Target Population: 44,000 persons, Union Council Shawal Muizullah and Union Council Talhatta

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2 RMF-HOAP Health Project Talhatta, Balakot Mansehra NWFP, Pakistan 3- Months Consolidated Morbidity Report Reporting Period : January 1,2007 to March Background The earthquake of October 8, 2005 destroyed most of the Frontier (NWFP) and Kashmir (AJK) regions of Pakistan and caused widespread death and devastation. An area of approximately 30,000 kilometers was affected where more than 3 million lived in hamlets perched on Himalayan mountain slopes and valleys. This catastrophic disaster was described as the world s third deadliest natural disaster in the last 25 years that killed more than 87,000, injured more than a 100,000 and made 3 million people homeless in the highest mountain ranges in the world (Brennan RJ and Waldman RJ, New England Journal of Medicine, April 2006). Aside from the loss of life and property, this natural disaster also left thousands of people injured. Most of these people s suffering increased further as they were subjected to the harsh natural elements. HOAP established a medical relief camp in Jabri (UC Shohal Moizullah), District Mansehra) where doctors volunteered their services to help alleviate the sufferings of the residents of remote villages atop the mountains close to Balakot. The medical camp ran for more than three months. During that period, patients were treated for crushed injuries, infected wounds, orthopedics problems, post operative care and acute illnesses sustained as a result of the earthquake, others experienced treatment for chronic diseases lying dormant for years due to the remoteness of the region. As the BHU established by the Government had been completely destroyed, the need for sustained health care for the residents of the area was felt strongly. RMF-HOAP Health Care Project The result of this was a partnership with Real Medicine Foundation USA in mid- January This partnership resulted in the establishment of RMF-HOAP Health Care Unit Shohal Moizullah. This Health Unit employs a full time MBBS Doctor, a Medical Technician, two LHVs and a Dispenser. The Health Unit is outfitted with a complete range of medical equipments, including a Nebuliser, Glucometer, Deep Freezer/Refrigerator (for some medicines and vaccines), an Oxygen Gas Cylinder, a complete ENT Diagnostic set, and a well equipped room for examining Gynecological cases. Considering the weather conditions, the Health Unit is also furnished with two room coolers, heaters, and an

3 Electric Power Generator. An ECG machine and a laptop computer have recently been added to the list of equipment in the Health Unit. This assists in diagnosing Ischemic Hearth Disease patients and reduce referral load to other hospitals. In December 2006, considering the size of the catchment area, the health unit was shifted from Jabri, Shohal Moizullah to UC Talhatta where a larger population base could be served. Through this move, patients from Jabri, UC Shohal Moizullah and Union Council Talhatta could be served simultaneously.the health unit is now serving a larger number of people as the catchment area was smaller in Jabree. It is now accessible to a larger number of people. Major health problems in the area include Acute Respiratory Infections (ARIS), Diarrheal diseases, Infectious diseases, Gastric diseases, Gynecological diseases, Skin Infections and Cardio Vascular Diseases. This Health Unit is regularly supplied with IV Drips, IV Anti-biotics, IV sets, Oral Re-hydration Salts, Anti-hypertensive, Oral Anti-biotics, Anti-pyretics, Analgesics, Examination gloves & Masks, and Vitamins. As the terrain of the area is rugged and mountainous, a Jeep has been outfitted as an ambulance for the Health Unit. This vehicle can easily negotiate the difficult terrain, transporting referred patients to secondary and tertiary care units in neighboring larger cities and towns. PROGRAM STRUCTURE Goal To improve the health and wellbeing of those affected by the Pakistan earthquake of October 2005, particularly the 44,000 people located in the Union Council Shohal Muizullah and Union Council Talhatta. Target Population: 44,000 persons, Union Council Shawal Muizullah and Union Council Talhatta Project Objectives: o To provide a standard package of primary health care incorporating disease prevention, health promotion and health education o To improve a) the coverage and utilization of services by remote village populations; b) access to healthcare for girls and women; c) the standard of health care o To involve the government and local communities in the health care system and build their capacity to take ownership of the system after completion of the project. o To involve and train government health workers who wish to work in this area.

