Health, WASH and Livelihood Rapid Assessment in

Barmal and Urgon Districts of Paktika Province

June 2016

List of Acronyms:

BHCBasic Health Centre

BPHSBasic Packages of Health Services

CHCComprehensive Health Centre

DEWSDiseases Early Warning System

EPHSEssential Packages of Health Services

HFHealth Facility

HPHealth Post

HQHeadquarter

INGO International Non-Government Organization

INTERNATIONAL MEDICAL CORPSInternational Medical Corps

KhamakDress designing

KIIKey Informants Interview

KPKKhyber Pakhtunkhwa

MCHMother and Child Health

MoPHMinistry of Public Health

M&EMonitoring and Evaluation

NRVANational Risk and Vulnerability Assessment

OHPM Organization for Health Promotion and Management

ODOpen Deification

PHCPrimary Health Care

SHCSub Health Centre

UNCHRUnited Nationals High Commissioner for Refugee

UNICEFUnited Nations Children Fund

WASHWater Sanitation and Hygiene

Executive Summary

A long ongoing conflict between Pakistan government and Taliban insurgents has resulted a displacement of people from the KPK, Northern and Southern Waziristan Areas. A large number of people have immigrated to safer areas of neighboring provinces of Afghanistan such as Paktika, Khost and Paktya.

According to UNHCR reports approximately 12,090 families have been settled in Paktika province, while majority of themare residing in Bermal and Urgon districts. These two districts border with Northern Waziristan. Majority of these refugees have been settled either in the refugee camps or have been living with host communities inside the villages of Barmalor either with their relatives inside their homes. The Urgon district provides job opportunities, health services and livelihood support. As a result it attracted 60.33% of the total refugees to choose their destination of place to settle. According to UNHCR reports, approximately 98%families are living in Beramal district and294 refugee families in Urgon district of Paktika Province.

It has been revealed from the recent rapid assessment conducted by International Medical Corps during May/June 2016, that a large number of refugees living in Paktika are currently facing multiple serious problems including livelihood, health services and WASH facilities. Non-availabilityof safe potable drinking water, unsafe hygiene behaviour and practices, absence of adequate health services combined with poor or non-existent sanitation infrastructure practices have adversely causedon their living and health conditions. This has contributed an increased mortality and morbidities among 5> children and women of CBAs. Furthermore, psychosocial problems, communicable diseases and pregnancy issues are the most pressing health needs, are considered as a major health problem threatening the lives of refugees. Unavailability of safe drinking water, common open defecation practices and poor personal and environmental hygiene and sanitation conditions are serious health issues of refugees that need to be addressed urgently.

Based on the IMC needs assessment only 20% people have access to safe drinking water, less than 10 % have access to hygienic latrines and 37% of people were reported using soaps and applying hand washing practices at critical times. Access to health services is severely low, particularly in Bermal District. More than 80% of refugees are working as daily labourersor bringfire wood from mountains to sale. It was witnessed during the assessment that a large number of under aged children are working to support their families (i.e. working in local shops, bringing woods from mountains, selling mobile cards are commonly practiced jobs opportunities for children).

Lack of schools and vocational training programs were identified as serious problems affecting their livelihood conditions negatively. Lack of livelihood opportunities was repeatedly emphasized as a pressing need of refugees and host communities.

Situation Analysis

Paktika Province with 19 districts has a population of 434,742people and it is one the South-Eastern provinces of Afghanistan bordered with Northern Waziristan and KPK of Pakistan. Due to the ongoing conflict in KPK and Waziristan agency, people from this area immigrate to Paktika province of Afghanistan, to escape from the fighting between Pakistan Government forces and Taliban insurgents. Unrest in KPK and Waziristan has a long history and it will continue for foreseeable future. Whenever the security situationin KPK and Waziristan deteriorates, people are most likely to immigrate into the Paktika province. Though the security situationof Paktika is equally deteriorated but still the conflict affected population from Northern Waziristan choosePaktika Province as a first choice of settlement, due to its proximity.

According to UNHCR reports dated 10 May 2016, currently Paktika Province, one of the provinces with a large number of Pakistani refugees, is hosting more than 12,092refugee families and most of them are settled in Bermal, Urgon, Wazakhwa districts. In order to design a need based program, International Medical Corps conducted a rapid needs assessment of Barmal and Urgon districts of Paktika Province, which are hosting the largest concentration of refugees. The assessment included the recent refugees camps established in these districts as well.

Assessment Objective

Main objective of the Rapid Assessment was to identify critical gaps, needs, opportunities and capacities of refugee families covering health services, WASH and livelihood status and prioritize their needs and gaps based on the urgency.

Methodologies Adopted

Field level data collection through key informant interview was used as the principle method of the assessment. In addition, available secondary data and information were reviewed as reference.

  • Desk Review / Secondary Data Review:

The assessment team conducted a desk review of all the available documents, survey reports, journals issued by MoPH and UN agencies pertaining to respective districts of the province.

During the assessment, International Medical Corps had conducted meetings with key stakeholders(OHPM, Directorate of Public health , Community Elders ) to obtaintheir opinion and recommendation to identify priority needs as well as to address the refugees’ problems in an effective manner.

