Integrating health care for mothers and children in refugee camps and at district leve

Case study 1: Three Afghan refugee camps in Pakistan

Most of the five million refugxdees from Afghanistan live in Pakistan and Iran in camps or in squalid settlements in urban areas. They have high death rates among infants, neonates, children less than 5 years old, and mothers.2 3 Many births initially occurred without health worker support on the floor of filthy makeshift tents. The Government of Pakistan and aid agencies, led by the United Nations High Commission for Refugees, developed a well organised and effective system of primary health care. Specialist care remained dependent on distant government hospitals.

Assessment was undertaken with the help of interviews, group discussions, and questionnaires of families and health workers in one camp (New Jalozai). This revealed that most patients referred to hospital did not avail themselves of this care for the following reasons. The 60-80 km drive from the camps to hospitals in the nearest city, Peshawar, was tiring and difficult, taking about 1.5 hours. Payment for both the transport and any investigation or treatment at the hospital was beyond the means of most families; indirectly there was loss of several days' earnings. Women could not travel alone, requiring the company of a male relative. Many refugees did not realise the importance of medical care, never having had access to it before. The available government hospitals were grossly overburdened, with extremely limited resources, and most families who did make the effort were poorly satisfied with the care provided.

Afghan refugee camp (New Jalozai) in Pakistan

The Pakistan government and United Nations worked with Child Advocacy International to provide specialist (hospital based) maternal and child health care in two refugee camps (New Shamshatu and Shalman) initially containing around 150 000 people, largely women and children. Essential drug and medical supplies were supplemented to include oxygen, intravenous fluids, parenteral antibiotics, bronchodilators, and drugs for gynaecological and obstetric emergencies. A labour room with ultrasound scanner and a minor operations theatre were established. Operations were undertaken using ketamine and midazolam for anaesthesia. Inpatient beds were established for women, children, and neonates (including locally made, low cost equipment such as a resuscitaire, heated cots, and a phototherapy unit). Clean toilets and hand washing facilities were provided, as was a 24 hour electricity supply. There was an ambulance to evacuate individuals with serious or rare conditions to teaching hospitals in Peshawar. The presence of a trained paediatrician and obstetrician working in the two camps provided front line staff with opportunities to acquire further skills.

Malnutrition is a major concern in refugee Camps

Credit: PENNIE TWEEDIE/PANOS

Katcha Garhi refugee camp, Peshawar

Credit: FRANCESCO CITO/PANOS

A referral system was developed to streamline the flow of patients from all eight basic health units to the hospital services within each camp. From October 2001 to January 2004, 23 467 patients (12 850 babies and children and 10 617 mothers) were treated. Diseases included severe respiratory problems (45%) such as pneumonia, asthma, and tuberculosis; severe gastrointestinal infections (35%) with dehydration; chronic diarrhoea; and serious illnesses such as neonatal sepsis and meningitis. In mothers there was a bank of chronically neglected gynaecological diseases, many originating from previous and unsupported births. Obstetric care—including deliveries (47% of patients), contraceptive advice or procedures (8%), and gynaecological procedures (30%)—was undertaken daily.

The additional cost (over and above the primary care expenses) for this hospital based service was estimated as $0.15/person/day (for women and children only).

About 8% of those receiving primary care attended for specialist treatment, with only two or three patients each day requiring referral to the teaching hospitals in Peshawar. This is a lower referral rate for hospital care than has been reported from other countries (10-20%).4^–6

Chronic diseases had been largely neglected, probably because they lacked urgency. Yet they caused suffering, not only for the individual, but also for the whole family (particularly if a mother had, for example, depression or a vesicovaginal fistula).7 We have already reported a high prevalence of severe mental illness in mothers caring for children in these camps.8 There is good evidence that maternal health has a substantial effect on the wellbeing of children.9 10 The importance of linking maternal and child health care was borne out.

Case study 2: Emergency maternal and child health care in two districts of Pakistan

Each of the two districts, Nowshera and Gujranwala, has one main government hospital serving local populations of approximately one million and 3.5 million people respectively. A network of primary care facilities existed but without effective linkage with hospitals, where maternal and child health care was available. Outside morning hours, obstetric and paediatric services were provided only by poorly trained generalist nurses and doctors.

The vast majority of pregnant mothers had so little confidence in the care they would receive at these local hospitals that they preferred to deliver their baby at home, usually with support from untrained or poorly trained health workers. Those who developed life threatening complications around delivery were usually not referred or evacuated in time to the hospital.

In the two hospitals we assessed, about 75% of the essential emergency equipment, drugs, and medical supplies were not present, and staff adequately trained in emergency maternal and child health care were available for only a small part of each day. The transport system between communities and the hospitals serving them was poor. Many ambulances were broken, funds to pay the drivers or for fuel were limited or absent, and ambulance staff were not trained in basic life support. As a result, the small proportion of the population who could afford it attended private hospitals. The rest remained at home, suffered, and often died.

If deaths and long term or permanent disability are to be avoided, emergency obstetric, neonatal, and paediatric services must be strengthened. The links between home based and hospital services must also be improved by better communication and more coordinated transport systems.

Child Advocacy International and the Advanced Life Support Group, in partnership with WHO Pakistan and the government of Pakistan, are piloting a project termed Emergency Maternal and Child Health (EMCH) in these two districts. It aims to enhance the effectiveness of care in the first few hours after presentation of an emergency by an educational approach that uses skill stations, drills, workshops, and scenarios to train doctors, nurses, and paramedics, with particular emphasis on frontline health workers, predominantly nurses. The project also ensures that, before training starts, sufficient emergency drugs and medical supplies as well as basic low cost but appropriate essential emergency equipment are in place. Local governments in the two districts have agreed to supply all of the missing emergency drugs and medical supplies. Missing equipment is largely being donated.

Conclusions

The integration of hospital and home based health care in emergency situations such as refugee camps and at the district level of poorly resourced countries can be achieved at relatively low cost. Much effort has been put into enhancing primary (home based) care, as this is cost effective. However, we argue that there has been a relative neglect of hospital based care by both governments and the international community, and the integration of the two requires urgent evaluation and implementation. Local public sector hospitals need to be configured to serve a community and not just to provide episodic care for the few patients who transiently pass through their doors.