Annex IV: Rapid Assessment – Medical Infrastructure and Capacity:
“The burden of malaria is much too much” Abukar Public Health Officer, Mandera
There are considerable needs in the medical field existing across Mandera and Wajir
districts. The main causes of morbidity and mortality in both districts were malaria,
diarrhoeal disease (with an increase in acute watery diarrhoea after the flooding), acute
respiratory tract infections, and TB. However Wajir district is also on high alert for typhoid
fever after past outbreaks, the public health officer is attempting to vaccinate all food
vendors against typhoid with some success in Wajir town. Wajir has also had several cases
of Kala-azar, although these were cases brought in from a neighbouring district. The cases
were treated in Merlin & MoH facilities, however it is thought the caseload may rise once
roads reopen.
The flooding is potentially a public health disaster, and as malaria and diarrhoeal disease
case loads rise, the threat of cholera and typhoid remain ever present for agencies in Wajir
and Mandera. In Mandera district the MoH, AAH, and MSF Belgium (pulling out mid
December 2006) are focussing on nutrition and public health.
Mandera district population is approximately 563,763. The number of under-fives is
estimated to be 90,202, constituting 16% of the population. Approx family size is 7-9. Wajir
district population is estimated at 505,000 with approx 85,850 under 5s. 1 As with Mandera
district approx family size is 7-9.
Mandera District Medical Infrastructure and Agencies Working:
In both districts the basic infrastructure is of district hospitals, in Mandera and Wajir towns,
with two sub district hospitals & Health Posts in outlying areas. It is aimed to have a health
post in each division, however this has not yet been achieved and areas such as Malkamari
& Warankara are without, with approx 40-50km walk/drive (currently not possible due to
the flooding) to reach health services. In Mandera district there are approx 18 GoK
facilities, however these are severely restricted by human resource issues. Some are
without qualified medical personnel, although the government aim to have two qualified
medical personnel in each facility.
Clinical facilities:
MoH district hospital – Mandera town (secondary level hospital with surgical unit, 80 bed
capacity, capacity to cope with complications in child birth and most common diseases,
however closest tertiary level hospital said to be Nairobi.)
MoH subdistrict hospitals
MoH mobile teams – across district, focussing on health and nutrition, EPI and distribution
of aquatabs.
MoH Health Posts - one in all but Malkamari & Warankara: Clinical screening, EPI, ANC,
PNC, no surgical facility. Short on drugs and personnel.
Kenya Red Cross – three medical centres
EPI:
EPI coverage is estimated at approx 55%2 with mobile teams covering the districts and
referring communities to health posts, or district hospitals. A major issue concerning EPI is
cold chain management, this was reported to be very difficult to maintain with many solar
powered fridges breaking down and no moneys allocated to maintenance.
Referral Services:
AMREF – offers a referral or medical evacuation service, however it was reported that
AMREF cannot come every time, and the service has to be funded, thus it is a negotiated
process, sometimes the patient can pay for evacuation to tertiary level hospital, sometimes
this is waived by AMREF, or the MoH may pay.
1
2
1999 Population census estimates. Wajir under 5s estimated using 17%.
MoH Mandera District
MoH Ambulance – one for the district, not currently in service.
Nutrition facilities:
MoH – SFC, and TFCs supported by Merlin in Wajir district.
AAH CTC (TFC, SFC, & OPT) – Mandera town and mobile units across the district
MSF (leaving mid December) – Nutrition programme, and clinical support through MoH.
Pharmaceutical Supplies:
MoH – standard drug list distribution to health posts.
DANIDA – pharmaceutical support, capacity building for MoH staff.
Pharmaceutical supplies are “cost shared”, i.e. available at significantly discounted prices.
However targeting needs to ensure those who cannot afford medical care have access to
treatments.
Human resources are a huge issue within the district, many health posts are not staffed by
qualified personnel, or have low staffing levels, such as one nurse per post. Those better
staffed would house a clinical officer (sub medical doctor level) and a nurse. More
information is currently being gathered concerning health post staffing and mapping of
where and what facilities these offer.
