Working for disease control in emergency situations and post-conflict areas

Situation:

Conflict in northern Uganda has resulted in over 2 million people being displaced into Internally Displaced People (IDP) camps. These IDP camps have limited access to basic health care services and have high infant, child and maternal mortality. Malaria is the leading cause of deaths reported in a recent mortality survey in northern Uganda (Ministry of Health, 2005), the disease accounts for 14% of all hospital deaths, 20% of all hospital admissions and 40% of all hospital outpatient attendances. In Sudan, there are two different situations; in southern Sudan the signing of the Comprehensive Peace agreement in January 2005 has led to the establishment of the Government of southern Sudan, in an area which has seen 10 years of peace since 1956. Access to health services is extremely limited and the area suffers the highest child and maternal mortality rates in the world. In northern Sudan, the ongoing conflict in the Darfur region has led to the displacement of a third of the population with another third being conflict-affected. With ongoing conflict, these 4 million people have increasingly restricted access to life saving services, with malaria consistently in the top three causes of morbidity.

Response:

The Malaria Consortium has been engaged with countries affected by, and partners working in complex emergency settings for the last ten years. The organisation has most recently been working with the governments and communicable disease partners in Uganda, Somalia, Sudan, southern Sudan, Burundi, Ethiopia, Myanmar and Cambodia to develop and implement evidence-based policies and strategies for effective disease control interventions in complex emergency and/or post-conflict settings. Due to the high burden and urgent need for communicable disease control, the Malaria Consortium has been supporting the Ministry of Health and partners implement a communicable disease emergency response in northern Uganda since 2003 covering the two million displaced population. This response has included the control of malaria, diarrhoeal diseases and tuberculosis as well as strengthening reproductive and child health services in northern Uganda. More specifically providing home based management of fever, delivering long-lasting insecticide treated nets, spraying of institutions and improving existing antenatal clinics and other health delivery systems.

Our work in conflict-affected northern Sudan and in the post-conflict southern Sudan began in April 2005 and a country office was opened in October of that year. One of the main tasks in post-conflict settings is supporting the re-establishment of government structures and programmes. We are contributing to this by strengthening management capacity, supporting the fledgling government prepare policies and strategic plans, training Ministry of Health and NGO staff on technical issues (case management, malaria in pregnancy) and establishing systems that are then integrated into government structures such as insecticide-treated net (ITN) delivery through the governmental health systems, monitoring and evaluation and surveillance systems.

In conflict-affected northern Sudan, we are working to ensure the victims of conflict have access to effective treatment through the training of staff supplying services in diagnostics and treatment to IDPs, Long Lasting Insecticide-Treated Net (LLIN) distributions and malaria prevention education, as well as providing health education to returnees to areas of high disease burden, such as those who fled from southern Sudan and are now going home. Because of our expertise in emergency areas, we were commissioned by the World Health Organisation (WHO) as lead authors on the publication “Malaria Control in Complex Emergencies: an Inter-agency Field Handbook”.

Points to Note:

In the northern Uganda setting the focus is now on significantly scaling-up the proven successful models of delivery. The US President’s Malaria Initiative is funding the scale-up of the ANC based LLIN delivery model to 15 districts from the existing 5 and the Ugandan Ministry of Health is considering introducing it elsewhere in the country. The home based management of fever system has been updated to include Artemisinin Combination Therapies (ACTs) and this delivery model is being integrated within the broader home based care system funded by UNICEF. With resettlement beginning in some areas of northern Uganda we will be delivering an integrated ‘going-home’ package of communicable disease prevention interventions, including sanitation and hygiene activities, home based care of childhood illnesses, home based management of fever and LLINs.

We have demonstrated that it is possible to deliver high impact interventions at low cost and achieve high levels of coverage and use, even when the interventions are free. This is essential for communities who have been devastated by conflict, are displaced and desperately poor. We have also been able to demonstrate that in conflict affected areas where the government has limited access, that quality services can be provided to displaced persons, through partnership with humanitarian organizations. It would be unethical to expect such poor vulnerable groups to pay to save the life of their young child. It is now considered unacceptable to charge user fees at government health facilities in the poorest populations in the world. We feel that donor funded, NGO/CBO led activities should not be different.

Please refer to "Strengthening Health Systems for Effective Scale-up of Malaria Control and other Communicable Diseases", "Support to TB Management", and "Bridging the Gaps in Malaria Control".