  • Data Collection Methods:

Key informants Interviews (KII): 15 Key Informant Interviews were conducted with community representatives and influential individuals from refugee communities in various locations of these two districts. The questionnaires enabled the team to collect information on quantitative and qualitative data. The qualitative part of the assessment covered the type and magnitude of needs, challenges, access and quality of services available to,while quantitative data included numbers and figures of refugees who have access to WASH (safe drinking water, hygienic latrines, health services and percentage of families using soap and practicing hand washing behaviour). Information collected from the assessment will provide a broader picture that will inform us to design appropriate interventions for short and medium term periods. The details of settlements covered by assessment is as follows:

District / Villages / Sites / # KIIs
Bermal / Rokha , Chakhori Ada , Raghzi , Poshan Kaly , Laman , Chokhori Ada , Sorzghami , Khina , Rakha , Sulhakhail Nawe Ada , Faqiran / 10
urgon / Balishi , Dasht , Munda , Khwaja Hasan , urgon Kalan / 5
  • Data Collection Tools and Training for Enumerators:

For necessary data collection, International Medical Corps had developed specific tools and conducted a training session for enumerators in the field. The tools used for data collection was reviewed by technical team at HQ, while the training session on these tools was facilitated by WASH coordinator of International Medical Corps. The one day training contained all topics included in questionnaire, practical works and a complete briefing session on need assessment particularly on KIIs conduction methods.

  • Data Management and Analysis:
  • Data was collected at field levels, each team of two surveyors was supervised by a supervisor in each survey site. They had an introductory meeting with the community elders prior to the data collection and explained the survey objectives.
  • On a daily basis the translated soft copy of filled questionnaires were received from the supervisor and reviewed by WASH coordinator.
  • Supervisor reviewed the questionnaire and provided feedback on the quality of data and unclear figures/answers .
  • Hard copies (original questionnaires) were collected by supervisors,labeled, filed and sent to the Kabul office for translation and transcriptions and further process.
  • Hard copies stored separately in the carton files in M&E apartment
  • After ensuring the data quality, coding process begun at Kabul level by M&E coordinator and qualitative data has been coded in all section.
  • Quantitative data has been calculated by % and for each indicator separately.
  • Analysis of coded data was done byM&E department .
  • The first draft of the assessment report is shared by June 15 , 2016.
  • Markets Assessment:

In order to get an understanding of current job opportunities in local area, potential livelihood interventions including vocational trainings, International Medical Corps had conducted a rapid assessment of local markets nearby the refugee settlements. The assessment shows the current condition of markets in these two districts in terms of markets, access to existing markets with nearby settlements, investment opportunities and availability of jobsopportunities for men and women.

Urgon is one of the districts with a large market,merchants, investments and job opportunities. It has a good markets for all types of products or livelihood activities. While Barmal is one of the remote districts where there is no larger a market available for nearby refugee settlements and livelihood activities. It is necessary to link these communities with other nearby markets in Urgon or angoor ada.

  • Stakeholder Analysis

To avoid duplication through an effective coordination, International Medical Corps’ assessment team conducted a detailed stockholder analysis including preparation of a 3 Ws (who is doing what and where) chart for all organizations thatare active in the targeted districts of Paktika.

Organization / Working Areas / Projects / Donors / District
International Medical Corps / Health:
Providing secondary health services for the people of Paktika. / EPHS / MoPH/WB / Sharana Hospital
International Medical Corps / Health:
INTERNATIONAL MEDICAL CORPS is providing life – saving trauma care service for war and conflict effected victims / Emergency Trauma Care Project / CHF/
UNOCHA / Sharana Hospital
International Medical Corps / WASH
INTERNATIONAL MEDICAL CORPS is responsible for bellow activities.
Hygiene promotion
Construction of hygienic latrines
Construction of drilling bore well
Distribution of hygiene kits / WASH Project / CHF / Urgon & Bermal
PPHD / Health:
This mobile health team project is providing PHC services for refugees in Barmal District / Mobile Health Team / UNICEF / Bermal
OHPM / Health:
OHPM is responsible to provide quality health services (basic health services) and running 35 different type HFs including (SHC, BHC, CHC and DH). / BPHS / MoPH/WB / Paktika

Assessment Results

The assessment results are elaborated below for each Sector (WASH, Livelihood, and Health) separately based on the Information from the desk review, Key Informant Interviews and other sources. Information categorized into relevant sections while for issues addressing and data presentation, charts have been provided under each sections, which contains the exact quoted speeches of the particular Interviewers.

1-WASH:

Portable Water:

Basically an access to portable water is a lesser issue in newly established refugees camps or settlement. However, the water supply situation outside of newly established camps is totally different. This assessment findings tell us that the majority of refugee families have no access to safe drinking water. Only 20% of these refugees have access to water through ground water sources (drilled bore wellsequipped with hand pumps). Piped water system is not available inside the refugee camps or settlements. Remaining 80% of population is using unsafe water points such as Kariz, springs and other traditional sources (ravines and Mountains water).