4 3- Months Consolidated Morbidity Report from January to March, 2007 From 1st January 2007 to 31 st March 2007, 2903, patients were diagnosed and treated at the RMF-HOAP Health Unit. Since its relocation in December 2006, the RMF- HOAP Health Unit is more accessible to the people of this area, especially women and children. During the last quarter the figures showed 55% male, 45% female and 22% children visiting the RMF-HOAP Health Unit. However, the new location of the Health Unit saw a greater number of women and children diagnosed and treated at the RMF-HOAP Health Unit. The numbers included 56% females, 28% children and 44 % male patients from the surrounding villages during January March The diseases diagnosed and treated in the area were a result of the weather and living conditions of these people. Most patients complained of Acute Respiratory Infections (ARI), making up more than 25 % and Diarrhea (Bloody and Non Bloody), making up 7.3 % of the total consultations. At the same time, Dyspepsia stood at 7.34 %, while Scabies constituted 8.23%, General Body Aches and Weaknesses made up 8 % and 2.38% were treated for Constipation.9.34% patients were treated for Urinary Tract Infections(UTIs).Considering the trauma these people had been through, Anxiety and Hyper-tension were also among the major conditions treated at the Health Unit making up 6.07%. Cases of suspected Meningitis(2), Acute Abdomen(2), Mumps(1), Burns(3), BPH(2), Acute Appendicitis(3), Spinal Cord Injured(SCI) and Acute Jaundice Syndrome(2) were few in number. The Health Unit played a pivotal role in diagnosis and initial treatment for these conditions. These were subsequently referred to Secondary and Tertiary Care Hospitals for further treatment. Around 10 to 15 patients are seen at their own locations each month The Health Unit has generated Monthly Morbidity Reports(MMR) for patients and diseases treated at the Unit. These reports have also been shared with the Ministry of Health(MOH) and the World Health Organization (WHO). Activities carried out during Reporting Period: January to March 2007 Outreach Community Program Dr. Martina s Visit to RMF-HOAP Health Project in,talhatta Brett R. William s Visit to RMF -HOAP Health Unit in,talhatta

5 Outreach Community Program (Maternal and Child Health Training Workshop- February 2007) Real Medicine s country director for Pakistan Dr. Rubina Mumtaz arranged this program for number of potential females from the project area. This training workshop was considered necessary because the 8-months consolidated morbidity report of the health unit indicated that there was a seasonal variation of the most commonly prevailing diseases. The majority of these diseases were preventable at gross root level, by simply educating the people. The first phase of this outreach program was to meet with the key stakeholders in the two Union Councils. Series of meeting with these stakeholders were held in Nov-Dec 2006 in which there cooperation was sought and obtained. The main discussion with the stakeholders was the need for health education at the gross root level where the importance of hygienic living and eating conditions was a first step for preventive care in the home. The response from the people was so positive therefore it was decided to launch the program in February To this connection, a two-day training session was organized for the females of union council Talhata, Shohal Moezullah and the nearby catchment UCs. The training was aimed at taking pro-active measures by raising general awareness hence enabling them overcoming issues regarding family health. These females were trained as CHWs with the quest to protect families from certain health hazards. The trainers were Dr. Rubina Mumtaz and Dr. Javeria Abdullah who has had 10 years of experience as a trainer in LHW Program of the Pakistan Government that was launched in 1996 in collaboration with WHO. 47 females from 13 villages under the outreach program conducted at RMF-HOAP s female staff house in Talhata. The specific objectives of the training course were to make the audience learn about the following themes; To identify high risks potentially involved during pregnancies Encouraging family planning. Counseling over nutrition during pregnancies Breast feeding Post-partum care Educating community members on preventing and protecting from scabies and their side affects Raising awareness regarding social hygiene Antenatal care

