AAI-OILEX Health Project. Timor-Leste - Atauro Sub-District. ACTIVITIES REPORT TO THE MINISTRY OF HEALTH (MoH) (SEPT 08)

Transcription

1 AAI-OILEX Health Project Timor-Leste - Atauro Sub-District ACTIVITIES REPORT TO THE MINISTRY OF HEALTH (MoH) (SEPT 08) Project Name: AAI-OILEX Rural Healthcare Project Location: Atauro Island, Dili District, Timor-Leste Report prepared by: Australian Aid International, Timor-Leste Report submitted to: MoH on 10 Oct 2008 Oilex Ltd Level 3, 50 Kings Park Road West Perth WA 6005 Australia Mail: P.O. Box 588, West Perth, WA 6872, Australia T: F: E: oilex@oilex.com.au Australian Aid International Timor-Leste Headquarters Av. De Portugal Kamop Alor Dili T: F: E: infor@aai.org.au

2 TABLE OF CONTENTS Page 1.0 Operations Objectives Evaluation Recommendations 14 2 page of 18

3 1.0 OPERATIONS Australian Aid International (AAI) conducted operations in partnership with the Ministry of Health of the Democratic Republic of Timor-Leste (MoH) in the Sub-District of Atauro during the month Sept Atauro Island has been assessed as one of the most remote and needy communities in Timor-Leste. AAI have established the foundations of a long-term healthcare project on Atauro that aims at providing support and supervision for the District Health Service (DHS). This is being achieved by developing the capabilities of local healthcare staff in order that they can provide sustainable healthcare management within the community, thus minimising the need for outside intervention. AAI strategic health plan in conjunction with the MoH is to continue operations on Atauro for a further 2 5 year period. AAI Objectives 1. Mobile outreach healthcare clinic support 2. Health promotion activities 3. Capacity building of local healthcare staff This report covers the period of September 2008 in which AAI conducted operations on Atauro Island. AAI Field Personnel Penny Sizer Julie Alexander Nairana da Silva Caesar Conceicao Eduardo Soares Nuno Rui Health Coordinator Volunteer Doctor Project Nurse Project Nurse Project Nurse Project Officer 3 page of 18

4 2.0 OBJECTIVES Objective 1 Mobile Outreach Healthcare Clinic Support AAI conducted six mobile and outreach healthcare clinics utilising the AAI vehicle and six mobile and outreach healthcare clinics by the Community Health Centre (CHC) outrigger boat. A total of 472 patient consultations were conducted. Health Coordinator attending a burn on a child Dr Julie Alexander examines a patient at a mobile medical clinic Health Coordinator, Penny Sizer treating a child with burns Beloi village 6 & 20 September 08 A total of 96 patients received consultation at these clinics. Transportation to the clinic was by AAI vehicle. The number of consultations includes 19 patients who received medical treatment at AAI s accommodation site in Beloi. As this is not a standard clinic in accordance with the CHC schedule, AAI is working with the community to reduce the number of patients attending for consultation and referring most patients to the normal clinic held at the CHC. AAI are examining all children and un-well adults until such time that the community returns to using the CHC for their healthcare needs. One house call was conducted to a patient who had previously been treated at Dili National Hospital. The patient has a chronic lung condition and requires ongoing care. Bequeli village 8 & 22 September 08 A total of 102 patients received consultation at this clinic. Transportation to the clinic was by AAI vehicle. Two patients were escorted to Dili for further assessment for suspect TB. One patient was confirmed with TB and admitted to Dili National Hospital for treatment. The other patient will be followed up at the Dili National Hospital during the week. 4 page of 18

