Overview of MSF projects in Pakistan

Médecins Sans Frontières (MSF) has been present in Pakistan since 1988, when our teams set up a base to support medical activities in Afghanistan. In 1998 MSF started to provide medical care in Pakistan to Afghan refugees in Jalozai and Shamshatoo camps near Peshawar. On an ongoing basis since that time, MSF volunteers continue to provide medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care and natural disasters.

Pakistan suffers from one of the highest infant and maternal mortality rates in the region. There is poor access to good quality and affordable health services, particularly in remote rural areas. Women and children tend to be most affected by the shortage of medical staff and unaffordable health services.

Over the past two years, difficult living conditions of communities in remote regions have been compounded by the escalation of fighting between Pakistani armed forces and armed opposition groups. In some areas this has been exacerbated by a rise in sectarian violence. Since August 2008, more than two million people have been displaced by fighting raging in the North West Frontier Province and the Federally Administered Tribal Areas (FATA).

Insecurity and travel restrictions are limiting access to and provision of medical services to communities hit hardest by the fighting. Most recently, this has impeded MSF teams from providing medical support to communities displaced towards Tank and Dera Ismael Khan Districts by the fighting in South Waziristan. An independent MSF assessment found huge needs in the hospitals’ emergency rooms and in the women’s hospital operating theatre. MSF is in contact with all authorities to obtain authorization to implement medical activities in Dera Ismael Khan.

In a region where Western powers involved in counter-insurgency strategies are also major donors, the provision of humanitarian aid has largely been linked with political objectives. MSF completely disassociates itself from these policies, and our teams strive to clarify that MSF is a private medical organisation, independent of political, religious and economic objectives. In Pakistan, MSF does not accept funding from any government and relies solely on private donations from the general public to carry out its work.
Despite the difficulties, MSF volunteers currently provide free emergency medical and relief services in over a dozen sites in the North West Frontier Province (NWFP), in the Federally Administered Tribal Areas (FATA) and notably in Balochistan Province, where MSF has considerably improved access to provide essential support for mother and child care, emergency obstetrics and nutritional programmes in Chaman and Dera Murad Jamali. In Pakistan, MSF is prepared to respond to emergencies with 750 national and international staffs.

Medical care and support to idp camps for the displaced

and conflict affected population in the NWFP and FATA

Waves of displaced families in Lower Dir and Mardan Districts

Since August 2008, several waves of displaced people have sought refuge from violence and arrived in Lower Dir district in Pakistan’s North West Frontier Province. Most of the displaced have come from neighbouring Bajaur Agency and Maidan district where conflict between armed opposition groups and the Pakistani army has been raging.

In May 2009, one million people fled fighting in Swat valley and Buner district to Mardan, a district in Pakistan’s North West Frontier Province. More than 80 percent of the displaced stayed with host families. MSF helped local health clinics and hospitals to cope with the massive influx of people and provided medical care, tents and relief items such as soap and blankets to 500 displaced families staying in a camp in Mazdurabad and to displaced families living in public building in neighbouring Mardan town. In the medical complex of Mardan, MSF ran a 40-bed inpatient department, and managed activities in the emergency room. MSF also set up a cholera treatment ward. Up until November 2009, more than 3,000 consultations were carried out in the emergency room, 817 patients hospitalised and 1,672 patients treated for cholera.
From July 2009 onwards, families started to return to Swat and Buner. As a result, MSF projects in Mardan were closed down in November.

On-going displacement of families towards Lower Dir district

Early November, as a new wave of displaced people fleeing violence in Bajaur Agency arrived in Lower Dir, MSF resumed its support of families staying in Munda camp, in a public building of the market place, and in Sumer Bagh, distributing tents to families staying inside Munda camp, as well as basic hygiene items such as soap and blankets to 1,300 displaced families. Access to clean water, showers and latrines is also ensured by MSF teams in Munda camp and for families staying in the market place.

MSF medical teams currently provide free medical care to both displaced and host population of Munda, both of them being directly affected by the conflict. Currently, the displaced population represents up to 40% of the total population of Munda.
As with other parts of North West Frontier Province, Lower Dir remains insecure and providing assistance and medical care for both the resident population and displaced people is still an uphill battle.

Lower Dir and Malakand districts: support to referral hospitals

In Lower Dir, MSF also supports the hospital at Timurgara which is the district referral hospital situated 20 km from Munda. 1,100 patients are treated each week at the hospital’s emergency room, both by Ministry of Health and MSF medical teams, who take care of the patients most at risk. MSF is also in the final stage of developing a new operating theatre, a post operating unit and setting up a sterilisation and waste management system for the entire hospital.