6 Dr. Martina s Visit to RMF-HOAP Health Project Dr. Martina Fuchs, CEO of Real Medicine Foundation USA, paid a detailed visit to RMF-HOAP health centre in Talhata, district Mansehra. She was accompanied by Dr. Rubina (RMF s country director for Pakistan), Aslam Aman (CEO HOAP) and Dr. Zahoor (HOAP Health Coordinator). On the first day of her visit a meeting with public representatives and notables of the area was arranged at the RMF-HOAP Health Unit, Talhatta site. The purpose of this meeting was to discuss issues pertaining to the health unit, review the progress and develop a consensus on the future operations. While discussing about the possibilities of upgrading the existing health setup to a full-fledged MCH centre, Dr. Martina, said that keeping in view the performance of the health centre, Real Medicine Foundation would make efforts to upgrade the centre in future. Dr Martina also took a round of the health centre to assess the infrastructure and the facilities provided. On the second day of her visit Dr. Martina traveled to Balakot city to review the landscape and the living conditions of the earthquake affected people. She then went on to visit two SCI patients who were injured during the earthquake. These patients were Awais and Mohammad Rafiq. HOAP has been providing these and many other SCI patients stipends worth of Rs.6000 every month in order to enable them to bear out the expenses occurring during treatments. It is an attempt to make them continue with and maintain their livelihoods options with modest possible levels. Awais and Rafiq are students whom sustained injuries when their school collapsed upon the many students during the earthquakes. Dr. Martina met with these two scholarship holders as well as their parents to see the impact of the financial support provided to them.

7 Coming back from Jabree, we arrived the health unit, where we had lunch. Dr. Martina went around to see the facilities available to staff and patients at the base camp. After seeing the situation, she very graciously offered some extra funds to be used for building toilets, bathrooms and other related facilities in the unit. Dr Martina thanked the project staff for the great achievements hence expressed great satisfaction over the extraordinary performance of the project while serving the poor communities.

8 Brett R. William s Visit to Real Medicine Foundation (RMF) -HOAP Health Unit in,talhatta Mr. Brett R. William from Direct Relief International (DRI) visited the RMF-HOAP health centre in Talhatta, in the district of Mansehra on 22 nd March The project covers a population of approximately 119,364 people, from the five union councils such as Talhatta, Shohal Mazulla, Garlat, Gari Habibullah and Balakot. Thus far, the health unit has provided treatments to approximately 12,800 patients (54 percent females and 46 percent males). We left for Balakot, a major city of the district of Mansehra, early in the morning to ensure we would have enough time to visit the RMF-HOAP Health Unit and two spinal chord injury (SCI) patients in one day. We started with a visit to a health project (HOPE clinic) funded by DRI, similar to the Talhatta health unit in the city of Mansehra, which began after the October 2005 earthquake. Then we moved to a school project called HOPE School, where Mr. William met with schoolchildren and staff. On our way to Balakot, we visited the HOAP Regional office in Mansehra where Mr. William met with the staff. We reached Balakot at about 12am and visited the RMF-HOAP Health Unit where Mr. William was greeted by HOAP staff. They enthusiastically gave him a detailed tour of the different facilities, including the pharmacy, LHV room, OPD room, emergency room and ward. The staff told Mr. William that patients are not charged for health services such as doctor consultations, treatments and medicines. When patients are unable to reach the unit on their own, the medical staff members visit them in their homes. Alternatively, patients can use ambulance services (RMF vehicle) to travel from their house and back. The unit is open round the clock.

9 After Talhatta health unit, we went to visit two SCI patients in Jabri. Our first patient was fifteen year-old Mian Rafique. His shelter home was crowded with ten family members, including aunts and sisters not yet married. Rafique s elder brother who is his full time caretaker explained their need of a proper home, treatment, and education for Rafique. He also wants to be able to go to school and live in a disable-friendly home. Our next patient was fifteen year-old Awais Rehman's. His parents took us to his shelter where he lays on a small charpai in a dark and little area. He seemed in excellent condition and managed to get up and walk by himself. However, he is still suffering from back pain and could walk for only a limited time. We then came back from Jabri and had lunch with Mr. William at the Health Unit before departing for Islamabad.

