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Disease outbreaks and malnutrition are the major public health concerns in emergencies. They are the main causes of high mortality associated with public health.
Health, nutrition and WASH are closely linked. Make sure that these sectors are coordinated at all levels.
Establish mechanisms to identify major health risks and persons with serious medical needs/conditions, including malnutrition and prioritize vaccination of children against measles and polio as early as possible from the first entry or access point (including reception/transit centers).
The provision of health services is one component of an overall public health response to emergencies. The overall aim of any public health intervention is to prevent and reduce excess mortality and morbidity.
In the first phases of an emergency, the public health response focuses on identifying and addressing life-saving needs. The best outcome is to provide refugees with full access to essential health services and wherever possible to ensure access to national services. To achieve this, it is crucial to collaborate closely and support from the beginning the ministries and local authorities responsible for public health.
Public Health interventions in camp settings aim to meet the basic health needs of refugees. Health services are closely linked to nutrition and WASH services to prevent disease outbreaks and reduce public health risks as well as providing a favourable environment for protection of nutrition status and food security.
Health is a human right and a protection priority
To respect the right to health and to ensure that refugees enjoy access to health services that are equivalent to the services enjoyed by their host population; in all circumstances, these services must meet minimum humanitarian standards.
To ensure public health interventions save lives and address the most urgent survival needs. Implementation should start at the earliest possible stage When existing services, such as those provided by the Ministry of Health, are insufficient or do not exist in the area of displacement, UNHCR and its partners must provide the core services outlined below.
Underlying principles and standards
UNHCR's Public Health Strategic Objectives 2014-2018
1. Improve access to quality primary health care programmes.
2. Decrease morbidity from communicable diseases and epidemics.
3. Improve childhood survival.
4. Facilitate access to integrated prevention and control of non-communicable diseases, including mental health services.
5. Ensure rational access to specialist referral care.
6. Ensure integration into national services and explore health financing mechanisms.
UNHCR has developed a comprehensive public health strategy that applies to emergency and non-emergency operations in both camp and out-of-camp settings. UNHCR and its partners follow national standards wherever available and applicable. In addition, the following SPHERE standards may apply as minimum international standards.
SPHERE, Health systems standard 1.1: Health service delivery. People have access to integrated quality healthcare that is safe, effective and patient-centred.
SPHERE, Health systems standard 1.2: Healthcare workforce. People have access to healthcare workers with adequate skills at all levels of healthcare.
SPHERE, Health systems standard 1.3: Essential medicines and medical devices. People have access to essential medicines and medical devices that are safe, effective and of assured quality.
SPHERE, Health systems standard 1.4: Health financing. People have access to free priority healthcare for the duration of the crisis.
SPHERE, Health systems standard 1.5: Health information management. Healthcare is guided by evidence through the collection, analysis and use if relevant public health data.
SPHERE, Communicable diseases standard 2.1.1: Prevention. People have access to healthcare and information to prevent communicable diseases.
SPHERE, Communicable diseases standard 2.1.2: Surveillance, outbreak detection and early response. Surveillance and reporting systems provide early outbreak detection and early response.
SPHERE, Communicable diseases standard 2.1.3: Diagnosis and case management. People have access to effective diagnosis and treatment for infectious diseases that contribute most significantly to morbidity and mortality.
SPHERE, Communicable diseases standard 2.1.4: Outbreak preparedness and response. Outbreaks are adequately prepared for and controlled in a timely and effective manner.
SPHERE, Child health standard 2.2.1: Childhood vaccine-preventable disease. Children aged six months to 15 years have immunity against disease and access to routine Expanded Programme on Immunization (EPI) services during crises.
SPHERE, Child health standard 2.2.2: Management of newborn and childhood illness. Children have access to priority healthcare that addresses the major causes of newborn and childhood morbidity and mortality.
SPHERE, Sexual and reproductive health standard 2.3.1: Reproductive, Maternal and newborn healthcare. People have access to healthcare and family planning that prevents excessive maternal and newborn morbidity and mortality.
SPHERE, Sexual and reproductive health standard 2.3.2: Sexual violence and clinical management of rape. People have access to healthcare that is safe and responds to the needs of survivors of sexual violence.
SPHERE, Sexual and reproductive health standard 2.3.3: HIV. People have access to healthcare that prevents transmission and reduces morbidity and mortality due to HIV.
SPHERE, Injury and trauma care standard 2.4: Injury and trauma care. People have access to safe and effective trauma care during crises to prevent avoidable mortality, morbidity, suffering and disability.
SPHERE, Mental health standard 2.5: Mental health care. People of all ages have access to healthcare that addresses mental health conditions and associated impaired functioning.
SPHERE, Non-communicable diseases standard 2.6: Care of non-communicable diseases. People have access to preventive programmes, diagnostics and essential therapies for acute complications and long term management of non-communicable diseases.
SPHERE, Palliative care standard 2.7: Palliative care. People have access to palliative and end-of-life care that relieves pain and suffering, maximises the comfort, dignity and quality of life of patients, and provides support for family members.
The main causes of death and diseases in emergency situations are vaccine-preventable and communicable disease. Children especially those under-five years old are at most risk.
Reproductive health problems (in particular pregnancy and obstetric complications) are more likely during emergencies.
Emergency situations amplify the risk of exposure to gender-based violence, especially for women and children.
Displacement situations are often associated with armed conflict, resulting in (mass) casualties and injuries.
