The provision of health services is one component of an overall public health response to emergencies. The overall aim of any public health intervention (emergency or not) 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 with and support the ministries and local authorities responsible for public health.
Public Health interventions for refugees who are not in camps, i.e., located in urban or rural areas, aim to meet their basic health needs. Similar to camps, services available must include preventive health activities, surveillance and curative care with a focus on the primary health care level and a referral system for emergencies.
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 out of camps whether in urban or rural dispersed 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 Ministry of Health and other relevant actors in the area to establish new services or improve those that exist, for the benefit of both refugee and host populations.
Health conditions and health risks are associated and depend on many factors, including food security, shelter, WASH and availability of non-food items. Public health interventions are, therefore, multi-sectoral in character. Programmes must be coordinated and linked.
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.
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 the entire population.
- Priority-based. Emergency public health interventions and services should be prioritized 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.
- Establish strong co-ordination with the Ministry of Health (MoH), NGOs, UNICEF, WHO, UNFPA and other relevant actors, to ensure refugees are included in available national public health services and programmes as much as possible.
- Conduct an initial health needs assessment, including 3W (Who? What? Where?). Refer to entry on Health Needs Assessment.
- Map the existing public health services.
- Assist the MoH to strengthen existing services to ensure they cover the needs of the increased population (refugees as well as host communities). Avoid setting up parallel services.
- Where refugees are dispersed across many urban or rural areas, gaps in health care services may need to be filled.
- If needed, identify and support local partners (civil society organizations, facilities run by NGOs).
- The choice and form of facility will depend on the number of refugees, their geographical location, and the capacity, quality and cost of services provided. Health services in urban areas almost always cater for both refugee and host populations. Factor this into planning.
- Assess the need for additional staff, equipment or medicines.
- Partners must follow national norms and standards.
- Develop clear standard operational procedures (SOP) for primary and referral care support by UNHCR.
- Make sure that refugees receive information about the services available to them, where these are located, and the conditions under which they can be accessed.
- Ensure translation is available when refugees do not speak the same language as the country of asylum.
- Ensure that refugees have access to essential primary health care services and emergency and obstetric care. The following services should be available:
- Measles, polio vaccination, and vitamin A supplementation.
- Screening for acute malnutrition (where indicated) and provision of nutrition support.
- Communicable disease control, notably:
- Prevention (including immunization, distribution of mosquito nets).
- Outbreak preparedness and response planning.
- Outbreak control.
- Monitoring of disease outbreaks.
- Primary health care services:
- Curative health care (out-patient care and limited in patient depending on contexts).
- Immunization (EPI).
- Non-communicable disease care.
- Mental health and psychosocial support.
- Reproductive health (RH) and HIV. (See entry on SRH and HIV for detail).
- Nutrition screening and care. (See Nutrition entries)
Where RH services are not yet available
Where the MISP or RH/HIV components already exist
Implement the minimum initial service package (MISP).
Expand to comprehensive RH services.
- 24/7 emergency obstetric and neonatal care.
- Prevention of gender-based violence (GBV) and clinical management of rape (CMR).
- High impact STI/HIV prevention and continuation of ART / EMTCT (elimination of Mother-to-Child Transmission).
All of the MISP, plus:
- Antenatal care
- Postnatal care
- Family planning
- Post-abortion care
- Fistula detection and management
- Adolescent sexual and reproductive health services (SRH)
- Comprehensive GBV response
- Comprehensive HIV services
Timeframe: 0-6 months.
Timeframe: >6 months.
- Establish a referral network and mechanisms for life-saving and obstetric referrals, based on country specific standard operating procedures.
- Explore reinforcing or establishing a community health workforce and priority community-based health prevention activities in line with national approaches.
- Integrate refugees in national health information system ideally with access to disaggregated data. If no HIS is in place, implement UNHCR's integrated refugee health information system (iRHIS) as soon as possible.
- 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.
- If patients are expected to pay for health care, make arrangements to ensure that all refugees can afford access to essential primary health care services and emergency and obstetric care.
- Use UNHCR's procurement and supply system to support provision of medicines and medical supplies, if insufficient through the national supply chain, in line with the UNHCR/AI/2023/03 Administrative Instruction on Public Health Programming and the UNHCR Essential Medicine and Medical Supply Guidance 2023.
- Refugees with specific needs, who require assistance to access or use health services should be prioritized and supported.
- Apply an Age-Gender-Diversity perspective in programming.
- Ensure links to national programmes (e.g. to treat HIV, TB, malaria, etc.) and inclusion of refugees in these programmes.
- Ensure linkages with partners across sectors, including health, nutrition, WASH and protection.
Post emergency phase
After the first 6 months, ensure expansion to full reproductive health services beyond the MISP if not already done.
Ensure monitoring of access and utilization of health services and address identified barriers.