10 % of Male & Female Patients ( Jan-March 07) Gender Total % Female % Male % Grand Total % % of Male and Female patients Male 44% Female 56% Monthwise flow of patients Date Total % Jan % Feb % Mar % Grand Total % Monthwise flow of patients 40% 35% 30% 25% 20% 15% 10% 5% 0% Jan Feb Mar

11 Age and monthwise flow of patients Age Jan Feb Mar Grand Total % 0-5 years % 5-12 years % 12 and above % Grand Total % Age and monthwise flow of patients (Jan to March 07) 0-5 years 13% 5-12 years 15% Jan Feb Mar 5-12 years 0-5 years 12 and above 12 and above 72% Weekwise flow of patients ( Jan to March 2007) Date Female Male Grand Total % 1/4/2007-1/10/ % 1/11/2007-1/17/ % 1/18/2007-1/24/ % 1/25/2007-1/31/ % 2/1/2007-2/7/ % 2/8/2007-2/14/ % 2/15/2007-2/21/ % 2/22/2007-2/28/ % 3/1/2007-3/7/ % 3/8/2007-3/14/ % 3/15/2007-3/21/ % 3/22/2007-3/28/ % 3/29/2007-4/1/ % Grand Total %

12 300 4 to 10 Jan to 17 Jan to 24 Jan to 31 Jan to 7 Feb to Feb to 21 Feb to 28 Feb to 7 March to Marach to 21 March to 028 March to to to to 1 April 99 Jan Jan Jan Weekwise flow of patients ( Jan to March 2007) 25 to 31 Jan 1 to 7 Feb 8 to 14 Feb 15 to 21 Feb 22 to 28 Feb 1 to 7 March 8 to 14 Marach 15 to 21 March 22 to 28 March 29 to 1 April Age, monthwise and genderwise flow of patients Age Months Female Male Grand Total % Jan % 0-5 years Feb % Mar % <5 Total % Jan % 5-12 years Feb % Mar % 5-12 Total % Jan % Above 12 years Feb % Mar % Above 12 Total % Grand Total % Age and genderwise flow of patients Age Female Male 0-5 years years Above 12 years years 5-12 years Above 12 years Female Male

13 Daily # of Consultation ( Jan -March 2007) Date Female Male Total Date Female Male Total Date Female Male Total 4-Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Jan Feb Mar Total Total Mar Mar Mar Total Average flow of patients for 3 months 33

14 Daily # of Consultation (Jan 2007) Female Male 1/4/2007 1/6/2007 1/8/2007 1/10/2007 1/12/2007 1/14/2007 1/16/2007 1/18/2007 1/20/2007 1/22/2007 1/24/2007 1/26/2007 1/28/2007 1/30/ Daily # of Consultancies ( Feb 2007) Female Male /1/2007 2/3/2007 2/5/2007 2/7/2007 2/9/2007 2/11/2007 2/13/2007 2/15/2007 2/17/2007 2/19/2007 2/21/2007 2/23/2007 2/25/2007 2/27/2007 Female Male Daily # of Consultancies ( March 2007) 3/1/2007 3/3/2007 3/5/2007 3/7/2007 3/9/2007 3/11/2007 3/13/2007 3/15/2007 3/17/2007 3/19/2007 3/21/2007 3/23/2007 3/25/2007 3/27/2007 3/29/2007 3/31/2007

15 S.# Provisional Diagnosis Jan Feb Mar Grand Total Average per month % overall 1 A / N Visit % 2 Acute Abdomen % 3 Acute Appendicitis % 4 Acute Jaundice Syndrome % 5 Allergic Rashes % 6 Anxiety % 7 ARI (Acute Respiratory Infection) % 8 ARI (Pharyngitis/ Sore throat) % 9 ARI(Acute Respiratory Infection) % 10 ARI(Pharyngitis/ Sore Throat) % 11 Arthritis (Osteo) % 12 Backache % 13 Boils % 14 BPH % 15 Burn % 16 Constipation % 17 Diarrhoea (Bloody) % 18 Diarrhoea (Non Bloody) % 19 Dyspepsia % 20 Eczema % 21 Enteric Fever % 22 Frozen Shoulder % 23 Fungal (Oral thrush) % 24 Generaliesd Body Aches % 25 Generalized body Weakness % 26 Gynecological problems % 27 Headache % 28 Hiccup % 29 Hypertension % 30 Injuries/wounds % 31 Joint Sprain % 32 K/C T B % 33 Knee Joint Pain % 34 Mumps % 35 Scabies % 36 Suspected Meningitis % 37 Toothache % 38 Urinary Tract Infection (UTI) % 39 Vomiting % 40 Worms Infestation % Grand Total Provisional monthwise diagnosis ( Jan- March 2007 ) %

