Right to Health of Internally Displaced Persons - IDP SriLanka
Right to Health of Internally Displaced Persons - IDP SriLanka
Right to Health of Internally Displaced Persons - IDP SriLanka
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Taken from : http://www.flickr.com/pho<strong>to</strong>s/ifrc/2382535600/<br />
RIGHT TO HEAL H OF<br />
INTERNALLY DISPLACED PERSONS<br />
National Protection and Durable Solutions for<br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> Project<br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka
“<strong>Right</strong> <strong>to</strong> <strong>Health</strong>”<br />
<strong>of</strong> <strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong><br />
NATIONAL PROTECTION AND DURABLE SOLUTIONS FOR<br />
INTERNALLY DISPLACED PERSONS PROJECT<br />
HUMAN RIGHTS COMMISSION OF SRI LANKA<br />
No: 65/1, Muththaiyahpillai Avenue, Ward Place, Colombo 07.<br />
Tele: 011 2662587, 2681734 Fax : 011 2688145<br />
E-mail: hrccidp@sltnet.lk Web : www.idpsrilanka.lk
Title<br />
Author<br />
First Edition<br />
: “<strong>Right</strong> <strong>to</strong> <strong>Health</strong>” <strong>of</strong> <strong>Internally</strong><br />
<strong>Displaced</strong> <strong>Persons</strong><br />
: National Protection and Durable Solutions for<br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> Project<br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka<br />
: 2009 March<br />
Published by<br />
Funded by<br />
Printed by<br />
Cover Designs by<br />
Cover Pho<strong>to</strong><br />
: National Protection and Durable Solutions for<br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> Project<br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka<br />
: UNHCR<br />
: V & U Printers<br />
: National Protection and Durable Solution for<br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> Project<br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka<br />
: http://www.flickr.com/pho<strong>to</strong>s/ifrc/2382535600/<br />
ISBN Number : 978-955-8929-12-4<br />
02
PREFACE<br />
E<br />
Due <strong>to</strong> the prolonged war, many people were displaced and living in<br />
Welfare Centres, Relocation Villages, Resettlement Villages and with<br />
friends and relatives. The plight <strong>of</strong> these <strong>IDP</strong>s was more intensified with<br />
the health condition.<br />
National Protection and Durable Solutions for <strong>Internally</strong> <strong>Displaced</strong><br />
<strong>Persons</strong> Project <strong>of</strong> the Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka<br />
established in the year 2002 with the mandate <strong>of</strong> protection and<br />
promotion <strong>of</strong> the rights <strong>of</strong> <strong>IDP</strong>s, conducted this study on “<strong>Right</strong> <strong>to</strong> <strong>Health</strong><br />
<strong>of</strong> <strong>IDP</strong>s” and has made recommendations <strong>to</strong> address those issues.<br />
The Study does not focus its attention <strong>to</strong> the health issues in the other<br />
areas <strong>of</strong> the country and it is believed that there may be areas with similar<br />
health conditions. The situation <strong>of</strong> <strong>IDP</strong>s who were displaced due <strong>to</strong> the<br />
Wanni humanitarian operations, has not been considered, since the study<br />
was at the final stages <strong>of</strong> completion when the displacements began.<br />
It is a pleasure <strong>to</strong> acknowledge the assistance provided by Ms. Danitha<br />
Lanka Vitharana (L.L.B, At<strong>to</strong>rney At Law) former Legal Officer <strong>of</strong> the<br />
Project, for carrying out the study with so much enthusiasm. I am most<br />
thankful <strong>to</strong> the Project staff who worked hard <strong>to</strong> analyze the situation in<br />
the regions and <strong>to</strong> all others who rendered their kind support <strong>to</strong> conduct<br />
this study.<br />
Mr. Senaka Dissanayake<br />
Programme Manager<br />
NPDS for <strong>IDP</strong>s Project,<br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka,<br />
No: 65/1, MuttiahpillaiAvenue,<br />
Ward Place,<br />
Colombo 07.<br />
27th March 2009.<br />
03
BH<br />
CD & MH<br />
CD<br />
CEDAW<br />
CERD<br />
CRC<br />
DDHS<br />
DGH<br />
DH<br />
DPDHS<br />
DS<br />
FHB<br />
GH<br />
GLs<br />
GPID<br />
ICESCR<br />
ICU<br />
<strong>IDP</strong>s<br />
LTTE<br />
MDGs<br />
MH<br />
MOH<br />
MPCS<br />
NDRSC<br />
NGOs<br />
NPDS for <strong>IDP</strong>s<br />
Project <strong>of</strong><br />
HRCSL<br />
OPD<br />
PDHS<br />
PGH<br />
PHI<br />
ABBRIVIATIONS<br />
B I A I - Base Hospitals<br />
- Central Dispensaries & Maternity Homes<br />
- Central Dispensaries<br />
- Convention on the Elimination <strong>of</strong> All Forms <strong>of</strong><br />
Discrimination Against Women<br />
- Convention on the Elimination <strong>of</strong> All Forms <strong>of</strong><br />
Racial Discrimination<br />
- Convention on the <strong>Right</strong>s <strong>of</strong> the Child<br />
- Divisional Direc<strong>to</strong>rs <strong>of</strong> <strong>Health</strong> Services<br />
- District General Hospital<br />
- District Hospitals<br />
- Deputy Provincial Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Service<br />
- Divisional Secretary<br />
- Family <strong>Health</strong> Bureau<br />
- General Hospitals<br />
- Provisional guidelines for emergency management<br />
<strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s”<br />
- Guiding Principles on Internal Displacement<br />
- International Covenant on Economic, Social and<br />
Cultural <strong>Right</strong>s<br />
- Intensive Care Units<br />
- <strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong><br />
- Liberation Tigers <strong>of</strong> Tamil Eelam<br />
- Millennium Development Goals<br />
- Maternity Homes<br />
- Medical Officer <strong>of</strong> <strong>Health</strong><br />
- Multi Purpose Cooperating Societies<br />
- National Disaster Relief Service Center<br />
- Non Governmental Organizations<br />
- National Protection and Durable Solutions for<br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> Project <strong>of</strong><br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka<br />
- Out Patient Division<br />
- Provincial Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Service<br />
- Provincial General Hospital<br />
- Public <strong>Health</strong> Inspec<strong>to</strong>r<br />
04
PHM<br />
PHNS<br />
PHS<br />
PU<br />
RDHS<br />
RE<br />
RGD<br />
RH<br />
RLVs<br />
SPHM<br />
SPHM<br />
TB<br />
TH<br />
UDHR<br />
UNCESCR<br />
<strong>Right</strong>s<br />
UNHCR<br />
UNICEF<br />
WC<br />
WFP<br />
WHO<br />
- Public <strong>Health</strong> Midwife<br />
- Public <strong>Health</strong> Nursing Sister<br />
- Public <strong>Health</strong> Service<br />
- Peripheral Unit<br />
- Regional Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Service<br />
- Regional Epidemiologist<br />
- Register General Department<br />
- Rural Hospitals<br />
- Relocated Villages<br />
- Supervising Public <strong>Health</strong> Inspec<strong>to</strong>r<br />
- Supervising Public <strong>Health</strong> Midwife<br />
- Tuberculosis<br />
- Teaching Hospitals<br />
- Universal Declaration <strong>of</strong> Human <strong>Right</strong>s<br />
- UN Committee on Economic &Social & Cultural<br />
- United Nation's High Commissioner for Refugees<br />
- United Nations' Children Fund<br />
- Welfare Center<br />
- World Food Programme<br />
- World <strong>Health</strong> Organization<br />
05
Table <strong>of</strong> Contents<br />
n t 1. Executive Summery................................................................... 08<br />
2. Introduction............................................................................... 12<br />
3. Universal Human <strong>Right</strong>s Norms on “<strong>Right</strong> <strong>to</strong> <strong>Health</strong>”............ 16<br />
4. Justiciability <strong>of</strong> <strong>Right</strong> <strong>to</strong> <strong>Health</strong> in Sri Lanka........................... 22<br />
4.1 A Constitutional <strong>Right</strong>............................................... 22<br />
4.2 A Statu<strong>to</strong>ry right........................................................ 23<br />
5. Do the <strong>Health</strong> <strong>Right</strong>s <strong>of</strong> the <strong>IDP</strong>s Require a Special Attention. 26<br />
6. General Curative health situation <strong>of</strong> the districts...................... 32<br />
6.1. Analysis on General Curative <strong>Health</strong> Sec<strong>to</strong>r<br />
<strong>of</strong> the Districts............................................................ 36<br />
7. <strong>Health</strong> Issues <strong>of</strong> <strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong>........................... 40<br />
7.1. Access <strong>to</strong> health clinics.............................................. 40<br />
7.2. Public <strong>Health</strong> Services............................................... 42<br />
7.3. Shelter, water, sanitation and hygiene and disease<br />
Prevalence.................................................................. 45<br />
7.4. Adequate Food Supply and Nutrition........................ 54<br />
7.5. Nutrition status <strong>of</strong> more vulnerable groups............... 57<br />
7.6. Risk <strong>of</strong> HIV infections............................................... 61<br />
7.7. Mental health <strong>of</strong> <strong>IDP</strong>s................................................ 61<br />
7.8. Addressing similar issues differently-unequal<br />
responses <strong>to</strong> different types <strong>of</strong> displacements............ 62<br />
7.9. Security problems...................................................... 64<br />
7.10. Role <strong>of</strong> health pr<strong>of</strong>essionals..................................... 65<br />
8. Conclusion................................................................................. 68<br />
9. Recommendations..................................................................... 70<br />
Annexures.................................................................................. 76<br />
06
“<strong>Right</strong> <strong>to</strong> <strong>Health</strong>” <strong>of</strong> <strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong><br />
1. Executive Summar y<br />
<strong>Health</strong>y population is very much imperative for a country because it<br />
increases the capacities <strong>of</strong> human resources <strong>of</strong> the country. Owing <strong>to</strong> the<br />
“welfare state concept” developed during the first decades <strong>of</strong> 20th<br />
century, Sri Lanka possesses a developed healthcare system comparing<br />
<strong>to</strong> other developing countries. However prolonged conflict situation in<br />
the country has caused the health system <strong>of</strong> the conflict affected areas <strong>to</strong><br />
be broken down despite the several steps by the health authorities and<br />
other agencies. Meanwhile, post disaster situation urges special attention<br />
on health <strong>of</strong> those displaced people, especially on community health.<br />
There are about 225 000 internally displaced people(<strong>IDP</strong>s) are living in<br />
the selected six districts for the study, namely Trinvcomalee, Batticaloa,<br />
Vavuniya, Mannar, Anuradhapura and Puttalam. This selected sample<br />
represents nearly 50 percent <strong>of</strong> conflict affected <strong>IDP</strong>s in Sri Lanka.<br />
The right <strong>of</strong> everyone <strong>to</strong> the enjoyment <strong>of</strong> the highest attainable standard<br />
<strong>of</strong> physical and mental health has been recognized by many universal<br />
human rights instruments and this comprises the right <strong>to</strong> adequate<br />
standard <strong>of</strong> living. There are avenues in Sri Lankan fundamental rights<br />
field <strong>to</strong>o, <strong>to</strong> identify the <strong>Right</strong> <strong>to</strong> <strong>Health</strong> as a right, though it is not directly<br />
stipulated in the Constitution as a right. In addition, the statutes like<br />
Penal Code, Food Act, <strong>Health</strong> Service Act and provincial statues on<br />
health service have specifically laid down provisions <strong>to</strong> maintain and<br />
preserve public health. <strong>IDP</strong>s <strong>to</strong>o, entitled <strong>to</strong> these constitutional and<br />
statu<strong>to</strong>ry rights, with no distinctions <strong>to</strong> their status as <strong>IDP</strong>s. In addition <strong>to</strong><br />
this general legal framework, Principle 18 & 19 <strong>of</strong> the Guiding<br />
Principles on Internal Displacement (GPID) and the Humanitarian<br />
Charter and Minimum Standards in Disaster Response <strong>of</strong> the Sphere<br />
Project stipulate the means and ways <strong>of</strong> protecting displaced person's<br />
health rights in detail.<br />
Being a devolved subject under the 13th Amendment, “<strong>Health</strong>” comes<br />
under the purview <strong>of</strong> both central and provincial council but<br />
considerable powers have been conferred <strong>to</strong> the provinces regarding<br />
preventive health and curative health sec<strong>to</strong>rs. Analyzing the general<br />
08
curative health sec<strong>to</strong>r in the selected districts, the lack <strong>of</strong> medical<br />
infrastructure and human resources have caused <strong>to</strong> minimize the service<br />
given <strong>to</strong> the public despite <strong>of</strong> several steps by government <strong>to</strong> improve the<br />
status <strong>of</strong> the health institutions. Especially, lack <strong>of</strong> psychiatrists and<br />
counselors <strong>to</strong> deal with the mentally depressed people in those areas is<br />
remarkable. Regarding the access <strong>to</strong> curative health care <strong>of</strong> <strong>IDP</strong>s<br />
sometimes due <strong>to</strong> unavailability <strong>of</strong> transport facility <strong>to</strong> the closest health<br />
institution, they have <strong>to</strong> walk more than 10 Km while they are not<br />
physically well enough. Some mobile clinics s<strong>to</strong>p their visits <strong>to</strong> <strong>IDP</strong><br />
locations soon after the resettlement or relocation underwent.<br />
Regarding the preventive health sec<strong>to</strong>r, the duty is upon relevant<br />
provincial councils <strong>to</strong> preserve the public health as per 13th Amendment<br />
<strong>to</strong> the Constitution. However some administrative issues in preventive<br />
health sec<strong>to</strong>r have resulted in public health <strong>of</strong> the <strong>IDP</strong>s <strong>to</strong> be less-<strong>to</strong>uched<br />
and sometimes they were refused <strong>to</strong> be given services. Disability <strong>of</strong> the<br />
host district health authorities <strong>to</strong> meet the heath needs <strong>of</strong> the both <strong>IDP</strong>s<br />
and host community, consequent <strong>to</strong> a displacement, has caused some<br />
issues <strong>to</strong> be raised in relation <strong>to</strong> allocation <strong>of</strong> health infrastructure and<br />
human resources. Unavailability <strong>of</strong> uniform system in allocating<br />
community health workers has originated some anomalies in the field<br />
and it has caused overload <strong>of</strong> works <strong>to</strong> some health workers. The<br />
available living standards, especially regarding water, shelter, sanitation<br />
and hygiene issues <strong>to</strong> some sets <strong>of</strong> <strong>IDP</strong>s is also questionable because<br />
there is a lack <strong>of</strong> services providing by the relevant local authorities and<br />
also lack <strong>of</strong> supervision by the health authorities in that regard. Though<br />
the health authorities were able <strong>to</strong> control out-break <strong>of</strong> diseases after a<br />
disaster, some ad-hoc cases were reported due <strong>to</strong> the inaction or improper<br />
management <strong>of</strong> the diseases by the health worker and also due <strong>to</strong><br />
unhealthy practices <strong>of</strong> <strong>IDP</strong>s.<br />
Regarding the nutritional status <strong>of</strong> the <strong>IDP</strong>s, the available dry ration<br />
package is considered as not sufficient, especially <strong>to</strong> those depending<br />
only on it such as Child headed families, and women headed families. In<br />
addition, irregularities in issuing dry ration and problems regarding low<br />
quality <strong>of</strong> dry ration given <strong>to</strong> <strong>IDP</strong>s also reported. In such a backdrop, the<br />
nutritional status <strong>of</strong> extremely vulnerable groups such as pregnant and<br />
lactating mothers, infants and children has gone down and the security<br />
problems and lack <strong>of</strong> livelihood opportunities have enlarged the plight.<br />
09
Concerning all health aspects <strong>of</strong> the conflict affected internally displaced<br />
people, a sort <strong>of</strong> unequal responses has been given <strong>to</strong> Tsunami <strong>IDP</strong>s visà-vis<br />
other <strong>IDP</strong>s. The way <strong>of</strong> addressing health hazards consequent <strong>to</strong> the<br />
tsunami disaster, is not carrying out in relation <strong>to</strong> conflict affected <strong>IDP</strong>s<br />
though the outcomes are similar. At the same time, having experienced<br />
sudden displacements due <strong>to</strong> unavoidable reasons several times in the<br />
country, health authorities have <strong>to</strong> develop the system <strong>to</strong> handle health<br />
hazards after displacements, in a uniform way.<br />
Therefore, following recommendations were made <strong>to</strong> tackle those<br />
problems.<br />
Improving health related infrastructure in hospitals.<br />
Proper management <strong>of</strong> human recourses in health sec<strong>to</strong>r.<br />
Special health measures/mechanisms <strong>to</strong> deal with<br />
displacement.<br />
Addressing health concerns in planning resettlement /<br />
relocation <strong>of</strong> <strong>IDP</strong>s.<br />
The quantity and nutrition status <strong>of</strong> dry ration <strong>to</strong> be increased.<br />
Inclusion <strong>of</strong> <strong>Right</strong> <strong>to</strong> health in the Constitution.<br />
Development <strong>of</strong> the medical record system.<br />
Promote health education and community involvement in<br />
health concerns among <strong>IDP</strong>s.<br />
Those recommendations should be implemented giving paramount<br />
importance <strong>to</strong> the areas where there is frequent displacements and where<br />
the bulk <strong>of</strong> displaced people living. Accomplishment <strong>of</strong> them is <strong>to</strong> be<br />
carried out with the cooperation <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong> Care and Nutrition<br />
with the participation <strong>of</strong> relevant provincial councils, local authorities<br />
and other disaster related Ministries.<br />
10
Introduction<br />
Taken From :Http://www.flickr.com
2. Introduction<br />
t o n<br />
<strong>Health</strong>y mankind is a great treasure for the society since it reduces the<br />
social cost and increases the development. <strong>Right</strong>s perspectives <strong>of</strong> health<br />
tracks beyond the ancient monarchy period where it was considered as a<br />
duty <strong>of</strong> the king <strong>to</strong> control the epidemics like leprosy and they have built<br />
and maintained a system <strong>of</strong> hospital in the country. In the present globe,<br />
right <strong>to</strong> health is considered as a social and economic right <strong>to</strong> which a<br />
heavy weight is given in many universal human rights instruments.<br />
<strong>Right</strong> <strong>to</strong> health is not a right <strong>to</strong> be healthy but it is a right <strong>to</strong> the enjoyment<br />
<strong>of</strong> other connected facilities and conditions that are necessary for good<br />
health. The scope <strong>of</strong> the right <strong>to</strong> health can be identified by giving a<br />
closer look at two basic components <strong>of</strong> this right:<br />
Matters related <strong>to</strong> health care<br />
Matters related <strong>to</strong> general living conditions affecting health,<br />
such as safe water, food, sanitation and shelter.<br />
Therefore it is unders<strong>to</strong>od that right <strong>to</strong> health should encompass both<br />
these components <strong>to</strong> make it effective and thereby it will facilitate <strong>to</strong><br />
achieve ones' right <strong>to</strong> life with dignity.<br />
In Sri Lanka, Ministry <strong>of</strong> <strong>Health</strong> Care & Nutrition with the help <strong>of</strong><br />
1<br />
Provincial <strong>Health</strong> Sec<strong>to</strong>rs provide preventive, curative and<br />
rehabilitative health care facilities <strong>to</strong> the public and private sec<strong>to</strong>r also<br />
provides curative health care <strong>to</strong> the people. Interestingly Sri Lankan<br />
health situation was commended as follows by British Medical<br />
Association in their Article <strong>of</strong> THE RIGHT TO HEALTH: A TOOLKIT<br />
2<br />
FOR HEALTH PROFESSIONALS .<br />
1As per 13th amendment <strong>to</strong> the Constitution <strong>of</strong> Sri Lanka- This will be discussed latter in<br />
the study<br />
2 Judith Asher, Danielle Hamm, BMA House, Tavis<strong>to</strong>ck Square, London, WC1H 9JP,<br />
September 2007.<br />
12
“Despite its status as a 'less-developed' country, Sri Lanka has<br />
achieved impressive results in health, nutrition and family<br />
planning with levels <strong>of</strong> public health expenditure lower than<br />
countries with similar incomes whose health outcomes are<br />
considerably worse. Current life expectancy is 73 years,<br />
compared <strong>to</strong> a regional average <strong>of</strong> only 61 years, infant<br />
mortality is around 16 per 1,000 births, fertility is near<br />
replacement level, and the population growth rate is less than 1<br />
percent a year and falling. The maternal mortality ratio, at 30<br />
deaths per 100,000 live births, is well below that <strong>of</strong> countries<br />
with similar levels <strong>of</strong> per capita income”.<br />
This illustration is true as long as the overall condition <strong>of</strong> the health in the<br />
whole country is considered. But in district wise and segment wise, the<br />
situation <strong>of</strong> health condition is different, sometimes very much worse.<br />
This difference can be seen among the rural population, estate<br />
population in the up-country and also among internally displaced<br />
