Annex 3. Health. Introduction

Transcription

1 Annex 3 Health Introduction The devastating earthquake in Gujarat on the morning of January 26, 2001 has left behind a trail of death and disintegration of families, thousands seriously injured and handicapped, both physically and psychologically and a severely damaged health infrastructure. As the time of writing, the number of confirmed human deaths was over 20,000 (of which over 17,000 have been reported from Kutch alone) and the number of persons injured was nearly 167,000. Persons have been admitted with orthopedic injuries, head injuries, tissue losses, abdominal and thoracic trauma and amputations. A large proportion of these patients are likely to develop permanent disabilities, requiring rehabilitation and care in the future. Widespread damage has occurred in six districts: Kutch, Rajkot, Jamnagar, Surendranagar, Patan and Ahmedabad. Kutch, the district closest to the epicenter is the worst affected in terms of lives lost, injuries, and damage to infrastructure. Kutch is an arid area and has faced a cyclone and drought in the last three years. Government health care facilities had been the main source of medical care for the majority of the population in this district. The allopathic private sector was primarily located in Bhuj, with about 80 medical practitioners of different specialties. In addition the government had an extensive setup of Ayurvedic hospitals and dispensaries. Consultations and Site Visits In order to assess the damage caused by the earthquake a team visited Kutch, Rajkot and Surendranagar districts between February 13 to 15, Health facilities at district, taluka and primary health care levels, including sub-centers and Anganwadi centers, were visited in Bhuj, Anjar, Bhachau, Rapar, Malia, Surendranagar, Dhrangadhra and Halwad. The team had an opportunity to witness the extensive relief measures in place and the mechanisms being put in place for longer term management of the sick and injured and their rehabilitation. Discussions were held in Gandhinagar with the Additional Chief Secretary, Department of Health and Family Welfare (DOHFW), GOG; the Additional Chief Secretary and Commissioner Family Welfare, GOG; the Commissioner, Health, Medical Services and Medical Education, GOG and their team. In the field, discussions were held with the Chief Medical Officers, Chief Health Officers and their teams in different districts. In addition the team met with representatives of WHO, UNICEF and a number of bilateral aid agencies and Non-governmental organizations (NGOs). These visits and consultations supplemented various written reports and data provided by GOG. Information available was based on data from rapid surveys conducted by one Deputy Engineer with a medical personnel visiting each site. More detailed assessment of damage is ongoing. Damage to Assets The damages to assets in the heath sector are estimated to be about Rs. 220 crores ($47 million) (Table 1). Infrastructure. Damage to health infrastructure in the affected areas is severe, as a result of which service delivery at the facilities, including maternal and child health services, has been seriously disrupted. Many health buildings have been completely destroyed, others partially damaged, still others structurally weakened and more will require minor repairs. Power and water supply to the facilities has also been damaged. A total of 2 District Hospitals (Bhuj and Gandhidham), 21 Community Health Centers (CHCs), 48 Primary Health Centers (PHCs), 227

