives of strengthening
community and health sector response of preventing and containing the priority
reproductive health problems exacerbated by HIV/AIDS pandemic and increasing
poverty levels. The RH project supports the overall health sector plan in the CHAP
specifically objective (b) improving accessibility of health services to the most vulnerable
population groups.
Expected Outcome
The main expected outcome will be improved prompt referrals to access emergency
obstetric care using appropriate rural transport, the 4 wheel scotch carts “Haka wagons”,
recognition of problems related to pregnancy by community early and vulnerable
pregnant women especially pregnant young girls in rural areas. Creating awareness and
strengthening diagnosis and critical interventions in the clinical areas through training of
staff in health centres and district hospitals using the HARP Rapid Assessment report for
selection.
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48
WHO Health brief on Southern Africa-July 2002
Financial Summary
A total of US$1.4 million is being requested to accelerate and strengthen community
education and develop partnership in RH for prompt health seeking behaviour during
pregnancy, setting up a supportive system of prompt referrals at village level to the
nearest health centre and training nurses/midwives and doctors in emergency obstetric
and abortion care. Procuring transport for outreach work and ensuring availability of
vital and essential drugs including medical supplies.
FINANCIAL SUMMARY
Budget Item
Training of community based workers/VHW in recognizing early
problems
Training Health Professionals in emergency obstetric and abortion care
Procuring transport for outreach work
Fuel and mileage for outreach work
Community mobilisation
Procuring four wheeled scotch carts (Haka wagons) for prompt Referrals
x 8 Districts
Monitoring and Evaluation
Project Management (Coordinator of project, travel costs etc)
Program support costs(6%)
TOTAL
- -
US$
200,000
250,000
200,000
100,000
50,000
500,000
50,000
50,000
84,000
1,484,000
49
WHO Health brief on Southern Africa-July 2002
Zambia
Health and Nutrition
Analysis of need
The health and nutrition status of Zambia’s people has been in decline for at least two
decades. Zambia is a poor country. Entrenched grinding poverty and the almost total
failure of economic recovery efforts have undercut Government’s struggle to provide
basic drugs and services. HIV/AIDS, a new challenge, has ravaged the country and is
now the leading killer in Zambia. As a consequence, life expectancy at birth has declined
to a mere 37 years – the third lowest in the world. It should be noted, however, that even
that grim figure fails to capture the reality for most Zambian’s. In 1999, it is officially
estimated that the prevalence of HIV/AIDS was 20%, but as in many southern African
countries, this estimate may be low. Those who have the disease find themselves in a
country where anti-retroviral drugs are still beyond their reach. For most, the drugs and
healthcare they need to cope with Tuberculosis, cancers and the opportunistic infections
they suffer are simply unavailable. The sick and dying seek shelter within the extended
family and in so doing, undermine the capacity of those families to cope with the
impending food and water crisis.
The downward spiral reaches every household and spares no age group. Estimates
indicate that from 1990 to 1999, the infant mortality rate has increased from 108 to 122,
and the under 5 mortality rate has increased from 191 to 202 per 1,000 live births.
Amongst children under-5 malaria remains the number one direct cause of death. But the
real cause is the inability of Zambia’s people to access basic drugs and health care or to
pay for bed nets to protect their children. Malaria may be the coup de grâce, but it is
poverty and the dilapidation of the health system that sentence million of children in
Zambia to an early death.
Health service delivery has been decentralized to the districts who are now responsible
for planning management and implementation in the districts. While considerable effort
and resources have gone into Zambia’s health sector reform process, the capacity to
deliver quality services varies considerably among districts. Throughout the country there
is a shortage of qualified staff at all levels as well as insufficient stocks of essential drugs
and equipment. This is particularly noticeable in rural areas, many of which are affected
by the current food shortages.
Another indicator of the stress experienced by Zambia’s children is the high prevalence
of stunting. Among under-5’s this has increased from 39% in 1992 to 53% in 1996 and is
now estimated at 54%. While, admittedly, stunting is a trailing rather than a leading
indicator of malnutrition, it makes clear that many children in Zambia have little reserves
to carry them through an extended “hungry season” and they are therefore highly
vulnerable in the current crisis.