persons (<strong>IDP</strong>s).<br />
The purpose <strong>of</strong> this study is <strong>to</strong> assess the “<strong>Right</strong> <strong>to</strong> Heath <strong>of</strong> the <strong>IDP</strong>s” and<br />
address the issues raised therewith. In this regard, the health situation in<br />
six Districts <strong>of</strong> Sri Lanka, namely Batticaloa and Trincomalee in the<br />
Eastern Province, Mannar and Vavuniya in the Northern Province,<br />
Puttalam in North Western Province and Anuradhapura in North Central<br />
Province were identified. This sample was selected for the research<br />
because they are <strong>of</strong>ten affected by the conflict and access <strong>to</strong> relevant<br />
information is comparatively trouble-free in these districts than the other<br />
conflict affected areas. As for Puttalam, though it is somewhat far from<br />
the conflict, many <strong>IDP</strong>s have been relocated within that district and<br />
selected therefore. The <strong>to</strong>tal <strong>IDP</strong> population in these districts is 224,818<br />
and they represent more than 50 percent <strong>of</strong> the <strong>to</strong>tal Sri Lankan conflict<br />
affected <strong>IDP</strong> population. However, the limitation <strong>of</strong> this study is that the<br />
unavailability <strong>of</strong> the facts and problems faced by displaced persons in the<br />
district like Jaffna, Mulathivu, Kilinochchi and Ampara where the<br />
condition <strong>of</strong> health and living standards are sometimes more aggregative<br />
than the selected sample and access <strong>to</strong> information is also comparatively<br />
13
trouble-free in these districts than the other conflict affected areas.As for<br />
Puttalam, though it is somewhat far from the conflict, many <strong>IDP</strong>s have<br />
been relocated within that district and selected therefore. The <strong>to</strong>tal <strong>IDP</strong><br />
population in these districts is 224,818 and they represent more than 50<br />
3<br />
percent <strong>of</strong> the <strong>to</strong>tal Sri Lankan conflict affected <strong>IDP</strong> population .<br />
However, the limitation <strong>of</strong> this study is that the unavailability <strong>of</strong> the facts<br />
and problems faced by displaced persons in the district like Jaffna,<br />
Mulathivu, Kilinochchi and Ampara where the condition <strong>of</strong> health and<br />
living standards are sometimes more aggregative than the selected<br />
sample and access <strong>to</strong> information is also comparatively cumbersome.<br />
Therefore when the authorities take decisions <strong>to</strong> facilitate health <strong>of</strong><br />
displaced persons in selected districts, the persons in other conflict<br />
affected districts should also be benefited from such a decision.<br />
3 See theAnnexure I, Source-District Secretariats <strong>of</strong> particular districts.<br />
14
“<strong>Right</strong> <strong>to</strong> <strong>Health</strong>” as a<br />
Universal Human <strong>Right</strong> Norm<br />
Taken From :Http://www.flickr.com
3. “<strong>Right</strong> <strong>to</strong> <strong>Health</strong>” as a Universal Human <strong>Right</strong> Norm<br />
Almost all universal instruments <strong>of</strong> human rights have identified and<br />
expressed the values <strong>of</strong> human rights for advancing health <strong>of</strong> the people.<br />
Article 25 <strong>of</strong> the Universal Declaration <strong>of</strong> Human <strong>Right</strong>s (UDHR)<br />
enumerates that "Everyone has the right <strong>to</strong> a standard <strong>of</strong> living adequate<br />
for the health <strong>of</strong> himself and <strong>of</strong> his family, including food, clothing,<br />
housing and medical care and necessary social services".<br />
According <strong>to</strong> Article 12 <strong>of</strong> the International Covenant on Economic<br />
Social and Cultural <strong>Right</strong>s (ICESCR), the States parties recognize the<br />
right <strong>of</strong> everyone <strong>to</strong> the enjoyment <strong>of</strong> the highest attainable standard <strong>of</strong><br />
physical and mental health. Under this Covenant States parties should<br />
take steps <strong>to</strong> achieve the full realization <strong>of</strong> this right by the provision for<br />
the reduction <strong>of</strong> the stillbirth-rate and <strong>of</strong> infant mortality and for the<br />
healthy development <strong>of</strong> the child; the improvement <strong>of</strong> all aspects <strong>of</strong><br />
environmental and industrial hygiene; the prevention, treatment and<br />
control <strong>of</strong> epidemic, endemic, occupational and other diseases and the<br />
creation <strong>of</strong> conditions which would assure <strong>to</strong> all medical service and<br />
medical attention in the event <strong>of</strong> sickness. State party is also under an<br />
obligation <strong>to</strong> protect, respect and fulfill the right <strong>to</strong> health within their<br />
jurisdictions. The obligation <strong>to</strong> respect implies a duty <strong>of</strong> the state not <strong>to</strong><br />
4<br />
violate the right <strong>to</strong> health by its actions . The obligation <strong>to</strong> protect implies<br />
a duty <strong>of</strong> the state <strong>to</strong> prevent violations <strong>of</strong> the right <strong>to</strong> health by others. It<br />
must take measures which prevent third parties from interfering with or<br />
5<br />
violating the right <strong>to</strong> health . The obligation <strong>to</strong> fulfill means that<br />
6<br />
governments must act in order <strong>to</strong> ensure those rights can be enjoyed .<br />
4<br />
The state must refrain from denying or limiting equal access for all persons, including<br />
prisoners, detainees, minorities, asylum seekers and illegal immigrants; the state must<br />
refrain from censoring, withholding or intentionally misrepresenting accurate healthrelated<br />
information, including sexual health education and information. Source-U.N.<br />
Doc. HRI\GEN\1\Rev.1 at 45 (1994)<br />
5<br />
The government must introduce and enforce appropriate controls for the marketing <strong>of</strong><br />
medical equipment and medicines by third parties; the government must ensure that<br />
medical practitioners and other health pr<strong>of</strong>essionals meet appropriate recognized<br />
standards <strong>of</strong> education, skill and ethical codes <strong>of</strong> conduct. . Source-U.N. Doc.<br />
HRI\GEN\1\Rev.1 at 45 (1994)<br />
6<br />
The government must focus on rectifying existing imbalances in the provision <strong>of</strong> health<br />
facilities, goods and services. For example, it should allocate sufficient public resources<br />
<strong>to</strong> the most deprived regions in the country, in particular <strong>to</strong> the poor and otherwise<br />
vulnerable and disadvantaged groups. The government must promote activities that<br />
benefit good health and ensure the dissemination <strong>of</strong> appropriate information. Source-<br />
U.N. Doc HRI\GEN\1\Rev.1 at 45 (1994)<br />
16
According <strong>to</strong> UN Committee on Economic & Social & Cultural <strong>Right</strong>s<br />
7<br />
(UNCESCR), General Comment 14 , elements for respect for right <strong>to</strong><br />
health include:<br />
(a)Availability : functioning public health and health care facilities,<br />
goods, services and programmes must be available in sufficient quantity.<br />
(b) Accessibility: <strong>Health</strong> facilities, goods and services have <strong>to</strong> be<br />
accessible <strong>to</strong> everyone without discrimination, within the jurisdiction <strong>of</strong><br />
the State party.Accessibility has four overlapping dimensions:<br />
Non-discrimination : health facilities, goods and services must<br />
be accessible <strong>to</strong> all, especially the most vulnerable or<br />
marginalized sections <strong>of</strong> the population, in law and in fact,<br />
without discrimination on any <strong>of</strong> the prohibited grounds.<br />
Physical accessibility : health facilities, goods and services must<br />
be within safe physical reach for all sections <strong>of</strong> the population,<br />
especially vulnerable or marginalized groups, such as ethnic<br />
minorities and indigenous populations, women, children,<br />
adolescents, older persons, persons with disabilities and persons<br />
with HIV/AIDS. Accessibility also implies that medical<br />
services and underlying determinants <strong>of</strong> health, such as safe and<br />
potable water and adequate sanitation facilities, are within safe<br />
physical reach, including in rural areas.<br />
Economic accessibility : health facilities, goods and services<br />
must be affordable for all.<br />
Information accessibility: accessibility includes the right <strong>to</strong><br />
seek, receive and impart information and ideas concerning<br />
8<br />
health issues .<br />
7<br />
United Nations, 2000, Committee on Economic, Social and Cultural <strong>Right</strong>s<br />
(UNCESCR), General Comment No. 14 (Eleventh Session).The right <strong>to</strong> the highest<br />
attainable standard <strong>of</strong> health UN Document, E/C.12/2000/4. UN, Geneva. No 30<br />
8<br />
However, accessibility <strong>of</strong> information should not impair the right <strong>to</strong> have personal<br />
health data treated with confidentiality<br />
17
(c) Acceptability: All health facilities, goods and services must be<br />
respectful <strong>of</strong> medical ethics and culturally appropriate.<br />
(d) Quality : All health facilities, goods and services must also be<br />
scientifically and medically appropriate and <strong>of</strong> good quality.<br />
According <strong>to</strong> the Article 2 <strong>of</strong> the ICESCR each state party undertakes <strong>to</strong><br />
take steps <strong>to</strong> the maximum <strong>of</strong> its available resources, with a view <strong>to</strong><br />
achieving progressively the full realization <strong>of</strong> the recognized rights by<br />
all appropriate means. In General Comment No. 3 on the Nature <strong>of</strong> States<br />
9<br />
Parties Obligations , it was stipulated that States parties have a core<br />
obligation <strong>to</strong> ensure the satisfaction <strong>of</strong>, at the very least, minimum<br />
essential levels <strong>of</strong> each <strong>of</strong> the rights enunciated in the Covenant<br />
10<br />
(ICESCR), including essential primary health care .<br />
These obligations are further clarified by The Limburg Principles on the<br />
11<br />
Implementation <strong>of</strong> ICESCR and Maastricht Guidelines on Violations<br />
12<br />
<strong>of</strong> Economic, Social and Cultural <strong>Right</strong>s .<br />
9<br />
Committee on Economic, Social and Cultural <strong>Right</strong>s, General Comment 3, The nature<br />
<strong>of</strong> States parties obligations (Art. 2, para.1 <strong>of</strong> the Covenant) (Fifth session, 1990),<br />
Compilation <strong>of</strong> General Comments and General Recommendations Adopted by Human<br />
<strong>Right</strong>s Treaty Bodies, U.N. Doc. HRI\GEN\1\Rev.1 at 45 (1994).<br />
10<br />
According <strong>to</strong> the Committee's view, core obligation includes at least the following<br />
obligations: (a) To ensure the right <strong>of</strong> access <strong>to</strong> health facilities, goods and services on a<br />
non-discrimina<strong>to</strong>ry basis, especially for vulnerable or marginalized groups; (b) To<br />
ensure access <strong>to</strong> the minimum essential food which is nutritionally adequate and safe, <strong>to</strong><br />
ensure freedom from hunger <strong>to</strong> everyone; (c) To ensure access <strong>to</strong> basic shelter, housing<br />
and sanitation, and an adequate supply <strong>of</strong> safe and potable water; (d) To provide essential<br />
drugs, as from time <strong>to</strong> time defined under the WHO Action Programme on Essential<br />
Drugs; (e) To ensure equitable distribution <strong>of</strong> all health facilities, goods and services;(f)<br />
To adopt and implement a national public health strategy and plan <strong>of</strong> action, on the basis<br />
<strong>of</strong> epidemiological evidence, addressing the health concerns <strong>of</strong> the whole population.<br />
11<br />
The Limburg Principles on the Implementation <strong>of</strong> the International Covenant on<br />
Economic, Social and Cultural <strong>Right</strong>s, United Nations document (UN Doc.<br />
E/CN.4/1987/ 17).<br />
12<br />
By the International Commission <strong>of</strong> Jurists at the Maastricht Centre for Human <strong>Right</strong>s<br />
and the Urban Morgan Institute for Human <strong>Right</strong>s in Maastricht, January 22-26, 1997<br />
18
In addition <strong>to</strong> the above, Article 12 <strong>of</strong> the Convention on the Elimination<br />
<strong>of</strong> All Forms <strong>of</strong> Discrimination Against Women (CEDAW) states that<br />
state parties shall ensure <strong>to</strong> women, appropriate services in connection<br />
with pregnancy, confinement and post natal period, granting free<br />
services where necessary, as well as adequate nutrition during pregnancy<br />
and lactation. Article 24 <strong>of</strong> the Convention on the <strong>Right</strong>s <strong>of</strong> the Child<br />
(CRC) enumerates that right <strong>of</strong> the child <strong>to</strong> the enjoyment <strong>of</strong> the highest<br />
attainable standard <strong>of</strong> health and <strong>to</strong> facilitate for the treatment <strong>of</strong> illness<br />
and rehabilitation <strong>of</strong> health and Article 5 <strong>of</strong> the Convention on the<br />
Elimination <strong>of</strong> All Forms <strong>of</strong> Racial Discrimination (CERD) discusses<br />
the importance <strong>of</strong> the right <strong>to</strong> health. Regional human rights<br />
13<br />
instruments also elaborate on the health concerns in addition <strong>to</strong> those<br />
universal instruments.<br />
The Alma-Ata Declaration on Primary <strong>Health</strong> Care <strong>of</strong> 1978(declared in<br />
the International Conference on Primary <strong>Health</strong> Care) also identified<br />
primary health care as the key <strong>to</strong> the attainment <strong>of</strong> the goal <strong>of</strong> <strong>Health</strong> for<br />
All. Under this declaration, State parties should recognize the essential<br />
role <strong>of</strong> international cooperation and comply with their commitment <strong>to</strong><br />
take joint and separate action <strong>to</strong> achieve the full realization <strong>of</strong> the right <strong>to</strong><br />
health. In addition, out <strong>of</strong> 8 “Millennium Development Goals”<br />
14<br />
(MDGs) , 3 goals are focused on health. While Goal 4 is <strong>to</strong> reduce child<br />
mortality, Goal 5 is <strong>to</strong> improve maternal health and Goal 6 is supposed <strong>to</strong><br />
combat HIV/AIDS, malaria and other diseases.<br />
13<br />
Article XI <strong>of</strong> the American Declaration <strong>of</strong> the <strong>Right</strong>s and Duties <strong>of</strong> Man<br />
(ADHR),Article 28 <strong>of</strong> the Convention on the Protection <strong>of</strong> the <strong>Right</strong>s <strong>of</strong> All Migrant<br />
Workers, Chapter 12 The survival rights (economic, social and cultural rights) and<br />
Members <strong>of</strong> Their Families (CMW),Article 10 <strong>of</strong> the Pro<strong>to</strong>col <strong>of</strong> San Salvador,Article 16<br />
<strong>of</strong> the African Charter on Human and Peoples' <strong>Right</strong>s (African Charter),Article 14 <strong>of</strong> the<br />
Pro<strong>to</strong>col <strong>to</strong> theAfrican Charter on Human and Peoples' <strong>Right</strong>s on the <strong>Right</strong>s <strong>of</strong> Women in<br />
Africa,Article 14 <strong>of</strong> theAfrican Charter on the <strong>Right</strong>s and Welfare <strong>of</strong> the Child,Article 11<br />
<strong>of</strong> the European Social Charter (ESC)<br />
14<br />
The Millennium Development Goals (MDGs) are eight goals <strong>to</strong> be achieved by 2015<br />
that respond <strong>to</strong> the world's main development challenges. The MDGs are drawn from the<br />
actions and targets contained in the Millennium Declaration that was adopted by 189<br />
nations-and signed by 147 heads <strong>of</strong> state and governments during the UN Millennium<br />
Summit in September 2000.<br />
19
Justifiability <strong>of</strong> <strong>Right</strong><br />
<strong>to</strong> <strong>Health</strong> in Sri Lanka<br />
Taken From :Http://www.flickr.com
4. Justifiability i i i t <strong>of</strong> <strong>Right</strong> <strong>to</strong> <strong>Health</strong> in Sri Lanka<br />
a<br />
4.1. As a Constitutional <strong>Right</strong><br />
Under Article 27(2) (c) <strong>of</strong> the Directive Principles <strong>of</strong> the Constitution, it<br />
should be one <strong>of</strong> the objectives <strong>of</strong> the state <strong>to</strong> realize adequate standard <strong>of</strong><br />
living <strong>of</strong> all citizens for themselves and their families, including<br />
adequate food, clothing and housing, the continuous improvement <strong>of</strong><br />
living conditions. However the Fundamental <strong>Right</strong>s Chapter <strong>of</strong> the Sri<br />
Lankan Constitution does not expressly recognize the right <strong>to</strong> health in<br />
Sri Lanka. But the development <strong>of</strong> Sri Lankan legal system by<br />
innovative judicial decisions has implied certain optional avenues in<br />
which one can entertain a right based approach as <strong>to</strong> the health under the<br />
Constitution.<br />
One <strong>of</strong> such avenue is the identification <strong>of</strong> right <strong>to</strong> life as an enforceable<br />
right. Though there is no expressed recognition in the Constitution, the<br />
15<br />
right <strong>to</strong> life has been identified by the Judiciary in several cases , as it is<br />
implied in theArticle 11 and 13(4) <strong>of</strong> the constitution. While the freedom<br />
from <strong>to</strong>rture or cruel, inhuman or degrading treatment or punishment is<br />
conferred by Article 11, Article 13 (4) stipulates that no person shall be<br />
punished except by order <strong>of</strong> a competent court, made in accordance with<br />
procedure established by law. It is very much obvious that right <strong>to</strong> health<br />
is a concomitant <strong>of</strong> right <strong>to</strong> life because right <strong>to</strong> life would be pointless if<br />
it is unhealthy. Therefore it is submitted that the infringement <strong>of</strong> a right <strong>to</strong><br />
health can be justiciable under the Sri Lankan Constitution because the<br />
right <strong>to</strong> life would be meaningless without primary health care. This is<br />
inferred from the land mark decision <strong>of</strong> the Supreme Court in the case <strong>of</strong><br />
Sanjeewa, AAL (on behalf <strong>of</strong> G.M.Perera) V Suraweera, OIC,<br />
16<br />
Wattala and others . The bench ruled in this case that citizens have the<br />
right <strong>to</strong> choose between state and private medical care <strong>to</strong> save one <strong>to</strong>rture<br />
victim's life. While identifying the interrelationship between <strong>of</strong> right <strong>to</strong><br />
life and right <strong>to</strong> health has, Justice Fernando also made a citation <strong>of</strong> the<br />
Article 12 <strong>of</strong> the ICESCR <strong>to</strong> support his views.<br />
15<br />
Silva v Iddamalgoda 2003 2 SLR 63, Rani Fernando v OIC Seeduwa Police,<br />
SC/FR/700/2000, SC Minutes 26.07.2004<br />
16<br />
2003 1 SLR 317<br />
22
The next avenue is the equal protection <strong>of</strong> the law or the principle <strong>of</strong> non<br />
discrimination in relation <strong>to</strong> health facilities as it is enshrined in article 12<br />
<strong>of</strong> the constitution. The equality <strong>of</strong> access <strong>to</strong> health care and services<br />
should be established by the government and also any discrimination on<br />
the grounds <strong>of</strong> race, colour, sex, language, religion, political or other<br />
opinion, national or social origin, property, birth, physical or mental<br />
disability, health status and civil, political, social or other status can be<br />
considered as an infringement <strong>of</strong> Article 12. In addition, according <strong>to</strong><br />
Article 12.4, it is legitimate <strong>to</strong> provide special health protection for the<br />
advancement <strong>of</strong> women, children and disables.<br />
The third avenue in this regard is the Freedom from <strong>to</strong>rture, cruel,<br />
inhuman and degrading treatment or punishment. When required health<br />
care is not being provided or mal-treatments in giving health care or<br />
related facilities can be interpreted as inhuman and degrading<br />
treatments. European Court <strong>of</strong> Human <strong>Right</strong>s has held that an expulsion<br />
<strong>of</strong> anAIDS victim from the country who has been in serious condition as<br />
17<br />
amounting inhuman and degrading treatment . Therefore Sri Lankan<br />
judiciary, in the near future, will not be hesitated <strong>to</strong> consider such matters<br />
under the purview <strong>of</strong>Article 11, if the circumstances are required so.<br />
4.2. As a Statu<strong>to</strong>ry right<br />
<strong>Right</strong> <strong>to</strong> health is given a statu<strong>to</strong>ry recognition in so many statutes in Sri<br />
18<br />
Lanka. Before the 13th Amendment, the <strong>Health</strong> Services Act ,had been<br />
enacted <strong>to</strong> provide for the constitution and responsibilities <strong>of</strong> the<br />
department <strong>of</strong> health and for the establishment <strong>of</strong> regional hospitals<br />
boards and hospital committees, and <strong>to</strong> secure more efficient<br />
administration by the local Authorities in relation <strong>to</strong> public health. But,<br />
inconsistent with this <strong>Health</strong> Services Act, after the 13th Amendment,<br />
most <strong>of</strong> the Provincial Councils have enacted Provincial <strong>Health</strong> Services<br />
Statutes <strong>to</strong> provide for an efficient and productive health service in the<br />
provinces while implementing the subject <strong>of</strong> health as se<strong>to</strong>ut in List<br />
No:01 <strong>of</strong> the ninth schedule <strong>of</strong> the Constitution and other related matters.<br />
17<br />
18<br />
D v United Kingdom, 2 May 1997, European Court <strong>of</strong> Human <strong>Right</strong>s<br />
