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CHRISTIAN HOSPITAL EXTENSION PROGRAMDr. HOLLAND HEALTH CENTER, MASTUNG ROAD Progress Report for the Year 2000Background In March 1886, Rev. Shirt and Dr. Sutton working under the Church Missionary Society (CMS) with all their personal belongings, hospital equipment, tents and camp furniture came by rail up to Sibi, the only route then open. They continued their journey on foot and reached Quetta, which is 160 kms. away from Sibi, on 4th April 1886 where they established the Mission Hospital Quetta. Two years later, March 1888, Dr. Sutton visited the villages in Mastung District. The people needed health care very much and received Dr. Sutton with a lot of enthusiasm. One of the tribal elders of Mastung Road, Wali Khan, whose wife was sick and received medical care from Dr. Sutton, provided a piece of his land for the Mission Hospital Quetta to establish a rural health center, so that other members of the community, particularly the women and children who are less mobile, can be assisted. And, so, the first outreach health work of the Mission Hospital Quetta (now called Christian Hospital Quetta) was started. Today the Christian Hospital Quetta, through its outreach program, Christian Hospital Extension Program (CHEP), continues to operate in the same health center. Mastung district is situated 50 km. south of Quetta. The geographical area of the district is 589,600 ha. The potential area available for cultivation is 247,466 ha, of which, nearly 45,600 ha is arable land and 165,466 ha is cultivable waste, mainly due to scarcity of water. The year 2000 has been a very difficult year caused by the drought situation, which has hit several parts of the provinces of Balochistan and Sind in Pakistan and Afghanistan from where several refugees have come to the district. The climate of the district is subject to considerable variations. Winter lasts from September to March. Many of the families do migrate during the winter season and the health center is closed during those months. The excessive use of groundwater through tubewells has been a major environmental problem. Wheat , barley, onion, fruits, fodder, vegetables and potato are the main agricultural products. According to estimates prepared by the National Institute of Population for 1995, the population of the district is 200,000 and it is growing at a rate of 3% per annum. The average household size is 6.9. More than 80% of the population live in rural areas. In Mastung, there are 280 villages. They are small with some 10 to 250 households scattered over the district. The ethnic composition is dominated by Brahuis, who make 85% of the households. Mastung is a tribal society, and the tribal chiefs have much influence. Women are very much involved in domestic activities, but have no major role and social status in society. Their social status is determined by their husbands' social status. Most people in the district live in a joint family system. The tribal system is very deeply rooted. Faith Statement One of the scribes came up to Jesus and put a question to him, ' Which is the first of all the commandments?' Jesus replied, 'This is the first: Listen, Israel, the Lord Our God is the one Lord, and you must love the Lord your God with all your heart, with all your soul, with all your mind and with all your strength. The second is this: you must love your neighbor as yourself. There is no commandment greater than these.' It is that love for the neighbor that brought Sutton, the Hollands and all the others who have served in Mastung. Moreover, to secure the future of our planet, and its people, we have a moral duty to help the poor and needy and to try to create a more just world, which is in the interest of all of us. Mission Statement CHEP's mission with respect to the Dr. Holland Health Center is to accompany the communities in Mastung District and the surrounding areas in raising questions about their health and to be a partner in their efforts to take charge of their health situations in order to find solutions to achieve better health for all members of their communities. Overall Program Focus Building on the experiences of Christian Hospital Extension Program (CHEP), Dr. Holland Health Center, under the auspices of the Christian Hospital Quetta (CHQ), inter alia, will continue to provide preventive, promotive, curative, and rehabilitative health care, with the necessary supportive and referral services, that is feasible, sustainable and satisfactorily addresses the health needs of the people in Mastung district and surrounding areas. Situation Analysis Although there has been a steady and slow progress with some of the key indicators like immunization coverage, under-5 mortality rates, coverage of maternity care, nutritional status and the provision of potable water, however, there is a unanimous consensus that the overall achievement is poor and there is a wide disparity between the rural and urban areas. Without going too much into details, if we just compare the percentage reduction in under-5 mortality rates from 1980 to 1995, according to UNICEF, the percentage reduction was 63 for Sri Lanka, 45 for Bangladesh, 37 for Nepal, 35 for India and only 9 for Pakistan. That shows that the status of most Pakistani children has not changed significantly. The under-5 mortality rate is 111 per 1,000 live births suggesting that one in nine Pakistani children die before his/her fifth birthday. The current overall infant mortality rate (IMR) is 101 in 1,000 live births. Provincial data indicate that Balochistan has the highest IMR at 117 in 1,000 live births. The immediate causes of infant mortality are acute respiratory infections, diarrhoeal