2 Sub-centers, about 800 Anganwadi Centers, 6 Integrated Child Development Services Scheme (ICDS) Go-downs, 11 Chief District Project Officer (CDPO) offices, 96 Ayurvedic dispensaries, 21 Homeopathic dispensaries and 1 Food Laboratory have been completely destroyed. In addition, all types of facilities at different levels of health care have suffered major and minor damages. In total, damages are assessed at about Rs. 203 crores ($44 million) or about percent of total health sector asset losses. District Hospital, Bhuj, a 281-bedded facility, was completely destroyed. 161 patients and 10 staff nurses died in the collapsed building. In addition to the main hospital building, the Nursing School and hostel, Auxiliary Nurse Midwife (ANM) Training School, District Tuberculosis Center, Mental Hospital and staff quarters, all located in the same campus, have been destroyed or suffered major damage. The District Hospital was the referral hospital for the entire district of Kutch, which in terms of area, is the second largest district in the country. It was also the hub of all training activities in the district. Food Laboratory, Bhuj. The building has been destroyed; however most of the equipment has been salvaged. There are three such laboratories in Gujarat. The one at Bhuj was a state-ofthe-art laboratory catering to the Western Region of Gujarat, including the Port of Kandla. The laboratory at Vadodara has taken on the work-load of the Bhuj laboratory for the interim, but a permanent facility in the Kutch region is required. Integrated Child Development Services (ICDS) Scheme. The ICDS scheme has suffered considerable loss of its infrastructure. This program provides services to children in the 0-6 age group and pregnant and lactating women. The capacity of the program to target the most vulnerable sections of the population who are at risk of developing malnutrition and its management, has been affected by the earthquake. The loss to this program is about Rs.13 crores ($2.8 million), which is about 6 percent of the total damage to the health infrastructure. This damage is included in the total infrastructure damage estimates. Indian Systems of Medicine. The Department of Health and Family Welfare supports a large network of hospitals and dispensaries in the state, providing services in Ayurveda and Homeopathy. Gujarat Ayurveda University, Jamnagar, is the only one of its kind in India. There is a section of the population which prefers this system of medicine and often Ayurvedic/Homeopathic dispensaries are located in villages where there is no PHC or sub-center. The damage to these hospitals and dispensaries is about Rs.3 crores ($0.7 million) and has been included in the estimate of total infrastructure damage to the sector. Municipalities. In Gujarat, public health services are primarily provided by the government health infrastructure described above. Municipalities are meant to provide services in urban areas through small dispensaries located in the municipality area. Ahmedabad Municipal Corporation has several health care facilities, including few large tertiary care hospitals. Damages assessed are about Rs. 5.3 crores ($1.14 million), of which about Rs. 5.0 crores ($1.1 million) is in Ahmedabad city hospitals. These damages are included in the total infrastructure losses. Equipment, Drugs and Medical Supplies. Equipment, including vehicles, at the facilities that have been completely destroyed has suffered damages. However, the health functionaries have been able to retrieve equipment and presently safe storage of this equipment is a priority. Small existing stocks of drugs and supplies were affected in the destroyed facilities, but there has been no damage to the Central or Regional Drug Stores, estimated losses to equipment, vehicles and supplies are valued at about Rs.17 crores ($3.7 million).

3 Private sector. The private sector, providing primarily curative services, has been maximally affected in Kutch. In Bhuj, there are about 80 doctors in the private sector, and almost all of them are reported to have suffered major losses during the earthquake, however no quantitative estimates of this are available. In other areas of Kutch the private sector was less active. Other Impacts Other impacts on the health sector are difficult to quantify at this time. The earthquake has resulted in disruption in provision of routine curative and preventative care, as a result of damage to the infrastructure and displacement of health staff. At the same time, the sector has been called upon to provide emergency curative (particularly surgery and orthopedics) and preventative care much beyond its capacity. The earthquake resulted in an unprecedented loss of human life, injuries and large scale destruction/damage to the health infrastructure. Loss of medical manpower has fortunately been small compared to the loss of infrastructure. However, this is based on available data, and a reliable inventory is awaited. One doctor, 10 staff nurses and 5-8 health workers are reported to have died. Post-traumatic stress. The psychosocial impact and mental trauma on the survivors of the earthquake is difficult to assess. There has been huge loss or injury of family and loved ones, loss of belongings and property and the persistent fear of another similar incident. The emotional effects may show up immediately or after many months Disease surveillance. The widespread damage to health infrastructure and displacement of medical manpower has resulted in disruption of routine disease surveillance. No outbreaks of any disease have been reported so far (February 19, 2001). Immunization program. The routine immunization program has been disrupted due to damage to the health infrastructure, dislocation of health personnel and damage to the cold chain. Potable water. Following the earthquake, water supply had been severely affected. Water supply has now been restored in all affected towns and villages by means of tankers or pipeline supply, but availability to all persons in adequate quantity is not ascertained. A field laboratory has been established in Bhuj to test the chlorine levels and growth of coliform bacteria in water to monitor water quality and reduce the chances of any outbreak of a water-borne disease. Sanitation and waste management. This has been completely disrupted in the affected areas. Though water supply has been restored, its quantity does not seem sufficient to ensure sanitation at temporary hospitals and relief camps.