In neighbouring Malakand district, in NWFP, the hospital emergency room in Dargai is functional with MSF medical staff and Ministry of Health teams working 24 hours a day, seven days a week. 2,300 patients are treated on a monthly basis in the emergency room.
MSF also supports an obstetrics service, an operating theatre notably for caesarean procedures, and an in-patient department with 40 beds in Dargai hospital. On average, 150 women come to the hospital each month to give birth.
In August, 2,300 patients sought treatment in the hospital; 142 of them were suffering from violence related injuries. Some patients arrived in very bad shape; ten of them died.
In Timurgara project: 41 Health Department staff work together with the MSF staff made of 127 Pakistan and 9 international staffs.

In Dargai project: 86 Health Department staffs work with 155 MSF Pakistan and 5 internationals staffs.

Basic healthcare support for IDPs in Peshawar and Charsadda districts

In Peshawar and neighbouring Charsadda, MSF has been supporting since February 2009 internally displaced people living in host communities. These displaced families come from a variety of areas hit by the on-going conflict, mainly from the FATA Agencies such as Bajaur, Kurram and Khyber. In addition to providing basic items such as hygiene kits, blankets and winterised tents last year, MSF is also supporting four basic health units to provide primary health care to displaced families. More than 50,000 displaced people live in these areas, where the resident population is around 60,000 people. Approximately 1,000 primary health care consultations are carried out each week.

MSF has also been providing support to the emergency services of Lady Reading Hospital in Peshawar, the main referral hospital of NFWP, rehabilitating a post operation ward and a sterilization room, and constructing a new trauma operating theatre. A post operative structure has also been set up in addition to the refurbishing of male and female wards.
In this project, 36 MSF Pakistan staffs work together with 2 internationals staffs.

Strengthening the access to healthcare in Mansehra district and Kala Dhaka tribal area

MSF is currently running a programme in Mansehra district to respond to provide free access to health care and to respond to an epidemic of cutaneous leishmaniasis in the remote Kala Dhaka valley, a provincial tribal area (PATA). The treatment of patients suffering from cutaneous leishmaniosis is based outside the valley, in the town of Darband, where MSF provides support to the rural hospital to ensure a functional referral system. Between mid-February and November 2009, 100 cases of cutaneous Leishmaniasis have been treated.

MSF medical staffs also work in the emergency room of Darband hospital, where around 120 patients are treated on a daily basis, and in the 20-bed inpatients ward of the hospital, where a total of 40 to 90 patients are admitted each month. Since June 2009, MSF medical teams have also been providing around 100 antenatal consultations per month in Darband hospital.
Depending on access and security, medical volunteers also provide outreach healthcare support to basic health units inside the Kala Dhaka valley, with an average of 100 consultations per day of consultations.
In this project, en Ministry of health work together with 56 MSF Pakistan and 3 international staffs.

Maintaining an access to healthcare despite the security situation in Kurram Agency (FATA)
In Kurram Agency in the Federally Administered Tribal Areas (FATA), MSF has been providing assistance since 2004. Sectarian tensions through 2007 and 2008 led to massive outbreaks of violence, resulting in the isolation of local communities, closure of supply routes, and the near- collapse of the state-sponsored healthcare system. Isolated but not forgotten, the people of Kurram seek medical and antenatal care for their children and families in MSF-supported clinics of Sadda and Alizai, with over 2,000 paediatric cases per month.

In June 2009, an outbreak of sectarian violence resulted in more than 200 war-wounded. MSF offered material support for surgical care and clash response kits to the hospitals of Sadda, Alizai and Parachinar. MSF has also responded to flooding, cholera, malnutrition and organophosphate poisoning in the area.
Since October 2009, fighting has intensified between the government forces and armed opposition groups in Kurram, resulting in a regional curfew and some temporary closure of activities in Sadda hospital. The on-going violence has also resulted in the flight of thousands of people. During the last weeks, more than 30,000 people have fled towards Sadda and surrounding villages. While the vast majority is staying with host families, others are sheltered inside public buildings or former afghan refugee camps. MSF medical teams, strengthened by additional resources, provided support to the emergency room and continue to provide mother and child care at the Sadda hospital. Moreover MSF plans to support the displaced families with basic items such as blankets, hygiene and cooking kits.
In this project, four Ministry of Health staff work together with 30 MSF Pakistan staff.

