Tunisian Ministry of Public Health Health Bulletin N 15 Refugee situation at the Tunisian-Libyan border From April 2 to 22, 2011 This Bulletin is prepared in collaboration with the World Health Organization (WHO). It is based on data received by health partners and on joint evaluations with the Ministry of Public Health and WHO. Main points: Tendency towards demographic stabilization at the Ras Jedir camps, of which 40% are migrants that cannot be repatriated. Sudden arrival of refugees, most recently through Dhibat, which has cumulatively led to an increase of approximately 20% in the total population of Tataouine governorate. This situation is constantly evolving. Negative impact on the public health system of the two Tunisian Southeastern governorates, and on the other regions of the country. Further support solicited from international organizations to the Tunisian health system. 1. Demographic data During the past three weeks, the characteristics of the persons fleeing Libya have changed, as well as the profile of the population housed in the camps. At the Ras Jedir border, while the IOM evacuations were under way, the flux of migrant arrivals progressively declined as of April 4, in particular between April 14 and 18 (fig.1). Simultaneously, the flux of Libyan arrivals at Ras Jedir increased considerably as of that same date (fig.2). The number of Libyans who found shelter in Tunisia through Ras Jedir border is not quantifiable and the extent of their dispersion into neighboring cities close to the border or within the country is currently unknown. On April 22, there remained a total of 5950 migrants at north end of the Libyan border, divided among 3 camps around Choucha: with 3348 persons at the Tunisian camp of Choucha, 840 persons at the Emirati camp and 1762 at the IFRC camp. Among them, 2374 persons cannot currently be repatriated to their country of origin. (fig.3 et tables 1 and 2). Figure 1 (source IOM) Figure 2(source IOM)
Figure 3 (source IOM/UNHCR) 3000 2500 2000 # of Eritreans, Iraqis, Palestinians and Somalis - End-day 1500 1000 500 0 310 549 549 805 805 682 695 708 748 748 748 2011-03-07 2011-03-09 2011-03-11 2011-03-13 2011-03-15 2011-03-17 823 910 1,019 1,250 1,519 1,607 1,724 1,789 2,430 2,493 2,464 2,646 2,707 2,718 2,728 2,736 2,744 2,748 2,766 2,759 2,737 2,732 2,756 2,357 2,327 2,330 2,339 2,360 2,360 2,380 2,364 2,366 2,364 2,375 2,374 2011-03-19 2011-03-21 2011-03-23 2011-03-25 2011-03-27 2011-03-29 2011-03-31 2011-04-02 2011-04-04 2011-04-06 2011-04-08 2011-04-10 2011-04-12 2011-04-14 2011-04-16 2011-04-18 2011-04-20 2011-04-22 The Choucha camp remains the most populated among all the three migrant camps (fig.4) Figure 4 Population distribution between the 3 migrant camps at the border at Ras Jedir, 2011 20,000 Distribution des populations entre les 3 camps de migrants de la frontière de Ras Jedir, 2011 15,000 Camp IFRC Camp Emirati Camp de Choucha 10,000 5,000 0 08-03-11 09-03-11 10-03-11 11-03-11 12-03-11 13-03-11 14-03-11 15-03-11 16-03-11 17-03-11 18-03-11 19-03-11 20-03-11 21-03-11 22-03-11 23-03-11 24-03-11 25-03-11 26-03-11 27-03-11 28-03-11 29-03-11 30-03-11 31-03-11 01-04-11 02-04-11 03-04-11 04-04-11 05-04-11 06-04-11 07-04-11 08-04-11 09-04-11 10-04-11 11-04-11 12-04-11 13-04-11 14-04-11 15-04-11 16-04-11 17-04-11 18-04-11 19-04-11 20-04-11 21-04-11 22-04-11 23-04-11 24-04-11 table 1 : Camp population profile on April 20, 2011 (source UNICEF) Population Categories Choucha Camp UAE Camp IFRC Camp Total Number of families* 577 34 110 721 Number of pregnant women 21 12 6 39 Total number of children 577 84 175 836 From 0 to 3 years 202 19 37 258 From 3 to 6 years 108 17 53 178 From 6 to 12 years 94 21 56 171 From 12 to 18 years 173 27 29 229 * A couple is counted as a family. Families with children in the Choucha camp also have on average fewer children than those residing in the other two camps. The Dhibat border, has also witnessed a massive number of arrivals (fig.6). More than 30,000 Libyans have crossed this border since April 6. Most of them are to be found in the Tataouine governorate (table 2). In addition, approximately 380 families (which account for approximately 2300 Libyan refugees) are dispersed between the cities of Zarzis and Djerba. However, these figures are unofficial and probably underestimated. Among these 30,000 persons, only slightly more than 2.200 of them (approx. 7.5%) are accounted for in the Remada camp and in the Dhibat transit center (fig.7). In terms of population profile, on April 17, the Remada camp had a total population of 731 persons, of which 350 were children, constituting 118 families, all of Libyan origin (source UNHCR). The updated camp profile for April 22 is not currently available. 2/13