5 Adara village 9 & 23 September 08 A total of 34 patients received consultations at the clinic. Transportation to the clinic included using the AAI vehicle to Bequeli. The CHC outrigger boat was then used to travel to Adara. The number of patients is low due to changes in clinic location. AAI is now conducting clinics in Adara and not Atekru village. The change of location is due to the employment of a local nurse at the established Health post of Adara. One patient was escorted to Dili National Hospital on the ferry by AAI for further investigation of abdominal symptoms. Macadade village 10 & 24 September 08 A total of 86 patients received consultation at this clinic. Transportation to the clinic was by the AAI vehicle. One child was referred to the CHC for further treatment of a severe skin infection. A transfer letter was written by the AAI Physician for the Cuban doctor however, these instructions were not followed by the CHC. This matter will be further discussed with the Health Coordinator of Atauro. Barauana village 11 and 25 September 08 A total of 119 patients received consultation at this clinic. Transportation to the clinic included using the AAI vehicle to Bequeli and then using the CHC outrigger boat to Baruana. Two patients were escorted to Dili by AAI for further assessment. One patient was a suspected case of TB and the other patient had abdominal symptoms of unknown cause. These patients will be followed up at the Dili National Hospital by AAI. Maquili village - 12 & 26 September 08 A total of 35 patients received consultation at this clinic. Transportation to the clinic included using the AAI vehicle and the CHC outrigger boat. These clinics were recommenced after an absence of 4 months due to sea conditions not been suitable for the landing of a small outrigger boat. Sea conditions remain very unpredictable and therefore, the AAI Health Coordinator has made the decision not to continue conducting clinics at Maquili. This decision was made with the safety of the AAI team as the primary consideration as well as AAI being unable to provide a regular service to the population of Maquili. The Health Coordinator of Atauro has been informed of the decision and the possibility of conducting health education in schools has been discussed. As AAI are unable to provide a regular service to the community of Maquili due to the inability of the outrigger boat to land safely, consequently the patient numbers have been low. The community of Maquili also does not assist AAI to transport equipment to the clinic, which is half a kilometer walk up a rocky and hilly path. This places extra burden on the AAI staff. This matter had been discussed with the Chefe de Suco who arranged for a member of the community to assist but this assistance is seldom provided. 5 page of 18

6 In total, 16 patients had Rapid Diagnostic Test (RDT) Parachecks and blood film slides taken at clinics to check for the incidence of malaria. Not all the test results for blood films are available as the laboratory technician was not on Atauro for the second week that AAI was on the island. These slides were left at the CHC for testing when the laboratory technician returns. Of the patients who had RDT Parachecks taken, only one tested positive for plasmodium falciparum malaria. Another 19 patients were referred to the CHC for sputum culture for TB. The incidence of TB is unknown on Atauro. AAI has commenced referring patients who have had a negative sputum culture for TB previously but remain symptomatic. These patients are referred to Dili National Hospital for chest X-rays and reviewed by a physician. This month, six patients with suspected TB were escorted by AAI to Dili for further assessment. Three of these patients were confirmed TB. Of these three patients, two patients have been admitted to the Dili National Hospital for treatment and one patient to be treated as an outpatient in Atauro. The other patients will be followed up by AAI when in Dili. Two patients with abdominal symptoms were escorted to Dili for further investigation. A two week old baby with a heart murmur was also escorted to Dili for a paediatric assessment. The referral system at Dili National Hospital has been problematic for patients and AAI. There is no clear system in place at the hospital for these referred patients and often no discharge letter is provided to patients upon discharge which should contain details of diagnosis, investigation results, treatment and further management. When patients returns to Atauro, AAI is then faced with the challenge of trying to determine this information in order to give or continue appropriate care. As a result AAI has commenced meeting patients at the hospital and discussing the case with the referring doctor so that a clear understanding is established about what treatment has been given and why the patient has been referred. AAI has tried to simplify the process by requesting that X-rays are undertaken in the morning before the outpatient clinic commences. This allows for patients to be reviewed by the physician with their X-ray and treatment commenced immediately if necessary. This request however, was met with resistance by hospital staff. The X-ray department did not want to give X-ray films to patients on the same day despite the AAI physician explaining that patients came from Atauro, transportation was a problem, and if treatment was required, it needed to occur early in the week so the patients could return to Atauro on the ferry that Saturday. 6 page of 18

7 This new process has been trialled once this month and was successful. Therefore, AAI will continue to meet patients at the Dili National Hospital for referrals. AAI staff member, Nuno registering Patients prior to consultation AAI local nurse, Cesar testing an infant for malaria 7 page of 18