diseases, neonatal tetanus, other immunizable diseases and a high rate of malnutrition. Pakistani women have very poor health. The maternal mortality rate (MMR) in Pakistan ranges from 286 in Karachi's urban settlement to 756 per 100,000 live births in rural Balochistan, where CHEP is operational. One can compare that with the average for developing countries, which is 384 per 100,000 live births. Rural Balochistan has one of the highest maternal mortality rates in the world. Moreover, we also need to keep in mind that with every woman who dies due to complication of pregnancy there are more than 20 other women who suffer from lifelong painful, disabling and embarrassing health complications. Hemorrhage, infection, hypertension, obstructed labour and abortion, combined with inadequate obstetric services, are the immediate causes of maternal morbidity and mortality. The underlying causes are malnutrition, poor health and reproductive behavior, including short intervals between pregnancies, high parity and lack of health knowledge. According to UNICEF, at least 31% of adult women and 42% of pregnant and lactating women are anaemic. Underlying these problems are issues such as widespread poverty, economic and social discrimination against women and girls, violence in the home and poor access to and quality of health services. Overall Objectives The wider objectives of Dr. Holland Health Center in Mastung Road are: 1. To help cut down on infant and maternal morbidity and mortality; 2. To help improve reproductive health; 3. To promote other community based primary health care services; 4. To study the health behavior and do advocacy. PROGRAM IMPLEMENTATION Health Survey During the period of September 1979 and December 1993, CHQ was heavily involved with a program for the people of Afghanistan, when 90% of its service was geared to address the needs of the Afghan refugees; And, consequently, the other outreach works of CHQ had slowed down. In August 1997, the Medical Director of CHQ asked Mark Southard, a social anthropologist from Bethlehem, Pennsylvania, to conduct a health survey that can help develop recommendations on how best to plan for and develop patient sensitive high-quality health services in the service area of CHQ's Mastung Road Health Center. Based on the survey recommendations CHEP initiated a phased long term plan for the Mastung health center, and started with phase I in July 1999. Field Staff CHEP now has a field staff who are committed and conscious of the need to understand the traditional and religious values, the environmental and socio-cultural factors that do effect health and of the need for advocacy and social mobilizations. At the moment, the core group of the field staff includes the field coordinator, who is a community health specialist with nursing and teaching background, a midwife with several years of work experience in a hospital and community set up, one lady health worker and one nurse assistant, who are both from Mastung, and a driver. The field staff have been supported by a male doctor, a pharmacist and student nurses from the Christian Hospital. An ophthalmologist from the Christian Hospital and a psychiatrist, who is a private practitioner and an old colleague, have both been separately, accompanying CHEP field team, regularly, once a month. CHEP is committed to provide quality service, which does require to have competent staff members. However, it does not plan to employ everyone full time, but develop a panel of professionals whom it can engage. CHEP will try to entice, particularly, those who belong to the community where it has a presence. Working with the Community CHEP now has a functional Community Management Health Team (CHMT) of eight: 2 tribal elders, 1 union council representative, 1 religious leader (mullah), the DHO (district health officer), 1 school principal, 1 teacher, and 1 medical officer of the Prime Minister's Health Program in the area. The Committee, inter alia, has a mandate to identify and prioritize needs, actively participate in policy and program development, mobilize the community and its resources (local and gov't) and provide support and security to CHEP operation. CHMT meets quarterly, and any one or more members can be approached, on any day, for any pressing needs. CHEP has to abide by the tribal values and has to accept, for now, a CHMT of only male members and dominated by the influential; However, CHEP is highly sensitive to the need of the participation of the marginalized. Since the program's main thrust is to address the health needs of women and children, at a gathering of some 40 influential women leaders of the area, CHEP formed a working committee of 10 ladies, inter alia, to liaze with CHEP, identify: needs, high risk cases and defaulters, mobilize the community, and participate in the implementation of certain preventive and promotive health activities. However, we do call meetings where the men, women and the LHWs do sit together and discuss general issues. CHEP has also established a work relationship with 10 of the lady health workers assigned to different parts of Mastung District, under the National Health Program. Those LHWs do run ' health houses'. Primarily, due to lack of support mechanism, proper monitoring and lack of resources like medicine, which resulted in lack of motivation, the program has not been able to achieve its objectives. No need of being critical, but what CHEP tries to do is be supportive and cooperative. CHEP's heath center is now, de facto, the first level referral institution for those health houses. CHEP's main focus continues to be building relationships with the communities, and win their trust and confidence in its partnership