The average quantity of water used per person per day is in between 5 to 15 lt. Approximately 70% of families have to walk 5 to 15 minutes to fetch water.

Sanitation and Hygiene:

The assessment informs us, that open deification is commonly practiced among these communities (seen in observation). Approximately, 90% of families are using un hygienic sanitation facilities. Improved sanitation facilities are non-existent. The team identified the higher need for provision of safe and hygienic sanitation facilities (latrine) as the most urgent need of refugees.

The assessment indicates that only 30% of families are using or possessing soap, observing Hand washing practice at critical times is 37%. Alimitednumber of families have access to bathrooms. Only 12% of families received hygiene kits since last year. Approximately 23 % of families are using food safety practices while preparing and storing foods. From reviewing the health data it emerged that the poor personal and environmental hygiene practices has caused significant increase in WASH related communicable diseases such as Diarrheal diseases,Malaria,ARI, Tuberculosis and others, while International Medical Corps also reviewed and compared the data of last two years (93 – 94) (1st Q) in Bermal District which shows raising trends in these diseases. Chart 1.1 - Bermal District Common Morbidities trend

HMIS – MoPH, Bermal District

2-Livelihood

Primary Source of Income:

Paktika is one of the insecure provinces in Afghanistan with fewer job opportunities, limited markets and income resources. About 60% respondents of the assessment indicated that the sale of woods brought from mountains is the primary activity that the refugee families are engaged for their livelihood. Daily wage work, labour, shops keeping are in second position from which the people fulfil their livelihood needs. A few families are involved in agriculture activities, though the two assessed districts are mountainous and have less agriculture lands.

During the assessment the interviewers indicated that vocational trainings programs,Poultry farming could help them to obtain their needs, however most interviewers were emphasized on vocational trainings such as tailoring, carpentering and other professions of livelihood.

In overall the economic conditions of the refugees is in worse condition as they are struggling to meet the two ends.

Vocational Trainings:

Vocational training and/or education programis on high demand by the refugees and host communities in both districts. No organization is currently implementing the vocational training program in these two districts. Primary education for children was indicated as a priority need of the refugee community in Bermal as they mentioned that there is no school in most areas for children and that is why the children are heading to works.

Poultry Farming:

Indicated as one of the easy and effective methods for supporting the refugees for their livelihood. However, a number of things have to be taken into considerations such as training, supply of feeding, supply of birds, preparing areas, veterinary service, cage and marketing. Two major markets are located in Bermal District is called angoor ada and the other markets for livelihood activities could be Urgon district main market. In addition local small market could be a good source of business forlocal products like chicken.

Major Challenges of Livelihood:

Severely limited job opportunitieslack of funds, and low education level are major challenges indicated by the Key informant interviewers that affects the normal lives of refugees and host communities negatively. Some interviewers mentioned about the security as a constraint and stated that insecure situation in thesedistricts has negatively affected the lives of refugees and host communities. Poor cultural practices (women’s low participation) in livelihood activities was also indicated by some KIIs as a challenge for livelihood.

Under aged children working:

According to KIIs survey results, child labour is commonly practiced to support their families. These children are doing hard works in local markets. Most of the KIIs stated that the children go to other cities for work. Activities that children are involved are --selling mobile cards and working inside shops for daily wages. Lack of schools and learning opportunities for children was identified another priority need of children.

Reason for the poverty:

Based on the assessment results, main reasons of the pervasive poverty of refugee families were as follows:

  • Low level of education
  • Unavailability of job opportunities
  • Limited income resources
  • Deteriorated Security situation
  • Lack of vocational trainings
  • Lack of schools
  • Unfavourable cultural and traditional norms

3-Health

Availability of Health Facilities:

Currently there are one CHC clinic and a Sub Health centre in Barmal and a 20 beds District hospital providing in Urgon, established to provide health care services to the local communities, but currently serving to ever increasing number of refugees as well.All these HFs are running by a local NGO (OHPM) since June 2015.In addition a mobile health team is providing primary health care services by the Provincial Health Directorate with funding from UNICEF. All HFs are located far from the refugeesettlements in Bermal, which limits the access to the essential Health services. On the other hand these HFs are established to serve the local communities only. They do not have capacity to provide the health care services to ever increasing number of refugee population. It is overburdened to the limits of these health facilities.

The assessment identified that the health care services either are not available or notsufficient to therefugees, both in camps and settlements. In Bermal District of Paktika, the assessment results indicate that no health services are available inside the refugee camp and settlements, while in UrgonDistrict, the refugees living nearby local communities benefit from pre-existed health facilities.

Common Morbidities (Illnesses)

Due to economic stress and tough security conditions, a large number of refugees have low or high level of mental disorders. Based on the assessment informants, it is in the rising trend. Common health problems of these communities explained by the informants arepoor personal and environmental hygienic conditions that causeanincrease incommunicable diseases among children, women and other vulnerable groups. Measles, malaria, diarrheal diseases can be named as common infectious diseases, while injuries and psychosocial problems are non-infectious diseases effecting people.