8 Objective 2 Health Promotion Activities There was a total 61 patients diagnosed with Scabies in the months of August and September. It was therefore decided that health promotion activities be focused on scabies during September. Information was focused on prevention and delivered using picture cards followed by group discussion. Health education was also provided individually during consultations and at pharmacy when patients receive medications. A total of 140 people received education on scabies Macadade Village: Scabies education provided to 90 outreach clinic patients Baruana Village: Scabies education provided to 40 mobile clinic patients Adara Village: Scabies education provided to 10 outreach clinic patients Due to the cancellation of Friday s mobile clinics in Maquili, a proposal has been made to the Atauro Sub- district Health Coordinator to utilise this day to provide health education in schools. AAI have previously conducted health education in schools when access to some villages was not possible due to rough sea conditions during the rainy season. Schools will recommence in October after a three month holiday period. A meeting will be held with the Atauro Sub-district health Coordinator in October to commence planning for health education in schools. Current materials need to be revised and a plan to produce future materials discussed. Dental care health promotion materials are currently being developed. Information is sourced from Ministry of Health Information Education and communication materials. AAI local nurse, Cesar, presenting health education material prior to commencement of medical consultations A patients looking at health education materials during a health education session 8 page of 18

9 Objective 3 Capacity Building of Local staff AAI is currently focusing on improving the clinical, health promotional and organizational skills of local healthcare staff. The key areas of capacity building include; Clinical skills/knowledge: Teaching and mentoring is being conducted during consultations. Standard disease definitions are being emphasized and reference is made to the MoH Standard Treatment Guidelines and IMCI. Local staff are conducting patient consultations under the supervision of the AAI doctor and Health Coordinator. IT skills: Local staff are being skilled in IT skills. Staff are learning basic skills in Microsoft Word and Excel. Daily teaching sessions whilst the team is in Dili are provided with revision of previous days learning. Local staff continue to be trained in pharmacy education with staff practising drug calculations. AAI is developing a pharmacy education quick reference chart to utilise in pharmacy so that all staff members are providing the same information to patients at clinics when dispensing medications. This will also be a good reference tool for any new staff members, the newly appointed nurse at Adara and Community volunteers. AAI continues to work closely with Community health volunteers to increase their capacity in three clinics. Community health volunteers assist with patient registration, clinical observations and translation. Often patients only speak their local dialect and therefore require translation from their local dialect to Tetun. AAI had met the community midwife from Macadade, who has been recently trained at Bario Pite Clinic, and this month the midwife joined AAI at clinic. The midwife asked the AAI Physician to examine several maternity patients who presented for general health check ups. This liaising with patients will continue. AAI continues to collect medication data for the MoH and the Atauro CHC so that they are aware of AAI s current drug usage. This will provide a clear picture of AAI s drug usage at outreach mobile medical clinics. The aim of this is to also improve the system for drug ordering so that that the CHC is supplied with adequate amounts of drugs for their clinics as well as the mobile and outreach clinics (Refer to Attachment 1). However, the problem with drug supply from the MoH remains as an emergency order which was placed at the beginning of the month is still not filled. The Health Coordinator will seek a further appointment with the director of the Central Pharmacy. A meeting was held with the AAI Health Coordinator and the Health Coordinator of Atauro to discuss the following issues: 1. Recruitment of the Nurse for Adara. The Health Coordinator discussed the nursing position for the Adara health post as the nurse who had been identified for employment was no longer available. A decision was made to employ another nurse although not a midwife. A suitable nurse was found by contacting the MoH where a list of unemployed nurses was kept. An interview was arranged and the successful applicant was organized to accompany AAI to Atauro at the beginning of September. The National Nurse has not worked within the health system of Timor- Leste for five years so an educational plan has been developed to up skill and enhance clinical competencies. The plan was agreed to by the Atauro Health Coordinator but is subject to change if required. 9 page of 18

