10 January 2017

Interagency visit to Gogjali, Mosul district: Health Cluster report

General overview: According to the Mayor, 75% of the eastern bank has been ‘liberated’ and an estimated population of approximately 700,000 individuals still reside in Mosul. Basic services are lacking, especially food, water, electricity, health, services for women and children, and education. There are internal displacements within neighbourhoods of Mosul city, where IDPs live with their relatives if they have any, or in abandoned buildings. The major sources of water are under control of IS, and there is a need to rehabilitate water pumping stations and the supply of electricity for the city. Wages have not been paid for government employees since 2014 and there are limited employment options. Need for food support and distributions to be more coordinated, and food items to be distributed fortnightly or monthly. The PDS system can function and the agents that are nominated to support the PDS distribution are still active and these agents are linked with the anti-terrorism security forces. Ration card system can still be used. Fourteen warehouses belonging to the Ministry of Trade in Gogjali can be used for storage and distribution purposes but they require generators for lighting. HEALTH SECTOR update from DoH Ninewa: Most health centres and hospitals are damaged by ware and alternate locations are being used in the interim to provide medical assistance. Hospitals that are damaged on the Eastern side of Mosul city are:

1. Al-Salaam hospital 2. Al-Khansaa hospital – maternity hospital 3. Rabee private hospital 4. Ibn-Athir hospital – recently bombed

At present, all cases that require hospital level care are sent to Hamdaniya or to Erbil. The distance from Mosul to Erbil is long for referral of emergency cases and it is challenging to follow-up with patients after discharge for their post-operative care. The DoH of Ninewa has offered their staff to work in Erbil hospitals to support the

increase in caseload. However, the solution must be to provide more secondary level care within Mosul. Needs from the Department of Health of Ninewa:

1. Human resources for health 2. Health service delivery - curative medicine 3. Preventive health services 4. Referrals – ambulances

DoH of Ninewa is covering health services from the camps all the way into Mosul. As there are a lot of hospitals destroyed, there is a need to provide health services in Mosul. Activation of primary health care centres are to follow the model of:

1. Staffing to be made present 2. Ambulances for referrals 3. Vaccination services – emergency and routine EPI 4. Labour and delivery units at the PHCC to overcome challenges of referrals

and curfew. This requires appropriate staffing for such services to be present at the PHCC

5. Emergency room services at each PHCC to deal with injuries that don’t require surgical interventions

6. Electricity and fuel at all PHCCs For hospitals, there is a need to revitalize at least part of the hospital in order to make it functional, as it will take time for complete rehabilitation.

Challenges:

1. Referral system is hampered but a critical challenge is referral of non-injury related medical emergencies. Medical emergencies for complications during pregnancy or delivery, or for children are challenged with the lack of ambulances or allowance to pass checkpoints into Erbil. Needs are for more ambulances and fuel.

2. Some NGOs work alone and without coordination with the DoH. They have found that some NGOs distribute medication without the knowledge of the DoH and it should be coordinated better.

Question about WASH standards in health facilities - DoH of Ninewa will consult with their engineering department to gather information on minimum standards for health facilities in terms of water supply, sanitation services, and medical waste disposal and share it with the health cluster and WASH cluster. Actions Points:

Mapping of health facilities that will be revitalized/reactivated in accessible neighbourhoods to provide a minimum package of health services

recommended by DoH (outpatient department services, emergency room services for basic injuries, referrals by ambulance, vaccination services, reproductive health services).

Work with DoH Ninewa on management of ambulances for both trauma and non-trauma medical emergency patient transfer by implementing standard operating procedures and referral criteria

Improve availability of in-patient and surgical care capacity within Mosul city through health implementing agencies in collaboration with the DoH

Reinforce message of coordination with DoH Ninewa and the health cluster to avoid instances of distributions of medication. Donations should comply with standard guidelines that are available from WHO.

Health Cluster to liaise with DoH Ninewa and the engineering department, alongside the WASH cluster, to define minimum standards for water supply, sanitation, and medical waste disposal for health care facilities

The team was then supposed to proceed to Gogjali PHCC. However, after visiting the warehouse, we were driven to a primary health care centre in Al-Samah. Objective to assess health service coverage and discern gaps or needs in Gogjali was not possible. Approximate arrival time was 13:15 hrs at the Al Arkan PHCC. General information (main respondent was Dr. Ali, resident doctor): Table 1: Facility identification

1. Facility Name Al- Arkan PHCC

2. Location Al-Samah neighbourhood 36°22'16.10"N 43°13'35.50"E

3. District Mosul

4. Type of facility Primary health care centre – branch

5. Managing authority DoH Ninewa – not yet registered

6. Urban/rural Peri-urban

Al-Arkan primary health care centre, is a ‘branch PHCC’ providing outpatient consultations only with DoH Ninewa staff. Main entrance was used for military health activities and locked. Side entrance to the PHCC is used for civilians. They reported that this is a new building and not yet ‘received’ by the DoH of Ninewa. The structure is permanent and has not suffered any major structural damage. A few bullet holes were seen on the exterior of the building and two water tanks on the roof were damaged. Physical access to the facility is good with stairs and ramps for men, women and persons with physical disabilities if there are assistive devices to transfer them up the ramps.