No 12 <strong>of</strong> 1952<br />
23
In addition, Penal Code contains a separate Chapter on the <strong>of</strong>fences<br />
affecting the public health, safety, convenience, decency, and<br />
19<br />
morals. By Sections 262 and 263 it has made punishable <strong>to</strong> do a<br />
negligent or malicious act likely <strong>to</strong> spread infection <strong>of</strong> any disease<br />
dangerous <strong>to</strong> life. In addition, adulteration <strong>of</strong> foods, making atmosphere<br />
noxious <strong>to</strong> health, fouling the water <strong>of</strong> a public spring or reservoir, inter<br />
alia are made as <strong>of</strong>fences under the Penal Code and also under the Food<br />
Act. Therefore, according <strong>to</strong> these provisions, no doubt exists as <strong>to</strong> the<br />
recognition <strong>of</strong> the statu<strong>to</strong>ry right regarding right <strong>to</strong> health.<br />
From these statu<strong>to</strong>ry rights, another constitutional right has been<br />
emerged. For an instance, if the relevant government body fails <strong>to</strong><br />
perform their statu<strong>to</strong>ry functions necessary <strong>to</strong> facilitate public health,<br />
then the aggrieved parties can entertain a Writ application for the proper<br />
discharge <strong>of</strong> functions according <strong>to</strong> theArticle 140 <strong>of</strong> the Constitution.<br />
19<br />
Chapter xiv <strong>of</strong> the Penal Code<br />
24
Do the <strong>Health</strong> <strong>Right</strong>s<br />
<strong>of</strong> the <strong>IDP</strong>s Require a Special<br />
Protection?<br />
Taken by : Ramesha Balasooriya
5. Do the <strong>Health</strong> <strong>Right</strong>s <strong>of</strong> the <strong>IDP</strong>s Require e a Special<br />
Protection?<br />
t o The international and local laws and standards on right <strong>to</strong> health are<br />
equally relevant <strong>to</strong> <strong>IDP</strong>s. Therefore an involuntary question will raised<br />
that why a special attention is required for health concerns <strong>of</strong> <strong>IDP</strong>s. The<br />
economic, social and security status after the displacement<br />
au<strong>to</strong>matically make them vulnerable <strong>to</strong> health hazards. This is <strong>to</strong> say that<br />
soon after the displacement, most <strong>of</strong>ten they have <strong>to</strong> live in community<br />
centers where the general living conditions such as essential foods,<br />
water, shelter and sanitation is very much poor and therefore, the risk <strong>of</strong><br />
health outbreaks are higher in those places. Even in the stages <strong>of</strong><br />
resettlement, homes, wells and latrines are being damaged and it takes<br />
time <strong>to</strong> come <strong>to</strong> the normal life. With the loss <strong>of</strong> livelihood opportunities<br />
and other economic barriers also prevent them from spending a<br />
considerable monetary allocation on health and other sanitary<br />
requirements. Especially, among this vulnerability, the extreme<br />
vulnerable groups such as pregnant mothers and women and child<br />
headed families require special protection. Ignorance <strong>of</strong> the health<br />
conditions after the displacement therefore, will lead <strong>to</strong> another disaster<br />
and at the same time, if the situation aggravates and if it leads <strong>to</strong> an<br />
epidemic situation, the rendering cost <strong>to</strong> overcome will be higher.<br />
Therefore, the Guiding Principles on Internal Displacement<br />
20<br />
(GPID) which deals with the rights <strong>of</strong> <strong>IDP</strong>s specifically need <strong>to</strong> be<br />
adhered in this regard. Principle 18 <strong>of</strong> GPID states that all <strong>IDP</strong>s have the<br />
right <strong>to</strong> an adequate standard <strong>of</strong> living and at the minimum, regardless <strong>of</strong><br />
the circumstances, and without discrimination. Competent authorities<br />
shall provide <strong>IDP</strong>s with and ensure access <strong>to</strong> essential food and<br />
portable water, basic shelter and housing, appropriate clothing and<br />
essential medical service and sanitation.<br />
20<br />
GPID comprises a normative framework drawn from established international<br />
humanitarian law and human rights law on the rights <strong>of</strong> the displaced persons and the<br />
governments' and other authorities' obligations <strong>to</strong>wards displaced persons introduced by<br />
the United Nations in 1998.<br />
26
Principle 19 (1) <strong>of</strong> GPID discusses about all wounded and sick<br />
internally displaced person's health rights and when necessary their right<br />
<strong>to</strong> have access <strong>to</strong> psychological and social services. Principle 19 (2)<br />
elaborates that special attention should be paid <strong>to</strong> the health needs <strong>of</strong><br />
women, including access <strong>to</strong> female care providers and services, such as<br />
reproductive health care, as well as appropriate counseling for victims <strong>of</strong><br />
sexual and other abuses. Principle19 (3) states that special attention<br />
should also be given <strong>to</strong> the prevention <strong>of</strong> contagious and infectious<br />
diseases, includingAIDS, among internally displaced persons.<br />
For the purpose <strong>of</strong> alleviating human suffering arising out <strong>of</strong> calamity<br />
and conflict, and <strong>to</strong> ascertain the right <strong>to</strong> live with dignity <strong>of</strong> those<br />
affected by disaster and their right <strong>to</strong> assistance, The Humanitarian<br />
Charter and Minimum Standards in Disaster Response <strong>of</strong> The<br />
21<br />
Sphere Project (Sphere Principles) has been formulated <strong>to</strong> develop a<br />
set <strong>of</strong> universal minimum standards in core areas <strong>of</strong> humanitarian<br />
assistance. The aim <strong>of</strong> the project is <strong>to</strong> improve the quality <strong>of</strong> assistance<br />
provided <strong>to</strong> people affected by disasters, and <strong>to</strong> enhance the<br />
accountability <strong>of</strong> the humanitarian system in disaster response. Since<br />
these Minimum Standards are very much crucial in assessing health<br />
rights <strong>of</strong> <strong>IDP</strong>s, it is worthy <strong>to</strong> brief on, in this research. They set out<br />
minimum standards on Hygiene Promotion, Water Supply, Excreta<br />
Disposal, Vec<strong>to</strong>r Control, Solid Waste Management and Drainage.<br />
22<br />
Since these sec<strong>to</strong>rs are significant determinants for survival in the<br />
initial stages <strong>of</strong> a disaster and they are more susceptible <strong>to</strong> diseases such<br />
as water-borne diseases due <strong>to</strong> inadequate sanitation, inadequate water<br />
supplies and poor hygiene. These standards are devised <strong>to</strong> ensure that<br />
people affected by disasters have access <strong>to</strong> at least the minimum<br />
requirements <strong>of</strong> water, sanitation, food, nutrition, shelter and health care<br />
<strong>to</strong> satisfy their basic right <strong>to</strong> life with dignity.<br />
21<br />
The Sphere Project is a programme <strong>of</strong> the Steering Committee for Humanitarian<br />
Response (SCHR) and Inter Action with VOICE and ICVA with the help <strong>of</strong> so many<br />
agencies, launched in 1997. Source- http://www.sphereproject.org<br />
22<br />
SeeAnnexure II for the Minimum standards on each sec<strong>to</strong>r<br />
27
It is submitted therefore that the right <strong>to</strong> health <strong>of</strong> <strong>IDP</strong>s should receive the<br />
same protection available <strong>to</strong> other citizens. According <strong>to</strong> the Article 12<br />
(1), all persons are equal before the law and are entitled <strong>to</strong> the equal<br />
protection <strong>of</strong> the law. Therefore, special mechanisms, if the situation<br />
requires should be provided <strong>to</strong> uplift their rights because different<br />
qualities <strong>of</strong> health standards for persons residing in different geographic<br />
locations may constitute discrimination under the international law and<br />
alsoArticle 12 <strong>of</strong> Sri Lankan Constitution.<br />
The adoption <strong>of</strong> special measures intended <strong>to</strong> bring about de fac<strong>to</strong><br />
equality for disadvantaged groups such as special measures for the<br />
development <strong>of</strong> living standards in welfare centers is not a violation <strong>of</strong><br />
the right <strong>to</strong> equality <strong>of</strong> other normal public, so long as such measures do<br />
not lead <strong>to</strong> the maintenance <strong>of</strong> unequal or separate standards for different<br />
groups, and provided they are not continued after the objectives for<br />
which they were taken have been achieved.Article 12 (4) also stipulates<br />
that Nothing in the Article 12 shall prevent special provisions being<br />
made, by law, subordinate legislation or executive action, for the<br />
advancement <strong>of</strong> women, children or disabled persons. Therefore an<br />
affirmative action <strong>to</strong> protect the right <strong>to</strong> health <strong>of</strong> conflict affected<br />
displaced persons will not be discrimina<strong>to</strong>ry <strong>to</strong> other Sri Lankan citizens.<br />
28
<strong>Health</strong> Administrative System in Sri Lanka<br />
Public Sec<strong>to</strong>r<br />
(Preventive, Curative &<br />
Rehabilitative Care)<br />
Private Sec<strong>to</strong>r<br />
(Curative Care)<br />
Ministry <strong>of</strong> <strong>Health</strong> Care &<br />
Nutrition.(Protection &<br />
Promotion <strong>of</strong> Peoples'<br />
<strong>Health</strong><br />
Provincial <strong>Health</strong><br />
Administration<br />
(Management and effective<br />
Implementation <strong>of</strong> <strong>Health</strong><br />
Services)<br />
Minister <strong>of</strong> <strong>Health</strong> Care & Nutrition<br />
Provincial Minister (<strong>Health</strong>)<br />
Department <strong>of</strong> <strong>Health</strong> Services<br />
Direc<strong>to</strong>rs <strong>of</strong> health<br />
Teaching Hospitals<br />
National Hospitals<br />
General Hospitals<br />
National <strong>Health</strong> Council<br />
National Institute <strong>of</strong> <strong>Health</strong> Science<br />
State Pharmaceutical Corporation<br />
Provincial Secretary<br />
Provincial Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Service (PDHS)<br />
Deputy Provincial Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong><br />
Service (DPDHS)<br />
Medical Officers<br />
Provincial Hospitals<br />
<strong>Health</strong> Education Officer Divisional Direc<strong>to</strong>rs <strong>of</strong> <strong>Health</strong> Services/<br />
Planning and Programming Officer<br />
Medical Officer <strong>of</strong> <strong>Health</strong> (DDHS/MOH)<br />
Regional Supervising PHI/PHNO<br />
Food & Drug Inspec<strong>to</strong>r Preventive Curative<br />
Other Divisional Officers<br />
Supervising Public <strong>Health</strong> Inspec<strong>to</strong>r DMO District Hospital<br />
Public <strong>Health</strong> Inspec<strong>to</strong>r<br />
MO Peripheral Unit<br />
Public <strong>Health</strong> Nursing Sister<br />
RMO/AMO Rural Hospital<br />
Supervising Public <strong>Health</strong> Midwife RMO/AMO Central Dispensary<br />
Public <strong>Health</strong> Midwife<br />
Maternity Homes<br />
Branch Dispensaries<br />
Visiting Stations<br />
Source- www.health.gov.lk<br />
29
General Curative health<br />
situation <strong>of</strong> the districts<br />
Taken by : NPDS for <strong>IDP</strong>s Project, Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka
6. General e Curative health h situation t i <strong>of</strong> the districts<br />
i t s<br />
As per the List I (Provincial Council List <strong>of</strong> 9th Schedule) referred in<br />
Article 154 A <strong>of</strong> 13th Amendment <strong>to</strong> the Constitution, the establishment<br />
and maintenance <strong>of</strong> public hospitals, rural hospitals, maternity homes,<br />
dispensaries (other than teaching hospitals and hospitals established for<br />
special purposes) ; Public health services, health education, nutrition,<br />
family health, maternity and child care, food and food sanitation,<br />
environmental health and Formulation and implementation <strong>of</strong> <strong>Health</strong><br />
Development Plan and <strong>of</strong> the Annual <strong>Health</strong> Plan for the Province come<br />
under the purview <strong>of</strong> relevant Provincial councils. According <strong>to</strong> the<br />
Concurrent List (List III referred 13th Amendment <strong>of</strong> the Constitution),<br />
schools for training <strong>of</strong> Auxiliary Medical Personnel; the supervision <strong>of</strong><br />
private medical care, control <strong>of</strong> nursing homes and <strong>of</strong> diagnostic<br />
facilities within a Province; Population control and family planning and<br />
Constitution <strong>of</strong> Provincial Medical Boards are <strong>to</strong> be done by both parties.<br />
Other Subjects and Functions not Specified in List I or List III are<br />
reserved by the Central Government.<br />
Out <strong>of</strong> 182 Government Medical Institutions located in the selected<br />
districts, only two institutions (GH-Batticaloa and TH-Anuradhapura)<br />
come under the management <strong>of</strong> central government. All the other<br />
hospitals/institutions come under the supervision <strong>of</strong> relevant Provincial<br />
Councils. Following are some <strong>of</strong> the general observations about the<br />
curative health facilities in the selected districts.<br />
Mannar<br />
Mannar district comprises 1,880 Sq Km land area (3% <strong>of</strong> country land)<br />
23<br />
and 99,000 populations (0.5% <strong>of</strong> <strong>to</strong>tal population) and around 30,000<br />
24<br />
<strong>IDP</strong>s (30 % 0f district population) . There are 6 government medical<br />
institutions and out <strong>of</strong> them only 10 institutions are functioning and their<br />
<strong>to</strong>tal bed strength is 345. DH Adampan and RH Vidataltivu<br />
23<br />
24<br />
Source-Survey General's Department & Registrar General's Department,2005<br />
30,112 <strong>of</strong> <strong>IDP</strong>s as at 31st June 2008-See Annexure I<br />
32
are Functioning only as OPDs and it was also reported that the Adampan<br />
25<br />
DH was relocated <strong>to</strong> Vellankaulm in Manthai West due <strong>to</strong> shelling . RH<br />
Chilavaturai is closed and CDs in Periyamadu, Periyapandivrichchan,<br />
Thirukeetheswaram, Marichukkaddy and Iranaiiluppaikulam are not<br />
26<br />
functioning from 2003 .<br />
Puttalam<br />
Puttalam district covers 2,882 sq km <strong>of</strong> land and 812,601 numbers <strong>of</strong><br />
27<br />
people are living there and among them, 61,274 are <strong>IDP</strong>s (7.5% 0f<br />
28<br />
district population) . There are 40 health institutions operating in the<br />
district and all <strong>of</strong> them come under the supervision <strong>of</strong> North Western<br />
Provincial Council. There are more than 70,000 <strong>IDP</strong>s relocated in<br />
Puttalam and they are relocated mainly in the Puttalam,<br />
Wanathawilluwa, Kalpitiya and Mundal DS divisions. There are 5<br />
Central Dispensaries functioning in 5 RLVs in Puttalam district, under<br />
the supervision <strong>of</strong> Mannar DPDHS.Among the other GH and BHs in the<br />
district, <strong>IDP</strong>s have easy access <strong>to</strong> the Puttalam BH comparatively.<br />
Puttalam BH encompasses 40 doc<strong>to</strong>rs, 90 nurses and 14 midwives and its<br />
bed strength is 344. According <strong>to</strong> DMO this amount <strong>of</strong> staff is<br />
insufficient <strong>to</strong> treat such large amount <strong>of</strong> host communities and <strong>IDP</strong>s.<br />
Due these scarce resources, both <strong>IDP</strong> community and host communities<br />
have <strong>to</strong> face big competition in fulfilling their health needs.<br />
25<br />
26<br />
27<br />
28<br />
Source- relief web - http://www.reliefweb.int/ ,30 November 2007<br />
Www.health.gov.lk/beds%20recata2006.xls<br />
DPDHS-Puttalam<br />
SeeAnnexure I for <strong>IDP</strong>s population in each district.<br />
33
Vavuniya<br />
29<br />
Population <strong>of</strong> Vavuniya is 182,808 , including 82,176 numbers <strong>of</strong> <strong>IDP</strong>s<br />
30<br />
(45 % <strong>of</strong> district population) and it covers 1966.9 Sq km <strong>of</strong> land . Out <strong>of</strong><br />
10 medical institutions, the RH in Ulukulam, CD & MH in Pavatkulam<br />
and Neriyakulam function only as CDs and CD in Pulliyamkulam is<br />
31<br />
temporally closed .<br />
The General Hospital Vavuniya is the focal referral point among all the<br />
hospitals in the region. Although this Base Hospital <strong>of</strong> Vavuniya was<br />
upgraded <strong>to</strong> the District General Hospital status after re-categorization<br />
32<br />
<strong>of</strong> hospitals , the service delivery <strong>of</strong> the hospital is still reported as far<br />
below even than the Base Hospital level. Regarding the hospital health<br />
service facilities, it was evident that the inadequate infrastructure<br />
facilities have led <strong>to</strong> several difficulties, for a instance the <strong>to</strong>tal bed<br />
strength <strong>of</strong> the hospital is 302 beds and it has caused an over crowding<br />
status. Inadequate treatment facilities in the Vavuniya DGH such as lack<br />
<strong>of</strong> medical specialists in the hospital compel patients <strong>to</strong> be transferred<br />
33<br />
either <strong>to</strong> Anuradhapura and/or <strong>to</strong> Colombo and it causes immense<br />
hardships <strong>to</strong> the people <strong>of</strong> the region. In addition <strong>to</strong> those, there are so<br />
many infrastructure scarcities faced by GH Vavuniya despite its status as<br />
a focal referral hospital. Problems as <strong>to</strong> quarters, <strong>of</strong>ficial transports,<br />
<strong>of</strong>ficial vehicles and lack <strong>of</strong> proper drainage system are affecting the<br />
value <strong>of</strong> the service given <strong>to</strong> the people by the hospital. Insufficient<br />
number <strong>of</strong> wards, specially, not having wards for mentally disordered<br />
persons are among other burning issues <strong>of</strong> the hospital.<br />
29<br />
Source-GAOffice-Vavuniya, as at 31.12.2006<br />
30<br />
Source- Survey Department, Vavuniya<br />
31<br />
www.health.gov.lk<br />
32<br />
Circular 02-61/2005 on Re-categorization <strong>of</strong> Hospitals by Ministry <strong>of</strong> <strong>Health</strong> care and<br />
Nutrition<br />
33<br />
Observed in the discussion with Dr. Mrs. B. Pasupathirajah,GH- Vavuniya.<br />
34
Anuradhapura<br />
Anuradhapura district comprises 782,000 (4% <strong>of</strong> the <strong>to</strong>tal population)<br />
and 6,664 Sq. km <strong>of</strong> land (10.6% <strong>of</strong> <strong>to</strong>tal country lands) and 15,120 <strong>IDP</strong>s<br />
(2 % <strong>of</strong> district population). There are 60 government medical<br />
institutions in the district and the <strong>to</strong>tal bed strength <strong>of</strong> the district is 2,858.<br />
GH-Anuradhapura has been upgraded as a Teaching Hospital (TH) and<br />
managed by the central government from 01.03.2006 and it has 1273<br />
beds in strength (apart from ICU) whereas the normal patient's in-take<br />
rate is about 1450 per day. RH- Kebethigollewa has been upgraded as BH<br />
(bed strength - 30) but still functioning as RH and RH Nachchiyaduwa<br />
and CD & MH in Koonwewa, Tittagonewa, Welioya are functioning<br />
only as Cds.<br />
Batticaloa<br />
Batticaloa district covers 2,610 Sq.Km in lands (4.16% <strong>of</strong> <strong>to</strong>tal land) and<br />
comprises 549,000 populations (2.8% <strong>of</strong> <strong>to</strong>tal population) 18,171 <strong>IDP</strong>s<br />
(3.3 % <strong>of</strong> district population). There are 28 health institutions in the<br />
district the <strong>to</strong>tal bed strength <strong>of</strong> the district is 1295. GH - Batticaloa has<br />
been re-categorized as PGH (696 bed strength) and out <strong>of</strong> all health<br />
institutions in the selected districts, this is one <strong>of</strong> the two health<br />
institutions managed by the central government.<br />
The DH in Kattankudy is completely damaged by Tsunami and Vakarai<br />
Peripheral Unit (PU) has been destroyed in 1990 from conflict and it was<br />
further damaged by tsunami and after the resettlement it was upgraded as<br />
a DH. But it was reported that the infrastructure and the facilities<br />
available, are not sufficient. There is only one medical <strong>of</strong>ficer working<br />
whereas the requirement is 3 and there are only 3 nurses when they need<br />
8. Also they need further dispensary facilities <strong>to</strong> conduct the OPD<br />
effectively. Among other requirements, more delivery kits, additional<br />
nebulizers, communication facilities between other hospitals and the<br />
department, separate wards for children, elders and pregnant women and<br />
separate units for Surgical and Pediatric section are needed for a smooth<br />
34<br />
health service for the public .<br />
34<br />
Source- Fact Finding Mission at Vakarai- Batticaloa district by NPDS for <strong>IDP</strong>s Project<br />
on 5th June 2007.<br />
35
Among other Medical institutions in the district, prison hospital in<br />
Baticaloa is not functioning, the CD & MH in Navatkadu is functioning<br />
only as a CD and the CD in Thuraimulavanie has been completely<br />
35<br />
damaged by Tsunami .<br />
Trincomalee<br />
Having 388,000 (2% <strong>of</strong> <strong>to</strong>tal population) population, possessing 2,529<br />
sq.km <strong>of</strong> land (4.03% <strong>of</strong> <strong>to</strong>tal land) and among them 17,965 are conflict<br />
affected <strong>IDP</strong>s (4.6 % <strong>of</strong> district population). Trincomalee district has 28<br />
governmental medical institutions. DGH-Trincomalee is having 344<br />
beds in its strength and 15 wards. District Base Hospital, Kinniya has<br />
been completely destroyed by the tsunami. In RH -Kuchchaveli and in<br />
Rural Hospital <strong>of</strong> Thoppur has been re-categorized as a CD.<br />
6.1. Analysis on General Curative <strong>Health</strong> Sec<strong>to</strong>r <strong>of</strong> the Districts<br />