10 2. Competence of the Cuban Doctor. AAI had further serious reservations regarding the competence of the Cuban Doctor currently in position at the CHC on Atauro. The instructions given for the care of an infant with a severe skin infection were not followed even though the child was escorted to the CHC by AAI staff and a handover given to the doctor. The doctor s total disregard for the welfare of the patients increases the number of patients that are seen at the AAI s accommodation. The concerns of the AAI Physician have been expressed to the Health Coordinator of Atauro and shall be put in writing. A copy of this letter will be given to the Director of Dili District Health Service and the MoH. 3. Clinics at Maquili The AAI Health Coordinator discussed the dangers of the beach landing of the outrigger boat at Maquili Village. AAI also rarely receives any assistance to disembark. Previously this matter had been discussed with the Chefe de Suco by the Health Coordinator on several occasions but assistance remains unreliable. With staff safety issues to consider, the decision that no further clinics would be conducted at Maquili was made by the Health Coordinator. 4. Adara Village Nurse With partial funding obtained from WHO, a National Nurse was employed for one year for the remote health post at Adara which is situated on the western side of Atauro. This health post has been without a nurse for over five years, is very isolated and transportation via sea is problematic from December to August due to rough sea conditions. This information was conveyed to the applicant during the interview as well as lack of communication channels available at Adara. Telephone communication are also unavailable. Transportation is by boat or walking over ruggered hilly terrain which can take up to 4.5 hours from Vila CHC to Adara. The successful nurse was still willing to take the position even with the limitations as he had not been employed in his profession for over five years. He had not been to Atauro before so orientation was organized for the following: Adara Village nurse Viscente, on way to Adara from Beloi 10 page of 18

11 To the geographical layout of Atauro To the administrative structure of Atauro To the clinical management of clinics To the administrative and reporting requirements for the CHC The nurse was able to join AAI at one clinic on arrival to Atauro so that he could familiarize himself with the structure and clinical management of clinics as well as the referral system of patients. One day was spent at the CHC so that reporting requirements for the monthly report were given to the nurse. AAI staff travelled to Adara to introduce the nurse to the community and church leaders and help him settle into his new home. On further discussion with Snr Lucas, Health Coordinator Atauro, an educational plan was implemented for the nurse as he had not been in the health industry for 5 years. The plan: At the end of each month, the nurse will travel to Dili with AAI and work in the office for the following week. The emphasis will be on health education to the community to prevent illness. If time allows, one day will be devoted to clinical competence at another clinic. Upon returning to Atauro with AAI, attendance has been arranged at one mobile and outreach clinic with AAI to enhance clinical competencies. All staff will attend the clinic at Adara where AAI will assist in patient and clinical management. This plan is for review at the end of the year The educational plan for September: Diagnosing and treating scabies and practicing delivering education to the community Diagnosing and treating bacterial skin infections Diagnosing and treating malaria and providing education to the community Diagnosing and treating dengue fever and providing education to the community Commenced basic computer skills 11 page of 18

12 3.0 EVALUATION Health Data from Mobile Outreach Healthcare Clinics Figure 1. Mobile Clinic Diagnoses in August at Atuaro, Under 5 years (n=85) Under 5 No. of cases Nervous system disorders Eye disorders Ear disorders Dental and oral disorders Respiratory disorder Gastroenterohepatology disorder Genitourinary disorders Cardiovascular disorders Neuromusculosceletal disorders Skin disorders Viral infection Fever Tropical infection Metabolism disorders Nutritional disorders Obstetric and Gynecologic disorders Trauma and injury Mental disorder Neoplasm Surgical cases A total of 85 presentations in the 0-5 age group were seen at AAI clinics in the month of September. Respiratory tract infections, skin conditions, tropical infections including malaria and gastroenterohepatology disorders continued to make up the majority of the diagnoses in young children. Respiratory tract infections accounted for a total of 42% (36 cases) of clinical presentations in this age group. Skin condition accounted to a total of 20% (17 cases) of total presentations. Tropical infections including malaria accounted for 12% (10 cases) and Gastroenterohepatology disorders accounted to a total of 11% (9 cases) of all presentations. 12 page of 18

13 Figure 2. Mobile Clinic Diagnoses in August at Atuaro, Age 5-15 years (n=35) 5<15yrs No. of cases Nervous system disorders Eye disorders Ear disorders Dental and oral disorders Respiratory disorder Gastroenterohepatology disorder Genitourinary disorders Cardiovascular disorders Neuromusculosceletal disorders Skin disorders Viral infection Fever Tropical infection Metabolism disorders Nutritional disorders Obstetric and Gynecologic disorders Trauma and injury Mental disorder Neoplasm Surgical cases A total of 35 presentations in the 5-15 age group were seen at the AAI clinics in September. Respiratory tract infections, skin disorders, trauma and injury account for the majority of the diagnoses in this age group. Repiratory disorders account for the majority of presentations in this age group with 37% (13 cases) of presentations, skin disorders account for 17% (6 cases) of presentations and trauma and injury account for 11% (4 cases) of presentations. 13 page of 18