Increased hunger will compound maternal health problems, including miscarriages, selfinduced abortions and problematic labours. While fertility levels are likely to drop
during severe food shortages family planning services and supplies should be ensured,
including condoms. Zambia already has high maternal mortality and morbidity rates.
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50
WHO Health brief on Southern Africa-July 2002
Vulnerable people are more likely to engage in unsafe sexual practices, and considering
the high prevalence of HIV, it is important that people have access to condoms.
Strategy
During the current emergency, the UN system proposes a strategic framework that
will address both immediate and underlying problems. The first element will be to
identify, target and feed the vulnerable and to provide on an emergent basis new water
sources (boreholes and wells) for the Southern province. This work will be done in
close collaboration with local NGOs and will build on already existing programmes of
food and water assistance.
Weakness in the capacity of national and local authorities to monitor and analyze changes
in the nutritional status of high risk groups mandates urgent intervention. While the
timely acquisition of quality data for programme planning is an imperative, so too is the
need for strengthening of local capacity, capability and commitment in nutrition
surveillance. Competent external technical advisors will need to be mobilized to lead in
the conduct of nutrition surveys and in efforts to train local workers. Funds and technical
assistance will be provided for the Government to assume a coordinating role and
enhance future capacity to prevent and mitigate the results of a food crisis.
An adequate surveillance system providing timely information on food, nutrition and
health will help avert severe malnutrition and death. The cost of rehabilitating severely
malnourished children is very high, and so is the mortality rate among the severely
malnourished. All efforts will be made to avoid an increase in malnutrition rates. To the
extent possible establishment of therapeutic feeding centres will be avoided, care will be
home-based. Because the relief ration is largely maize, potential nutritional deficiencies
will be addressed through the provision of multivitamin supplements.
Strengthening of the existing health system to provide basic services to women and
children will be the main strategy for health service delivery. Local and international
NGOs will fill identified gaps. Efforts will be made not only to address the immediate
problems and save lives but also strengthen local capacity to detect, prevent and respond
to disease outbreaks and other emergencies in the future. Cost effective interventions,
proven to be effective in emergencies, such measles immunization, vitamin A and other
micronutrient supplementation, malaria prevention and treatment will be core activities.
Objectives
The overall goal is to minimize the impact of the present food crisis on the health and
nutritional status of vulnerable populations.
More specifically the objectives are to:
 To prevent further worsening of the global malnutrition rates at the present level
until the next harvest
 To provide micronutrient supplements and reach a biannual coverage above 80%
among children below 5 years of age in the affected districts
 To provide therapeutic food for rehabilitation of 3,000 severely malnourished
children
 To train 75 health workers on management of severe malnutrition
 To provide essential drugs and medical equipment for 100,000 people for one year
 To immunize more than 90% of all children between 9 months and 15 years of age in
the 10 worst affected districts
 To provide insecticide treated bed nets to the most vulnerable 10% of the population
in the affected districts
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51
WHO Health brief on Southern Africa-July 2002




To train surveillance officers in the affected districts and strengthen the capacity of
government to recognize and respond to disease outbreaks
To increase availability of condoms and other family planning services and provide
information to prevent the spread of HIV/AIDS
To reduce the impact on maternal morbidity and mortality and increase the likelihood
of positive birth outcomes
To decrease the prevalence STD infections by providing contraceptives including
condoms and STD drugs
Proposed action
 Establish a surveillance system to monitor change in the nutritional status of
vulnerable populations and measure the impact of food and nutrition interventions
and provide timely data for adapting programme interventions.
 Support rehabilitation of severely malnourished children through training and
capacity building in the management of severe malnutrition. Provision of therapeutic
food (F75, F100 and Plumpy Nut) and technical assistance.
 Strengthen the existing disease surveillance, recognition and response system.
Provision of essential drugs and equipment and ensure adequate monitoring and
response capacity for the management of cholera outbreaks.
 Provision of micronutrient supplements to children and pregnant and lactating
women.