Figure 6 (source UNHCR) Figure 7 Distribution of Libyan refugees per camp, Dhibat border 2011 2,500 2,000 Transit EAU Camp UNHCR Repartition des réfugiés Libyen par camp, frontière de Dhibat 2011 1,500 1,000 500 0 10-4-11 11-4-11 12-4-11 13-4-11 14-4-11 15-4-11 16-4-11 17-4-11 18-4-11 19-4-11 20-4-11 21-4-11 22-4-11 23-4-11 24-4-11 Table 2. Migrant populations and refugees arriving from Libya, estimations per site, 2011 (partial figures) Migrants, Medenine Governorate * Refugees, Tataouine Governorate ** In host Youth and DATE Can be Cannot be Remada families Total transit house in repatriated repatriated Camp around Dhibat Tataouine *** Total April 10 7265 2756 10021 268 0 780 1048 April 14 4218 2339 6557 800 485 2610 3895 April 20 4042 2364 6406 +/-1000 914 4984 6898 April 21 3882 2375 6257 +/-1000 930 11000 12930 April 22 3576 2374 5950 1314 907 21400 23621 * IOM and HCR Estimate **Estimate based on unofficial figures *** Number of arrivals (unknown number of persons who have left the governorate) 2. The medical-surgical care system 2.1. At Ras Jedir border At the actual border, a frontline care system is set up at the level of each advanced medical post (AMP) to respond accordingly in case of a flux of persons and wounded. It is composed of Civil Protection, which in turn will probably receive support from Merlin for medical triage; a surgical triage post managed by Military health authorities and a clinic managed by IMC in the transit camp of Taaoun. Primary health care services for migrants are still being provided by the medical teams in the UAE camp, by the Tunisian Red Crescent and the International Federation of Red Cross and Red Crescent Societies (IFRC) in the IFRC camp. In the Tunisian camp of Choucha, primary health care services are now distributed between the Tunisian military hospital with support from SAMU 01 teams, the Moroccan field hospital and the doctors and volunteer paramedical staff from the Sfax region. WHO standards 1 in terms of access to health care are currently fulfilled in the Ras Jedir-Choucha axis. Vaccination of children under 2 years of age according to the Tunisian vaccination calendar with an extension to cover children from ages 9 months to 14 years against measles. Pregnant women are vaccinated against tetanus. Vaccinations are carried out by district level teams from Ben Guerdane, Medenine and Zarzis, in collaboration with the UNFPA team on site. Changes in the camp population profile now composed of 40% of persons living in families 1 Key indicators per category and their reference criteria proposed by global health cluster http://www.who.int/hac/network/global_health_cluster/indicateurs_cles_par_categorie_fr.pdf 3/13
who cannot be repatriated (table 1), has led to a revision of the vaccination strategies. Vaccination is now carried out on different days in different camps (on Tuesdays in Choucha, on Wednesdays in the Emirati camp and on Fridays in the IFRC camp). Coverage data remain to be produced. Reproductive health services are provided by UNFPA, in partnership with the Association Tunisienne en Santé Reproductive (ATSR) and the Tunisian National Board for Family and Population (ONFP) and in coordination with the gynecologist- obstetrician at the Moroccan military camp. The activities include the provision of care to victims of gender based violence. Cases with obstetric and gynecological complications are referred to the Ben Guerdane hospital, under the coordination of the Tunisian military hospital and SAMU 01 teams (ambulance management). Psychological support is provided by Médecins Sans Frontières (individual consultations and group discussion sessions) in coordination with psychiatrists from the Tunisian and Moroccan field hospitals. In addition, many organizations participate in the provision of psycho-social programmes by organizing discussion groups, particularly MSF, UNFPA and UNICEF. Secondary level reference management is undertaken, on a case by case basis, by the Tunisian military hospital, the Moroccan field hospitals and the Ben Guerdane hospital. Regional hospitals in Ben Guerdane, Zarzis, Medenine and Djerba with a broad technical medical platform receive acute cases, including tuberculosis cases (at Medenine), in need of long-term or intensive care. Hospitals in Gabes, and particularly in Sfax, are especially called upon for the treatment of surgical and psychiatric cases and for the provision of care in medical specialties that are lacking in the southern regions. 