Refugee populations can be stigmatized or suffer discrimination or xenophobia,for example if they are seen as taking away resources from nationals or as bringing disease.
Large-scale population movements may overburden a host area's capacity to cope, in terms of essential services.
Barriers to accessing health care services or disparities between the quality or the cost of services, may harm relations between refugees and host populations.
Failure to provide adequate health and nutrition services in refugee camps may generate a number of risks, for example:
The security in refugee camps maybe compromised, by riots, demonstrations, or violent behaviour.
Refugees may take risks and adopt unsafe coping strategies.
Malnourished individuals may suffer long-term effects, such as impeded growth or development.
Key decision points
Public health Interventions save lives and address immediate survival needs. They are therefore operational and programme priorities.
Public health programmes should always be available to refugees living in camp settings. UNHCR should encourage the authorities to grant refugees access to national services, where these are available and adequate. Where they are not, UNHCR should collaborate with the local Ministry of Health and other relevant actors to establish new services or improve those that exist, for the benefit of both refugee and host populations.
Public health interventions must always be:
Evidence-based. Activities should be planned and implemented, based on the findings of the initial assessment.
Needs-based. Interventions should be scaled and resources should be allocated to meet the needs of the population.
Technically sound. Services should be based on current scientific evidence and operational guidance, and implemented by skilled staff.
Impact oriented. UNHCR promotes the primary health care approach, which ensures that essential health services address the health needs of to the entire population.
Priority-based. Emergency public health interventions and services should be prioritised to achieve maximum impact across the population. Interventions to address immediate health risks, such as disease outbreaks and malnutrition, must be priorities.
Integrated. Avoid setting up costly parallel services. Assist the national health system to extend its services to refugees.
1. Ensure strong coordination to ensure the response covers all needs, and that referral across services as well as individual follow up are assured.
2. Ensure refugees have access to information and know where services are available and are able to voice their opinions.
3. Conduct an initial assessment, including 3W (Who? What? Where?).
4. Develop a priority action plan and 3W matrix that focuses on the following programme components:
a. Measles, polio vaccination, and vitamin A supplements.
b. Screening for acute malnutrition in the community, where indicated and (as required) provision of nutrition support.
c. Communicable disease control, notably:
Prevention (including immunisation).
Surveillance (establish an early warning system).
Preparedness and response planning.
Monitoring of disease outbreaks.
d. Primary health care services:
Curative health care (out-patient care).
Immunisation (measles and vitamin A supplements plus EPI).
e. Constitute a community-based health workforce (CBHW), and set up priority community-based health prevention activities.
f. Reproductive health and HIV.
Where reproductive health services (RH) are not available
Where MISP or RH/HIV components exist
Implement the minimum initial service package(MISP).
Expand to comprehensive RH.
24/7 emergency obstetric neonatal care.
Prevention of sexual and gender-based violence (SGBV) and clinical management of rape survivors.
High impact STI/HIV prevention and continuation of ART / EMTCT.
All the MISP, plus:
Fistula detection and management.
Adolescent sexual and reproductive health services (SRH).
Comprehensive SGBV response.
Comprehensive HIV services.
Timeframe: 0-6 months.
Timeframe: >6 months.
Note. HIV testing during the acute phase should only be done to ensure that ART treatment can continue.
g. Establish a referral network and mechanisms for life-saving and obstetric referrals, based on country specific standard operating procedures.
h. Where no health information system has been established, use UNHCR's Basic Indicator Report and set up as soon as possible integrated refugee health information system (iRHIS).
i. Where required, identify and select NGO partners to implement these priority actions. Partners should be available, have operational capacity, and possess the required technical expertise and skills.
5. Use UNHCR's procurement and supply system to obtain medicines and medical supplies, in line with the 2013 UNHCR policy.
6. Develop a multi-year public health strategy in conjunction with key actors and partners.
7. Integrate key indicators from the health information system into the programme monitoring framework.
8. Refugees with specific needs, who require assistance to access or use health services should be supported and prioritised.
9. Apply and Age-Gender-Diversity perspective and use community-based approaches
Key management considerations
The efficient implementation of public health measures hinges on effective health sector coordination, technical support, and management. Technical expertise is required to provide the necessary oversight.
Given that UNHCR has an overall accountability for the refugee response, UNHCR should deploy public health staff as soon as possible to support the assessment, develop a public health and nutrition strategy and support the operational response.
The cost of referrals can be excessive. Make sure that resources are used efficiently by developing from the start a strong accountability framework and SOP for referrals (life-saving and obstetric care) to secondary and tertiary care.
Data management is vital, especially in the health sector. iRHIS is designed to manage public health information in emergencies. It is widely accepted and used by partners working in refugee camps. It provides tools to monitor essential emergency health impact indicators (such as mortality and malnutrition), and performance indicators (such as health care utilization). Setting up data collection tools using a health information system is a priority. The data collection tools in Twine should be introduced.
The HIS team is available to provide remote and direct support. Contact [email protected].
Resources and partnerships
A UNHCR Public health officer needs to be on the ground as soon as possible to support support the establishment of a sound emergency response and public health and nutrition strategy.
UNHCR's public health strategy promotes the inclusion of refugees in national systems. The Ministry of Health should remain the key partner for health interventions. When possible, public services should be used and supported.
Links to national programmes (to treat HIV, TB, malaria, etc.) should be established
Ensure linkages with partners across sectors, including health, nutrition and WASH.
Parallel services may be set up with support of partners, however ensure a strong linkage to the national health services and the Ministry of Health.