 Ensure provision of Vitamin A, Iron, Folic Acid
 Support to malaria prevention and control through the distribution of impregnated
bed nets and anti-malarial drugs
 Ensure targeted measles vaccination of children under 15's in vulnerable areas.
Strengthen existing
 Maintain and increase EPI coverage through support to the cold chain and improving
injection safety.
 Ensure pregnant women if affected areas are identified and provided with ante-natal,
birthing and post-natal care, including parasite control, nutritional supplementation,
malaria prophylaxis, obstetric care and if necessary emergency obstetric care, family
planning and STD treatment.
- -
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WHO Health brief on Southern Africa-July 2002
ZAMBIA – PROJECT
Appealing Agency
Project Title
Project Code
Sector
Objective
Targeted Beneficiaries
Implementing
Partners
Project Duration
TOTAL
World Health Organization
Disease surveillance, prevention and control
ZAM-02/H01
Health and Nutrition
To strengthen disease surveillance and response
To strengthen disease prevention and control systems
To provide basic health services to people in the affected
areas
To reduce morbidity and mortality from measles and
malaria
The food crisis is assumed to affect 2 million people, incl.
Children: 400,000; Women: 440,000
Ministry of Health, Central Board of Health, District
Health Management Teams, UNICEF
July 2002 – June 2003
US$ 1,805,000
Summary
The overall aim of this project is to reduce morbidity and mortality among women
and children in the affected area.
The project will strengthen the existing disease surveillance system, recognition and
response system, and in particular the response capacity for the management of cholera
outbreaks. Essential drugs for treatment of main diseases such as malaria, diarrhea and
acute respiratory diseases will also be provided to health facilities in the affected districts
together with basic medical equipment. To reduce death from measles and stop
transmission in the worst affected areas, measles vaccination of all children 9 months -15
years of age will be carried out in selected geographical areas (contiguous zones).
Emphasis will be place on both coverage and the quality of the campaign including
injection safety and safe disposal of sharps. To ensure potent vaccine a limit amount of
cold chain equipment will be provided.
Malaria is the main killer of children in Zambia where insecticide treated nets (ITNs) are
sold by the private sector in urban areas at high cost and through health facilities in rural
areas. Because the current crisis will greatly diminish the possibility of households to
purchase nets and protect the members against malaria, subsidized ITNs will be provided
to vulnerable households. Drugs will also be provided for treatment of malaria. To ensure
proper use of the nets social mobilisation and training on malaria control will be
supported.The Integrated Management of Childhood illnesses (IMCI) will be
implemented in targeted localities, in order to ensure proper case management of the
most common causes of mortality and morbidity among children.
- -
53
WHO Health brief on Southern Africa-July 2002
FINANCIAL SUMMARY
Activities
Capacity building in integrated disease surveillance
Essential diagnostic supplies for surveillance and case
management
Malaria drugs
Targeted IMCI
Disease surveillance/cholera outbreak control
Essential drugs and basic equipment
Measles immunization campaign
Malaria prevention and control
Monitoring and supervision
Programme support costs/technical assistance
Admin costs
TOTAL
- -
Requirements (US$)
100,000
100,000
200,000
200,000
50,000
150,000
300,000
400,000
100,000
170,000
35,000
1,805,000
54
WHO Health brief on Southern Africa-July 2002
Mozambique
Appealing Agency
Project Title
Project Code
Sector
Themes
Objective
Targeted
beneficiaries
Implementing
partners
Project duration
Funds requested
World Health Organization
Preparedness and response to diarrhoeal diseases,
malnutrition, immunisable diseases and other drought related
health threats
Health and Nutrition
Preparedness and contingency planning.
Support health services
Monitor nutritional situation and manage malnutrition cases.
Prevent and treat drought related diseases.
The 43 districts in 5 affected provinces (Gaza, Manica,
Inhambane, Sofala & Tete) with a population of 515,000
WHO, MOH, NGOs, CBOs
12 months
US$ 1,300,000.00
1. NUTRITION
Background/Justification
Malnutrition is a major problem in Mozambique, the total chronic malnutrition (stunting)
rate is 36% and the acute malnutrition rate (wasting) is 8% among children 0-35 months
(DHS, 1997). These malnutrition rates are already extremely high “in normal times”, as
the proportion of stunting is 17 times and that of wasting is 4 times the rates expected in a
healthy well-nourished population.