to accompany them in the process of taking charge of their health situation and meeting their needs. Even in the most unfortunate incidences when two babies who were under treatment at the health center and were referred to the Christian Hospital where they died, and another baby who was also under the health center's care and died in his own village, today, three of those mothers are, de facto, CHEP's active community health workers! CHEP now has a relationship not only with those three mothers, who come from different localities, but, also, with the communities that they do come from. The field staff have managed to identify with the respective community members. The people have come to appreciate the work of CHEP and that the field staff are there to share their sorrows and share their happiness, and that together they are to make a difference in the quality of their lives. The team and the people do realize of the challenges and that they are a long way from addressing the many basic, underlying and intermediate causes of their deprivations and lack of opportunities, but CHEP's presence does bring hope to many of them. Health Care CHEP continues to demystify the significance of its clinical work and emphasizes the preventive and promotive aspects and, also, put emphasis in understanding their health behaviours. There is a great need to pursue more vigorously on health education. . On the curative side, during the program year of 2000, the health center in Mastung Road had a total number of 1,829 patient visits, of whom 949 patients were women, 500 patients were men and 380 patients were children. Patient visits by women and children were 72.7% of the total visits. Gyne and neurological problems amongst women, eye problems, gastritis and respiratory tract infection were some of the most common complaints. During the 2000 program year, CHEP did consider raising the examination fee, but CHMT was of the opinion that because of the drought situation, there is lack of job opportunity and many are getting poorer. The general examination fee is PRs. 30.00, and CHEP provides them free medication. The maternal mortality is high mostly because of lack of knowledge and failure to recognize the danger signs of pregnancy by the woman, her family members and the majority of the health care providers. Most studies indicate that most maternal deaths occur due to causes which can be prevented through existing medical technology and better access to health services. CHEP does have plans to introduce new medical technology that is relevant, manageable and sustainable, like the ultrasonic machine, which can help achieve CHEP's objectives of bringing down MMR and improve some aspects of the reproductive health. Having an emergency obstetric care has been a long time wish of the people in Mastung, and a main reason for donating the land to the Christian Hospital in 1888. CHEP tries to underscore the fact that the people are, primarily, responsible for the improvement of their health situations. CHEP will try to help them understand the causes and the means and resources that they can tap on to improve the quality of their lives. CHEP also tries to do advocacy on their rights for better health and better quality of lives. They should demand of CHEP, the Gov't and the other agencies, who have a presence in the area and are in business under the pretext of providing services to them, be accountable on what they all claim to do. When one is engaged in facilitating and accompanying people in their efforts to empower themselves, there surely will be a time when their will be a conflict between those who are getting empowered and the other forces who would loose because of that, like the private practitioners and the traditional healers who have very high traditional status and could also be religious leaders. Under such circumstances, facilitators like CHEP, particularly in a context where religion is a very sensitive issue, could be easy targets as an scapegoat. Everything is fine for now, but CHEP always has to be cautious of the opportunities and threats. The work is challenging and at times overwhelming, but, however small CHEP's input might be, humane stories like that of the three mothers are very rewarding and keep the field team going to reach out to more babies, even the dying ones, and to more mothers and their respective families. FUTURE PLANS Depending on the financial and managerial support staff that CHEP can mobilize and more specifically, depending on having the 2 vacant senior staff posts of program coordinator and lady obstetrician filled, during the 2001 program year, CHEP will, inter alia, implement the following program activities. Woman Health Care The health care need of the women has been one of the major priorities of CHEP. During the 2000 program year, 60% of all the patient visitors were women. Beyond the statistical fact, the impact of CHEP's health care in addressing the health need of the women has been very significant and a source of tremendous job satisfaction. Women health need has always been the main bondage between CHQ and the people of Mastung district. During 2001, CHEP will continue to expand and improve the quality of its health care for women. If CHEP does get a senior lady obstetrician, she will be responsible to develop emergency obstetric services and provide on the job training to CHEP staff and health workers in Mastung. Having an emergency obstetric care has been a longtime felt need and request of the community, and a main reason for inviting CHQ in 1888 and donating the land where the health center is built. Approximately 75% of maternity assistance in rural areas are by traditional birth attendant (TBA) and a