It was observed during the study that the main set back <strong>of</strong> the health<br />
systems in the districts is the inadequacy <strong>of</strong> the health infrastructure and<br />
the shortage <strong>of</strong> the human resources <strong>to</strong> meet primary health needs <strong>of</strong> the<br />
displaced people and the host communities. Especially, the on-going war<br />
between the government and the LTTE has put so many civilians in<br />
danger <strong>of</strong> their lives and health but the health infrastructure is reported as<br />
minimum when comparing <strong>to</strong> the needs arising against the backdrop <strong>of</strong><br />
war. Therefore, capacitating hospitals with required equipments for a<br />
smooth functioning is also urgent matter <strong>to</strong> be resolved. Especially<br />
during the time <strong>of</strong> civil war, wounded people and soldiers are very <strong>of</strong>ten<br />
referred <strong>to</strong> these hospitals. But due <strong>to</strong> lack <strong>of</strong> facilities available in<br />
particular hospitals, government has <strong>to</strong> bear additional cost for transport<br />
and the threat <strong>to</strong> the life during the traveling is high. If those hospitals are<br />
well facilitated <strong>to</strong> face emergencies and displacements these additional<br />
costs can be used for development and the threats <strong>to</strong> lives also would be<br />
minimal.<br />
35<br />
www.health.gov.lk<br />
36
It was found that many heath institutions were destroyed either by<br />
Tsunami or due <strong>to</strong> the conflict, and still not rehabilitated properly.<br />
According <strong>to</strong> the General Circular No: 02-61/2005 <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong><br />
on Re-categorization <strong>of</strong> Hospitals, five categories <strong>of</strong> hospitals were<br />
introduced namely, Teaching Hospitals/Provincial Hospitals, District<br />
General /District Base Hospitals (all existing General and Base<br />
Hospitals), Divisional Hospitals ( all District Hospitals, Rural hospitals,<br />
Peripheral Units), Primary Medical Care Units( Central Dispensaries &<br />
Maternity Homes) and Special Hospitals <strong>to</strong> enable the development <strong>of</strong><br />
these hospitals in a uniform manner in order <strong>to</strong> provide equitable service<br />
<strong>to</strong> all districts and provinces. This circular recommends certain<br />
minimum facilities <strong>to</strong> be available in particular institutions. But it was<br />
observed that those recommendations are not been carried out and many<br />
hospitals are far beyond even than the minimum requirements.<br />
Regarding insufficiency <strong>of</strong> human resources in health sec<strong>to</strong>r in those<br />
areas, it was revealed that retention <strong>of</strong> health staff is the most difficult<br />
task for health administra<strong>to</strong>rs. According <strong>to</strong> the Secretary <strong>to</strong> the<br />
provincial Ministry <strong>of</strong> <strong>Health</strong>, Eastern Province, the main problem in the<br />
Eastern province is the retaining doc<strong>to</strong>rs and other staff within the<br />
province out <strong>of</strong> 23 doc<strong>to</strong>rs appointed only 12 reported <strong>to</strong> work and 32<br />
doc<strong>to</strong>rs have taken transfers <strong>to</strong> other districts.<br />
Having familiarize with the rights perspective <strong>of</strong> health and the above<br />
curative health issues in the selected districts it is inevitable <strong>to</strong> suggest<br />
that there is something lack in the system <strong>to</strong> address those raised health<br />
issues. It is obvious that the government is fighting with scars <strong>of</strong><br />
resources and cost for social welfare but there is a particular sum<br />
allocated <strong>to</strong> health in every year. Such funds needs <strong>to</strong> be distributed<br />
according <strong>to</strong> the needs <strong>of</strong> the people and that needs are <strong>to</strong> be calculated on<br />
various fac<strong>to</strong>rs. Population, availability <strong>of</strong> health facilities and<br />
institutions and health indica<strong>to</strong>rs <strong>of</strong> each district are among the deciding<br />
fac<strong>to</strong>rs when taking a decision by the authorities. But, the most<br />
depressing s<strong>to</strong>ry here is the unavailability or reliability <strong>of</strong> such health<br />
36<br />
By the General Circular Letter No:02-59/2008, the Ministry has given directions <strong>to</strong><br />
subdivide the category <strong>of</strong> Divisional Hospitals according <strong>to</strong> the bed capacity namely, if it<br />
is more than 100 patient beds-Type A DH, between 50 <strong>to</strong> 100 beds-Type B DH, less than<br />
50 beds-Type C DH<br />
37
indica<strong>to</strong>rs in some districts. According <strong>to</strong> the National <strong>Health</strong> Policy,<br />
allocation <strong>of</strong> resources between provinces/ districts is being done based<br />
on their health needs and national priorities. To identify health needs <strong>of</strong><br />
districts, the accurate medical records from all districts should be<br />
available. However, it is submitted that in some instances, funds are<br />
allocated without looking at real health needs <strong>of</strong> the particular districts.<br />
For an instance, Maternal Mortality Rate is reported as 1.4 per 10,000<br />
37<br />
live births in 2002 but with the cero maternal deaths from seven districts<br />
38<br />
including, Mannar, Vavuniya and Mulathivu and according <strong>to</strong> the data<br />
from Family <strong>Health</strong> Bureau, it is 5.3 in 2002 . In 2005 also the number <strong>of</strong><br />
39<br />
maternity deaths in Mannar and Vavuniya is uncounted . Therefore the<br />
reliability <strong>of</strong> health indica<strong>to</strong>rs is questionable due <strong>to</strong> poor reporting<br />
system.<br />
37<br />
Annual <strong>Health</strong> Bulletin 2003, Table 1.3-“Vital Statistics 1945-2003”, source -<br />
RGD,www.health.gov.lk<br />
38<br />
District Variation in Maternal and Infant Mortality Rates 2002- without figures from<br />
Mulathiw, Mannar ,Kaluthara, Vavuniya ,Kegalle, Matale and.Pollonnaruwa. -RGD<br />
39<br />
Annual <strong>Health</strong> Bulletin 2005,Medical Statistics Unit, Ministry <strong>of</strong> <strong>Health</strong><br />
38
<strong>Health</strong> Issues <strong>of</strong><br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong><br />
Taken by : NPDS for <strong>IDP</strong>s Project, Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka
7. <strong>Health</strong> Issues s s <strong>of</strong> <strong>Internally</strong> n l <strong>Displaced</strong> <strong>Persons</strong><br />
s<br />
7.1. Access <strong>to</strong> health clinics<br />
Above, the availability <strong>of</strong> the health facilities in particular districts was<br />
discussed and the next step is <strong>to</strong> assess the “accessibility” <strong>of</strong> such health<br />
facilities <strong>to</strong> the <strong>IDP</strong>s. It is accepted that <strong>to</strong> establish utmost utilize <strong>of</strong> the<br />
rights those health facilities should be within the safe physical reach and<br />
at the same time it should be economically affordable. According <strong>to</strong> the<br />
Handbook for Emergencies by UNHCR, 1 health center should be there<br />
for 20,000 people and 1 referral hospital for 200,000 persons. However<br />
during the study it was found out in some welfare centers do have regular<br />
mobile clinics but for some WCs were visited by mobile clinics very<br />
rarely. It was also observed that in resettlement or relocation planning,<br />
the health concerns <strong>of</strong> such people have not been fairly considered. In<br />
selecting a transit camp or a relocation center, the fac<strong>to</strong>rs like proper<br />
access <strong>to</strong> roads, hospitals, the availability <strong>of</strong> water, proper drainage,<br />
adequate conditions for sanitation and strategically located <strong>to</strong> serve the<br />
purpose <strong>of</strong> the operation should be the primary criteria for site<br />
40<br />
selection .<br />
Mannar, it is also reported that resettled people in Thampanikkulam and<br />
Kattaiyadampan resettled villages are facing serious health problems<br />
since they do not have any dispensary nearby, for every health needs,<br />
including minor illnesses they have <strong>to</strong> travel Murunkan DH which is<br />
situated about 10 kilometers away from their villages.<br />
Anuradhapura, in Padaviya MOH area (including Padaviya and Welioya<br />
DS Divisions), most <strong>of</strong> the <strong>IDP</strong>s relocated in Gravel kanda, Gajabapura<br />
and Monarawewa and they are still living under the threat <strong>of</strong> LTTE<br />
attacks. There are only two medical institutions available in these areas,<br />
namely; Padaviya District Hospital & Sampath Nuwara RH. In Sampath<br />
Nuwara RH, two doc<strong>to</strong>rs, 4 nurses, and 9 attendants are serving in RH<br />
and in the case <strong>of</strong> emergency, Medical staff <strong>of</strong> Army helps <strong>to</strong> provide<br />
services. However the difficulties <strong>of</strong> transport and security in areas such<br />
40<br />
Handbook for Emergencies by UNHCR, p 223, Para 98<br />
40
as Janakapura , Kiri Ibbanwewa, Athawetunuwewa have reduce the<br />
number <strong>of</strong> patients coming <strong>to</strong> hospitals including, pregnant and feeding<br />
mothers. This indirectly causes the patients <strong>to</strong> disregard their illnesses at<br />
first stage and only after it become worse; it is being referred <strong>to</strong> the<br />
doc<strong>to</strong>r. Soon after the resettlement <strong>of</strong> people in Yakawewa,<br />
Kanugahawewa <strong>of</strong> Kebithigollewa, the mobile medical services was<br />
functioned once a week but at present it is functioning only twice a<br />
month. People <strong>of</strong> the area appreciated the previous visits carried out once<br />
a week and the security problems and transport difficulties urge frequent<br />
mobile services <strong>to</strong> the villages.<br />
Lack <strong>of</strong> transport facility is one <strong>of</strong> other issues that affect the people in<br />
Batticaloa and pregnant mothers in most <strong>of</strong> the villages in Batticaloa<br />
west, have <strong>to</strong> walk 2km or 3km distance <strong>to</strong> arrive <strong>to</strong> the available<br />
hospital. In villages like Iruddusolaimadu, Pawatkodichchenai,<br />
Ganthinagar and Unnichchai <strong>of</strong> Vavunathivu it was reported that there<br />
have been numbers <strong>of</strong> snake bites but due <strong>to</strong> lack <strong>of</strong> transport facilities<br />
they could not take the patients <strong>to</strong> the hospitals on time. In some villages<br />
people face difficulties <strong>to</strong> go <strong>to</strong> the hospitals during the night because<br />
41<br />
during the emergency, traveling by mo<strong>to</strong>rbike and trac<strong>to</strong>r is prohibited .<br />
In Trincomalee, it was also observed that since the road from Seruwila <strong>to</strong><br />
Uppural is closed since April 2006, the resettled people in Uppural have<br />
<strong>to</strong> walk Illankaithuraimugathuwaram medical clinic which is situated 5<br />
Kilometers away from their village and this fact has caused irregular<br />
42<br />
attendance <strong>to</strong> clinics .<br />
Treatment and management <strong>of</strong> minor ailments<br />
Co-ordinate with the local medical institutions/authorities <strong>to</strong> establish mobile<br />
medical teams <strong>to</strong> visit temporary shelters for the displaced daily and provide<br />
treatment.<br />
Refer and transport those that require institutional care.<br />
“Provisional guidelines for emergency management <strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s” issued by the<br />
Epidemiological Unit <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong>care & Nutrition for Batticaloa <strong>Health</strong> Staff-Section 5-See<br />
Annexure VI<br />
41<br />
Source- Fact finding mission at Batticaloa West by NPDS for <strong>IDP</strong>s Project on 27th,<br />
28th , 29th <strong>of</strong>August 2007<br />
42<br />
Source-Remedial Institution's Co-ordination Mechanism Meeting Tricomalee<br />
District MINUTES, 26th February 2008<br />
41
7.2. Public <strong>Health</strong> Services<br />
The promotion <strong>of</strong> health and prevention <strong>of</strong> diseases is the main function<br />
<strong>of</strong> the Public <strong>Health</strong> Services and it is carried out by the Medical Officers<br />
<strong>of</strong> the <strong>Health</strong> (MOH) or by a Divisional Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Service<br />
(DDHS) <strong>of</strong> the relevant provinces with the help <strong>of</strong> PHIs, PHNS, PHMs<br />
and other health workers. They are responsible for family health care,<br />
environmental sanitation, health education and control <strong>of</strong> communicable<br />
diseases <strong>of</strong> the particular area.<br />
Administration issues relating <strong>to</strong> preventive health care <strong>of</strong> <strong>IDP</strong>s<br />
Regarding the public health services <strong>to</strong> the displaced population in the<br />
selected districts, it was evidenced that there is a scarcity <strong>of</strong> the required<br />
health carders in many districts. According <strong>to</strong> “the proposed norms for<br />
public health technical staff” approved at the workshop held on<br />
11.06.1999 chaired by Deputy Direc<strong>to</strong>r General (PHS) the DDHS/MOH<br />
area should be an area <strong>of</strong> 60,000 population and DDHS/MOH should be<br />
43<br />
assisted by 2 A/MOH <strong>to</strong> fulfill their duties . The required ratio for a PHI<br />
is that one (1) PHI for 9000 population and for PHM it is 3000. However<br />
the preventive health sec<strong>to</strong>r including environmental sanitation and<br />
reproductive health <strong>of</strong> displaced has been ignored due <strong>to</strong> the lack <strong>of</strong> staffs<br />
<strong>of</strong> particular areas. According <strong>to</strong> the health authorities the number <strong>of</strong><br />
approved carder is calculated using these norms, but during the study<br />
that it was revealed it is not being practically carried out.<br />
Puttalam MOH area covers two <strong>IDP</strong> living areas, namely, Puttalam and<br />
Wanathawilluwa and there is 109,760 host community population and<br />
44<br />
24,344 <strong>IDP</strong>s are living in there . According <strong>to</strong> above “the proposed<br />
norms for public health technical staff”, 14 PHIs and 44 PHMs are<br />
43<br />
The duties <strong>of</strong> MOH comprise planning and managing community health activities,<br />
supervision <strong>of</strong> health institutions below district hospital levels, co-ordination with other<br />
sec<strong>to</strong>rs and agencies, financial management and logistics, training and research, health<br />
education and promotion <strong>of</strong> healthy lifestyle, Emphasis on problems <strong>of</strong> special groups<br />
like displaced, disabled, estate sec<strong>to</strong>r, etc environmental and occupational health,<br />
nutrition, control <strong>of</strong> communicable and non communicable diseases, home visiting<br />
when necessary, and being on call <strong>to</strong> the community, food safety and hygiene<br />
44<br />
Source-Puttalam MOH Office<br />
42
equired for the division, but currently only 4 PHIs and 19 PHMs and<br />
have been deployed <strong>to</strong> provide the health services <strong>to</strong> both Local<br />
communities and <strong>IDP</strong>s. But based on DPDHS-Puttalam data, “the<br />
approved PHI carder” is 5 positions as at fourth quarter <strong>of</strong> 2007, where<br />
only host community population exceeds 100,000 people.<br />
A Case Study<br />
Al Qassimi Relocation/Resetlement Village – Puttalam<br />
- 500 displaced families (From Mannar & Mulathivu)<br />
- 500 permanent houses<br />
- A Central Dispensary and a School are operating in RL V and administered by<br />
Mannar district administration.<br />
Nearest Maternity Clinic- Rathmalyaya Maternity Clinic (1 km away from RLV)<br />
The issue-<br />
Puttalam Regional Office <strong>of</strong> NPDS for <strong>IDP</strong>s Project <strong>of</strong> HRCSL received a complaint from six<br />
Vavuniya there are 4 MOH areas namely, Vavuniya, Vavuniya South,<br />
Vavuniya North and Cheddikulam and it was reported that though there<br />
45<br />
were 19 PHM vacant positions in the district as at July 2007 and it has<br />
been cured now. Only 4 PHM vacancies are prevailing as at 31st<br />
December 2007 in Vavuniya. However numbers <strong>of</strong> MOH and PHI<br />
vacancies have been increased at the end <strong>of</strong> 2007. Analyzing the data, it<br />
was found out that though the number <strong>of</strong> vacancies has been reduced,<br />
irregularities are existing in allocating man power <strong>to</strong> different MOH<br />
areas. Because all PHM vacancies <strong>of</strong> the district are reported from<br />
Vavuniya North MOH area (4 vacancies) and no MOH and no PHI was<br />
46<br />
assigned in that MOH area at the end <strong>of</strong> 2007 .<br />
45<br />
46<br />
See theAnnexure III.<br />
See theAnnexure IV<br />
43
In Trincomalee, it was observed that there is no SPHI is working in the<br />
MOH areas <strong>of</strong> Padavisiripura, Kuchcheveli, Morawewa and<br />
Ichchalampattu. For Gomarankadawala and Morawewa, no PHI has<br />
been assigned and no PHM is serving in Eachchalampattu where<br />
47<br />
resettlement is on going recently . There are only 83 PHMs in<br />
Trincomalee district whereas there should be 115 (32 vacant positions)<br />
48<br />
and no PHM was serving in Eachchalampattu MOH area . In<br />
Anuradhapura <strong>to</strong>o, 30 PHM positions are vacant at while 22 Public<br />
<strong>Health</strong> Nursing Sisters are needed for MOH <strong>of</strong>fices <strong>of</strong> the district, there<br />
are only 05 sisters attached <strong>to</strong> the Office(17 vacant positions) as at<br />
December 2006.<br />
Following is the current details on prevailing vacancies in the preventive<br />
health sec<strong>to</strong>r <strong>of</strong> the districts.<br />
Vacancies in Preventive <strong>Health</strong> Sec<strong>to</strong>r<br />
District<br />
Approved Cadre<br />
Vacancies<br />
MOH SPHI PHI PHNS SPHM PHM MOH SPHI PHI PHNS SPHM PHM<br />
Thrincomalee 10 6 37 10 10 115 1 -1 4 8 10 32<br />
As at September<br />
2007<br />
A’pura 22 13 80 22 19 422 -1 5 5 18 0 30<br />
As at March<br />
2008<br />
Vavuniya 5 15 41 2 5 4<br />
As at December<br />
2007<br />
Batticaloa 9 9 51 9 10 138 -2 4 -8 -6 1 -16<br />
As at January<br />
2008<br />
Puttalam<br />
As at 4 th Quarter<br />
2007<br />
9 9 44 10 9 172 0 4 8 3 5 -9<br />
Source- Relevant DPDHS <strong>of</strong>fices in the Particular districts<br />
However it is evidenced that “the approved carder” in above diagram is<br />
not calculated according <strong>to</strong>” the proposed norms for public health<br />
technical staff”. If it is calculated according <strong>to</strong> “the proposed norms for<br />
public health technical staff”, the numbers <strong>of</strong> vacancies would be much<br />
higher than these figures.<br />
47<br />
48<br />
See theAnnexure V<br />
See theAnnexure V<br />
44
However though there is a scarcity <strong>of</strong> human resources and the legal<br />
duties <strong>of</strong> the preventive health sec<strong>to</strong>r are being unable <strong>to</strong> fulfill, the<br />
dedicated health staff have managed <strong>to</strong> prevent further health disasters<br />
following the disasters. But in some areas, it was reported that though<br />
they have sufficient staff, day <strong>to</strong> day visits are not being done and due <strong>to</strong><br />
lack <strong>of</strong> moni<strong>to</strong>ring system regarding their conduct.<br />
The changes <strong>to</strong> ethnic composition <strong>of</strong> some districts after displacement,<br />
have also posed some administrative issues in public health sec<strong>to</strong>r. In<br />
Puttalam, in 1981 there were 83 % <strong>of</strong> Sinhalese, 17 % <strong>of</strong> Tamil speaking<br />
persons. However in 2001; the Tamil speaking people in the district has<br />
been increased up<strong>to</strong> 26 %t because <strong>of</strong> the large number <strong>of</strong> displaced<br />
Muslim community from the Northern Province after 1989. Therefore it<br />
is obvious administrative decisions such as the language ability <strong>of</strong> the<br />
government staffs should be revised according <strong>to</strong> the new statistics at<br />
least in the relevant areas. For instance, in Puttalam MOH area there<br />
about 25,000 Tamil speaking <strong>IDP</strong>s and among 4 PHIs only one can speak<br />
Tamil and among 19 PHMs only 3 can manage with Tamil language.<br />
Language <strong>of</strong> these staffs is imperative because in relocations, the<br />
knowledge on environmental sanitation and family health issues have <strong>to</strong><br />
be communicated <strong>to</strong> the displaced community by these <strong>of</strong>ficers.<br />
7.3. Shelter, water, sanitation and hygiene and disease prevalence<br />
<strong>Right</strong> <strong>to</strong> adequate housing, water, sanitation and hygiene is clearly<br />
enshrined in the human rights sphere. These rights are combined with<br />
other human rights such as right <strong>to</strong> live in security and with dignity.<br />
However, concerning displaced people this is quite different. After<br />
loosing their natural habitats and wealth, they are compelled <strong>to</strong> live<br />
either in community centers or with their friends and relatives. It was<br />
very much obvious during the study that the basic living standards <strong>to</strong> live<br />
in dignity are not being observed at the temporary shelters, welfare<br />
centers and in relocations. It is estimated that this catastrophe is being<br />
49<br />
“Population by ethnic group and district, Census 1981 & 2001” ,Department <strong>of</strong><br />
Census and Statistics <strong>of</strong> Sri Lanka,<br />
http://www.statistics.gov.lk/Abstract_2006/abstract2006/table%202007/CHAP%202/<br />
AB2-11.pdf<br />
50<br />
Observed in discussion with MOH Puttalam.<br />
45
enlarged due <strong>to</strong> the unexpected influx <strong>of</strong> <strong>IDP</strong>s after the recent<br />
displacements in war-<strong>to</strong>ne areas. Therefore the poor living conditions in<br />