Extreme food shortages in an already non-optimal situation can be precarious and have
very negative consequences, as serious malnutrition results from an acute exacerbation of
chronic under-nutrition. Highly vulnerable groups among the population, usually children
<5 years may show an increased morbidity (especially infectious diseases) and mortality,
which is already high in Mozambique; 116.9 per 1,000 in children 1-<5 years. Therefore
even moderate malnutrition if left untreated rapidly may increase the case fatality rate.
Project Strategy and Complementarity
WHO proposes to participate in collaboration with WFP, FAO, UNICEF and other
humanitarian agencies to the monitoring of the nutritional situation and the survey of
food consumption patterns with the aim to promote good nutritional practices through
IEC activities. WHO will also participate in the training of nutrition focal points in the
management of malnutrition.
Main activities / Inputs
 Monitor the nutritional situation in the affected areas
 Participate in nutrition assessment in the affected areas, together with the
Ministry of Health and other development humanitarian partners
 Assist the Ministry of Health in active monitoring or increased surveillance of the
nutrition status of children <5 in the affected areas
 Participate in surveys of food consumption patterns
 Participate in training of nutrition focal points at the province level in nutrition
interventions during emergency including IEC
- -
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WHO Health brief on Southern Africa-July 2002
Major outputs
 Quarterly reports of the nutritional situation
 Technical assistance provided to MoH for nutritional assessment in the affected
areas
 Technical assistance provided to conduct surveys of food consumption patterns
 15 nutrition focal points at the province level trained in nutrition interventions
during emergency
 IEC materials updated and adapted
FINANCIAL SUMMARY
Budget items
Technical assistance
Nutrition assessment and surveillance in affected areas
Training of 15 nutrition focal points at provincial level
Update and adaptation of IEC materials
Nutrition education activities in affected areas
TOTAL
- -
US$
120,000
10,000
15,000
10,000
10,000
165,000
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WHO Health brief on Southern Africa-July 2002
2. HEALTH
Background/Justification
Cholera, dysentery and Other Diarrhoeal Diseases
The incidence of diarrhoeal diseases usually increases during a drought. This is
exacerbated by a reduced access to clean drinking water, to sufficient water for personal
and household hygiene, and to existing poor sanitation practices. Cholera is endemic in
Mozambique and therefore the likelihood of an outbreak can be considered as high.
Immunisable Diseases
In 2001, only 47% of children between 12 and 23 months were fully immunised: 67.5%
measles, which is still endemic in Mozambique with outbreaks yearly. Urban/rural
immunisation disparities exist (85% and 36% respectively. Coverage of tetanus toxoid
vaccination for mothers giving birth stands at 34% (urban 58% and rural 27%). In 1998
Mozambique experienced outbreaks of Meningococcal Meningitis and with the drought
there is an increased risk.
Skin / Eye Infections
A reduced access to sufficient water for personal and household hygiene can lead to
escalation in the number of cases of infections relating to cleanliness. Skin irritations and
conjunctivitis are the most common of these, and previous experience in Mozambique
shows that this is likely to become a significant issue.
Malaria
Accounting for 70% of all paediatric admissions, malaria is also the major cause of
anaemia, low birth weight and miscarriages. In dry conditions, a reduction of malaria
transmission could normally be expected. However this can reverse if even reduced
rainfall creates mosquito-breeding sites. Again, the morbidity and mortality rates will be
influenced by the nutritional status of the population.
Plague
Plague is endemic in Mutarara and Morrumbala districts in Tete and Zambezia provinces
with the first outbreak reported in 1976. Past outbreaks have been related to the great
droughts that affected the Southern Africa as contacts with rats is increased with search
of food from both humans and rats. In 2002, Morrumbala district reported 73 cases up to
the end of May and the Malawi neighbouring district of Nsanje 71 cases.
