Post-Nargis Periodic Review I

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2 Post-Nargis Periodic Review I 9 Section 2: Fi n d i n g s This section presents the findings of both the quantitative and qualitative research conducted for the first round of the Periodic Review. Information from the quantitative survey is presented in the maps and histograms while extracts from the quantitative research are presented in text boxes. Supplementary text draws on both qualitative and quantitative information, and is informed by consultation with the Clusters. Thawtar Khin s story We want to rebuild our home. The tent we built is not in good shape. The whole family is living in it and it may collapse. There s a very big puddle with a bad smel nearby that makes the tent unliveable. I m looking forward to the day when my children can attend school. Right now food is our greatest need. The findings are presented by sector. Taken together, they provide a snapshot of the situation for communities living in the areas worst affected by Cyclone Nargis. The principal focus of the findings is a needs assessment. The receipt of relief and steps towards recovery since May 28 are also considered to some extent. It is important to note that many of the challenges facing the Cyclone-affected population are interlinked and cut across sectors. For example, the loss of boats directly affected the ability of people who caught fish before the Cyclone to earn a living. However, without boats to travel on the networks of rivers and canals that link the communities of the Delta, the mobility of the entire population was reduced. This made it more difficult to reach education and health services or to trade goods at markets. Similarly, the lack of boats makes delivering aid and assistance more difficult. Therefore it is recommended that results be considered in an integrated manner, drawing linkages between sectors. Where possible, results from the VTA are used to inform the analysis. However, having drawn on the experience of the VTA to improve the methodology used for the Periodic Review, direct comparisons are not always possible. Some indicators, such as those relating to aspects of maternal and child health, have not been collected for the Periodic Review. This is because a general household survey may yield very small sample sizes for indicators that apply to a small proportion of the population being surveyed. Such small sample sizes give rise to very imprecise estimates at the community level that can be very difficult to map. For example, in 18 communities analysed there were only 17 children, on average just one or two children per community. Figure 5 shows the sample size from the quantitative survey. Figure 5: Quantitative sample size Number of Communities 18 Number of Households 2,376 Household population 13,546 Number of Children 4,862 < 6 months 17 6 months to 5 years 1,456 > 5 years to 15 years 3,236

3 1 Post-Nargis Periodic Review I 2.1 He a l t h Three components reflecting the health situation in the Cyclone-affected area are covered in this chapter: the functioning of the existing health system; disease burden in the community; and receipt of relief items. In addition, linkages are drawn with nutrition and WASH. The VTA reported that close to 75 per cent of health facilities in the survey area were damaged. At the same time, an additional burden of health problems could be expected in the community as a result of the Cyclone, in particular, gastro-intestinal and mental health problems.. 1 In a well functioning health sector, people have access to facilities and staff, health services are available from those facilities and staff, and those services are utilised. The indicators used here seek to give an overview of these characteristics. Figure H1: PHC facilities are within 1 hour travel time Time to nearest PHC is <= 6 minutes 1% G u l f o f M o t t a m a ( G u l f o f M a r t a b a n ) Low: % For access to health care indicators, high proportions with good access to health care is the desired outcome and shown in green on the Maps. The percentage of households in surveyed communities that reported travel times to Primary Health Care (PHC) facilities being within one hour ranged from to 1 per cent. In more than half of the communities surveyed, almost all households said that their travel time was less than one hour (the highest bar in the histogram and shown in green and yellow on Figure H1). Communities in the southern and central parts of the Delta, such as Myaungmya District, and and Ngapudaw Townships, reported the lowest access to PHC as measured by travel times (shown in red on Figure H1). 1 TCG (June 28) Post-Nargis Joint Assessment, pp 7-8.