welfare centers are very much prevalent and following, is a bit <strong>of</strong> the<br />
above tragedy.<br />
Shelter<br />
According <strong>to</strong> the UNHCR and Sphere Principles, minimum shelter space<br />
for a person is 3.5 m2. Minimum site for a family is 500 Sq/ft. Minimum<br />
surface for a person 45 m2. But it was observed that these standards are<br />
not complied in many instances, in some welfare centers the floor area<br />
for a family is as low as 15 x 12 (180 Sq/ft) and this does not allow <strong>to</strong><br />
maintain privacy and sometimes it helps <strong>to</strong> increase sexual exploitations<br />
<strong>of</strong> women and children by family members. For an example, in the<br />
Welfare Centre at Zahira College, Batticaloa, there are 549 people (165<br />
families) living in the camp since 2006 and among them 30 are lactating<br />
mothers and 6 are pregnant mothers. They are living in partitioned rooms<br />
<strong>of</strong> which floor area is about 15 x 15 (225) sq/ft and light and ventilation<br />
inside the dwellings is not sufficient for a healthy life. It is also observed<br />
that these dwellings are not roomy enough <strong>to</strong> maintain privacy. This is<br />
common in many welfare centers in those regions.<br />
In selecting sites for welfare centers and settlements, the lowest point <strong>of</strong><br />
the site should be not less<br />
than 3 meters above the<br />
estimated level <strong>of</strong> the water<br />
table in the rainy season.<br />
However, in Santhinagar,<br />
Mannar, the relocated people<br />
had <strong>to</strong> move again from the<br />
relocations due <strong>to</strong> the flood<br />
situation <strong>of</strong> the area. In<br />
addition, over-crowding<br />
status in welfare center in<br />
Batticaloa is a critical problem. This is evident in Arthiviravar and<br />
Thiraimadu Welfare centers and in latter WC, one tent house is occupied<br />
by two-three families. This situation become worse when there is heavy<br />
rain and the transitional shelters were reported as inadequate and<br />
unsustainable.<br />
46
In Batticaloa West, the drinking water is distributed by bowsers in<br />
collaboration with Pradeshiya Sabha and UNICEF. But some villages<br />
get water only for three days in a week and because <strong>of</strong> the salty nature <strong>of</strong><br />
the available bathing water some are opted <strong>to</strong> use drinking water for<br />
bathing. It was reported that the drinking water is not supplied <strong>to</strong> people<br />
in Pudhumandapathadi, Gandhinagar and the people in Unnichchei get<br />
55<br />
water from Unnichchai tank which is nearby . People in<br />
Sinnakudiruppuwa <strong>IDP</strong> relocation (150 persons, 42 families) in<br />
Kalpitiya DS Division, Puttalam due <strong>to</strong> the unsuitability <strong>of</strong> drinking<br />
water used <strong>to</strong> buy water from visiting water sellers <strong>to</strong> the village.<br />
Availability <strong>of</strong> safe water is always concomitant with other health<br />
aspects .In Anuradhapura it was observed in Gravel Kanda, Gajabapura,<br />
Monarawewa relocations that most <strong>of</strong> natural deaths are happening due<br />
<strong>to</strong> unidentified reason and they also facing problems as <strong>to</strong> the suitable<br />
drinking water since still there is no any drinking water project for these<br />
areas. In Fact Finding Mission at Weli Oya by the Project, it was pointed<br />
out that there is high concentration <strong>of</strong> chloride in water and it is not<br />
suitable for drinking purposes without proper treatment and it was<br />
mentioned by the people that already 2 or 3 people have died from kidney<br />
failure as a result <strong>of</strong> this untreated water.<br />
55<br />
Source- Fact finding mission at Batticaloa West by NPDS for <strong>IDP</strong>s Project on 27th,<br />
28th , 29th <strong>of</strong>August 2007<br />
47
Water<br />
<strong>Right</strong> <strong>to</strong> water accomplishes the availability <strong>of</strong> sufficient, safe,<br />
acceptable, physically accessible and affordable water for personal and<br />
domestic uses. According <strong>to</strong> the ministry <strong>of</strong> health 93.90% <strong>of</strong><br />
51<br />
populations have the sustainable access <strong>to</strong> an improved water source .<br />
But according <strong>to</strong> the WFP only 21 percent in Mannar have access <strong>to</strong> safe<br />
52<br />
water . This shows the discrepancies <strong>of</strong> data between districts and<br />
situation <strong>of</strong> displaced population is quite problematic regarding access <strong>to</strong><br />
water.<br />
Minimum water needs for a person for drinking purpose is 7 liters per<br />
day (UNHCR) and according <strong>to</strong> the Sphere Principles it is 15 liters <strong>of</strong><br />
water is required for drinking, cooking, and personal hygiene. Maximum<br />
number <strong>of</strong> persons per tap is 250 persons and for a hand pump or dug well<br />
it is 400 persons. The maximum distance from any household <strong>to</strong> the<br />
nearest water point is 500 meters. Queuing time at a water source is no<br />
more than 15 minutes. Water sources and systems should be maintained<br />
such that appropriate quantities <strong>of</strong> water are available consistently or on<br />
a regular basis. However these standards are not observed in relation <strong>to</strong><br />
many <strong>IDP</strong>s and following observations were notified during the study.<br />
In Mannar it was reported that in Nanattan, Kalimottai and<br />
Jeevothayam people are facing difficulties in getting suitable drinking<br />
water, especially, in dry and rainy seasons. It was also complained that<br />
the water, supplied by the local government authorities is not in good<br />
condition and PHI is hardly ever checking the Chlorine level <strong>of</strong> the water.<br />
In Padipalai DS division, Batticaloa there is a serious need for drinking<br />
water and it is reported that the particular Pradeshiya Sabhas are also<br />
unable <strong>to</strong> meet the needs <strong>of</strong> communities.It is observed that some<br />
<strong>of</strong> the common wells at Kirmichchodai, Vakarei are not chlorinated and<br />
54<br />
therefore not suitable for drinking or even for cleaning purposes .<br />
51<br />
Annul <strong>Health</strong> Statictics-2005,Organisation <strong>of</strong> health services, Table 17.b, “<strong>Health</strong><br />
Indica<strong>to</strong>rs as in the MGD in Sri Lanka-Ministry <strong>of</strong> <strong>Health</strong><br />
52<br />
Sri Lanka Food Security Assessment, based on the Integrated Food Security &<br />
Humanitarian Phase Classification Approach, 15-30,April,2007,WFP,Page 48.<br />
53<br />
Source- relief web - http://www.reliefweb.int/ ,30 November 2007<br />
54<br />
Source- Fact Finding Mission at Vakarai- Batticaloa district by NPDS for <strong>IDP</strong>s<br />
Project on 5th June 2007<br />
48
Ensuring safety <strong>of</strong> water<br />
Ensure adequate supply <strong>of</strong> safe drinking water. If pipeborne<br />
water is not available, water <strong>to</strong> be collected in<br />
tanks or barrels and chlorinated.<br />
Co-ordinate with the Divisional Secretary <strong>to</strong> ensure that<br />
water supplied by local authorities and other sources is<br />
properly chlorinated before distribution.<br />
“Provisional guidelines for emergency management <strong>of</strong> public health problems<br />
<strong>of</strong> the <strong>IDP</strong>s” issued by the Epidemiological Unit <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong>care &<br />
Nutrition for Batticaloa <strong>Health</strong> Staff- Section 1-See Annexure VI<br />
Sanitation<br />
Regarding displaced persons, sanitation and hygiene should be utmost<br />
importance due <strong>to</strong> the nature <strong>of</strong> common usage <strong>of</strong> relevant facilities and<br />
they are normally much more susceptible <strong>to</strong> illness and death from<br />
disease, which are related <strong>to</strong> a large extent <strong>to</strong> inadequate sanitation,<br />
inadequate water supplies and poor hygiene excreta disposal, vec<strong>to</strong>r<br />
control, solid waste disposal and drainage. However according <strong>to</strong> the<br />
available statistics published by Ministry <strong>of</strong> health, only 75.40% <strong>of</strong><br />
56<br />
population have the access <strong>to</strong> improved sanitation . According <strong>to</strong> the<br />
Sphere Principles, minimum latrine facility for persons is one (1) latrine<br />
for 20 persons or ideally one (1) per family and Minimum distance<br />
between shelter and latrine should be 50m or more. Pit latrines and soak<br />
ways should be at least 30 meters away from any ground water source.<br />
One <strong>of</strong> the general observations made by the study is the open defecation<br />
by the people due <strong>to</strong> unavailability or lack <strong>of</strong> <strong>to</strong>ilet facilities. The<br />
displaced people in Thanthamalai, Mavadi Munmari, Paddipalai,<br />
Sinnapullumalai in Batticaloa do not have enough <strong>to</strong>ilet facilities and<br />
they used <strong>to</strong> use jungle for this purpose, but due <strong>to</strong> securitry reasons,<br />
sometimes that usage is also become problamatic especially at night.<br />
56<br />
Annul <strong>Health</strong> Statictics-2005,Organisation <strong>of</strong> health services, Table 17.b, “<strong>Health</strong><br />
Indica<strong>to</strong>rs as in the MGD in Sri Lanka-Ministry <strong>of</strong> <strong>Health</strong><br />
49
Another pathetic situation when they are using jungle at night and early<br />
in the morning is the security <strong>of</strong> women and children and this has <strong>to</strong> be<br />
serioursly conserned for thire protection and security. Manalchenai<br />
Transit camp is located in Muthur DS division, Trincomalee possessing<br />
<strong>IDP</strong>s from Batticaloa and Trincomalee now providing shelter <strong>to</strong> 199<br />
members <strong>of</strong> 69 families staying in the Transit camp. However there are<br />
only 6 <strong>to</strong>ilets erected and therefore 1 <strong>to</strong>ilet has <strong>to</strong> be shared by 34 people<br />
57<br />
whereas it should be 1 for 20 persons . Unfortunately it was also<br />
revealed though they have enough latrine facilities, sometimes some<br />
<strong>IDP</strong>s used <strong>to</strong> continue with open air defecation which is more<br />
aggregative for health concerns.<br />
In Puttalam, Alankuda B relocation center, out <strong>of</strong> 35 persons only 7<br />
persons have <strong>to</strong>ilets and those are temporary in nature. Those temporary<br />
<strong>to</strong>ilets only have a pit, a base, squatting slab and covered with cadjan<br />
58<br />
walls and with no ro<strong>of</strong> . There are about 20 <strong>to</strong>ilets made by an NGO but<br />
some <strong>of</strong> them cannot be used due <strong>to</strong> overflowing. Others are still<br />
continuing with open air defecation. The reasons for not having <strong>to</strong>ilets<br />
are the financial difficulties <strong>of</strong> the families and the ambiguity regarding<br />
the ownership <strong>of</strong> the lands. This undermines the privacy and increases<br />
59<br />
number <strong>of</strong> flies and bad smell and caused a serious threat <strong>to</strong> healthy life .<br />
57<br />
Visit Report <strong>of</strong> Manalchenai Transit camp by NPDS for <strong>IDP</strong>s Project <strong>of</strong> HRCSL,<br />
Trincomalee, 18April 2008<br />
58<br />
Observed in Fact Finding Mission <strong>to</strong> Alankuda B welfare center, Puttalam through a<br />
Focal Group Discussion on 22nd September 2008 by NPDS for <strong>IDP</strong>s Project <strong>of</strong> HRCSL<br />
59<br />
Fact Finding Mission <strong>to</strong> Alankuda B welfare center,Puttalam, 22nd September 2008<br />
by NPDS for <strong>IDP</strong>s Project <strong>of</strong> HRCSL.<br />
50
The lack <strong>of</strong> coordination between the MOH and local authorities when<br />
erecting <strong>to</strong>ilets, the failure <strong>of</strong> local authorities in garbage disposal and in<br />
supplying equipments and <strong>to</strong>ols <strong>to</strong> control communicable diseases have<br />
also collectively caused the living standards <strong>of</strong> <strong>IDP</strong>s <strong>to</strong> be fallen down. In<br />
Puttalam, there is no proper drainage system in welfare centers and<br />
relocation centers and they also lack proper water supply. Another<br />
burning issue affecting health conditions <strong>of</strong> <strong>IDP</strong>s is the lack <strong>of</strong> proper<br />
mechanism for garbage collection. Urban Council <strong>of</strong> Puttalam possesses<br />
only 6 trac<strong>to</strong>rs for garbage collection and the less number <strong>of</strong> staff for this<br />
purpose has caused the situation worse.<br />
Safe disposal <strong>of</strong> excreta<br />
• Ensure adequate sanitary facilities at all temporary camps for the displaced.<br />
Where necessary, make arrangements <strong>to</strong> construct adequate number <strong>of</strong><br />
temporary latrines according <strong>to</strong> the guidelines.<br />
Disposal <strong>of</strong> refuse<br />
• Co-ordinate disposal <strong>of</strong> garbage by sanitary burial or burning in suitable<br />
adjacent areas <strong>of</strong> temporary shelters.<br />
• Control flies, insects and rodents by proper use <strong>of</strong> physical and chemical<br />
methods (insecticides and TCL powder).<br />
• If garbage is removed daily by the local authorities using trac<strong>to</strong>rs, ensure<br />
enough barrels (garbage bins) are available in the temporary shelters for<br />
collection <strong>of</strong> garbage.<br />
“Provisional guidelines for emergency management <strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s” issued by the<br />
Epidemiological Unit <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong>care & Nutrition for Batticaloa <strong>Health</strong> Staff - Section 3 & 4 -<br />
SeeAnnexureVI<br />
Disease Prevalence<br />
It is palpable that the disease prevalence is comparatively high in the<br />
aftermath <strong>of</strong> a disaster. Especially soon after a disaster the <strong>IDP</strong>s live in<br />
community wise and therefore the incidence <strong>of</strong> viral infections,<br />
diarrhoeal diseases are easy <strong>to</strong> outbreak among the community. In<br />
Arthiviravar camp where there were over 1,400 people, there were only 8<br />
<strong>to</strong>ilets available and a high incidence <strong>of</strong> diarrhea was reported in this<br />
60<br />
camp . However it was revealed things have been changed after the<br />
resettlement and in present they only have about 300 members and<br />
authorities were able <strong>to</strong> manage the situation. Trincomalee also it is<br />
60<br />
Centre for Policy Alternatives, INFORM Human <strong>Right</strong>s Documentation Centre, Law<br />
and Society Trust, Women and Media Collective, Report <strong>of</strong> the Fact-Finding Visit <strong>to</strong><br />
Batticaloa and Vakarai,April 2007, p.3<br />
51
eported that <strong>IDP</strong>s in the welfare centers are infected with some<br />
communicable diseases such as diarrhea, skin diseases, infected<br />
because <strong>of</strong> unhygienic condition <strong>of</strong> the welfare centers due <strong>to</strong> the<br />
improper maintenance <strong>of</strong> <strong>to</strong>ilets; contaminated drinking water and<br />
irregular garbage disposal system. Recently it was reported that two<br />
persons in Orr's Hill and Moor Street <strong>of</strong> Trincomalee were dead due <strong>to</strong><br />
61<br />
Dengue fever .According <strong>to</strong> findings <strong>of</strong> PHI the main reason for fever is<br />
the availability <strong>of</strong> water s<strong>to</strong>res for mosqui<strong>to</strong> breading, in many areas <strong>of</strong><br />
Trincomalee district, the system <strong>of</strong> water supply is not proper and water<br />
is coming with low pressure. Therefore it is not enough <strong>to</strong> uplift the water<br />
<strong>to</strong> water tank. Due <strong>to</strong> this the people are s<strong>to</strong>ring the available water in big<br />
drums and barrels (without lids) and it is very much feasible <strong>to</strong> mosqui<strong>to</strong><br />
breeding and the disease spreading thereby. It was also reported that<br />
though there is reported TB patients among <strong>IDP</strong> community, the TB<br />
Center <strong>of</strong> Puttalum has been unable <strong>to</strong> hold any program for <strong>IDP</strong>s areas<br />
62<br />
due <strong>to</strong> insufficient funds .<br />
Following the influx <strong>of</strong> displaced population in Trincomalee and<br />
Batticaloa districts, the Epidemiological Unit <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong>care<br />
& Nutrition, has issued “Provisional guidelines for emergency<br />
63<br />
management <strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s” which is very<br />
much worthy <strong>to</strong> be discussed. These guidelines (GLs) are recommended<br />
<strong>to</strong> minimize the adverse public health impact and <strong>to</strong> prevent the spread <strong>of</strong><br />
communicable diseases <strong>of</strong> <strong>IDP</strong>s living in temporary shelters. Ensuring<br />
safety <strong>of</strong> water and water, safe disposal <strong>of</strong> excreta, disposal <strong>of</strong> refuse,<br />
treatment and management <strong>of</strong> minor ailments, prevention <strong>of</strong> control <strong>of</strong><br />
potential outbreaks and disease surveillance are the important aspects<br />
health addressed by these GLs. The enforceability <strong>of</strong> these GLs are being<br />
fallen on the PHI and other field health staff under the supervision <strong>of</strong><br />
DDHS/MOH and under the overall moni<strong>to</strong>ring and supervision <strong>of</strong> the<br />
relevant Regional Epidemiologist (RE).<br />
61<br />
Remedial Institution's Co-ordination Mechanism Meeting Tricomalee District<br />
MINUTES, 26th February 2008<br />
62<br />
Field Study on <strong>Right</strong> <strong>to</strong> <strong>Health</strong>, NPDS for <strong>IDP</strong>s Project, Puttalam, July 2008<br />
63<br />
SeeAnnexure VI<br />
52
Regarding the impact <strong>of</strong> these GLs, an appreciation <strong>of</strong> them is inevitable<br />
because it address the many health hazards after a displacement and the<br />
guidelines were elaborative on the subjects. However the guidelines<br />
have been issued only for Batticaloa and Trincomalee districts while<br />
several other districts also providing shelter <strong>to</strong> similar or more number <strong>of</strong><br />
64<br />
<strong>IDP</strong>s . Meanwhile it has not addressed the health aspects on personal<br />
hygiene, Provision <strong>of</strong> maternal and child health care services,<br />
immunization as it is laid down in detail, in the “Guidelines for<br />
management <strong>of</strong> public health effects in the community following<br />
Tsunami disaster”. In addition, regarding the enforceability, the above<br />
GLs were issued by Deputy Epidemiologist whereas the “Tsunami<br />
guidelines were issued by Direc<strong>to</strong>r General <strong>of</strong> <strong>Health</strong> Services, which<br />
seems <strong>to</strong> have comparatively more powerful enforceability among the<br />
health staff.<br />
Sometimes it was detectable that the lack <strong>of</strong> knowledge and enthusiasm<br />
in healthy practices among <strong>IDP</strong>s, have contribute <strong>to</strong> down grade health<br />
<strong>of</strong> the people. It is evident when anti mosqui<strong>to</strong> bed nets were distributed<br />
among the <strong>IDP</strong>s they do not use them properly. In Mujhahidanpuram<br />
relocation center, Wanthawillu Division, Puttalam the skin diseases have<br />
been infected among the children but their parents did not keen <strong>to</strong> direct<br />
them <strong>to</strong> basic medical treatments.<br />
Prevention and control <strong>of</strong> potential outbreaks<br />
In a case <strong>of</strong> in particular, prompt action must be taken <strong>to</strong> ensure early treatment and<br />
prevention <strong>of</strong> further spread.<br />
In case <strong>of</strong> contagious diseases such as acute respira<strong>to</strong>ry tract infections and<br />
chickenpox, these cases should be isolated and referred <strong>to</strong> hospitals if necessary.<br />
Steps should be taken <strong>to</strong> control mosqui<strong>to</strong> breeding <strong>to</strong> prevent and control mosqui<strong>to</strong><br />
borne diseases such as dengue, malaria and JE.<br />
Disease surveillance<br />
MOH/PHI should visit the camps daily <strong>to</strong> inquire in<strong>to</strong> unusual occurrence <strong>of</strong><br />
disease events/outbreaks.<br />
Collect and report data related <strong>to</strong> health events in camps according <strong>to</strong> the format<br />
provided by the Epidemiology unit (annexure).<br />
MOH should consolidate the above data weekly and send a consolidated report <strong>to</strong><br />
RE with a copy <strong>to</strong> Epidemiology Unit (annexure).<br />
“Provisional guidelines for emergency management <strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s” issued by the<br />
Epidemiological Unit <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong>care & Nutrition for Batticaloa <strong>Health</strong> Staff- Section 6 & 7-See<br />
Annexure VI<br />
64<br />
SeeAnnexure I.<br />
53
7.4. Adequate Food Supply and Nutrition<br />
According <strong>to</strong> the Article 11 <strong>of</strong> ICESCR everyone has the right <strong>to</strong> food<br />
and right <strong>to</strong> be free from hunger. Especially during a period <strong>of</strong> internal<br />
displacement the food security <strong>of</strong> people is undoubtedly become worse<br />
due <strong>to</strong> loss <strong>of</strong> occupations, deterioration or the destruction <strong>of</strong> harvest and<br />
also due <strong>to</strong> loss <strong>of</strong> breadwinner <strong>of</strong> many families. This lack <strong>of</strong> food<br />
security is the main determinate <strong>of</strong> health and one <strong>of</strong> the causes <strong>of</strong><br />
undernutrition status <strong>of</strong> Sri Lanka and according <strong>to</strong> the WFP, Northern<br />
and Eastern districts have much more child undernutrition than other<br />
65<br />
