Health in rural areas

Protection objectives

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.

Note that UNHCR has developed a comprehensive public health strategy that applies to emergency and non-emergency operations in both camp and out-of-camp settings. Since in rural dispersed settings UNHCR aims to integrate refugees into national services, UNHCR and its partners follow national standards. In addition, the following SPHERE standards may apply as minimum international standard.

• 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.

Protection Risks

• 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.

Other risks

In rare cases, a government, local authority or service provider deters refugees from making use of public services, including health care. UNHCR's protection mandate requires advocating that refugees should have access on the same footing as nationals.

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 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 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.

Health conditions and health risks are associated and depend on many factors, including food security, shelter, WASH, availability of non-food items. Public health interventions are therefore multi-sectoral in character. The strongest links are between the health, nutrition and WASH sectors. Programmes must be coordinated and linked.

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.

Key steps

1. Establish strong co-ordination with the Ministry of Health (MoH), NGOs, UNICEF, WHO and other relevant actors, to ensure refugees are integrated in available national public health services and programmes.
2. Development of clear standard operational procedures (SOP) for primary and referral care support by UNHCR is critical.
3. 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).
• Where refugees are dispersed across many rural settlements or a large geographical area, gaps in health care services may need to be filled.

a. Assist the MoH to improve existing health facilities and service coverage or increase the number of facilities.
b. 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 rural dispersed settings almost always cater for both refugee and host populations. Factor this into planning.
• Assess the need for additional staff, equipment or medicines.

4. Make sure that refugees receive information about the services available to them, where these are located, and the conditions under which refugees can access them. (Are some services restricted? Do they need to pay? Are clinics private? Etc.).
5. Ensure translation is available when refugees do not speak the same language as the country of asylum.
6. Ensure that refugees have access to essential primary health care services and emergency and obstetric care. These take precedence over more specialized medical care. The following services should be offered:
a. Prevention and communicable disease control.
b. Services for infants and young children, including immunizations, clinical consultations, referral, observations.
c. Reproductive health.
d. Non-communicable diseases, including mental health and psychosocial support.
e. Nutrition.
f. Health and hygiene promotion.
g. Emergency medical and obstetric care.
7. Ensure that all needs are covered and that referrals across services and individual follow-up are consistent, given that service structures in rural settings are sometimes diverse and further away from each other.
8. If refugees choose not to use the public health system, and pay for private medical care, UNHCR should not provide support (even retrospectively).
9. 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. Options might include alternative financing methods, such as health insurance schemes.
10. Do not establish vertical services. Support the MoH to expand its services to the area hosting refugees.
11. Only when the local public health system is incapable of providing adequate services should support from partners be sought.
12. When you set up services with partners, they should be fully integrated in the national health system and should be accessible both to refugee and to host populations.
13. If no national health information system exists, set up integrated refugee health information system (iRHIS) .
14. Ensure that HIS data and assessments are integrated in the programme monitoring framework.
15. Refugees with specific needs, who require assistance to access or use health services should be supported and prioritised.
16. Apply and Age-Gender-Diversity perspective and use community-based approaches in assessment and response.

Key management considerations

The efficient implementation of public health measures hinges on effective health sector coordination, technical support, and management.

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 to secondary and tertiary care.

Data management is vital, especially in the health sector. Emergency situations can easily result in excess mortality, disease outbreaks, and elevated rates of malnutrition. Without data collection and management, it is impossible to manage public health interventions. iRHIS is designed to manage public health information in emergencies. It is widely accepted and used by partners. It provides tools to monitor essential emergency health impact indicators (such as mortality and malnutrition), and performance indicators (such as health care use). Setting up data collection tools using a health information system is a priority. During the early onset of an emergency operation, the Basic Indicator Reports should be used. As soon as services expand in scope and extend the comprehensive data collection tools in iRHIS should be introduced.

The HIS team is available to provide remote and direct support. Contact [email protected].

Resources and partnerships

Staffing

• A UNHCR Public health officer needs to be on the ground as soon as possible to support the establishment of a sound emergency response and public health and nutrition strategy.

Partners

• 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.
• Ensure linkages with partners across sectors, including health, nutrition and WASH.
• Links to national programmes (to treat HIV, TB, malaria, etc.) should be established.