4 Post-Nargis Periodic Review I 11 Figure H2: Waiting time at PHC facilities is less than 1 hour 1% Low: 63% When people arrive at PHC facilities, the waiting times are usually less than one hour. The percentage of households reporting waiting times of less than one hour ranges from 1 per cent to a low of around 6 per cent in the far south of the Delta and parts of greater Yangon (shown in red on Figure H2). In more than 8 per cent of communities, almost all households reported waiting time of less than one hour (the highest bar in the histogram and shown in green and yellow on Figure H2). Thawtar Khin s story Currently, Thawtar Khin s mother is sick and the family does not have enough money to send her to a clinic. There is no doctor in the village and the nearest one is very far away, so they cannot send her.

5 12 Post-Nargis Periodic Review I Figure H3: Health workers in the community 1% Low: % Community Health Care Workers (HCWs) are particularly important in rural and remote settings, where accessing health facilities can be costly in terms of time and transport costs. These considerations are less important in urban settings which may explain the concentration of low values (shown in red on Figure H3) around Yangon. The percentage of households reporting the presence of a HCW in their communities ranged from to 1 per cent. As seen for previous indicators, the most common response was in the 9 to 1 per cent bracket (the highest bar in the histogram and shown in green and yellow on Figure H3). Together, H1, H2 and H3 give a picture of the level of access to health facilities and HCWs. The areas that have the least access across the three indicators are concentrated in the Delta south of and.

6 Post-Nargis Periodic Review I 13 Figure H4: Coverage of Measles vaccination 1% Low: 44% The coverage of Measles vaccination directly represents the protection of a population from Measles, and is also a proxy indicator of outreach by the health system into communities and the coverage of other vaccines. The range of coverage is from 44 to 1 per cent. The benefits of herd immunity 2 begin at around 8 per cent coverage (the two tallest bars of the histogram and shown in green and yellow on Figure H4). Less than 2 of the communities surveyed had coverage below 8 per cent, concentrated in Township (shown in red on the Map). 2 Herd immunity is the resistance of a group or community to invasion by the spread of an infectious agent. It results from the lower probability of the agent being transmitted from an infected person to a susceptible person when a high proportion of people are immunised.

7 14 Post-Nargis Periodic Review I Figure H5: Medicine available at PHC facilities all or most of the time 1% Low: % Availability of medicines is a proxy indicator for the functioning of the health system. In only one third of communities did all households report that medicine was available all or most of the time at Primary Health Care (PHC) facilities (shown in green on Figure H5). On the histogram, the distribution of communities is more spread out than for previous maps where results were concentrated on the far right. There is also a discontinuity between access to health care and availability of medicine. The greatest issues with availability occur in the central part of the Delta north of around (shown in red on Figure H5) where access to health care, as indicated on Figures H1 and H2, is relatively good.

8 Post-Nargis Periodic Review I 15 Figure H6: Prevalence of diarrhoea 55% Low: % For indicators of disease prevalence, a low prevalence is the desired result and is shown in green on the maps. The prevalence of diarrhoea in children reported by 14 day maternal recall (mothers recollection of the 14 day period preceding the household survey) shows significant spatial variation. The most common results are between to 2 per cent (shown in green and yellow on Figure H6), with around one in four communities having a prevalence of diarrhoea in children of more than 2 per cent. The highest percentage of households in a community reporting diarrhoea was up to 55 per cent. Prevalence of more than 4 per cent was found in part of Ngapudaw Township and Myaungmya District (areas shown in red on Figure H6). Of particular concern is part of Ngapudaw Township (west of ) where there is also a high proportion of households with severe food insecurity (see Figure F3). The combination of food insecurity and diarrhoea predisposes communities to increased rates of undernutrition. The same area appears to have relatively poor sanitation practices (see W6 and W7) that may also contribute to the prevalence of diarrhoeal disease.

9 16 Post-Nargis Periodic Review I Figure H7: Prevalence of fever 8% Low: % The distribution of the prevalence of fever by 14 day maternal recall, which is a non-specific indicator of infectious disease, is clustered within the high prevalence areas. This clustering is consistent with infectious phenomenon. As reported by maternal recall during the 14 day period preceding the household survey, the prevalence of fever ranges from to 8 per cent. The highest prevalence is in the central delta region (shown in red on Figure H7). Taken together, the indicators of fever, diarrhoea (Figure H6) and undernutrition (Figure N2) suggest a significant infectious disease issue in the central and western areas of the Delta, mainly in Myaungmya District, and north of Yangon.