districts . Therefore the availability and adequacy <strong>of</strong> the food packages<br />
given <strong>to</strong> displaced people is being assessed here.<br />
Cooked meals<br />
According <strong>to</strong> The circular (No: NDRSC 2007/10), cooked meals <strong>of</strong><br />
Rs.70.00 for an adult and <strong>of</strong> Rs.50.00 for child under 12 yrs per diem are<br />
provided <strong>to</strong> all those who vacate their permanent places <strong>of</strong> residence and<br />
seek shelter at welfare centers temporally irrespective <strong>of</strong> their level <strong>of</strong><br />
income for maximum <strong>of</strong> 3 days and this period can be extended.<br />
Dry rations<br />
The persons who have lost their places <strong>of</strong> residence and all properties as a<br />
result <strong>of</strong> a disaster and living in a temporary camp are provided with dry<br />
rations for the period they stay in camps irrespective <strong>of</strong> their level <strong>of</strong><br />
income. The circular (No: NDRSC 2007/10) authorizes that dry ration<br />
can be issued for one week and if the period is <strong>to</strong> be extended the<br />
approval <strong>of</strong> the Direc<strong>to</strong>r <strong>of</strong> the National Disaster Relief Service Center<br />
(NDRSC) is needed. However it is reported that in relation <strong>to</strong> conflict<br />
affected <strong>IDP</strong>s, the dry ration will be given <strong>to</strong> them as long as they stay in<br />
the WCs and in relation <strong>to</strong> resettled and returned <strong>IDP</strong>s, dry ration will be<br />
given <strong>to</strong> them as long as the need for dry ration is prevailing. This period<br />
is different from district <strong>to</strong> district and it was evidenced that in<br />
Trincomalee for resettled and returned people dry ration will be given for<br />
six months after resettlement.<br />
65<br />
Sri Lanka Food Security Assessment, based on the Integrated Food Security &<br />
Humanitarian Phase ClassificationApproach,15-30,April,2007,WFP,Page 43<br />
54
As per the circular No: CGES/ER/95/01 issued by Ministry <strong>of</strong> Shipping,<br />
Ports, Rehabilitation and Reconstruction on 16th November 1995,<br />
scheme <strong>of</strong> dry ration is issued <strong>to</strong> the displaced families whose income is<br />
less than Rs.1500.00. However thereafter two circulars have been issued<br />
in this regard, namely, Circular No: D.S.S 2003/1, issued by the<br />
Department <strong>of</strong> Social Service and Circular No: NDRSC 2007/10 but the<br />
amount <strong>of</strong> dry ration is still remain as the previous circular. Under the<br />
later circulars the monthly income limit <strong>of</strong> the family should be less than<br />
3000.<br />
Following is the comparison <strong>of</strong> quantity <strong>of</strong> dry ration by those circulars.<br />
No:<strong>of</strong>personsin<br />
the family<br />
Quantity <strong>of</strong> dry ration for a month (Rupees)<br />
Circular No: Circular No :<br />
CGES/ER/95/01 D.S.S 2003/1<br />
5 persons or more 1260 (315 x 4) 1960 (490 x 4) 2100 (525 x 4)<br />
4 persons 1008 (252 x 4) 1540 (385 x 4) 1820 (455 x 4)<br />
3persons 840(210x4) 1260(315x4) 1540(385x4)<br />
Circular No:<br />
NDRSC 2007/10<br />
2persons 616(154x4) 980(245x4) 1260(315x4)<br />
1 person 336 (84 x 4) 560 (140 x 4) 980 (245 x 4)<br />
According <strong>to</strong> WFP, usually a food intake <strong>of</strong> a person should comprise <strong>of</strong> a<br />
range <strong>of</strong> foods from at least four main food groups including;<br />
carbohydrates (Rice or Wheat form the bulk <strong>of</strong> the diet), proteins (Pulse,<br />
Grams, fish (tinned), Meat), Fats (Oil, Butter), micronutrient-rich foods<br />
(Vegetables and fruits are good sources <strong>of</strong> micronutrients).As per health<br />
consultants, one person needs energy <strong>of</strong> 2100 Kcal per day couple with<br />
66<br />
other nutrition requirements . Since the later circulars (2003/1 &<br />
2007/10) are still not carried out, one family with or more 5 persons is<br />
given only 42 rupees per day. This scenario is regrettable<br />
66<br />
Protein 10-12% <strong>to</strong>tal energy (52g-63g), but
when we compare with the rising cost <strong>of</strong> living, especially high prices for<br />
foods. According <strong>to</strong> the prevailing retail price index in Sri Lanka, June<br />
2008; one has <strong>to</strong> bear cost <strong>of</strong> 55-70 rupees only for a one (1) Kg <strong>of</strong> rice.<br />
This clearly shows the inadequacy <strong>of</strong> the quantity <strong>of</strong> dry ration and the<br />
adverse effect <strong>of</strong> these provisions greatly falls on families like single<br />
headed, women headed, child headed families and the families with a<br />
disabled breadwinner. Comparatively, consequent <strong>to</strong> Tsunami disaster,<br />
each member <strong>of</strong> a family unit were received dry ration worth Rs.375 /=<br />
67<br />
per week (1500/= per person for a month) and whereas according <strong>to</strong> the<br />
present provision <strong>of</strong> dry ration <strong>to</strong> conflict affected <strong>IDP</strong>s it is only 1260/=<br />
for a family with 5 or more members for a month.<br />
In addition, the poor quality <strong>of</strong> dry rations and discrepancies in issuing<br />
dry rations by Multi Purpose Cooperating Societies (MPCS) also<br />
reported by <strong>IDP</strong>s. <strong>IDP</strong>s in Wahalkada and Mawathawewa relocations in<br />
Anuradhapura complained about the availability <strong>of</strong> low quality food<br />
68<br />
items in cooperative societies issued for dry ration . Although the<br />
Project managed <strong>to</strong> solve the particular problem by arranging PHI <strong>to</strong> visit<br />
particular cooperative societies once a month still there is no proper<br />
mechanism <strong>to</strong> address the mater in long term basis. Meanwhile, due <strong>to</strong><br />
“rice crisis” prevailed in around April, 2008 MPCS did not provide rice<br />
and flour was provided instead. However it was evident that even before<br />
and after “rice crisis” this pattern is being carried out due <strong>to</strong> the lack <strong>of</strong><br />
required food s<strong>to</strong>cks in MPCS. It was reported that there are 108 recently<br />
resettled families in Kalmadu (Ieeswaripuram) Resettlement village,<br />
69 70<br />
Vavuniya , have not received ration since Oc<strong>to</strong>ber <strong>of</strong> 2007 . Recently it<br />
was also observed followed by Project visits <strong>to</strong> Hidayath Nagar RLV,<br />
Hijrath Nagar RLV, Poonaipitty RLV in Puttalam that 17 Families,<br />
displaced from Trincomalee & settled in Poonaippitty in 2006 and 7<br />
families displaced from Muttur 2006, living in Pulichchakulam<br />
67<br />
According <strong>to</strong> the Circular dated 05.01.2005 issued by the Direc<strong>to</strong>r <strong>of</strong> Social<br />
Services <strong>of</strong> Department <strong>of</strong> Social Services<br />
68<br />
Complaint No :( HRC/<strong>IDP</strong>/AP/06/17) <strong>of</strong> NPDS for <strong>IDP</strong>s Project <strong>of</strong> HRCSL<br />
69<br />
These people were resettled on September and Oc<strong>to</strong>ber 2007 from Poonthoddam<br />
WC<br />
70<br />
This particular incident is cured at this moment but it is mentioned <strong>to</strong> as an example<br />
<strong>of</strong> prevailing irregularity.<br />
56
are not receiving dry ration since government has taken a decision <strong>to</strong> not<br />
71<br />
provide dry ration for new <strong>IDP</strong>s . However no evidence <strong>of</strong> pro<strong>of</strong> was<br />
found <strong>to</strong> establish such government decision. Differential treatments<br />
between <strong>IDP</strong>s were also evidenced in this regard since there is no well<br />
planed machinery or scheme <strong>to</strong> provide dry ration <strong>to</strong> those who stay with<br />
their friends and relatives.<br />
Ensuring safety <strong>of</strong> food<br />
Co-ordinate with the Divisional Secretary <strong>to</strong> ensure that food supplied by local<br />
authorities and other sources are hygienically prepared before distribution.<br />
Ensure all the food supplies <strong>to</strong> the displaced are hygienically s<strong>to</strong>red, prepared and<br />
distributed.<br />
Strictly moni<strong>to</strong>r the preparation <strong>of</strong> food in food handling establishments.<br />
“Provisional guidelines for emergency management <strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s” issued by the<br />
Epidemiological Unit <strong>of</strong> Ministry <strong>of</strong> <strong>Health</strong>care & Nutrition for Batticaloa <strong>Health</strong> Staff- Section 2-See Annexure<br />
VI<br />
7.5. Nutrition status <strong>of</strong> extremely vulnerable groups<br />
The impacts <strong>of</strong> displacement are heavily felt <strong>to</strong> the women and children<br />
since they are more vulnerable <strong>to</strong> the troubles and diseases. The<br />
difficulties like loss <strong>of</strong> income earning opportunities, unstable house<br />
hold, food security, frequent displacement, low food protection, poor<br />
living conditions pave the way <strong>to</strong> deterioration <strong>of</strong> nutritional status <strong>of</strong><br />
women and children. Following are some <strong>of</strong> the health problems posed<br />
<strong>to</strong> them.<br />
Undernutrition<br />
The prevalence <strong>of</strong> undernutrition is assessed by identifying 3 criteria<br />
namely, underweight (weight for age), stunting (height for age) and<br />
wasting (weight for height). It was observed that the status <strong>of</strong> reported<br />
undernutrition is comparatively higher in the district like Mannar,<br />
Batticaloa,Anuradhapura and Trincomalee.<br />
71<br />
Observed from the Visit report done by NPDS for <strong>IDP</strong>s Project, Puttalam on<br />
18.03.2008<br />
57
72<br />
While National underweight average is 33.4 percent , Mannar,<br />
Batticalia and Anuradhapura are among 12 districts, where underweight<br />
73<br />
prevalence is more than 35 percent . Regarding stunting also the rates in<br />
Batticaloa and Mannar are higher than national average <strong>of</strong> 16.6 percent.<br />
Addressing the wasting status higher rate <strong>of</strong> wasting is reported from the<br />
districts <strong>of</strong>Anuradhapura, Mannar, Trincomlee, Vavuniya wasting rate is<br />
74<br />
higher than national average (16 percent) . In addition, according <strong>to</strong> the<br />
information from Family <strong>Health</strong> Bureau, the percentage <strong>of</strong> children (1-3<br />
years & 3-5 years) who are below 3rd centile level in Trincomalee and<br />
Batticaloa districts is comparatively higher than the national<br />
75<br />
percentage . In Vavuniya Protein energy malnutrition is the most<br />
prevalent nutritional problem and out <strong>of</strong> 6617, only 2952 children are<br />
tallied <strong>to</strong> normal weight and the rest, 55.4% children are suffering<br />
76<br />
malnutrition .<br />
Since the general status <strong>of</strong> district is such, more aggregative inference<br />
can be drawn on the conditions <strong>of</strong> <strong>IDP</strong>s in this regard. According <strong>to</strong><br />
UNICEF Assessment data, 2007 in Batticaloa more than 5 percent <strong>of</strong><br />
severe wasting was reported amongst <strong>IDP</strong>s. However the collecting data<br />
from <strong>IDP</strong>s was very much difficult in this regard since they do not<br />
possess those “birth cards” after the displacement.<br />
72<br />
UNICEF surveys (2003, 2004, 2005/6, 2006, WFP survey for Mulathivu, DHS 2000<br />
for some districts<br />
73<br />
Sri Lanka Food Security Assessment, based on the Integrated Food Security &<br />
Humanitarian Phase ClassificationApproach,15-30,April,2007,WFP,Page 44<br />
74<br />
ibid<br />
75<br />
Percentage <strong>of</strong> children 1-3 years below 3rd centile- Sri Lanka-24.9,Trincomalee<br />
34.9,Batticaloa- 36.2, Percentage <strong>of</strong> children 3-5 years below 3rd centile- Sri Lanka-<br />
27.4,Trincomalee- 36.8,Batticaloa- 40.3 ,Source-FHB<br />
76<br />
SeeAnnexure VIII, Source- DPDHS Office - Vuvuniya<br />
58
Nutritional status <strong>of</strong> pregnant women and lactating mothers<br />
The nourishment <strong>of</strong> pregnant mothers is vital since it affects not only on<br />
health condition <strong>of</strong> the mother but also on the child. The recommended<br />
weight gain during the pregnancy is 10 Kg, but it is reported according <strong>to</strong><br />
National Nutrition Policy, 2007 the average weight gain reported in Sri<br />
Lanka is less than 7.5 Kg. Despite the provision <strong>of</strong> iron, folic acid and<br />
other vitamins by the health authorities through PHM, average anemia<br />
77<br />
prevalence is being reported as 37 percent amongst pregnant women .<br />
According <strong>to</strong> the data from DPDHS- Trincomalee, 2007, 5 percent <strong>of</strong><br />
pregnant mothers are suffering from moderate anemia and 1.33 percent<br />
is suffering from severe anemia. It was also observed that while 87.3<br />
Percentage <strong>of</strong> pregnant mothers were protected against the rubella in the<br />
districts <strong>of</strong> Vavuniya, Trincomalee and Mannar, only 50 percent <strong>of</strong> them<br />
78<br />
were protected .<br />
Repercussions <strong>of</strong> above fac<strong>to</strong>rs were greatly felt on the women <strong>of</strong> the<br />
above conflict affected area it is evidenced by higher Maternal Mortality<br />
Rates, low birth weigh rates reported in those districts. In 2005,<br />
Batticaloa and Vavuniya reported 81.2 and 68.7 <strong>of</strong> maternal mortality<br />
79<br />
rate per 1000 live births while national average is 38 . Low Birth Weight<br />
rate was also reported in the district <strong>of</strong> Batticaloa, Puttalam and<br />
80<br />
Anuradhapura as higher than national average and District like<br />
81<br />
Batticaloa and Anuradhapura possess higher Infant Mortality Rate . In<br />
Trincomalee, reported percentage <strong>of</strong> babies born with low birth weight<br />
approximately was about 12.8 %( 971 out <strong>of</strong> 7587 births) in 2006 and in<br />
82<br />
2007, it was 14.95% (964 out <strong>of</strong> 5457 births in June) . According <strong>to</strong> the<br />
77<br />
Medical Research Institute, Ministry <strong>of</strong> <strong>Health</strong> Care Nutrition and Uva Wellassa<br />
Development, UNICEF: Rapid assessment <strong>of</strong> coverage <strong>of</strong> micronutrient<br />
supplementation in Sri Lanka,2004<br />
78<br />
79<br />
80<br />
81<br />
Vavuniya 50.9,Trincomalee 54.2, Mannar 45.6-FHB- 2005<br />
FHB-2005, See theAnnexure VII<br />
National- 16.9,Batticaloa 20.2, Puttalam 21.1,Anuradhapura 19.2- FHB-2004<br />
National average- 11.2-per 1000 LB, Batticaloa 19.6, Anuradhapura 19.4-- Table<br />
4.Vital statistics by District,Annual <strong>Health</strong> Bulletin, 2005<br />
82<br />
See theAnnexure IX<br />
59
83<br />
details <strong>of</strong> conducted Maternity and Child <strong>Health</strong> Clinics , it was<br />
observed that the number <strong>of</strong> conducted Well Women Clinics in<br />
Trincomalee district were inadequate during the 2004 and 2005.<br />
Considering Nutrition status <strong>of</strong> pregnant mothers and lactating mothers,<br />
special nutritional intervention by the government, worth <strong>of</strong> Rupees<br />
500.00 is given <strong>to</strong> the target group in selected DS divisions.According <strong>to</strong><br />
the circular No: 21, dated 2006.07.31 (amended 2007.02.19) the<br />
Commissioner General <strong>of</strong> Samurdhi, applicant should be a Samurdhi<br />
beneficiary <strong>to</strong> be entitled under this scheme. In addition <strong>to</strong> this category,<br />
if the mother is not from a Samurdhi beneficiary family, she should<br />
established that her family income is below the poverty line and her<br />
nutrition status is low and it has <strong>to</strong> be recommended by relevant MOH<br />
and further certified by Samurdhi development <strong>of</strong>ficer. However during<br />
the study it was revealed that the displaced expectant and lactating<br />
mothers do not receive this nutritional package even though they were<br />
qualified before their displacement. The fact that they are receiving the<br />
dry ration instead <strong>of</strong> Samurdhi has disqualified them from being<br />
qualified under this package.<br />
Regarding health <strong>of</strong> women, the incidents <strong>of</strong> “minor parents” are<br />
reported as a much common fac<strong>to</strong>r in Kuchchevelli DS division <strong>of</strong><br />
84<br />
Trincomalee district. In 2005 10.55 percentage <strong>of</strong> teenage pregnancy<br />
was reported from Trincomalee while national average is 6.2(FHB). This<br />
has led <strong>to</strong> many health issues <strong>of</strong> young girls and as well as infants due <strong>to</strong><br />
the risk faced them at the period <strong>of</strong> pregnancy and due <strong>to</strong> malnutrition<br />
issues.<br />
83<br />
84<br />
See the Annexure X & XI<br />
See the Annexure XII<br />
60
7.6. Risk <strong>of</strong> HIV infections<br />
Sri Lanka is considered as having low prevalence <strong>of</strong> HIV notably less<br />
85<br />
than 0.1 percent (3800 persons) . The Government <strong>of</strong> Sri Lanka initiated<br />
HIV prevention and control efforts through the National STD and AIDS<br />
Control Program (NSACP) <strong>of</strong> the Ministry <strong>of</strong> <strong>Health</strong> in 1992.<strong>IDP</strong><br />
community can be considered as most-at-risk population (MARP) <strong>to</strong><br />
HIV and among the displaced community, especially women and<br />
children are vulnerable <strong>to</strong> sexual abuses and such incidents are not<br />
revealed <strong>to</strong> the world easily and most <strong>of</strong>ten remain as hidden crimes.<br />
86<br />
At present there are about 81,000 Sri Lankan refugees living in India ,<br />
and the only humanitarian package, available <strong>to</strong> them is the dry ration.<br />
Due <strong>to</strong> their poverty, they are being forced <strong>to</strong> engage in prostitution.<br />
During the study it was observed that those Indian refugees are coming<br />
back in<strong>to</strong> Sri Lanka through illegal ways. The problem posed here is that<br />
the unavailability <strong>of</strong> a mechanism <strong>to</strong> test them whether they are infected<br />
with HIV or not. However such kind <strong>of</strong> unavailability is understandable<br />
since the migration is done by illegal ways. But re-integration <strong>of</strong> them<br />
in<strong>to</strong> the community will pose serious health risks because they<br />
themselves may not be aware <strong>of</strong> the infection and this fact urges a<br />
mechanism <strong>to</strong> check the infectious status at the grass root level.<br />
7.7. Mental health <strong>of</strong> <strong>IDP</strong>s<br />
Inheriting a civil conflict for more than 25 years the fac<strong>to</strong>rs like loss <strong>of</strong><br />
loved ones, families, wealth and livelihood have caused majority <strong>of</strong> the<br />
people in war affected area <strong>to</strong> be mentally disordered. The security<br />
concerns and frequent threats <strong>to</strong> the life have also amplified the number<br />
<strong>of</strong> mentally affected patients. In Puttalam, it was reported that out <strong>of</strong> 300<br />
87<br />
patients coming for the psychiatric clinics, majority are <strong>IDP</strong>s .<br />
85<br />
http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/<br />
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86<br />
87<br />
http://www.refugeesinternational.org/content/article/detail/933/, as at 20.01.2004<br />
Observed from the discussion with Dr. Fareed District Medical Officer<br />
61
In Mannar, a unit called Psycho Social Forum has been formed and under<br />
88<br />
the coordination <strong>of</strong> this Forum , 11 governmental and nongovernmental<br />
administra<strong>to</strong>rs including 20 NGOs are working <strong>to</strong> develop<br />
mental health conditions <strong>of</strong> the people. Its objective is <strong>to</strong> provide and<br />
promote the mental health <strong>of</strong> the needy people. According <strong>to</strong> their<br />
statistics from 2006 <strong>to</strong> 2007, 208 numbers <strong>of</strong> mental patients had come<br />
for counseling and treatment. It is reported by this unit that the suicide<br />
rate is also high in Mannar and most <strong>of</strong> them are between the ages <strong>of</strong> 14 -<br />
24 years.<br />
Trincomalee Mental <strong>Health</strong> Unit is also dearth <strong>of</strong> enough staff <strong>to</strong> take<br />
care <strong>of</strong> patients. There are only 3 female nurses, 3 female minor staff<br />
persons and one male staff. Therefore it is difficult <strong>to</strong> control some<br />
patients during the critical situations. The most pathetic situation relating<br />
<strong>to</strong> mental health <strong>of</strong> <strong>IDP</strong>s is that the shortage <strong>of</strong> psychiatrists in those<br />
areas. It is evidenced that though there are 49 psychiatrists are present in<br />
the country they are not evenly distributed among the districts as in 13<br />
89<br />
districts out <strong>of</strong> 25, no psychiatrist is available . In Mannar, Vavuniya,<br />
Trincomalee andAnuradhapura, no psychiatric is serving.<br />
7.8. Addressing similar issues differently-unequal responses <strong>to</strong><br />
different types <strong>of</strong> displacements<br />
The health problems after Tsunami devastation was addressed by issuing<br />
certain guidelines as circulars, <strong>to</strong> health workers, especially <strong>to</strong><br />
community health workers by the Ministry <strong>of</strong> <strong>Health</strong> care & Nutrition.<br />
Following are some <strong>of</strong> those circulars.<br />
29.12.2004-General Circular Letter No: 01-28/2004, Actions<br />
<strong>to</strong> prevent possible health problems after the Tsunami disaster,<br />
by Direc<strong>to</strong>r General <strong>of</strong> <strong>Health</strong> Services.<br />
29.12.2004- General Circular Letter No: 02-170/2004,<br />
Psychosocial support for <strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> due <strong>to</strong><br />
Tsunami disaster, by Deputy Direc<strong>to</strong>r General <strong>of</strong> <strong>Health</strong><br />
Services.<br />
88<br />
Officially started on 01.06.2006<br />
89<br />