Average distance from the farthest point that people would access the facility was said to be 2 km (from Hay Noor, Hay Al Akhor or Qulan Tapa). People would generally walk to the health facility and it takes 30-45 minutes. Staffing: 2 doctors – 1 male and 1 female 1 dentist 10 male nurses 4 female nurses Respondent said that there are 50 nurses in total available to work in this location. None of the practitioners have been trained to identify patients that require mental health and psychosocial support. No community health activities were mentioned. There are attendance registers for medical and non-medical staff. The non-medical staffs were listed as engineers, drivers, cleaners, guards, and administration staff. At the reception area, there is a sign saying that there is a charge of 500 IQD for an entrance ‘ticket’ but that no other charges are levied to patients for the consultation or medications. The closest referral facility is Al Zahraa PHCC, Gogjali trauma stabilisation point, and Erbil hospitals. There were no ambulances seen or said to be associated with this PHCC. The respondent said that a volunteer with his car assists in patient transfer. The facility has separate rooms for males and females for wound dressing, washrooms on the outer edge of the facility, a private examination room with an examination table, emergency care in terms of first aid ability and a room with 5-6 cots that can be used for stabilisation of patients. No IV poles or evidence of use was noted in the trauma room. Outpatient services: Outpatient services are provided by the doctor between 08:00 - 13:00 hrs., 6 days a week. When asked about laboratory services, another respondent said that there was no equipment for laboratory. Another person was heard as saying that the laboratory equipment was taken by IS. We were not shown any laboratory room and when asked about the ability to test for Hb or pregnancy test in urine, the doctor mentioned that it is not available.

Figure1: Patient examination room There are 5-6 cots in a room meant for stabilisation, and no IV poles present

Figure2: room for stabilisation No routine immunization services available, or equipment to maintain cold chain. Patients are sent to Al-Zahraa PHCC for vaccinations, but not clear about the availability of vaccinations in that location. No reproductive health services available and all cases are referred to Erbil or to Zahraa PHCC. A patient came to the clinic at the time of the visit and could not be seen. Majority of cases seen were reported as upper respiratory tract infections in the registration book. Asked to see the pharmacy, but the doctor said that it was not possible. (Note: when walking around the perimeter of the clinic, there were medications seen through the window in the section controlled by the military). Request was made for medications for hypertension and diabetes. The doctor said that triage was done by the doctor where they took BP and pulse rate.

Figure3: dressing room – separate for males and females There is a generator on site and a one-time donation of fuel (1,000 L) was given by an international NGO. Infection Prevention and Control: Guidelines for standards on IPC not posted or visible. Clear running water in the taps in the consultation rooms. Water is reportedly trucked in and the tanks on the roof filled. Chlorine tabs were reported as available at the clinic No soap in the dispensers in the toilet or the patient examination and dressing rooms.

Figure4 : Containers available for waste segregation but not all in use No alcohol based hand sanitizer Boxes of disposable latex gloves not visible Disposable syringes and needles and a safety box for disposal were present. Medical waste disposal – coloured containers available for different types of waste collection, but not in use. Medical waste management done through incineration in a drum at the back of the clinic.

Figure 5: drum incinerator at the back of the clinic Essential medical supplies and equipment provided by the Ministry of Health: Antibiotics such as amoxicillin and ceftriaxone reported as present but not seen No topical ointments, ORS or vaccines present Waiting to receive supplies, such as antipyretics and dressing materials on the day of the visit from the DoH. No adult or child weighing scales present. Stethoscope and blood pressure apparatus present. Basic register to record name of patient, diagnosis and treatment was present in a handwritten book. No EWARN reporting system in place. Recommended support actions:

1. Vaccination services and cold chain support 2. Ambulance referral system to be managed to include coverage of this PHCC 3. Supply of essential pharmaceutical supplies, basic laboratory supplies, and

medical equipment to support outpatient services a. Training on rational use of medicines

4. Reporting – notifiable diseases and morbidity reporting 5. Training to medical staff on casualty management beyond first aid 6. Infection prevention and control measures

a. Recommendation from WASH cluster on medical waste segregation and incineration on site (if temperature can reach over 800 Celsius) or off site

7. Support to female medical staff (doctor and nurses) to provide sexual and reproductive health services

8. Training staff on identification and referral for mental health