4 S.No. Type of Damage Table 1: Damage Assessment Damage to Buildings Complete Partial Damage to Buildings in Rs. crores Damage to equipment in Rs. crores Total Rs. crores 1. Sub-center (7.78) (7.78) 2. PHC (10.89) 4.3(0.93) 55.0 (11.82) 3. CHC (12.37) 9.6 (2.05) 67.1 (14.42) 4. District/Taluka Hospital (6.12) 3.2(0.69) 31.7 (6.82) 5. ICDS : (i)anganwadi center (ii)cdpo office (iii)go-down (2.62) 0.2 (0.05) (2.62) 0.2 (0.05) 0.4 (0.08) (0.03) 0.2 (0.04) 6. Ayurvedic hospital/dispensary (0.65) - 3.0(0.65) 7. District TB Hospital/Training Center (0.22) (0.22) 8. Adm building/training Center (0.43) (0.43) 9. Food and Drug Lab (0.10) (0.10) 10. Medical colleges and (1.18) (1.18) specialty hospitals 11. Municipalities (1.14) - 5.3(1.14) including Ahmedabad Corporation TOTAL (47.29) Source : Department of Health and Family Welfare (DOHFW), Government of Gujarat Reconstruction/Recovery needs Ongoing reconstruction works. Relief works have been managed and coordinated by the GOG. The immediate challenge was to manage the thousands of injured persons and provide appropriate surgical care for the orthopedic and spinal injuries. Assistance in the form of medical and surgical teams, drugs and medical supplies, mobile and temporary hospitals, evacuation and transportation of patients and disinfection of water was forthcoming from UN agencies, several state governments, the private sector, NGOs and other countries. Temporary hospitals have been established in pre-fabricated structures and tents. Since the day after the disaster the private sector doctors have been working together with the public sector doctors in the temporary hospital in Bhuj The DOHFW is planning to provide pre-fabricated structures to re-establish health care service provision at the taluka and primary level. In addition to government supplies, large quantities of medical supplies were made available by different state Governments, private sector and NGOs, and hence there has been no shortage of drugs and supplies for relief

5 operations. GOG has sufficient stocks from the donations and an adequate drug budget to cater to continuing needs. UNICEF has been taking the le ad in assessing this damage and re-establishing the routine immunization network and maternal and child health (MCH) services. In addition, UNICEF and WHO with the state government have initiated a mass measles immunization program and Vitamin A supplementation to all children in the nine-months to five years age-group in all affected areas. The main focus of WHO during the immediate post-disaster period has been to setup a surveillance system for infectious diseases and early warning of epidemics, in cooperation with the state and district health authorities. Public Health Specialists from the National Institute of Communicable Diseases (NICD) are also in the field. A Disease Surveillance Cell has been established in Bhuj since February 5, Quality control of water supply has been initiated by WHO. Chlorine tablets and Oral Re-hydration Solution (ORS) packets are being distributed systematically and regularly. WFP is providing 178,000 children below five-years of age, as well as pregnant and nursing mothers, with nutritious biscuits for the immediate term. Subsequently, daily rations of fortified blended food will be distributed to the vulnerable population to prevent severe malnutrition. This activity is being coordinated by the ICDS program in the state. The ICDS program will need to put in place a mechanism to reach the vulnerable children and women, and ensure that there is no deterioration in pre-existing levels of nutrition. The DOHFW with the assistance of the Maharashtra Institute of Mental Health, Pune (who did similar work with the survivors of the 1993 Latur earthquake), the Government of the Netherlands, UNICEF and other UN agencies is discussing a program for post-traumatic stress management. Several NGOs are currently working in the affected areas and providing support for acute stress management. Short and Medium-term Needs Health infrastructure. Rebuilding the destroyed/damaged health infrastructure at district, taluka and primary levels, including that of the ICDS scheme, is the major infrastructural need. This would enable re-establishing effective service delivery at the appropriate level. The public sector will continue to be the main provider of health services in the affected areas, especially Kutch. The existing private sector in Bhuj has suffered major losses, and it does have the option to relocate outside Kutch. Rationalization of service norms based on past utilization rates data is being done by the Department. The extensive damage sustained by health facilities makes it imperative to design and construct hazard resistant buildings. This upgradation in technical norms will reflect in replacement costs higher by about 20 percent over the base replacement cost. All building plans and designs should be reviewed by an architect/structural engineer to ensure conformity with appropriate hazard-resistant standards. Reconstruction should be completed as quickly as possible ideally district hospitals in about 18 months, taluka hospitals and PHCs in about 12 months and sub-centers and anganwadi centers in about eight months. It is estimated that the replacement cost with upgradation could be as much as Rs. 280 crores ($60 million). Equipment and supplies. Equipment for the reconstructed health facilities and the Rehabilitation Center will be procured by the Central Medical Stores Organization Central Medical Stores Organization. Technical specifications of equipment and its rationalization will be based on agreed service norms.