2.2 In the Tataouine Governorate As of April 10, the care system in place at the level of Tataouine Governorate was transformed to service arriving refugees. It is currently made up of the following: Near the border, a medical-surgical triage center is managed, this time, by MSF. This system was recently upgraded with a second sorting center set up by the Tunisian Military Health team. The Basic Health Care Center in Dhibat has also been refurbished by the Military Health and Ministry of Public Health teams to ensure immediate provision of care to wounded patients. Primary healthcare services are provided by Tunisian Military Health teams who work sideby-side with the Tunisian Red Crescent, to ensure prescription renewals for chronic pathologies, in a medical post in the Dhibat transit center. Reproductive health services are provided by an ATSR team and mental health support is provided by MSF. A similar system exists in the Remada camp. Refugees housed in the Tataouine youth center are cared for by an on-call system organized by the Tunisian Red Crescent. In addition, free consultation services for refugees are provided in Tataouine by private medical doctors, a network of regional organizations and with the support of the Tataouine Regional Health Directorate. Refugees living in host families around Tataouine have access to health care services in the governorate s public health structures. Access to care by refugees living in host families needs further scrutiny. Vaccinations: The breakdown of children per age group on April 22 is not yet available. At this level, vaccination activities will be managed by outreach services, namely the Primary Healthcare Center of Dhibat located 300 meters from the transit site and the Remada district hospital for the UNHCR camp of Remada. Vaccinations in this context will also be conducted by governorate level public health teams (expanded vaccination programme and vaccination of women against tetanus). 4/13
Secondary level management of referrals is provided by the Remada District Hospital (8 medical beds, 4 maternity and 2 observation beds), the surgical and obstetric cases are referred to the Tataouine regional hospital and beyond towards other different hospitals in neighboring regions. Merlin NGO is supporting the Tataouine hospital with an orthopedic surgeon specialized in war surgery. Tataouine hospital staff also needs to be supported with public health doctors to respond to the population flux into the region and to the existing needs of the region, especially in the provision of care to eventual patients wounded in war. Reproductive health activities are also covered by a system identical to the one in Choucha, with an ATSR team in the Remada camp; the Remada district hospital and the Tataouine regional hospital that respectively work as primary and secondary referral structures. 2.3 Healthcare structures for the wounded ICRC offers to train the medical staff from Sfax on the management of massive numbers of wounded patients and on war surgery. A new training will also be offered in Zarzis, as a follow-up to the training provided on March 23, 2011. Merlin NGO is currently developing a support structure for the Tataouine hospital, through a team specialized in war orthopedics and a training in the management of massive numbers of wounded patients. 3. Water and sanitation 3.1. At the Ras Jedir border UNICEF continues to lead the working group on water and sanitation. Since the number of migrants has decreased in the Choucha, Emirati and IFRC camps, in addition to new developments since the creation of the camps, the Sphere standards are now considered to be fully respected. The current priority is to begin the implementation of the second phase of activities, by replacing temporary structures, which were urgently set up in the Choucha camp, with more sustainable structures, especially in terms of latrines. This is a recommendation provided by the camp management coordination group in order to transform the camp from a transit camp for migrants expecting repatriation, to a longer term shelter for migrants who cannot be repatriated. A plan to implement these activities is currently under development. Simultaneously, UNICEF maintains its hygiene activities in support to the Ministry of Public Health (MPH) for another month in the Choucha and Ras Jedir camps. These activities are carried out through private companies. These contracts, financed by UNICEF, aim to ensure the cleaning and the disinfection of its sanitary installations and those of the MPH, and to continue with activities that monitor the presence of rats, snakes, insects and scorpions. In addition, a private company in Medenine will ensure the building and maintenance of sanitary facilities in the refugee camps. 3.2. On the Dhibat-Remada axis UNICEF, in collaboration with the MPH, has brought 2 showers, 1 latrine et 200 hygiene kits to the Dhibat Youth Center that housed the first refugees arriving from Libya. The Center is now equipped with 3 showers and 4 latrines in total. Furthermore, still in collaboration with the MPH, UNICEF has brought to the UNHCR camp in Remada some 20 chemical toilets, 2 showers, 200 water purification tablets, and 1 water quality testing device (borrowed from ACF) as well as 500 hygiene kits in order to help them face the 5/13