The GAM rates across Mandera district are alarmingly high – most actors estimated between
27-303, with the SAM estimated at 2.1.4There are concerns that this rate will rise rapidly
after the flooding, again due to access and increase in diarrhoeal diseases.
HIV/Aids is a growing concern, although rates are thought to be low (around 2% 5). There are
several VCTs (one with the district hospital, and one each with the sub district hospitals),
however they are little used, and culture and custom will be extremely important in
furthering this issue.
Maternal mortality is thought to be high, it is estimated at 570 per 100,0006 however, as
this is also thought to be hugely underreported. Traditional birth assistants operate across
the district and DANIDA is said to be training these health workers in best practice and
infection prevention to ensure safe practice. The MoH are advocating for births to take
place in the district or sub district hospital, however this is currently at odds with the
traditional practices of the community.
Wajir District Medical Infrastructure & Agencies Working:
Wajir also relies on district level hospitals (Wajir town), four sub district hospitals, and
health posts in outlying areas.
Clinical facilities:
MoH facilities – 38 health posts across the district.
Merlin – supporting 21 of the 38 HPs with basic equipment, capacity building, and EPI.
EPI:
EPI coverage is estimated at 51.4% with measles coverage at 66.1% (Areas supported by
Merlin has estimated coverage of 67.2%)
Referral Services:
AMREF – as above.
3
MSF-Belgium, although in their area of operations in El Wak subdistrict this has fallen to 15 after
therapeutic, supplemental and blanket feeding. AAH & MoH.
4
MoH Mandera District
5
MoH Mandera District
6
Public Health Officer, Mandera District
Referral is mainly to Wajir district hospital, or Nairobi if a tertiary level facility is required
or possible.
Nutrition facilities:
Merlin – 2 stabilisation centres for the severely malnourished a third is planned for Bute
division (accessible from Bute, Buna & Gurar divisions.) SFP, and OPT also covered.
Pharmaceutical Supplies:
Gaps in Information:
Due to the rapid nature of the assessment there left several gaps in information
MEDS – Mandera Educational Development Society
Health and hygiene promotion is completed through education networks within schools.
CHWs – Was not able to meet with or talk to any community health workers to find out
about their capacity or needs.
Key Contacts:
Mr Abukar – Public Health Officer Mandera District
Public Health Officer Wajir District
Dr Musillo – Head of MoH Nairobi tel. 0721 44 35 25
Dr Muqtar – Head of Mandera District Hospital tel. 0722 600991
Key Concerns and recommendations:
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Diarrhoeal disease admissions in the Wajir paediatric ward had doubled in
November from Octobers admissions (56 in October, 99 in November.)
Vector control – there is little evidence of vector control across the two districts
and a widespread long term campaign to combat the rising levels of mosquitoes is
urgently required.
Inaccessibility of areas and sites due to the flooding – mobile nutrition teams are
unable to move in western districts of Mandera, and health teams are unable to
access 17 sites across Wajir district due to damage to access routes.
Of immediate need are NFIs such as hygiene kits (soap, nail brush, nail cutter,
towel etc.) mosquito nets and water purification tablets. (it was felt that jerry cans
were commonly held.)
Pharmaceuticals need to reach those health posts, and hospitals, in particularly
coartem or other malarial treatments were requested.
Public health messages & health and hygiene promotion needs to be expanded to
be delivered to the community regarding avoidance of faeco-oral diseases, signs,
symptoms and treatment.
Targetting of distributions – it was reported that currently mosquito nets are
targeted at children of 9 months receiving first DPT dosage, this needs to be
reviewed to initially expand EPI coverage, but also to target through ANC to ensure
those first month’s of a childs life are protected.
The flooding may further exacerbate the nutritional situation, and therefore it will
be necessary to monitor this closely, especially if gaps arise as agencies depart.
Counselling service for survivors of SGBV and other violent crimes, there is
currently no facility for this, despite the high rate of occurrences in both districts,
this may be best covered in conjunction with the medical services, and through
local partners.
Cold chain maintenance – electricity is not available in many areas of Mandera and
Wajir district and budget is not currently available for maintenance of this.