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Prioritize vaccination of children against measles and polio as early as possible from the first entry or point of contact (including reception/transit centers)
Establish mechanisms to implement health screening and identify major health risks and persons with serious medical needs/conditions including malnutrition
Ensure an effective medical referral system for health emergencies from the beginning
Support local health facilities to accommodate refugees’ health needs wherever possible rather than establishing parallel services
Focus on the high impact lifesaving interventions initially that can be scaled up depending on length of stay in reception/ transit centers
Ensuring access to health care services during emergencies remain an integral part of UNHCR's overall public health approach. The overall aim of public health interventions during emergencies is to prevent and reduce excess mortality and morbidity.
Essential health screening and services should be provided as soon as possible and during population movements.
This may range from borders/ points of entry, transit and reception centres, waypoints or temporary accommodation before refugees reach a settlement.
Reception and transit centres should be equipped to provide health and nutrition services and access to food among the essential services. Additionally, clean water and proper sanitation facilities are essential to maintain hygiene and prevent the spread of infectious diseases. Ensure access to continuation of medication such as antiretroviral therapy for HIV (ART), access to medical referrals for acute life-threatening conditions as well as access to the SRH Minimal Initial Service Package (MISP) . Reception and transit centers should have emergency vehicles on standby for referral of emergency cases for more specialized care when available. Health promotion and health education to prevent spread of communicable diseases are an essential part of health services in reception/transit centres.
Relevance for emergency operations
The main causes of deaths and diseases in emergency situations are vaccine-preventable, and communicable diseases as well as vector-borne diseases in some geographical areas. Children, especially those under five years of age, are at most risk.
Access gaps for reproductive health needs (in particular pregnancy and obstetric complications) are increase the likelihood of complications.
Emergency situations increase the risk of gender-based violence, especially for women and children.
Displacement may be associated with armed conflict, resulting in casualties, injuries and mental health effects.
Large-scale population movements may overburden or exceed the response capacity of the host health system.
The first point of contact with refugees may be border crossing points or temporary access points such as reception centers, transit centres, waystations and temporary accommodation. Forcibly displaced populations should have access to a set of minimum essential health services at each contact point.
Points of entry/ border crossing points
Refugees may arrive exhausted. They may be dehydrated and have acute illnesses or injuries.
Where those border points are accessible, a minimum set of health interventions is recommended to be delivered together with national authorities and partners:
Triage: screening for severe illnesses that require immediate treatment and/ or referral as well as identification walk in cases with diseases of epidemic potentials (e.g. suspected cholera, measles).
Vaccinate all children (at minimum, up to 15 years) against measles and polio and provide Vitamin A supplements and deworming if feasible. If not, ensure vaccination as soon as possible e.g. at reception/ transit centres. Treatment for acute illnesses requiring urgent action.
Referral of emergency cases to nearby health facilities, including for emergency obstetric and newborn care (EmONC).
Other access points (e.g. reception and transit centres, waystations, temporary accommodation)
The following actions should be taken to ensure appropriate health services are provided to refugees at the temporary access points:
Identify and collaborate with partners, including national authorities, UN agencies, NGOs and civil society organizations.
Rapidly assess the health status of the population and map existing health and nutrition services and health and nutrition supplies using the 3Ws.
2. Plan for service delivery:
Collaborate with the Ministry of Health (MoH) and partners to reinforce existing services to meet the needs of refugees and host communities.
Coordinate and plan with MoH and partners to set up parallel services in support of the national health system, if the national system fails to address emergency health needs during the emergency phase of the influx. Plan for transitioning to national services from the onset wherever possible.
Consider that not all refugees might be in transit/ reception centers. If refugees are dispersed across vast areas, identify gaps in healthcare services of such refugee hosting areas and address them.
3. Immediate Health and nutrition Interventions:
Screen and identify:
Identify those with severe medical conditions and refer to nearby public hospitals with emphasis on emergency obstetric and neonatal care and life saving care.
Nutrition screening of the children under 5 and pregnant and lactating women for acute malnutrition and link them to nutrition assistance programs.
Identify patients who need continuous medication for chronic non-communicable diseases including HIV and TB and link them to health services.
Vaccinate all children (at minimum, up to 15 years) against measles and polio and provide Vitamin A supplements and deworming if not already done at point of entry.
Prioritize treatment of acute illnesses in line with local epidemiology.
Prioritize access to essential primary healthcare and the access to emergency obstetric and neonatal care. This includes communicable disease control, infant and young child services, essential reproductive health services including clinical management of rape (See also SRH and HIV entry), noncommunicable diseases (NCDs) and emergency medical care.
Treatment of severe acute malnutrition (see nutrition entry).
Food security: Provision of high energy biscuits, hot meals (depending on the situation)
Support providing psychological first aid (PFA) and connect those in need to services.
Set up epidemiological surveillance to identify diseases with a potential for outbreaks.
4. Sharing Information:
Engage Community Health Workers from the onset of an emergency and implement health, nutrition and hygiene promotion including on communicable disease control and timely health seeking.
Inform refugees about available services, services locations, and access conditions.
Ensure language translation services if there is a language barrier.
5. Financial and System Integration:
If healthcare services are chargeable and fees are a barrier, take measures to address this such as requesting waivers for refugee fees, developing reimbursement mechanisms with health facilities through establishing contracts or cash-based interventions.
Collaborate/coordinate with partners to establish parallel services only if the local public health system is inadequate. If the parallel services are established, ensure they have an inclusion plan to the national system from the onset.
Newly established services with partners should be integrated into the national health system and be accessible to both refugees and host communities.
6. Data Management and Monitoring:
Ensure that the public health situation at the access points is monitored and the stakeholders receive regular reports to enable rapid response if the situation changes.
Implement an integrated refugee health information system (iRHIS) if existing national system does not include refugee specific data.
HIS must include mortality data collection (ensure capture of deaths occurring both inside and outside of the health facility).
Collect/provide key initial data in first week: Influx numbers, mortality, key morbidities, nutrition situation.
Share data regularly with MoH and partners as well as with other sectors.
7. Special Considerations:
Prioritize and support refugees with specific needs and vulnerabilities in accessing health services.
Apply an Age-Gender-Diversity perspective and utilize community-based approaches in assessments and responses.
The package of services will depend on the location and the duration of stay. Identify trained health staff among refugees to support the response as health workers, including community health workers, in line with national policies.
Post emergency phase
Generally, post emergency, many refugees will have relocated or moved to settlements depending on the context. However, there can be a situation of ongoing movement across borders and new arrivals, in which case services at the first points of contact should be maintained. Seek integration with the national health system for such services as much as possible.
Health at points of entry and access points checklist
Set up triage and health and nutrition screening at points of entry.
Prioritize vaccination against measles and polio of children under 5 (and up to 15 years of age depending on local factors).
Identify people with immediate health needs and provide initial care.
Identify people with chronic conditions already on treatment ( eg TB, HIV, NCDs) and ensure continuation of their treatments.
Provide psychological first aid (PFA).
Ensure a referral system and transport for emergency cases including EmONC.
Provide essential package of primary health services including community health services at reception and transit centers.
Ensure coordination with national authorities and partners.
Set up surveillance and a HIS if not already in place.
UNHCR has a comprehensive public health strategy (currently 2021-2025) that applies to emergency and non-emergency operations in both camp and out-of-camp settings which includes urban settings.
UNHCR and its partners follow national standards wherever available and applicable.
The following SPHERE standards (Sphere handbook 2018) are applicable as minimum international standards:
Health systems standard 1.1: Health service delivery
People have access to integrated quality healthcare that is safe, effective and patient-centred.