Project Strategy and Complementarity
In accordance with the UN Contingency Plan, WHO in collaboration with UNICEF will
provide technical, financial and material support for the implementation of activities in
response to the drought. These include activities to reduce the threat of diarrhoeal
diseases including cholera and dysentery, and the threat of outbreaks of immunisable
diseases, meningitis, plague and the increase of severe cases of anaemia due to malaria.
WHO will assist the Ministry of Health with co-ordination efforts and with the planning
at central level, and at provincial level with the participation of 10 epidemiologists
Main activities / Inputs
 Trans-border cooperation with neighbouring districts of Malawi, Zimbabwe, South
Africa in surveillance and response on epidemic prone diseases (plague cholera etc..)
 Assessment of health facilities capacity in affected areas
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WHO Health brief on Southern Africa-July 2002





Guarantee normal functioning of the health services for provision of basic preventive
and curative health care
Provision of IEC materials to increase knowledge and to influence positively health
seeking behaviour especially in relation to diarrhoeal diseases, complications in
pregnancy, to complications (anaemia) in malaria and to sexual behaviour related to
HIV/STI/AIDS risk, alcohol abuse mental or psychological disorders
Acquisition of drugs, laboratory transport media and reagents.
Provision of financial support to operational costs of treatment centres in case of
outbreaks of cholera, dysentery, plague, meningitis and measles (fuel, additional
staff, communication etc.)
Reinforce surveillance of the priority diseases including HIV/AIDS at provincial
level with the involvement of 10 epidemiologists.
Major outputs
 Inter-country meetings
 Health Facility capacity to respond to increased health needs diagnosed
 Drugs, laboratory transport media and reagents provided to affected districts
 IEC materials reproduced and disseminated to affected districts
 Operational funds provided to treatment centres in case of outbreaks
 Monthly reports of epidemiological situation in the affected districts produced by
provincial epidemiologists
FINANCIAL SUMMARY
Budget items
Inter-country cooperation meetings on epidemics
Assessment of health facilities capacity in affected areas
Drugs, laboratory transport media and reagents provided to affected
districts
IEC materials reproduced and disseminated to affected districts
Operational funds provided to treatment centres in case of outbreaks
Technical assistance
TOTAL
- -
US$
60,000
120,000
800,000
10,000
80,000
65,000
1,135,000
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WHO Health brief on Southern Africa-July 2002
Health and Nutrition
GOAL
Sector
Objectives
To minimise the
impact of the
present
food
crisis on the
health
and
nutritional status
of the affected
population
To contribute to
the reduction in
malnutrition
through
the
management of
severe
malnutrition
To prevent and
control
the
outbreak
of
drought related
epidemic
diseases
Reduce morbidity and mortality due to drought related diseases
Ouptut
Indicator
Assumptions/Risks
Technical assistance
provided to MoH for
nutritional assessment
in the affected areas
Technical assistance
provided to conduct
surveys
of
food
consumption patterns
in the affected areas
IEC materials updated
and adapted
No. of assessments Willingness of Nutrition
conducted
Unit, of MoH to carry out
assessment
Report on food
consumption
patterns
IEC
material Funds for reproduction
available
in provided to the MoH by
affected districts
partners
15 nutrition focal No. of nutrition
points at the province focal
points
level
trained
in trained
nutrition interventions
during emergency
Health
facility Reports of health
capacity assessed
facility
assessments
Reinforcement
of Monthly reports
surveillance
of on epidemic prone
priority diseases by diseases
epidemiologists
Treatment centres for No.
of
staff
epidemics operational participated
in
refresher courses
in
case
management
Provision of drugs, Availability
of
laboratory transport specific essential
media and reagents
materials
for
diagnosis
and
treatment
IEC
materials IEC
material
reproduced
and available
in
disseminated
to affected districts
affected districts
Trans-border
No. of meetings
Meetings
held
- -
Willingness of MoH to
conduct assessments
Epidemiologists in place in
the affected provinces
Current knowledge and
skills of staff in case
management of the specific
disease
Availability and Interest of
neighbouring countries
59