10 Post-Nargis Periodic Review I 17 Figure H8: Received medical assistance since Cyclone Nargis 68% Low: % In around one third of communities, at least one of the households surveyed had received medical assistance since Cyclone Nargis (green and yellow on Figure H8). This is a simple indicator of reach, not the depth of coverage or of provision being sustained over time. The assistance given is geographically concentrated in the areas along the path of the Cyclone, particularly around where more than half the households had received medical relief assistance (shown in dark green on the Map). This includes northern Township and parts of and Townships). Lower rates of assistance may reflect less need in some cases (particularly in the less affected areas to the north), less access in others (such as Ngapudaw and Townships) or also a combination of the two.

11 18 Post-Nargis Periodic Review I 2.2 Nu t r i t i o n Nutrition reflects both the health status and food availability for a population. Following the Cyclone, the PONJA reported that people s diets had become more limited and that the population faced increased risk of malnutrition. 3 Three indicators of nutrition are discussed here: the proportion of children under six months exclusively breastfeeding; the proportion of children from six months to five years suffering from global acute under nutrition; and appropriate treatment of diarrhoea. Figure N1: Global acute under nutrition 3% Low: % The proportion of households where children aged 6 months to 5 years (or between 65 cms and 11 cms in height) were suffering global acute under nutrition was measured by Mid- Upper Arm Circumference (MUAC) of less than 125mm or the presence of bilateral pitting oedema. 4 In most communities the proportion of households where children are undernourished is less than 1 per cent (the highest bar on the histogram and shown the green on Figure N1). However, in some communities the proportion was over 15 per cent (shown in orange and red on Figure N1). This is principally in the periurban areas of greater Yangon and may reflect a chronic problem rather than being directly related to the Cyclone. Of the 17 children under 6 months included in the survey, 86 were exclusively breast fed. This is estimated at 5.6 per cent (95% C.I. 43.1% - 58.%), this is higher than expected and is not mapped due to the small sample size. 3 TCG (June 28) Post-Nargis Joint Assessment, p 7. 4 Bilateral pitting Oedema is an indicator of malnutrition.

12 Post-Nargis Periodic Review I 19 Thawtar Khin s story When the Cyclone destroyed the food stock in their house, they could not afford to buy food. Since Thawtar Khin is also breast feeding her two year old daughter, she has lost a lot of weight. Figure N2: Inappropriate treatment of diarrhoea 5% Low: % Diarrhoea that is treated inappropriately can result in undernutrition and death. Appropriate treatment is principally maintaining liquids and oral rehydration. The proportion of households using inappropriate treatment of diarrhoea was low in two out of three communities (shown in green and yellow on Figure N2 and represented by the highest bar on the histogram). In some communities between and, the rate of inappropriate treatment rose to over half of the households surveyed (red on Figure N2). Undernutrition in this area was around 15 per cent (Figure N1).

13 2 Post-Nargis Periodic Review I 2.3 Fo o d Cyclone Nargis damaged and destroyed food stocks, crops, livestock and equipment. When the VTA was conducted in early June, 55 per cent of the households reported having food stocks for only one day or less. 5 Half a year later, results of the Periodic Review assessment indicate that food aid had reached every surveyed community along the path of the Cyclone and indicators of food vulnerability show a clear impact in the areas where food aid efforts were concentrated. U Hl a So e s s t o r y We find it difficult just to find food each day, how can we repair our house or support our children? Food insecurity persists in some areas. In some of the communities that are food secure, this may be due to the receipt of food aid, rather than a recovery of production or purchasing power of communities. The problems facing the recovery of food production (including seed quality and harvest) and purchasing power may take some years to address. Food insecurity around Yangon and Pathein may be a result of chronic problems, rather than resulting directly from Cyclone Nargis. 5 TCG (June 28) Post-Nargis Joint Assessment, p 7.