consequences of the premature opening of the camp on April 10 while it was still under construction. 4. Summary of medicines and medical equipment donations received Ras Jedir-Choucha Axis In the beginning of March, IRD supported the Ras Jedir health post with essential medicines and intensive care equipment. The Moroccan hospital and the Emirati and IFRC clinics provide care to migrants in camps around Choucha thanks to their own stocks of essential medicines. In March, WHO supplied essential medicines to avoid shortages in the Choucha Camp and provided minute treatment for scabies at MPH s request. Dhibat- Tataouine Axis Early April, WHO provided a basic kit (1000 persons/3months) to the Tataouine Regional Directorate to help them face the population flux in Dhibat. The Hungarian Baptist Aid NGO donated essential medicines and mobile intensive care equipment to the Tataouine Regional Directorate. MDM provided the Tataouine Regional Directorate with a kit for the treatment of chronic pathologies among refugees. In addition, in the two governorates of Medenine and Tataouine Donations of medicines by the Tunisian population were handled by the Tunisian Red Crescent, Military Health and Public Health representatives. UNFPA distributed kits listed in table 3 within Tataouine and Medenine governorates. Table 3. Kits distributed by UNFPA to the MPH structures and to health partners in Tataouine and Medenine in March and April 2011. Nomination Indications / Utilization TOTAL EXITING Dignity Kits Bodily hygiene 2,306 Hygienic delivery kit Home delivery 15 Kit 1B Female Condoms 0 Kit 3A Rape treatment (pop 10000/p-3 month) 2 KIT 3b Rape treatment (pop 10000/p-3 month) 2 KIT 4 Oral and Injectable Contraceptives (pop 10000/p-3 month) 6 KIT 5 STI treatment(pop 10000/p-3 month) 14 KIT 6 Clinical Delivery Assistance (pop 30000/p-3 month) 7 KIT 8 Management of the Complications of Abortion (pop 30000/p-3 month) 6 KIT 9 Vaginal Examination and Suture of Cervical and Vaginal Tears (pop 30000/p-3 month) 4 KIT 11A Referral-Level Surgical (reusable equipment) (pop 150000/p-3 month) 3 KIT 11B Referral-Level Surgical (consumable items and drugs) (pop 150000/p-3 month) 3 KIT 12 Transfusion Emergency (pop 150000/p-3 month) 7 5. Epidemiological Surveillance 5.1 Gaps in the operation of the surveillance system The surveillance system mainly aims at rapidly detecting illnesses with epidemiological potential and to assess the clinical presentations at the points of care for migrants and refugees. As of March 2, 2011 it was set up the border of Ras Jedir and it was recently strengthened at the Dhibat border. However, since 2 weeks, due to a fall in completeness, this system encounters difficulties in performing its functions. Some consultation units are not providing data. For example, while finalizing this Bulletin (April 25 th ), only 19% of the structures had provided their data for April 22. For April 23 and 24, the MPH coordination team received no data what-so ever. (fig.8). In addition, 6/13
frequency in team turnovers without proper surveillance handover always impedes the analysis of data disaggregated by gender. Figure 8 Level of completeness, surveillance system at the Ras Jedir and Dhibat border, 2011 Niveau de complétude, système de surveillance sur les frontières de Ras Jedir et de Dhibat, 2011 100% 75% 50% 25% 0% 19-Apr 15-Apr 11-Apr 07-Apr 03-Apr 30-Mar 26-Mar 22 mars 18 mars 14 mars 10 mars 6 mars 5.2 Medical Consultations For the monitoring period, 3 suspected cases of hepatitis were reported (table 3) at Choucha, of which two on April 4 (non-notified) and one on April9, notified and transferred for diagnosis to the Ben Guerdane Hospital. No suspected cases have been identified in the past two weeks, since April 9. On the Ras Jedir-Ben Guerdane axis, the total number of listed consultations amounts to 56,466. There seems to have been a dip in the total number of consultations between April 11 and 17. It is impossible to currently evaluate the reduction in service usage for this week (table 4 and fig. 9). Even though there is an observed decrease in the frequency of care services since April 18, the percentage of daily consultations remains very high (5% on April 21), probably linked in part to the rapid renewal of the majority of the population (fig.10). Table 4. Distribution of medical consultations across migrant camps at the Ras Jedir border between February 23 and April 22, 2011 (partial figures) Consultation Site N of consultations N of consultations during the past 4 weeks (beginning date) Since the beginning 28/03-03/04 04-10/04 11-17/04 18-24/04* Ras Jedir (23/02) 8470 768 378 280 181 Choucha Camp de (24/02) 41087 5129 6383 3751 1035 Emirati Camp (13/03) 5194 1,010 1,131 586 413 IFRC Camp (6/03) 1715 0 371 766 578 Total 56466 6907 8263 5383 2207 *Current week and incomplete data for April 22 7/13