family member. CHEP will employ 4 lady health workers (LHWs) from the area who will help the TBAs in identifying and referring high-risk cases. The LHWs will work with the community to identify and register pregnant women and refer them to the health center for antenatal and postnatal care. Those who might need assistance by a specialist will be referred to CHQ or other specialized institutions and government hospitals in Quetta. CHEP will continue to work through its own staff and through other LHWs in the area to reach out to the community and to those who will visit the health center, in providing health information and education on issues like reproductive health, child care, breast feeding, nutrition, immunization, water and sanitation and environmental health. Informal teaching methods will be used, which include practical demonstrations, questions and answer, discussion and role-plays. During the 2000 program year, the nutrition and cooking demonstrations were very much appreciated by the mothers, and CHEP will continue to have similar demonstration and health talk sessions. Child Health Care Most of the child health care needs are preventive and promotive health services. During the last program year, CHEP did not have an expanded programme on immunization (EPI). The field staff referred the children and women of childbearing age to the Government EPI programme. After doing its own monitoring on the EPI coverage and with the advice of UNICEF, who is the major partner of the Government EPI programme, during 2001, CHEP will start its own EPI program, which will be implemented in close collaboration with the Government Programme. CHEP's main objective will be to strengthen the immunization programme to achieve and sustain a total coverage, and reduce the incidences of mortality and morbidity due to diseases like measles, polio and neo-natal tetanus. To reduce morbidity and mortality arising from diarrhoeal diseases and acute respiratory infections, CHEP will enhance its support to promote a healthy environment at household and community levels and work closely with the Government's sanitation, water and environmental education programme. CHEP will also promote the general concept and practice of childcare and care for the mother, personal hygiene, and promotion of breast-feeding and appropriate complementary feeding. Malnutrition in children is principally due to inadequate breastfeeding, poor complementary feeding practices and poverty. Eye Care The overall prevalence of blindness in Pakistan is estimated to be 1.78%, ranging from 1.0% in North West Frontier Province to 2.9% in Balochistan. The causes vary from region to region, but, overall, cataract is the single commonest cause. Other potentially avoidable causes include trachoma, glaucoma and blindness in children. CHEP does actively participate in the promotion of eye care and prevention of common conditions leading to blindness and visual impairment and runs monthly eye care days and two free eye camps during the year: once during the month of March and the second one in September. The free eye camps are held for 2-3 days each. During the eye camp in September, those who are screened for surgery are operated upon at the health center in Mastung. In March, it is too cold to have surgery in the field. All other surgery cases are referred to the Christian Hospital in Quetta. During 2001, CHEP will continue its cooperation with the National Programme for Comprehensive Eye Care, and will continue with its monthly eye care day and will run two free eye camps. Eye care days and eye camps are run by eye specialists. Eye patients during the other clinic days are assisted by a general practitioner and serious cases are referred to CHQ. Mental Health Care The community in Mastung did request CHEP to have a mental health day, and during 2000 program year, CHEP had a psychiatrist join the field team regularly once a month. The date was fixed for the whole program year, and the community was informed. During the current program year, CHEP, in collaboration with WHO and the Civil Hospital, does have plan to do more with its effort in integrating mental health into its primary health care. Health through Schools CHEP has a close work relationship with the Government High School for Boys and the Government Middle School for Girls, which are both adjacent to the health center. The principal, the religion teacher (mullah) and another teacher of the school for boys are members of CHEP's community health management team (CHMT). The health center does provide health coverage to the students and staff of both schools. During 2001, CHEP does have plans to initiate a formal and well-structured health through schools component and explore the potential of school children and teachers as health promoters. The health education will be provided by one of the teachers who will work closely with the health center. CHEP will also try to introduce child-to-child health component to reach out to the children who do not attend schools. Action Oriented Research During the last programme year, CHEP's main focus has been in helping to improve the health situation of the mothers, which has a direct and indirect impact on the health situations of the children and the family. From the discussions with the women who visited the health center and from discussions with the LHWs, the field staff have come to realize on the need to understand the traditional values and the health behavior of the community, particularly, in regards to the health care of the women. According to UNICEF, the burden of ill health that women experience is related to their disadvantaged social status, their gender and their reproductive role. Some