Assisting afghans and local pakistani communities in Balochistan: maternal health care, programmes to treat malnourished children and psychosocial support
In Balochistan, Pakistan's largest and least developed province, most people get very little healthcare. In Quetta district MSF provides free health care in the rural health centre and mother and child health centre of Kuchlak, a largely Afghan refugee settlement just north of Quetta, the capital of Balochistan Province. MSF medical teams carry out around 10,000 consultations every month, mostly for women and children coming from Kuchlak and surrounding towns and villages.
The medical assistance provided at the mother and child centre is part of a maternal health programme set up by MSF to improve the extremely poor maternal and neonatal survival rates in the region. Every month, 300 antenatal care consultations are performed in the Kuchlak clinic. Since MSF opened its project in 2005, the number of live births in the clinic has climbed from 10 per month to an average of 150 to 170 per month. In an area where home births are the norm and women’s movement is very restricted, this improvement is a sign of the trust and confidence the Kuchlak community has in MSF. Additionally an average of 150 postnatal consultations are conducted by female medical staff both at the health centre and at home.
MSF also runs a programme to treat malnourished children which not only receives patients from Kuchlak but also from some of the surrounding remote districts where poverty, poor land and conflict severely affect living conditions.
Besides these activities, mental health counsellors give 400 to 600 individual counselling sessions monthly for psychosocial support for men and women. Patients follow an average of three individuals sessions, their frequency depending on their capacity and availability to come to the health centre. In September 2008, MSF started treating cutaneous leishmaniasis with 15 to 30 patients treated per month.
In the town of Chaman situated on the border with Afghanistan, in the Qila Abdullah District, MSF has been working since 2002 and, since April 2006 has been assisting in the District Headquarter Hospital. In this hospital, MSF medical staff work alongside the Health Department staff to provide good quality health care to residents, to Afghan refugees and even to patients who cross the Pakistan-Afghanistan border to seek medical help.
In 2006, MSF started assisting Chaman hospital with free of charge mother and child health care, including emergency obstetrics and caesarean section, neonatal care, ante and postnatal services, a female inpatient department, and treatment for malnourished children. Turned into figures, these medical activities represented throughout 2009 more than 6,500 ante natal consultations, 1,490 deliveries, more than 970 post natal consultations and 550 malnourished children were treated in the therapeutic feeding centre of Chaman.
Since August 2009, MSF medical staff have also been assisting a basic health unit in old Chaman, where so far more than 15,860 patients have received primary health care.
In December 2009, the range of medical activities supported by MSF at Chaman district hospital increased, as support to the Emergency Room (ER) went into action. Basic equipment and supplies for surgical emergencies and immediate life-saving care have been put in place, and a small blood bank created. Refresher training for medical and paramedical Department of Health staff of the emergency care department is also part of the support MSF is providing, and an MSF medical doctor is working alongside the team.


In Quetta, Kuchlak and Chaman project: 25 Health Department staffs work together with 145 national and 7 internationals staffs
In the eastern part of Balochistan, a survey conducted by MSF team in July 2008 found concerning levels of malnutrition in Jafarabad and Nasirabad eastern districts. An emergency feeding programme for children under-five was opened in the towns of Dera Murad Jamali and Usta Muhammad (DMJ). By mid 2009, the feeding programme had been extended to the towns of Sobatpur and Mir Hassan. In 2009, more than 4,000 malnourished children were admitted to our therapeutic feeding centres. The ‘hunger’ season preceding the harvests, difficult access to food and pervasive general poverty due to the feudal landholding system are the underlying reasons for high admission to the feeding centres. Among certain displaced population, this situation is exacerbated by poor access to healthcare and marginalisation from society.
Changes in international staff access towards the end of 2009 have allowed the team also to start work in the DMJ District Headquarter Hospital where they are establishing emergency obstetric care services. Starting in February 2010 the DMJ programme will offer services for women needing complicated deliveries care and caesarean section which, it is hoped, will benefit internally displaced population as well as the indigenous population of Nasirabad and Jafarabad districts.
In Usta Muhammad, MSF supports mother and child healthcare, particularly safe delivery in the district hospital. Between 100 and 150 babies are delivered each month in the MSF maternity ward.
In these programs: 20 Health Department staffs work together with 60 national and 4 internationals staffs.
MSF also responds to natural emergencies which frequently hit Pakistan. In 2009, MSF teams responded to floods in North West Frontier Province (Mardan/Nowshera), in 2008 to an earthquake in Ziarat, and in 2007 to a series of natural disasters in Balochistan, including post-cyclone flooding, not to mention the response to the massive earthquake in Kashmir in 2005.

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