14 Figure 3. Adult Mobile Clinic Diagnoses in August at Atuaro, Age over 15 years (n=473) Adult 16+ No. of cases Nervous system disorders Eye disorders Ear disorders Dental and oral disorders Respiratory disorder Gastroenterohepatology disorder Genitourinary disorders Cardiovascular disorders Neuromusculosceletal disorders Skin disorders Viral infection Fever Tropical infection Metabolism disorders Nutritional disorders Obstetric and Gynecologic disorders Trauma and injury Mental disorder Neoplasm Surgical cases There were a total of 473 presentations over fifteen years of age presenting to AAI mobile clinics on Atauro in September. Neuromusculoskeletal presentations accounted for 30% (143 cases) of presentations in this age group. Nervous system, respiratory, gastroenterohepatology and cardiovascular disorders including hypertension were also common clinical presentations in adults. Nervous system disorders accounted for 16% (74 cases) of presentations, respiratory disorders accounted for 12% (57 cases), gastroenteroheaptology disorders accounted for 11% (53 cases) and cardiovascular disorders accounted for 9.4% (66 cases) of presentations in this age group. AAI continue to screen all adult patients at registration recording both blood pressures and weights. In September there were four new cases of hypertension based on diagnoses made in accordance with the MoH Standard Treatment Guidelines for Primary Health Care Facilities in Timor-Leste. Whilst ideal to confirm suspected cases of malaria with laboratory testing, clinics are held in rural areas with no access to microscopic diagnosis on site. There is one laboratory technician on the Island but he is based at the CHC in Vila. All suspected cases of Malaria are tested using the Malaria Rapid diagnostic tests (PARACHECK) and a Thick film blood sample is taken to confirm diagnosis at a later stage at the CHC. However, it has been found that with some patients who have tested negative on PARACHECK are later confirmed positive for p.falciparum malaria once thick flim analysis is made. Therefore, AAI continue to prescribe anti-malarial medications based on clinical presentation for suspected cases of malaria. All patients who clinically warrant treatment are transferred to the CHC for further management. 14 page of 18

15 Pharmacy & Medical Supply AAI drug supply remains seriously low. AAI received a drug order for the month of September from the MoH, the first in six months. However, the CHC did not order any drugs for the health post at Adara even though it was known for a month that a nurse would be employed there. Therefore, AAI was asked to supply drugs for the health post and an emergency order would be placed at central pharmacy to replace the drugs that AAI gave in order for the health post at Adara to commence operations. Unfortunately AAI is still waiting for the emergency order to be filled by the MoH which was placed three weeks ago. The AAI Health Coordinator and the Health Coordinator Atauro will seek an appointment with the Director of Central Pharmacy to ascertain what can be done regarding a reliable drug order. Presently AAI have no stock of Coartemether, the latest drug treatment for malaria, as the central pharmacy had no in date supply. AAI is using alternative drugs for the treatment of malaria. Water Supply Atauro Island has one main water supply which provides water to the eastern side of the island only. During September, the water supply was available daily however, only for a short period of time. This lack of water has required AAI to take extra bottled water for patient consumption. As advised by information from UNDESA, a contract has been signed by DNAS and a contractor to redo the Berau water intake system. The contract is for three months to repair the intake system however, the contractor will not be responsible for repairing any piping. Logistics & Transport The AAI vehicle was used to transport ill patients from AAI outreach healthcare clinics to the CHC at Vila for further assessment and treatment. Once again the CHC ambulance was not on the island as it was in Dili for repair. This meant that AAI had the only vehicle on the Island for transporting patients to the CHC. When the ambulance was repaired, the ambulance could not return to the island for another week as the DHS did not have funds to pay the $50.00 ferry cost. The CHC outrigger boat had been re-glued so that constant bailing was not required. The boat is in urgent need of repair or a more beneficial replacement boat is needed. 15 page of 18