of the major challenges and achievements have been through the intervention of the field staff in helping a woman or a girl child in getting the necessary health care and the support of her own family. During 2001, Mark Southard, who is now affiliated with the Department of Social Anthropology of Brunel University in England, will do research on Political Economy of Healing Systems in Balochistan. CHEP will benefit tremendously from Mark's research, and it will actively participate in his work on issues that are relevant to CHEP's work. Although it is a slow and long process, studying the socio-economic factors, traditions, domestic violence which is a major component of reproductive health, and the social status of women will help CHEP to understand the basic causes of maternal morbidity and mortality and develop its health care services accordingly. A better grasp of those basic factors will help CHEP in its efforts to build awareness and initiate behavioral changes. Beyond Health Services Today, if one would ask the people of Mastung District what their priority need is, it is more likely that they will opt for measures that will help in poverty alleviation. WHO has initiated a joint WHO-Government of Pakistan collaborative program, which aims at poverty alleviation. WHO's rational is that ill health of millions of people cannot be cured by the health sector alone. It can only be attained through coordinated inter-sectoral development approach. Studies by several agencies, including World Bank, UNDP and other specialized agencies, indicate of a high correlation between poverty and health standard. WHO has been working on a pilot project in 9 villages in Mastung District with a total population of 1,000 families, of whom 766 families have been participating in the micro- credit schemes of WHO. Some of the economic activities that received interest free loans include: dairy and poultry farming, stitching and embroidery work and for the purchase of seed, fertilizer and other agricultural inputs like mechanization and irrigation work. The project area of WHO is known as Paringabad, which is adjacent to Mastung Road where CHEP's health center is located. WHO, being a specialized agencies in health, does not have the managerial capacity to expand in socio-economic development activities, and WHO has requested CHEP if it can expand its cooperation in the health sector to also include efforts to replicate the basic minimum development program that they have initiated in Paringabad. The planning, implementation and evaluation of micro-financing schemes can often be very challenging and one needs to underscore the need for professionalism. A lot of good will and humanitarian feelings, which are the rational behind many income generation schemes, cannot compensate for ignorance of the most simple business fundamentals. One needs to understand the characteristics and dynamics of the informal sector where most of the economically active poor are engaged. The WHO Operation Officer for Balochistan, Dr. Mehboob Badini, said that it took him and his colleagues three years to kick-start the programme in Paringabad. During 2001, CHEP will start with the study of the entrepreneurial quality and the traditional organizational framework that can be used as a platform to initiate the micro-credit schemes sometime in the future when a full time programme coordinator joins CHEP. The study will be action oriented for CHEP will also be using the same structure to form clusters of families to identify and train community health workers and initiate preventive and promotive health activities as part of their daily economic and social activities. At the last Community Health Management Team (CHMT) meeting held on October 30, 2000, one major issue that was discussed at length was the need to address issues beyond the basic health needs of the people. A suggestion was made for CHEP to coordinate its efforts with other Government faculties including health, education, agriculture, livestock, social welfare, public health engineering and the District administration. When the members were making those comments and requesting CHEP to have a more holistic approach, they were speaking from their experiences and voicing the concerns and felt needs of the communities in Mastung. Those views were expressed when CHMT was discussing on the plans for the year 2001. CHEP agreed to make follow up discussions and will vigorously pursue on the suggestions made. CHEP's line of thinking does concur with the views expressed and that those needs will be the priority task of the new CHEP programme coordinator. Recent reports of World Bank, UNDP and other local research institutions in the country do underscore the increase in the number of families that are below the poverty line, and CHEP will not be able to have any meaningful level of cost sharing. Hence, CHEP needs to do some strategic thinking on how to help improve the financial capacity of the people who are served by the health center. Helping the communities get on their feet and be economically viable to support and manage their own health and educational needs is the long term mission of CHEP. Partnership During the last programme year, one of our achievements has been to build trust and establish a strong work relationship with the communities in Mastung and their leadership. We also did cooperate and coordinate our efforts with the District Administration and the Provincial Health Directorate. We will continue with that process of relationship development. Dr. Holland Health Center, Mastung Road STATISTICAL REPORT March 6 through October 30, 2000
CHEP Quetta March 15, 2001 |
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