Source-Table 22, Distribution <strong>of</strong> specialists in curative care services by districts,<br />
September 2005<br />
62
07.01.2005-General Circular: 01-01/2005, Guidelines<br />
for provision <strong>of</strong> <strong>Health</strong> Promotion and Education<br />
Services following the disaster caused by Tsunami, by<br />
Direc<strong>to</strong>r General <strong>of</strong> <strong>Health</strong> Services.<br />
10.01.2005- General Circular Letter No: Guidelines<br />
for management <strong>of</strong> public health effects in the<br />
community following Tsunami disaster, by Direc<strong>to</strong>r<br />
General <strong>of</strong> <strong>Health</strong> Services.<br />
In addition following guidelines/instructions were also issued<br />
01.01.2005-Guidelines for Provisions <strong>of</strong> Maternal and Child<br />
<strong>Health</strong> Services following the disaster caused by Tsunami, by<br />
Additional Secretary Medical Services<br />
07.01.2005-Distributuion <strong>of</strong> the health card for <strong>IDP</strong>s in campstsunami<br />
2004, by Deputy Direc<strong>to</strong>r General (PHS)<br />
13.01.2005-Guideline for feeding infants and young children<br />
(1-5 years) including orphans and those not living with mothers<br />
(Tsunami affected areas), by Direc<strong>to</strong>r, Maternal and Child<br />
<strong>Health</strong>, FHB.<br />
It is true that the tsunami devastation in 2004 destroyed and displaced a<br />
lager number <strong>of</strong> human lives. These types <strong>of</strong> approaches by health<br />
authorities should be admired and praised for preventing further health<br />
problems following the Tsunami. At the same time, the conflict for more<br />
than two decades has caused more than millions <strong>of</strong> people displaced<br />
from their natural habitats and such displacement is still happening. The<br />
difference <strong>of</strong> two types <strong>of</strong> disasters is one is man made and the other is<br />
natural. Especially displacement from conflict is always being treated as<br />
secondary vis-à-vis displacement by Tsunami, by both state authorities<br />
and also by private organizations. But it is obvious that the conflict<br />
affected <strong>IDP</strong>s are also being displaced without their wrongs and the state<br />
and other humanitarian ac<strong>to</strong>rs should have similar concern and<br />
responsibility for the problems aroused from such displacement.<br />
The above circulars and guidelines specifically demonstrate that they are<br />
<strong>to</strong> handle the health problems after Tsunami. But the health authorities <strong>of</strong><br />
the view that those circulars and guidelines equally address the health<br />
63
problems <strong>of</strong> conflict affected <strong>IDP</strong>s. But such kind <strong>of</strong> view is not legally<br />
valid since, no <strong>of</strong>ficial notice/letter/circular is saying that those circular<br />
is equally applicable <strong>to</strong> the health concerns <strong>of</strong> conflict affected <strong>IDP</strong>s. If<br />
they are equally applicable, there is no point <strong>of</strong> issuing “Provisional<br />
guidelines for emergency management <strong>of</strong> public health problems <strong>of</strong> the<br />
<strong>IDP</strong>s” by the Epidemiologist for the Batticaloa and Trincomalee in 2005.<br />
Therefore it shows inequitable responses by health authorities for the<br />
consequences <strong>of</strong> two disasters.<br />
According <strong>to</strong> the National <strong>Health</strong> Policy, services and programmes will<br />
be introduced by the Ministry <strong>to</strong> meet the emerging health needs, inter<br />
alia the health problems <strong>of</strong> displaced populations. Though they have<br />
established “Disaster Preparedness and Responses Unit” in the Ministry<br />
in line with that policy, any other services and programmes, specially<br />
addressing the health problems <strong>of</strong> conflict affected displaced population<br />
are not discernible yet.<br />
7.9. Security problems<br />
Inability <strong>to</strong> access <strong>to</strong> some areas due <strong>to</strong> security problems is another<br />
burning issue for the government health staff, NGOs and also <strong>to</strong> the<br />
patients. It was reported from RDHS-Mannar that closure <strong>of</strong> the<br />
Uyilankulam checkpoint is increasing travel costs for the majority <strong>of</strong><br />
health workers as 90% <strong>of</strong> staff working in Manthai West, now must travel<br />
from Mannar Island through the A9 road. However this is only one <strong>of</strong><br />
such reported incidents where security problems is a fac<strong>to</strong>r in deciding<br />
health conditions and people are also hesitated <strong>to</strong> travel from villages <strong>to</strong><br />
the <strong>to</strong>wn though more facilities and services are available, because the<br />
value <strong>of</strong> life is bigger than suffering from an illness.<br />
It is sometime evident that even though the funds and donations are there<br />
<strong>to</strong> facilitate the health requirements <strong>of</strong> the displaced people, the burdens<br />
such as security problems and lack <strong>of</strong> cooperation between the parties,<br />
undermine this process. In Wahalkada Central Dispensary, earlier it was<br />
reported that the doc<strong>to</strong>r is providing services only 2 days for a week, but<br />
after NPDS for <strong>IDP</strong>s Project's intervention residential doc<strong>to</strong>r was<br />
arranged <strong>to</strong> work for all the weekdays. Though MOH <strong>of</strong>fice is<br />
conducting mobile medical clinics in threaten areas with the help <strong>of</strong><br />
NGOs like World Vision & Sarvodaya it was reported as not sufficient.<br />
64
They also face with serious security problems and transport problems in<br />
their efforts <strong>to</strong> take medicines from outside.<br />
7.10. Role <strong>of</strong> health pr<strong>of</strong>essionals<br />
Role <strong>of</strong> health pr<strong>of</strong>essionals and hospital staff is also open <strong>to</strong> discussion<br />
because the right <strong>of</strong> every people <strong>to</strong> receive basic health care from the<br />
government for free and the governments' obligation there<strong>to</strong>, is not<br />
always observed by some health pr<strong>of</strong>essionals and health staff and this is<br />
a black mark for the rest <strong>of</strong> dedicated health pr<strong>of</strong>essionals serving in the<br />
country. Therefore the attitudes and the role <strong>of</strong> health staff have <strong>to</strong> be<br />
developed in focusing rights <strong>of</strong> people. Meanwhile incidents <strong>of</strong> medical<br />
90<br />
negligence are also reported due care and diligence by health staff and<br />
pr<strong>of</strong>essionals are required <strong>to</strong> facilitate these marginalized people.<br />
90<br />
Source- Complaint No: HRC/AP/01/436/06 mentioning that a boy was dead due <strong>to</strong><br />
wrong injection by a doc<strong>to</strong>r <strong>of</strong> Kekirawa hospital.- Complaint No:(HRC/AP/01/671/06)<br />
,two children have been disabled due <strong>to</strong> wrong injection by a doc<strong>to</strong>r <strong>of</strong> Anuradhapura<br />
hospital, NPDS for <strong>IDP</strong>s Project,Anuradhapura.<br />
65
Conclusion<br />
Taken by : NPDS for <strong>IDP</strong>s Project, Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka
8.C onclusion<br />
The need for physically and mentally healthy population for a country is<br />
therefore very much obvious as for a country like Sri Lanka, where<br />
human resource is its greatest asset, no matter these people from North or<br />
South. The observance <strong>of</strong> this study proves that the government has<br />
taken steps <strong>to</strong> protect and promote the health <strong>of</strong> people throughout the<br />
country, although there are some lacunas in the health services not only<br />
in the North and East in the other parts <strong>of</strong> the country as well. However, in<br />
the North and East the scenario is different since the people living in<br />
those areas are suffering from the consequences <strong>of</strong> the war and in case <strong>of</strong><br />
sudden displacements and in case <strong>of</strong> people living in Welfare Centres,<br />
where many a time there is a possibility <strong>of</strong> spread <strong>of</strong> diseases and it is<br />
necessary <strong>to</strong> make available health services <strong>to</strong> the people in North and<br />
East with special consideration. It can be seen from the study, that even<br />
though the health services are available in those areas it is inadequate <strong>to</strong><br />
cater the needs <strong>of</strong> the people.<br />
Therefore the government, as the care taker <strong>of</strong> the people, should take<br />
actions <strong>to</strong> strengthen the services <strong>of</strong> heath sec<strong>to</strong>r in the North and East<br />
with special consideration, as it is necessary <strong>to</strong> ensure the right <strong>to</strong> health<br />
<strong>of</strong> the people. In the case <strong>of</strong> government is unable <strong>to</strong> fulfill the need it is<br />
needed <strong>to</strong> obtain the services <strong>of</strong> humanitarian organizations <strong>to</strong> provide<br />
humanitarian assistance and protection <strong>to</strong> these people. Thus, it can be<br />
seen that, some discussed issues may be difficult <strong>to</strong> overcome in the<br />
short-term, long term strategies are required <strong>to</strong> handle these socially<br />
spread health problems <strong>of</strong> the people living in the North and East <strong>of</strong> the<br />
country.<br />
68
Recommendations<br />
Taken by : NPDS for <strong>IDP</strong>s Project, Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka
9. Recommendations<br />
1) Improvements <strong>of</strong> health related facilities and human<br />
resources in the districts.<br />
<strong>Health</strong> related facilities<br />
a) The minimum standards as it is required in “Re-categorization<br />
<strong>of</strong> Hospitals Circular” should be implemented so as <strong>to</strong> ensure<br />
qualitative service at the district level. Especially, in those areas<br />
the conflict it self requires a developed curative health service<br />
since the possibilities <strong>of</strong> accidents/injuries are frequent.<br />
b) Where there is a considerable addition <strong>of</strong> <strong>IDP</strong> population <strong>to</strong> the<br />
general population <strong>of</strong> a particular district, the amount <strong>of</strong><br />
allocations <strong>of</strong> medicine and other resources should be increased<br />
in proportionate <strong>to</strong> the addition.<br />
2) Human resources<br />
a) An appropriate system <strong>of</strong> deploying man power in health sec<strong>to</strong>r<br />
must be introduced and reasonable facilities and incentives<br />
should be made available <strong>to</strong> the health pr<strong>of</strong>essionals and staffs in<br />
rural and unsecured areas. It is only by encouraging them and<br />
giving more concessions, hardships happening while traveling<br />
from one hospital <strong>to</strong> another can be reduced.<br />
b) “The Proposed Norms for Public <strong>Health</strong> Technical Staff” is<br />
recommended <strong>to</strong> pursue with recent updates, if needed since it<br />
has been drafted in 1999. Therefore new recruitments should be<br />
carried out if there is less number <strong>of</strong> cadres <strong>to</strong> meet the needs <strong>of</strong><br />
the public. The monetary allocations from the treasury for such<br />
recruitments should be obtained on the basis <strong>of</strong> national<br />
importance.<br />
c) Regarding anomalies existing in allocating cadres, a proper<br />
moni<strong>to</strong>ring system should be worked out within the provincial<br />
level and national level <strong>to</strong> moni<strong>to</strong>r the deployment <strong>of</strong> human<br />
resources.<br />
70
d) In the case <strong>of</strong> security problems and inability <strong>to</strong> visit displaced<br />
persons, an appropriate system should be formed and<br />
moni<strong>to</strong>red, if needed with coordination <strong>of</strong> security forces. It is<br />
suggested <strong>to</strong> establish focal points within the Ministry <strong>of</strong> <strong>Health</strong><br />
in national level or <strong>to</strong> establish focal points at provincial or<br />
district levels. These focal points <strong>of</strong> the security forces will<br />
provide effective and efficient coordination in discharging the<br />
services. Because during and the post disaster period,<br />
maintaining a proper community health is imperative <strong>to</strong> prevent<br />
further calamities.<br />
e) Since there has been instances <strong>of</strong> the existing health staff <strong>of</strong> the<br />
host district unable <strong>to</strong> cope up with the new crowd, in case <strong>of</strong><br />
displacements <strong>of</strong> a larger number <strong>of</strong> persons <strong>to</strong> another district,<br />
the required number <strong>of</strong> health personnel should be allocated<br />
either from the previous district or from the central government<br />
as soon as possible. If it is taking time, incentives should be paid<br />
<strong>to</strong> them for the additional covering persons.<br />
4) Strengthening <strong>of</strong> medical record system.<br />
The absence <strong>of</strong> developed medical records system in the districts has<br />
caused <strong>of</strong>f beam or incorrect decision making in allocating financial and<br />
other resources and therefore, a well planned health recording system is<br />
needed <strong>to</strong> be implemented. The delay in forwarding Indoor Morbidity<br />
and Mortality Reports (IMMR) by the hospitals available throughout the<br />
country should be reduced and the statistical staff and required facilities<br />
there<strong>to</strong> needed <strong>to</strong> be provided effectively.<br />
5) Special measures/mechanisms <strong>to</strong> deal with displacement.<br />
a) The content and implementation <strong>of</strong> “Provisional guidelines for<br />
emergency management <strong>of</strong> public health problems <strong>of</strong> the <strong>IDP</strong>s”<br />
should be developed.<br />
Regarding the content, health aspects on personal hygiene,<br />
Provision <strong>of</strong> maternal and child health care services,<br />
immunization is not addressed in this guideline as it is<br />
71
elaborated in the “Guidelines for management <strong>of</strong> public health<br />
effects in the community following Tsunami disaster”. These<br />
aspects are <strong>of</strong> very much importance during and post disaster<br />
periods and this type <strong>of</strong> guideline or circular should address<br />
those fac<strong>to</strong>rs <strong>to</strong>o. In implementing, firstly, these types <strong>of</strong><br />
guidelines should guide all the districts where there are<br />
considerable numbers <strong>of</strong> <strong>IDP</strong>s. Secondly, the issuing authority<br />
<strong>of</strong> these guidelines is the Chief Epidemiologist and it is<br />
suggested that if it is issued in a manner <strong>of</strong> a “circular” by the<br />
Direc<strong>to</strong>r General <strong>of</strong> <strong>Health</strong> Service, it would be more<br />
enforceable.<br />
In addition, if a hand book could be prepared with all necessary<br />
fac<strong>to</strong>rs <strong>to</strong> be considered in assuring the health <strong>of</strong> the people in<br />
disasters it would benefit the displaced people and the<br />
humanitarian aid workers in discharging their activities. Such<br />
hand book should consider the standards mentioned in<br />
“minimum standards <strong>of</strong> Sphere Principles”, and etc. It will<br />
definitely make the moni<strong>to</strong>ring process much easy. The<br />
participation <strong>of</strong> other departments within the Ministry <strong>of</strong> <strong>Health</strong><br />
in drafting the hand book is necessary since each department is<br />
responsible for different activities.<br />
a) The health information system following a disaster should be<br />
more strengthened and alternatives ways should be used <strong>to</strong><br />
contact the people in the cases <strong>of</strong> daily visits are not possible.<br />
b) Auniform guideline is recommended <strong>to</strong> cover all types <strong>of</strong> health<br />
hazards in all types <strong>of</strong> displacements since the different type <strong>of</strong><br />
displacements have been addressed differently by the health<br />
authorities. However, if the Tsunami circulars equally<br />
applicable <strong>to</strong> conflict affected <strong>IDP</strong>s, it should be clearly<br />
demonstrated by another <strong>of</strong>ficial document and it should be<br />
distributed among all affected MOH areas and <strong>to</strong> the all level <strong>of</strong><br />
community health workers in their languages.<br />
c) The activities and services <strong>of</strong> the “Disaster Preparedness and<br />
Responses Unit” <strong>of</strong> the Ministry should publish among the<br />
displaced community and other stakeholders so as <strong>to</strong> make easy<br />
access <strong>to</strong> those services.<br />
73
e) In the cases <strong>of</strong> security problems and problems regarding long<br />
distance, mobile clinics both curative and preventive should be<br />
held in WCs or resettled areas, considering the need <strong>of</strong> the<br />
people with support <strong>of</strong> DPDHS, MOH and NGOs. i.e. it is<br />
suggested <strong>to</strong> conduct the clinics twice a month immediately after<br />
the displacement and subsequently it can be increased or<br />
reduced based on the requirement <strong>of</strong> the clinic.<br />
f) The curative heath <strong>of</strong> children, pregnant mothers, disabled and<br />
elders should be assured and their access <strong>to</strong> health clinics should<br />
be given a paramount concern.<br />
g) Public transport facilities should be made available with enough<br />
security <strong>to</strong> the people at least in the days <strong>of</strong> conducting clinics at<br />
hospitals.<br />
h) The maintenance <strong>of</strong> living standards is WCs and in resettled/<br />
relocated areas has <strong>to</strong> be carried out with a proper coordination<br />
between public health workers and relevant local government<br />
authorities, according <strong>to</strong> the accepted norms and minimum<br />
standards. Especially, a well planned garbage disposal system<br />
should be followed with the coordination <strong>of</strong> both parties.<br />
i) The availability <strong>of</strong> curative health care facilities and the lowest<br />
distance <strong>to</strong> the nearest center and availability <strong>of</strong> drinking water,<br />
sanitation facilities, drainages and the suitability <strong>of</strong> the slope <strong>of</strong><br />
the land in selecting temporary sites and in planning relocation<br />
and resettlement for <strong>of</strong> <strong>IDP</strong>s should be key fac<strong>to</strong>rs in deciding<br />
locations for <strong>IDP</strong>s.<br />
6) The quantity and nutrition status <strong>of</strong> dry ration <strong>to</strong> be<br />
increased.<br />
a) Though the quantity <strong>of</strong> dry ration has been increased, by the<br />
Circular (2007) <strong>of</strong> Ministry <strong>of</strong> Resettlement and Disaster Relief<br />
Services, it is not activated yet. The quantity <strong>of</strong> dry ration is still<br />
remained as issued under the 1995 circular, even after economic<br />
situation is completely different from the situation in 1995.<br />
Therefore the 2007 circular (No: NDRSC 2007/10) should be<br />
implemented as soon as possible.<br />
73
) Regarding the quality <strong>of</strong> dry rations, a constant inspection and<br />
moni<strong>to</strong>ring system should be carried out in order <strong>to</strong> check the<br />
quality <strong>of</strong> the dry ration <strong>of</strong> MPCS. The irregularities in issuing<br />
dry ration should be cured with enough monetary allocations <strong>to</strong><br />
meet sudden displacements.<br />
6) Special concerns for the nutritional status <strong>of</strong> vulnerable<br />
groups.<br />
Especially, special concerns should be made <strong>to</strong> improve the<br />
nutritional status <strong>of</strong> vulnerable groups such as, women and<br />
children. The nutritional packages such as “Poshana Malla”<br />
should be made available <strong>to</strong> the displaced pregnant women<br />
without considering the fact that they are having “dry ration”<br />
instead <strong>of</strong> “Samurdhi”.<br />
8) Promote health education among <strong>IDP</strong>s.<br />
Unhealthy practices such as open air defecation still happens<br />
and proper involvement <strong>of</strong> community health workers is<br />
essential in this regard. <strong>Health</strong> education, therefore should be<br />
promoted as soon as the displacements and also during the<br />
process <strong>of</strong> relocation, resettlement and return. Regarding risk <strong>of</strong><br />
sexually transmitted diseases as AIDS, the target group should<br />
be given advices by community health workers regularly. In<br />
addition <strong>to</strong> the promotion <strong>of</strong> education, adequate facilities<br />
should be provided <strong>to</strong> ensure the health <strong>of</strong> the people. Facilities,<br />
such as making available adequate <strong>to</strong>ilets, water, washing<br />
facilities and etc should be provided.<br />
9) Inclusion <strong>of</strong> <strong>Right</strong> <strong>to</strong> health in the Constitution<br />
Inclusion <strong>of</strong> right <strong>to</strong> health in the Constitution as a basic right is<br />
recommended having unders<strong>to</strong>od the importance <strong>of</strong> health <strong>to</strong> the<br />
life and <strong>to</strong> live in dignity. This is once tried in Draft Constitution<br />
<strong>of</strong> 2000 byArticle 25 and under that every citizen has the right <strong>to</strong><br />
access <strong>to</strong> health care services including emergency medical<br />
treatment and sufficient food and water. Therefore incorporation<br />
<strong>of</strong> right <strong>to</strong> health in the Constitution and progressive realization<br />
74
<strong>of</strong> that right by the government is recommended because then the<br />
uncertainty <strong>to</strong> make that right justicaible will be over.