16 Provisional agewise diagnosis ( Jan- March 2007 ) Provisional Diagnosis < >12 Grand Total % A / N Visit % Acute Abdomen % Acute Appendicitis % Acute Jaundice Syndrome % Allergic Rashes % Anxiety % ARI (Acute Respiratory Infection) % ARI (Pharyngitis/ Sore throat) % ARI(Acute Respiratory Infection) % ARI(Pharyngitis/ Sore Throat) % Arthritis (Osteo) % Backache % Boils % BPH % Burn % Constipation % Diarrhoea (Bloody) % Diarrhoea (Non Bloody) % Dyspepsia % Eczema % Enteric Fever % Frozen Shoulder % Fungal (Oral Thrush) % Generaliesd Body Aches % Generalized body Weakness % Gynecological problems % Headache % Hiccup % Hypertension % Injuries/wounds % Joint Sprain % K/C T B % Knee Joint Pain % Mumps % Scabies % Suspected Meningitis % Toothache % Urinary Tract Infection (UTI) % Vomiting % Worms Infestation % Grand Total % 13% 15% 72%

17 Villagewise flow of patients ( Jan- March 2007) Village Female Male Total % Alaree % Andrasi % Baga % Bajmury % Balakot % Batangi % Batura % Besaia % Chapra % Codi Pata % Dana % Dunkacha % Garihabibullah % Garlat % Guldairy % Gulmora % Hangrai % Jaba % Jabi % Jabree % Jagir % Janbi % Jania % Junia % Kagal % Kaghan % Kalish % Kashiya % Kashtara % Khaghan % Kotbala % Kumi % Machipura % Manour % Mansehra % Naka % Nala % Narwa % Noora % Pateka % Sarwai % Shawal % Sirya % Soum % Sugdar % Talhatta % Zamiree % Grand Total %

18 Village and agewise flow of patients ( Jan- March 2007) Village >12 Total Alaree Andrasi Baga 1 1 Bajmury 7 7 Balakot Batangi 3 3 Batura Besaia 1 1 Chapra Codi Pata Dana Dunkacha Garihabibullah Garlat Guldairy Gulmora Hangrai 2 2 Jaba 1 1 Jabi Jabree Jagir Janbi 2 2 Jania Kagal Kaghan 1 1 Kalish Kashiya Kashtara Khaghan Kotbala Kumi 1 1 Machipura 1 1 Manour 2 2 Mansehra 7 7 Naka 4 4 Nala Narwa Noora Pateka Sarwai Shawal Sirya Soum Sugdar Talhatta Zamiree Junia 1 1 Grand Total

19 Villagewise flow of Female patients (Jan-March 07) Villagewise flow of Male patients (Jan-March 07) Village Jan Feb Mar Total Village Jan Feb Mar Total Alaree Andrasi Andrasi Baga 1 1 Bajmury 2 2 Bajmury 5 5 Batura Balakot Balakot Besaia 1 1 Batangi 3 3 Batura Chapra Chapra Codi Pata 2 2 Dana Dunkacha 1 1 Dunkacha 1 1 Garihabibullah Garihabibullah Garlat Guldairy Guldairy Jaba 1 1 Gulmora 3 3 Hangrai 2 2 Jabi Jabi Jabree Jabree Jagir Jagir Janbi 2 2 Jania Jania Kagal Kagal Kalish Kalish Kashtara Kashtara Khaghan 2 2 Khaghan 1 1 Kotbala Kotbala Kumi 1 1 Manour 1 1 Manour 1 1 Machipura 1 1 Mansehra Mansehra Naka 3 3 Naka 1 1 Nala Nala Kashiya 2 2 Narwa Noora Noora Pateka Pateka Sarwai Sarwai Shawal Shawal Sirya Soum Soum Sugdar 1 1 Sugdar 1 1 Talhatta Talhatta Zamiree Zamiree 7 7 Total Total