Figure 9a Number of daily consultations per camp at the Ras Jedir Tunisian-Libyan border 2,000 Nombre de consultations quotidiennes par camp Frontière Tuniso-Lybienne de Ras Jedir, 2011 1,500 Camp de Choucha Frontière Ras Jedir Camp Emirati Camp IFRC 1,000 500 0 23 fev 28 fev 05-Mar 10-Mar 15-Mar 20-Mar 25-Mar 30-Mar 04-Apr 09-Apr 14-Apr 19-Apr Figure 9b Consultations/population ratio from migrant camps at the Ras Jedir border, 2011 30% Ratio consultations / population des camps de migrants de la frontière de Ras Jedir, 2011 25% 20% 15% 10% 5% 0% 11-03-08 11-03-11 11-03-14 11-03-17 11-03-20 11-03-23 11-03-26 11-03-29 11-04-01 11-04-04 11-04-07 11-04-10 11-04-13 11-04-16 11-04-19 11-04-22 Even though the proportion of respiratory pathologies is decreasing (flu/cold and chronic obstructive pulmonary disease symptoms), it represents more than 30% of the total number of consultations. (fig.10). 8/13
Figure 10 Percentage of respiratory, diarrheal infections and psychological disorders at the Tunisian-Libyan border, 2011 Blue line: % cold/flu symptoms Green line: % chronic obstructive pulmonary diseases Brown line: % of diarrheas (all types) Red line: % of psychological or psychiatric disorders Pourcentage de consultations pour infections respiratoires, diarrhées et syndromes psychologiques dans les camps de migrants la frontière tuniso-libyenne 2011 100% 75% % syndromes grippaux % broncho-pneumopathies % diarrhées (toutes confondues) % syndromes psychologiques ou hi t i 50% 25% 0% 02-Mar 04-Mar 06-Mar 08-Mar 10-Mar 12-Mar 14-Mar 16-Mar 18-Mar 20-Mar 22-Mar 24-Mar 26-Mar 28-Mar 30-Mar 01-Apr 03-Apr 05-Apr 07-Apr 09-Apr 11-Apr 13-Apr 15-Apr 17-Apr 19-Apr 21-Apr In addition, MSF mental health related activities are listed in table 5. Table 5. Mental health services provided to migrant populations in Choucha (Choucha camp, Emirati camp and Ras Jedir border: Consultations and discussion groups organized between March 27 and April 16 (unreported data in figure 10) Weeks Individual consultations Discussion groups March 27 to April 2 158 98 April 3 to 9 66 33 April 10 to 16 25 14 Total 249 145 Sice the number of children has increased within the camp, the percentage of pediatric consultations has increased and has currently reached approximately 5% of the daily total number of consultations (fig.11). 9/13
Figure 11 Percentage of children under the age of 5 years among the camp consultants at the Ras Jedir border, 2011 50% Pourcentage d'enfants de moins de 5 ans parmis les consultants des camps de la frontières de Ras Jedir, 2011 40% 30% 20% 10% 0% 23 fev 27 fev 03-Mar 07-Mar 11-Mar 15-Mar 19-Mar 23-Mar 27-Mar 31-Mar 04-Apr 08-Apr 12-Apr 16-Apr 20-Apr On the Dhibat-Tataouine axis Dhibat: Between April 10 and 16, during 5 consultation days, in support to the Dhibat Health Center, MSF carried out 132 consultations among Libyan refugees of which 23 (17.4%) were children under the age of 5 years. Women of all ages represented 61% of consultants. Diabetes, hypertension and epigastric pains accounted for 25.8% of pathologies. One case of acute malnutrition was discovered in a child under the age of 5 years. Not a single pathology case with epidemic potential was recorded. Two days of mobile consultations serviced 37 patients. Remada: A total of 179 consultations were recorded for the refugee population of Remada, of which 65% were carried out in the camp. Since April 20 there has been no available data (fig. 12). The percentage of consultations of children under the age of 5 years represents almost 30-40% of the total number of refugee consultations carried out in the camp and at Remada hospital (fig.13). Figure 12 Consultations in the Remada refugee camp, April 2011 Consultations au camp de réfugiés de Remada, avril 2011 60 Hopital de Remada Camp de Remada 40 20 0 13-4-11 14-4-11 15-4-11 16-4-11 17-4-11 18-4-11 19-4-11 20-4-11 10/13