Annexure<br />
Annexure 1<br />
<strong>IDP</strong>s Population Figures in the Districts<br />
The District<br />
<strong>IDP</strong>s Population(as at <strong>IDP</strong>s Population (31.06.2008)<br />
01.01.2008)<br />
Mannar 46,735 30,112<br />
Vavuniya 47,142 82,176<br />
Trincomalee 25,623 17,965<br />
Batticaloa 54,189 18,171<br />
Anuradhapura 9,912 15,120<br />
Puttlam 63,016 61,274<br />
Total 246,617 224,818<br />
Source- District Secretariats <strong>of</strong> the relevant districts.<br />
Annexure II<br />
Minimum Standards <strong>of</strong> the Basic Needs<br />
S.N<br />
O<br />
Subject Standard <strong>of</strong> UNHCR Standard <strong>of</strong> Sphere<br />
principal<br />
01 Minimum surface for the person 45m 2 – 30m 2 45m 2<br />
02 Minimum shelter space for the person 3.5m 2 3.5m 2<br />
03 Minimum site for a family 500Sq/ft<br />
04 Minimum site security area away from 50Km<br />
conflict area<br />
05 Minimum food energy requirement for 2,100Kcal<br />
2,100Kcal<br />
aperson<br />
06 Minimum food assuming per person for<br />
aday<br />
350 –<br />
400g/person/day <strong>of</strong><br />
staple cereal<br />
20 – 40 g/person/ day<br />
<strong>of</strong> an energy rich food<br />
(oil, fat)<br />
50g/person/day <strong>of</strong> a<br />
protein rich food<br />
(legumes)<br />
Protein–12%(52g–63g)<br />
Fat – 17%(40g)<br />
Vitamin A - 0.5mg<br />
ThiamineB1–0.9mg<br />
Rib<strong>of</strong>lavin B2 – 0.6mg<br />
Folic acid – 160g<br />
NiacinB3–6.6mg<br />
VitaminB12–0.9ug<br />
Vitamin C – 28mg<br />
VitaminD–3.2–3.2ug<br />
calciferol<br />
Iron–22mg<br />
76
07 Nutrition standard Emergency level ><br />
15% <strong>of</strong> the population<br />
under five years old<br />
below 80% weight for<br />
height<br />
Or<br />
10% <strong>of</strong> the population<br />
under five years old<br />
below 80% weight for<br />
height <strong>to</strong>gether with<br />
aggravating fac<strong>to</strong>rs.<br />
08 Crude Mortality rate (CMR)<br />
Normal rate among a settled population<br />
Emergency programme under control<br />
Emergency programme in serious<br />
trouble<br />
Emergency out <strong>of</strong> control<br />
Major catastrophe<br />
09 Mortality rate among children under 5<br />
years old<br />
Normal rate among a settled population<br />
Emergency programme under control<br />
Emergency programme in serious<br />
trouble<br />
Emergency out <strong>of</strong> control<br />
0.3 <strong>to</strong> 0.5 / 10,000/<br />
day<br />
1/10,000/day<br />
>2/10,000/day<br />
>5/10,000/day<br />
1/10,000/day<br />
2/10,000/day<br />
>4/10,000/day<br />
10 Minimum water needs for a person 7 Litres/person/per<br />
day<br />
11 Minimum water needs for health centre 40-<br />
60Litres/patient/per<br />
day<br />
12 Minimum water needs for feeding<br />
centre<br />
CMR is maintained at or<br />
reduced <strong>to</strong> less than twice<br />
the baseline rate<br />
documented for the<br />
population prior <strong>to</strong> the<br />
disaster<br />
15 Litres/per/person/day<br />
(Include drinking, cooking<br />
&personalhygiene<br />
40-60Litres/patient/per day<br />
20-<br />
30Litres/patient/per day<br />
30Litres/patient/per<br />
day<br />
1 per 200 persons 1 per 250 persons<br />
13 Maximum number <strong>of</strong> persons per Tab<br />
stand<br />
14 Maximum number <strong>of</strong> persons per Hand 1 per 200 persons 1 per 400 persons<br />
pump or dug well<br />
15 Minimum distance between shelter and 100m<br />
water tab<br />
16 Concentration <strong>of</strong> faecal coli form are<br />
usually expressed per 100ml <strong>of</strong> water Faecal Coli form Microbiological water<br />
Water Quality<br />
/100ml<br />
quality faecal coli form<br />
a. Reasonable quality<br />
1–10<br />
bacteria (>99% <strong>of</strong> which<br />
b. Polluted<br />
10–100<br />
are E.Coil)<br />
c. Very polluted<br />
100–1000<br />
Chlorine residual at the<br />
d. Grossly polluted<br />
> 1000<br />
tab: 0.5mg per litre<br />
17 Minimum Latrine facilities for persons 1 Latrine for 20 1 Latrine for 20 persons<br />
77
Annexure III<br />
Statistics relating <strong>to</strong> Public <strong>Health</strong> Midwifes in Vavuniya<br />
PHM Area<br />
Current<br />
Population<br />
Actual<br />
number <strong>of</strong><br />
<strong>of</strong>ficers<br />
required<br />
according <strong>to</strong><br />
the<br />
population<br />
The<br />
number <strong>of</strong><br />
<strong>of</strong>ficers<br />
attached<br />
<strong>to</strong> each at<br />
present<br />
area<br />
The<br />
number <strong>of</strong><br />
vacant<br />
positions<br />
01 Kovil Kulam 4309 01 01 -<br />
02 Vavuniya Town 4468 01 - Vacant<br />
03 Vairavapuliyankulam 7046 02 01 -<br />
04 Vavuniya North 6349 02 01 -<br />
05 Thanddikulam 4569 01 - Vacant<br />
06 Rambaikulam 5279 01 - Vacant<br />
07 Thonnikkal 12299 04 01 -<br />
08 Moonrumuripu 2543 01 01 -<br />
09 Pandarikulam 15374 05 01 -<br />
10 Sithamparapuram 3934 01 - Vacant<br />
11 Samalankulam 5279 02 01 -<br />
12 Koomankulam 11008 04 01 -<br />
13 Nellukkulam 9444 03 01 -<br />
14 Rajendrankulam 4146 01 01 -<br />
15 Pambaimadu 4646 01 - Vacant<br />
16 Poovarasankulam 4105 01 - Vacant<br />
17 Nochchimoddai 3711 01 01 -<br />
18 Sasthirikoolankulam 9659 03 01 -<br />
19 Maha Rambaikulam 12042 04 01 -<br />
20 Palamoddai 4057 01 - Vacant<br />
21 Semamadu 4773 01 - Vacant<br />
22 Omanthai 3092 01 - Vacant<br />
23 Echchankulam 10580 03 01 -<br />
Source- DPDHS Office Vavuniya as at July 2007<br />
78
MOH Office Carder Positions in Vavuniya as at 31.07.2007<br />
S/No<br />
DS Division<br />
MOH PHI PHM<br />
Cadre Present Cadre Present Cadre Present<br />
Strength<br />
Strength<br />
Strength<br />
01. Vavniya 2 2 9 6 23 14<br />
02. Vavuniya South 1 1 2 2 6 3<br />
03. Vengalacheddik 1 1 2 2 6 2<br />
ulam<br />
04. Vavuniya North 1 1 2 2 6 3<br />
Total 5 5 15 12 41 22<br />
Source- DPDHS Office Vavuniya<br />
Annexure IV<br />
MOH Office Carder Positions in Vavuniya as at 31.12.2007<br />
S/No<br />
DS Division<br />
MOH PHI PHM<br />
Cadre Present Cadre Present Cadre Present<br />
Strength<br />
Strength<br />
Strength<br />
01. Vavniya 2* 1 9 6 23 23<br />
02. Vavuniya South 1 1 2 2 6 6<br />
03. Vengalacheddik 1 1 2 2 6 6<br />
ulam<br />
04. Vavuniya North 1 0 2 0 6 2<br />
Total 5 3 15 10 41 37<br />
Source- DPDHS Office Vavuniya<br />
79
Annexure V<br />
Carder position as at September 2007-Trincomalee<br />
MOOOH<br />
AMOH<br />
Management Assistant<br />
SPHI<br />
PHI<br />
PPA<br />
OL<br />
SL<br />
Driver<br />
Watcher<br />
KKS/OES<br />
SDT<br />
SD Labourer<br />
PHNS<br />
SPHM<br />
Programme Assistant<br />
PHM<br />
PPHM<br />
Total<br />
MOH Office<br />
C 1 1 2 10 1 1 1 2 1 1 1 1 2 2 2 30 59<br />
1 Trincomalee I 1 1 1 1 7 1 4 2 1 2 1 1 20 8 51<br />
C 1 1 1 5 1 1 1 1 1 1 1 1 2 2 1 15 36<br />
2 Kantlai I 1 1 1 1 3 1 4 1 1 1 21 36<br />
C 1 1 1 5 1 1 1 1 1 1 1 1 2 2 1 17 38<br />
3 Muthur I 1 1 1 6 4 1 1 1 10 4 30<br />
C 1 1 1 6 1 1 1 1 1 1 1 1 2 2 1 12 34<br />
4 Kinniya I 1 1 1 7 2 3 1 1 1 9 22 49<br />
C 1 3 1 1 9 15<br />
5 Thampalagamam I 1 1 3 3 1 1 9 3 22<br />
C 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 5 22<br />
6 Padavisripura I 1 1 1 1 1 2 1 8<br />
C 1 2 1 6 10<br />
7 Seruwila I 1 1 2 2 1 4 11<br />
C 1 2 1 1 11 16<br />
8 Kuchchaveli I 3 1 2 1 5 7 19<br />
C 1 1 1 1 3 7<br />
9 Gomarangadawela I 1 1 1 1 4<br />
C 1 1 1 4 7<br />
10 Morawewa I 2 2<br />
C 1 1 1 3 6<br />
11 Ichchilampathai I 1 1 4 6<br />
25<br />
Sub Total C 10 0 5 6 37 10 5 5 6 5 5 5 5 10 10 11 115 0 0<br />
I 9 2 5 7 33 0 5 23 6 6 4 2 0 2 0 2 83 49<br />
23<br />
8<br />
Source- DPDHS Office-Trincomalee<br />
80
Annexure VI<br />
Ministry <strong>of</strong> <strong>Health</strong>care & Nutrition<br />
Epidemiological Unit<br />
231, de Saram Place, Colombo 01000, Sri Lanka<br />
Telephone: Epidemiologist :(+94-11-)2681548, Epid unit: (+94-11-)<br />
2695112 Fax: (+94-11-)2696583, E-mail: chepid@sltnet.lk<br />
and epidunit@sltnet.lk<br />
_____________________________________________________<br />
My No. EPID/22/2007<br />
19 April 2007.<br />
Deputy Provincial Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Services,<br />
Batticoloa.<br />
Provisional Guidelines for Emergency Management <strong>of</strong> Public<br />
<strong>Health</strong> Problems <strong>of</strong> the <strong>Internally</strong> <strong>Displaced</strong> People<br />
The following provisional guidelines are recommended <strong>to</strong> minimize the<br />
adverse public health impact and <strong>to</strong> prevent the spread <strong>of</strong> communicable<br />
diseases <strong>of</strong> the displaced population living in temporary shelters.<br />
1. Ensuring safety <strong>of</strong> water<br />
Ensure adequate supply <strong>of</strong> safe drinking water. If pipe-borne<br />
water is not available, water <strong>to</strong> be collected in tanks or barrels<br />
and chlorinated.<br />
Co-ordinate with the Divisional Secretary <strong>to</strong> ensure that water<br />
supplied by local authorities and other sources is properly<br />
chlorinated before distribution.<br />
2. Ensuring safety <strong>of</strong> food<br />
Co-ordinate with the Divisional Secretary <strong>to</strong> ensure that food<br />
supplied by local authorities and other sources are hygienically<br />
prepared before distribution.<br />
Ensure all the food supplies <strong>to</strong> the displaced are hygienically<br />
s<strong>to</strong>red, prepared and distributed.<br />
Strictly moni<strong>to</strong>r the preparation <strong>of</strong> food in food handling<br />
establishments.<br />
81
3. Safe disposal <strong>of</strong> excreta<br />
Ensure adequate sanitary facilities at all temporary camps for<br />
the displaced. Where necessary, make arrangements <strong>to</strong><br />
construct adequate number <strong>of</strong> temporary latrines according <strong>to</strong><br />
the guidelines.<br />
4. Disposal <strong>of</strong> refuse<br />
Co-ordinate disposal <strong>of</strong> garbage by sanitary burial or burning in<br />
suitable adjacent areas <strong>of</strong> temporary shelters.<br />
Control flies, insects and rodents by proper use <strong>of</strong> physical and<br />
chemical methods (insecticides and TCLpowder).<br />
If garbage is removed daily by the local authorities using<br />
trac<strong>to</strong>rs, ensure enough barrels (garbage bins) are available in<br />
the temporary shelters for collection <strong>of</strong> garbage.<br />
5. Treatment and management <strong>of</strong> minor ailments<br />
Co-ordinate with the local medical institutions/authorities <strong>to</strong><br />
establish mobile medical teams <strong>to</strong> visit temporary shelters for<br />
the displaced daily and provide treatment.<br />
Refer and transport those that require institutional care.<br />
6. Prevention and control <strong>of</strong> potential outbreaks<br />
In a case <strong>of</strong> diarrhoea in particular, prompt action must be taken<br />
<strong>to</strong> ensure early treatment and prevention <strong>of</strong> further spread.<br />
In case <strong>of</strong> contagious diseases such as acute respira<strong>to</strong>ry tract<br />
infections and chickenpox, these cases should be isolated and<br />
referred <strong>to</strong> hospitals if necessary.<br />
Steps should be taken <strong>to</strong> control mosqui<strong>to</strong> breeding <strong>to</strong> prevent<br />
and control mosqui<strong>to</strong> borne diseases such as dengue, malaria<br />
and JE.<br />
7. Disease surveillance<br />
MOH/PHI should visit the camps daily <strong>to</strong> inquire in<strong>to</strong> unusual<br />
occurrence <strong>of</strong> disease events/outbreaks.<br />
Collect and report data related <strong>to</strong> health events in camps<br />
according <strong>to</strong> the format provided by the Epidemiology unit<br />
(annexure).<br />
MOH should consolidate the above data weekly and send a<br />
consolidated report <strong>to</strong> RE with a copy <strong>to</strong> Epidemiology Unit<br />
(annexure).<br />
82
The above guidelines should be carried out by Public <strong>Health</strong> Inspec<strong>to</strong>rs<br />
and other field health staff under the supervision <strong>of</strong> DDHS/MOH. It is <strong>of</strong><br />
uttermost importance that the DDHS/MOH takes a personal interest in<br />
these activities.Asatisfac<strong>to</strong>ry outcome will depend on the enthusiasm <strong>of</strong><br />
the DDHS/MOH as well as his/her team.<br />
In order <strong>to</strong> carry out the above, it is strongly recommended that a<br />
committee should be formed in each and every camp, comprising <strong>of</strong><br />
selected responsible persons, village leaders and field level<br />
governmental and non-governmental <strong>of</strong>ficials.<br />
In addition, RE would be responsible for overall moni<strong>to</strong>ring and<br />
supervision <strong>of</strong> above activities carried out in the DPDHS division, with<br />
the guidance <strong>of</strong> PDHS, DPDHS and the Epidemiologist.<br />
Dr. P. Palihawadana<br />
Deputy Epidemiologist<br />
CC:<br />
Addl. Secretary, Ministry <strong>of</strong> <strong>Health</strong>care & Nutrition<br />
Direc<strong>to</strong>r General <strong>of</strong> <strong>Health</strong> Services<br />
Deputy Direc<strong>to</strong>r General (Public <strong>Health</strong> Services)<br />
Provincial Direc<strong>to</strong>r <strong>of</strong> <strong>Health</strong> Services, Eastern Province<br />
Regional Epidemiologist, Batticoloa<br />
MOH Batticoloa, Chenkalady, Kaluvanchikudy,<br />
Valaichchenai, Kathankudy, Eravoor, Pattipalai, Vavunativu,<br />
Vakarai, Vellaveli, Ottamavadi<br />
83
Annexure VII<br />
<strong>Health</strong> Indica<strong>to</strong>rs<br />
Island wide data<br />
Data <strong>of</strong> Districts<br />
Vavu<br />
Tri’<br />
male Manna Puttala<br />
Indica<strong>to</strong>rs Data(000) Year Source niya A’pura e r Batti mm<br />
Total Mid year population (000) 19,668 2005 RGD 145 782 838 99 549 737<br />
Total Number <strong>of</strong> Births 370,424 2005<br />
1275<br />
RGD 3465 15092 8415 2062 113330<br />
Crude Birth Rate (per 1000) 18.8 2005 RGD 18.3 19.5 21.2 18.3 21.2 18.1<br />
Total Number <strong>of</strong> Deaths 129,822 2005 RGD 665 3962 1817 331 4509 3324<br />
Crude Death Rates (1000 population) 6.6 2005 RGD 4.6 5.1 4.7 3.3 8.2 4.5<br />
Neonatal Mortality Rate (per 1000 Live Birth) 9.2 2003 RGD 5.2 17.6 1 5.8 15.3 5.6<br />
Infant Mortality Rate (per 1000 Live Birth) 11.2 2003 RGD 6.8 19.4 2.5 2.6 19.6 5.9<br />
Maternal Mortality Rate (per 1000 Live Birth) 38 2004 FHB 68.7 22.7 23.6 DNA 81.2 43.7<br />
New accep<strong>to</strong>rs Rate for family planning 75 2005 FHB 91.7 44.2 42.7 51.5 68.4<br />
Percentage <strong>of</strong> teenage pregnancy 6.2 2005 FHB 4.9 8 10.5 7.7 9.5 10.3<br />
Percentage <strong>of</strong> mothers Registered before 12 weeks<br />
<strong>of</strong> POA<br />
75.4 2005<br />
FHB 42.3 84.1 50.1 58.5 63.9 74.8<br />
Percentage <strong>of</strong> pregnant women protected with<br />
rubella<br />
87.3 2005<br />
FHB 50.9 93.5 54.2 45.6 70.7 82.7<br />
Percentage <strong>of</strong> low birth weight 16.9 2005 DHS 13.6 16.9 12.2 6.6 20.2 13.6<br />
Percentage <strong>of</strong> Mother Received post partum Care<br />
during 1st 10 Days <strong>of</strong> Delivery (out <strong>of</strong> Estimated<br />
Births)<br />
67 2005<br />
FHB 11.2 68 44.5 41.6 70.2 78<br />
Percentage <strong>of</strong> infant Weighted below 3rd centile 8.9 2005 FHB 13 7.3 10.1 7.2 11.9 6.1<br />
Percentage <strong>of</strong> Children 1-3 years below 3rd centile 24.9 2005 FHB 28.8 24.4 34.9 25.8 36.2 15.3<br />
Percentage <strong>of</strong> Children 3-5 years below 3rd centile 27.4 2005 FHB 32.3 25.9 36.8 28.7 40.3 15.9<br />
Coverage School Medical Infection 98.5 2005<br />
FHB 87* 80 77 94 100<br />
Number <strong>of</strong> Functioning Well women Clinic 426 2005 FHB 0 14 12 17 5 10<br />
Source- http://www.familyhealth.gov.lk * Including data from Mannar<br />
84
Annexure VIII<br />
Statistics relating <strong>to</strong> malnutrition <strong>of</strong> the children in Vavuniya<br />
Age<br />
No. <strong>of</strong> those<br />
who came<br />
<strong>to</strong> weigh<br />
the<br />
children.<br />
No. <strong>of</strong> those<br />
in normal<br />
weight<br />
(N).<br />
No. <strong>of</strong><br />
under<br />
growth<br />
children<br />
(O).<br />
No. <strong>of</strong><br />
children<br />
under<br />
weight<br />
(X).<br />
No. <strong>of</strong><br />
children<br />
under<br />
growth and<br />
under<br />
weight<br />
(OX).<br />
No. <strong>of</strong><br />
children<br />
below<br />
under<br />
weight<br />
(XX).<br />
Months 0-04 368 306 09 29 18 15<br />
Months 05-09 596 388 37 68 65 39<br />
Months 10-12 358 179 18 74 45 42<br />
Months 13-17 558 193 34 99 122 110<br />
Months 18-24 786 327 54 139 98 173<br />
Months 25-35 1179 487 86 193 153 261<br />
Months 36-42 861 342 41 140 137 203<br />
Months 43-60 1911 730 102 258 296 516<br />
Total 6617 2952 381 1000 934 1359<br />
Source- DPDHS Office - Vuvuniya<br />
Annexure IX<br />
Details <strong>of</strong> New born children who are in underweight (less than<br />
2.5Kg) in Trincomalee district<br />
Year 2003 2004 2005 2006 2007<br />
N0.<strong>of</strong> babies<br />
born with 853 1134 1139 971 964<br />
low weight<br />
%<strong>of</strong> babies<br />
born with 12.2 16.3 15.7 12.8 14.95<br />
low weight<br />
Source: DPDHS Trincomalee<br />
85
Annexure X<br />
MCH Clinics at Trincomalee District<br />
MOH Area<br />
Total<br />
no. <strong>of</strong><br />
clinics<br />
Clinic<br />
No<br />
Ante Natal<br />
Clinics<br />
Clinic<br />
session<br />
per<br />
month<br />
Child Welfare<br />
Clinic<br />
Clinic<br />
No<br />
Clinic<br />
session<br />
per<br />
month<br />
Family Planning<br />
Clinic<br />
Clinic<br />
No<br />
Clinic<br />
session<br />
per<br />
month<br />
WWC<br />
Clinic<br />
Clinic<br />
No<br />
Registered<br />
FP Clinics<br />
Clinic<br />
session per<br />
month<br />
Trincomalee 24 21 31 24 59 5 20 0 3<br />
Kantalai 11 11 23 10 22 9 20 1 5<br />
Muthur<br />
21 10 23 20 29 4 12 0 4<br />
Ichchilampathai<br />
Thampalagamam 8 6 18 7 18 7 18 0 3<br />
Kinniya 15 12 21 14 26 3 12 1 3<br />
Seruwila 3 3 5 3 5 3 5 0 1<br />
Kuchchaveli 6 5 12 6 15 4 9 0 4<br />
Gomarangadawela 1 1 4 1 2 1 1 0 1<br />
Morawewa 3 2 6 3 5 0 0 0 1<br />
Padavisripura 1 1 4 1 2 1 1 0 1<br />
Total 93 72 147 89 183 37 98 2 26<br />
Source: DPDHS Trincomalee<br />
Annexure XI<br />
Performance <strong>of</strong> Well Women ClinicActivities - Trincomalee<br />
2004 2005<br />
No. <strong>of</strong> functioning WWC 01 00<br />
First Visit 78 26<br />
Cervical Visualization 23 00<br />
Diabetes Mellitus 07 00<br />
Hypertension 09 08<br />
Breast abnormalities 00 01<br />
No Pap Smears taken 23 00<br />
No. Cervical smear reports<br />
08 00<br />
received<br />
Total CIN positives 00 00<br />
Source: DPDHS Trincomalee<br />
86
Annexure XII<br />
Registration <strong>of</strong> Pregnant mothers by Trincomalee RDHS<br />
Trincomalee<br />
/ RDHS<br />
Pregnant<br />
mothers<br />
registered<br />
Pregnant<br />
mothers<br />
registered<br />
under 12<br />
weeks (%)<br />
Pregnant<br />
mothers<br />
registered<br />
12-20 weeks<br />
(%)<br />
Pregnant<br />
mothers<br />
registered<br />
after 20<br />
weeks (%)<br />
2004 6327 53.6 19.2 5.7 10.3<br />
2005 8136 50.1 18.5 7.6 10.5<br />
Source: Annual Report Family <strong>Health</strong> <strong>of</strong> Sri Lanka (2004 & 2005)<br />
Teenage<br />
Pregnancy<br />
(%)<br />
87
Article 25 <strong>Right</strong> <strong>to</strong> adequate standard <strong>of</strong> living for health and well-being.<br />
(1) Everyone has the right <strong>to</strong> a standard <strong>of</strong> living adequate for the health<br />
and well-being <strong>of</strong> himself and <strong>of</strong> his family, including food, clothing, housing<br />
and medical care and necessary social services, and the right <strong>to</strong> security in<br />
the event <strong>of</strong> unemployment, sickness, disability, widowhood, old age or other<br />
lack <strong>of</strong> livelihood in circumstances beyond his control.<br />
(2) Motherhood and childhood are entitled <strong>to</strong> special care and assistance. All<br />
children, whether born in or out <strong>of</strong> wedlock, shall enjoy the same social<br />
protection<br />
- Article No.25 - UDHR<br />
National Protection and Durable Solutions for<br />
<strong>Internally</strong> <strong>Displaced</strong> <strong>Persons</strong> Project<br />
Human <strong>Right</strong>s Commission <strong>of</strong> Sri Lanka<br />
No 65/1, Muththaiyahpillai Avenue, Ward Place, Colombo 07<br />
Tel : +94112662587, +94112681734 Fax : +94112688145<br />
Email : hrccidp@sltnet.lk Web : www.idpsrilanka.lk