16 4.0 RECOMMENDATIONS TO THE MOH The priority areas of health remain mosquito borne disease (dengue and malaria), acute respiratory infection, cardiovascular disease, diarrhoeal disease and hygiene/sanitation related diseases, such as skin disease. Malaria diagnostic testing is urgently required to be provided for mobile clinics to: o reduce unnecessary treatment with Coartemether (presently this drug is not available to AAI) o focus on treatment of cases o better describe the epidemiology of the disease o Enable specific treatment of vivax and falciparum disease. Transportation remains a priority issue on the Island. This extends beyond the provision of transportation to the need for ongoing management and maintenance plans. However, currently Atauro Sub-District desperately needs an ambulance boat which could transport seriously ill patients to Dili within a much shorter time frame than it takes to organize and obtain approval for helicopter evacuations with the United Nations or after hours waiting for approval from the Health Coordinator at Aspen. A replacement road ambulance is desperately needed on Atauro as the present ambulance requires constant maintenance. It is unavailable more times than it is working and when it is repaired in Dili money must be available for its immediate return to Atauro Island. There needs to be a high priority placed on the review of pharmacy contracts with the MoH so that appropriate companies are monitored in order to maintain appropriate drug levels, quality and continuity of supply for all medications on the essential drug list. It is recommended that the MoH review the contract and the project management process so that an adequate supply of drugs is available to treat patients according to the standard treatment guidelines of Timor-Leste. The water supply remains problematic and requires constant monitoring for quality and consistency to the eastern side of the island. The water supply requires urgent maintenance from DINAS so that the communities have a consistent regular supply. A referral system with documentation between MoH healthcare providers needs to be established so that receiving healthcare providers are aware of patients diagnosis, previous treatments and further management required. This will facilitate continuity of care between facilities and therefore improve patient outcomes. End Statement 3 October 2008 AAI Medical team Timor-Leste 16 page of 18

17 ATTACHMENT 1 Monthly Medicine Usage ANTIBIOTICS Number Used Amoxicillin 250 mgs caps 42 Amoxicillin 500mgs caps 330 Amoxicillin Suspension bottles 22 Ciprofloxacin 250mg tabs 240 Chloramphenicol tabs Cloxacillin 250mgs caps 858 Cloxacillin Suspension bottle 29 Cotrimoxazole 480mg tabs Cotimoxazole Suspension bottle 3 Doxycycline 100mg tabs 48 Erythromycin 250mg tabs Erythromycin Suspension Metronidazole 250 mg tabs 28 Metronidazole Suspension Nystatin Tabs Nystatin drops bottle 1 Ofloxacin tabs Ofloxacin tabs Penicillin tabs Chloramphenicol 5% eye/ear drops 3 Chloramphenicol Eye Ointment 1% 9 Tetracycline Eye Ointment 1% ANTI-MALARIALS NUMBER USED Coartem 5-15 kgs Nil stock Coartem 15-25KGS Nil stock Coartem 25-35KGS Nil stock Coartem 35KGS ADULT Nil stock Chloroquine 66 Quinine Fansidar 30 ANALGESICS NUMBER USED Aluminium 500mg tabs 876 Aspirin 300mg Buscopan tabs 116 Diclofenac 50mg tabs Ibuprofen 200mgs Iboprofen 400mgs tabs 771 Paracetamol 500mg tabs Paracetamol Suspension bottle page of 18

18 OTHER DRUGS NUMBER USED Ranitidine 150 mg tabs 140 Metoclopramide 10 mg 30 Oral Rehydration Solution Sachets 19 Promethazine 50 mg tabs 161 Griseofluvin 500 mg tabs 120 Multivitamin tabs Allopurinol 100mg tab 516 Multivitamin syrup bottle Linctus 10 mg 9 Prednisone 5mg tab Vitamin A caps Bisacodyl tabs 14 Pyrantel Pamoate Solution Albendazole 400 mg tabs 9 Mebendazole 500mg Ventolin tabs 13 Ventolin Aerosols 4 ANTI-HYPERTENSIVES Atenolol 100mg tabs 98 HCT 50 mg tabs 672 Captopril 25 mgs tabs 84 Nifedipine 50mg tabs 84 IRON TABLETS Ferrous Sulphate tabs 252 Ferrous Sulphate + Folic acid tabs 30 Folic Acid 5mg tabs TOPICAL NUMBER USED Benzoic Acid +Salicylic Acid (WHITFIELDS) 9 nil stock Benzl Benoate Solution 6 Clotrimazole pessary 9 Hydrocortisone Cream 8 Permethrim Cream 47 nil stock Permethrim Shampoo 2 18 page of 18