Figure 13 Percentage of children under the age of 5 years among the refugee consultants in Remada camp and hospital, 2011 Pourcentage d'enfants de moins de 5 ans parmis les réfugiés consultants du camp et de l'hopital deremada, 2011 50% 40% 30% 20% 10% 0% 13-04-11 14-04-11 15-04-11 16-04-11 17-04-11 18-04-11 19-04-11 20-04-11 5.3 Impact of the presence of refugees and migrants on the regional structures Three boats arrived from Misrata with wounded or sick persons and their accompanying persons on April 4 in Sfax (71 patients), on April 16 in Zarzis (72 patients) and on April 24 in Sousse (57 patients). A study is currently underway to quantify the burden of the medical and surgical referrals on the secondary level health structures in the affected regions. A study on the impact of refugee populations on the primary health care centers in the Tataouine region is currently underway as well. 5.4 Deaths / Births Five deaths were registered between February 23 and April 1. Between April 2 and 22, 3 additional deaths have been recorded, of which two at the Tataouine regional hospital (multi trauma victim on April 9 and gunshot wound on April 16) and one death on April 7 at Zarzis hospital (deceased at arrival). 6 Current and future stakes at hand 6.1 Health Sector Contingency Plan Following the acute emergency phase, a contingency plan to respond to the health demands related to the presence of migrants and refugees in Tunisia was developed and presented by the government to its potential partners on April 14, 2011. The plan was approved by the Minister of Public Health and by WHO. Its outlines were discussed in Zarzis with the main international partners. The initial estimated budget to respond to the needs listed in the plan amounts to US $4,412,640. The means necessary for its execution can be drawn from bilateral or multilateral sources. The main objective of the intervention is to prevent excessive mortality and morbidity among refugee and immigrant populations by implementing coordinated and targeted health interventions that are adapted to the evolution of the situation and its needs. Specific objectives are: a. Support authorities and concerned health services in the coordination and evaluation of needs and in the monitoring of the implementation of health interventions. b. Ensure the implementation of life saving health initiatives among the injured patients; 11/13
c. Ensure indiscriminate access by refugee and migrant populations to healthcare, in particular through care provided to refugees, victims of war and their families and through special care provided to vulnerable and at risk groups; d. Ensure continued provision of primary and secondary health emergency care in the reference services for refugees and migrants, even in cases of accrued demand for services, without jeopardizing the Tunisian population s access to healthcare; e. Enable the detection and response, in real time, of transmitted disease epidemics among refugee and surrounding Tunisian populations; f. Guarantee access to the repatriation process of ill or wounded migrants. The means that need setting up include. 1. A frontline system (with two essential components): - Maintenance of the already existing frontline system - Health control at arrival and epidemiological and sanitary surveillance. 2. Medical Evacuation the two Norias The small Noria will be operational between the entry points of Ras Jedir and the field hospitals in Choucha on one hand, and between the entry point at Dhibat and the Tataouine hospital, on the other. The big Noria will be operational between the field hospitals in Choucha on one hand, and the Tataouine hospital on the other, to enable the dispatching of acute cases in need of hospitalization towards other regional hospitals in the three Southeastern governorates. In terms of extreme emergency cases, military health services plan on providing evacuations by helicopter or by air ambulance. 3. Support to the primary healthcare structures 4. Hospital support for acute and referred cases Strengthen the reception structures of these hospitals by providing an additional temporary capacity equivalent to 40% of their current capacity in each hospital. Establish, without further delay, a minimum stock of medicines and commodities at the regional level (Medenine, Tataouine, Gabes) to gradually replace hospital reserves. Each hospital will provide vans to ensure continuous stock refurbishment from the regional stocks described above. Some of the biomedical equipment is either dilapidated or incapable of facing an increasing demand. It is now time to either repair it or to purchase additional equipment. Strengthen professional capacities by bringing additional doctors and paramedical staff. It is also necessary to recruit additional general service staff: security agents, hospital porters, drivers, administrative staff, etc. For this purpose, funds will be allocated for the recruitment of a short-term staff and the payment of salaries, when the need may arise. 12/13
