A Rapid Health Assessment of Refugees in Adjumani district, August 2016
Authors: Susan Nakubulwa1, Joy Kusiima1, Andrew Illukol2, Esther Kisakye2, Robert Oliga2, Ivan Masete2, Ibrahim Wabembere2, Joyce Nguna3, Daniel Kadobera; Affiliations: 1Public Health Fellowship Program – Field Epidemiology Track, 2 Makerere University School of Public Health, 3 Ministry of Health – Epidemiology and Surveillance Division
Fresh political clashes in South Sudan in June 2016 led to a large influx of refugees to Uganda through the Elegu border post in Adjumani district. 41,154 refugees entered Uganda in July 2016, leading to an overstretch on supplies like water and shelter, posing a risk for communicable diseases outbreaks. The Ministry of Health (MoH) conducted a Rapid Health Assessment in Adjumani district on refugees who arrived in Uganda from June to August 2016 in order to; access their general health status, identify potential public health threats and service delivery gaps and recommend public health actions for rapid response. Findings revealed a shortage of community workers, health workers, shelters and human waste disposal facilities. Refugees had poor hygiene practices and a negative attitude towards health services. In conclusion, there was a shortage of health workers, shelter and waste disposal facilities for the refugees and they had poor hygiene practices. The recommendations were to increase health facility staffing levels, decongest the refugee reception centers, construct more pit latrines and provide health promotion packages ad
BACKGROUND: From January 2014 to date, refugees from South Sudan have been entering Uganda and have been resettled in Adjumani, Koboko, Kiryandongo, Yumbe and Arua districts as a result of a political conflict which started in December 2013. In June 2016, fresh political clashes broke out in South Sudan leading to a huge influx of refugees to Uganda. According to records in Adjumani district, 41,154 refugees were received in July 2016. Resources such as shelter, water and health services were over stretched at the refugee reception centers in Adjumani district. The large number of refugees entering Uganda also posed a risk for possible communicable diseases out- breaks. From 8th to 12th August, 2016, the Ministry of Health in Uganda (MoH) conducted a Rapid Health Assessment among the newly displaced refugees in Adjumani district with the following objectives; To assess the general health status of arriving refugees, to identify potential public health threats for the arriving refugees and health service delivery gaps and to recommend public health actions for rapid response.
METHODS: The assessment focused on refugees from South Sudan who had entered Uganda from June to August 2016. It was conducted at Pagirinya 1, Pagirinya 2, Nyumanzi refugee reception centers and Elegu border post.
The health centers and health posts serving the refugee population which were assessed were; Pagirinya Health Center III, Pagirinya Health Post and Nyumanzi Health Post.
A World Health Organization (WHO) standardized Health Assessment tool containing checklists guided the assessment process. It included components for health systems, essential services delivery, Water, Sanitation and Hygiene (WASH), shelter, Food and Nutrition. The tool was administered by interviewing health facility in-charges and Village Health Teams (VHTs) and observation.
An individual level questionnaire was administered to 197 refugees to assess their general health status. The District Health team and Implementing Partners shared experiences about the large influx of refugees with the Assessment team through dialogue meetings
FINDINGS Coordination; There was a high level of coordination and communication between the Adjumani District Health team and Implementing Partners regarding refugee related affairs. There were daily inter-organization meetings at health facilities and Patient management: There was a shortage of human resources for health; the Nurse: Population ratio was 1:2000 , Clinical Officer: Population ratio was 1:6725. These were overstretched given the frequent demand for medical attention. There was a negative attitude towards HIV prevention services like condom use and care services like ART. At Elegu border, there was triage and deworming for all, immunization of polio (0-5 years) and measles (6 months to 15 years), TT for expectant mothers, Nutritional assessment and Vitamin A supplementation (children 6 – 59 months)
Treatment protocols: There were no job aides and treatment e.g., Uganda Clinical Guidelines and IMCI charts.
Maternal and child health services: Pagirinya HC III offered maternal delivery services and Expanded Program on Immunization (EPI) services. Expectant mothers were provided with mosquito bed nets. Ambulances services on call for emergency referrals was available. It was noted that mothers delayed or failed to consent for caesarean sections as they relied on and waited for husbands’ consent, some of whom were soldiers way on duty back home in Sudan. Uptake of PMTCT services was poor.
Disease surveillance: Weekly Health Information System (HIS) reports were submitted by health facilities to Medical Teams International (MTI) . MTI was officially contracted by UNHCR to handle health related issues among refugees. MTI disseminated HIS reports to the Adjumani District Health office and other Implementing Partners (IPs). There had been cholera outbreak in the sites and by assessment time 16 suspects cases had been documented. Consumption of contaminated water was suspected to be the driver of the outbreak.
Infection control and medical supplies: Hand washing facilities with soap were available at health facilities. There was evidence of segregation of medical wastes in separate boxes although the waste cans were inadequate in number. There were no incinerators for disposal of medical waste. However, there was sufficient supply of medicines with a broad range of antibiotics, basic medical equipment and supplies such as gloves at health facilities.
Nutrition services: Nutrition assessment conducted on 7,275 children revealed Severe Acute Malnutrition in 2%, Moderate Acute Malnutrition in 4.9% . Global Acute Malnutrition among children was 6.8%. Nutrition surveillance was in place and food for lunch and supper was served only once a day. This meant cold food was consumed aiding transmission of food borne illnesses.
Shelter: There was overcrowding within the shelters at the reception centers.
Water, Sanitation and Hygiene (WASH): There was open defecation at reception centers. The water supply was over stretched . Each at Pagirinya received 7.8 litres of water per day (15 litres/day recommended). Some refugees resorted to use of river water for household use. Open pits and incomplete latrine pits with stagnant water were observed at reception centers. Pit latrines and hand washing facilities were available but insufficient in number.
Individual refugee interviews: The median age of inter- viewed refugees was 24 years. 42% (82/197) were males, 67% (131/197) of the refugees reported having health problems with cough as the prominent symptom in 20% (40/197). 37% (49/131) of those with health problems had not accessed health services. They of basic commodities like jerry cans 68% (134/197), soap 79% (156/197) and blankets 84% (166/197).
Dissemination of findings for policy engagement :The findings were disseminated at feedback meeting in Adjumani on 12th August 2016, MOH National Task Force meeting on 16th August, 2016, the inter-agency meeting on South Sudan, Office of the Prime Minister, Department of Refugees on 17th Au- gust, 2016 among others
CONCLUSIONS: There was a shortage of health and community workers at the refugee reception centers. Shelter and waste disposal facilities were insufficient. There were poor hygiene practices and a negative attitude towards HIV/AIDS and Maternal Child Health services. The limitation of the assessment was that it did not cover training levels of health workers to respond to disease outbreaks, for example, cholera.
RECOMMENDATIONS:
We recommended recruitment of more health and community workers, provision of treatment guidelines and protocols at health facilities, construction of incinerators for disposal of medical waste, decongestion of refugee reception centers, educating the food service providers to serve hot meals twice a day, sealing of incomplete drainage and latrine pits to get rid of stagnant water, increasing the number pit latrines and hand washing facilities, provision of appropriate and the training component to be included in future rapid assessments.