6 Rehabilitation center and prosthetic workshop. The majority of the serious injuries have been orthopedic/spinal injuries, including amputations. The need for a center to be established in Bhuj at the earliest, for long-term management of these patients is critical. The emphasis will be on providing the best possible rehabilitation technology for diversely handicapped individuals. The essential features at the center will include the following: splint workshop, prosthetic/ orthotic workshop, physiotherapy, occupational therapy and two mobile workshops. It is also proposed to provide for psychotherapy and counseling at this center, to build the capacity for future needs for management of post-traumatic stress. Food Laboratory, Bhuj. The Laboratory at Vadodara has taken on the work-load of the destroyed facility at Bhuj for the interim. The Food Laboratory at Bhuj caters to Kandla Port, rebuilding it will be a priority. Central Medical Stores Organization (CMSO) Regional Depots. The CMSO Depot at Ahmedabad is responsible for supplying drugs and supplies to all health facilities in Gujarat. There are six regional stores in the six administrative zones of the state. These stores are small, and the experience during the earthquake has clearly identified the need for larger stores which can immediately dispatch drugs and supplies in an emergency. Designs should be reviewed by an architect/engineer and construction completed within 18 months. Health care waste management. Reconstruction of health facilities will provide an opportunity to establish appropriate waste management measures, which can later be extended to facilities in other parts of the state. Procurement of equipment for implementing short and medium term measures and training health personnel will be done within 18 months Training. Training for doctors and para-medical personnel will be provided in the following areas: orthopedic rehabilitation, prosthetics and physiotherapy; equipment-based health care, waste management and disaster management. Implementation Arrangements. The DOHFW, GOG, will manage implementation of all activities. It will appoint a core team which will have the requisite managerial and technical expertise. Engineers will be deputed from the PWD, and consultants would also be used to supplement in-house resources. Third party inspection and quality assurance will be done through reputed external agencies. Training activities will be planned and implemented through established institutions.

7 Table 2: Possible Replacement Costs of Damage to Health Sector S.No. Type of Facility Total Damage Rs. Crores Total Replacement Cost Rs. Crores 1. Sub-center 36.2 (7.78) 23.4 (5.04) 2. PHC 54.9 (11.82) 32.8 (7.06) 3. CHC 67.1 (14.42) 65.2 (14.01) 4. District/Taluka Hospital 31.7 (6.82) 73.4 (15.77) 5. ICDS : 27.2 (5.84) (i)anganwadi center (ii)cdpo office (iii)go-down 12.2 (2.62) 0.2 (0.05) 0.4 (0.08) 6. Ayurvedic hospital/dispensary 3.0 (0.65) 3.0 (0.65) 7. District TB Hospital/Training 1.0 (0.22) 1.0 (0.22) Center 8. Adm building/training Center 2.0 (0.43) 2.0 (0.43) 9. Food & Drug Lab 0.5 (0.10) 0.5 (0.10) 10. Municipalities including 5.3 (1.14) 5.3 (1.14) Ahmedabad Corporation 11. Medical colleges &Specialty 5.5 (1.18) 5.5 (1.18) hospitals TOTAL (47.29) (50.17) TOTAL REPLACEMENT COST (60.20) WITH UPGRADATION* * Upgradation: additional 20 percent added to the civil works component for hazard-resistant designs and construction Source: Department of Health and Family Welfare, GOGovernment of Gujarat Table 3: Summary - Estimated Damage Assessment and Replacement costs Asset losses Total Loss Rs. ($) million Replacement Cost Rs. ($) million Replacement Cost with Upgradation Public (47.29) (50.17) (60.20 ) Private* Rural Urban** (44.45) 13.2 (2.84) (48.58) 7.4 (1.59) (58.29) 8.9 (1.90) * No data available ** Includes Municipalities, Drug stores, Food Laboratory and Administrative offices and training centers.