The plan has been submitted to donors and its implementation discussed with current health partners. 6.2 Access to primary healthcare The Tataouine reference hospital witnessed a significant increase in its medical and surgical activities. Merlin has lent its support trough the provision of orthopedic surgery and MPH has dispatched public health doctors to strengthen hospital staff capacity. The structures now need to be supported through the procurement of medicines, equipment, consumables, and deployment of paramedical staff. The provision of psychological care for victims and reproductive health services needs strengthening. The arrival of Libyan refugees, such as those arriving through the Dhibat border, has cumulatively increased the overall population of the governorate by at least 20% (90% of them living in host families). It is still difficult to estimate the impact of this arrival on the services of the primary healthcare centers and hospitals. Budgetary problems are to be expected in terms of procurement in essential medicines and vaccines. In addition, a culturally sensitive approach needs to be adopted to treat Libyans, namely to plan for female staff to conduct medical consultations for women. For the time being, except for the Dhibat health center and the Tataouine hospital, NGO support remains lacking to the regional health structures, either in terms of staffing, procurement, psychosocial support or in the provision of reproductive health services. A systematic needs assessment of the primary health care structures needs to be conducted and a system monitoring the workload (number of daily consultations) needs setting up to monitor the evolution of the demand and existing needs. It is urgent to identify partners who could potentially support this health needs assessment and set up a health response by strengthening health structure capacity in the southern governorates beyond the provision of support to care for war casualties. In addition to the health structures needs assessment, and taking into account existing cultural differences between Tunisians and Libyans in health services utilization, it is also urgent to find partners that could support the evaluation on the specific needs of refugees living in host families. This evaluation will inform the choice of intervention strategies to be adopted to respond to the specific needs of 90% of the refugees that are housed outside the camps, especially the most vulnerable. 6.3 Implementation of the vaccination activities On the Ras-Jedir-Ben Guerdane axis, it remains challenging to obtain a clear picture of vaccination activities carried out among migrant populations and it is also difficult to estimate coverage due to the mobility of these populations. Since the re-distribution of families according to their nationality across the 3 camps is now finished, a coverage survey will be carried out to evaluate the vaccine coverage of the stationary portion of the camp populations (40% to this day). Then, vaccination activities will primarily target newcomers of nationalities that might stay in the camps for longer periods of time (persons that cannot be repatriated due to an unstable political situation in their country of origin). This implies a systematic registration of families and their composition upon arrival to the camp. This data will then need to be transmitted to the MPH vaccination team. On the Dhibat-Tataouine axis: Vaccination activities in the camps will hinge on the mobility stability of camp populations, which for now is unpredictable. Nevertheless, logistical and vaccine-related needs are to be expected. 6.4 Coordination of the procurement in essential medicines and in vaccines 13/13
There is an urgent need to coordinate the procurement of essential medicines, consumables, first aid and surgical materials. Support for the procurement of vaccines and their distribution is also needed. The national contingency plan presented to donors and health partners on April 14 plans for the establishment of such a regional level coordination mechanism in the governorates affected by the arrival of refugees and migrants. Health partners that are able to contribute in this area need to be identified. 6.5 Coordination and coverage of medical and surgical references Ras Jedir - Ben Guerdane axis camps: The referral system previously prioritized the referral of patients according to life threatening complications and women about to give birth. Since the population profile has changed from a transit population of migrants and refugees to a more stable one, referral mechanisms need to be established for chronic illnesses conjunction with UNHCR and Military Health staff. Dhibat and Remada: Eventually, the issue of patient referral for chronic pathologies needing hospital care will occur here, considering that the distance between the camps and the referral structures is much wider than on the Ras Jedir axis (Remada is at 45km from Tataouine and Dhibat is at more than de 90 km away). 14/13