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.
Public Health interventions in transit centres aim to meet the basic health needs of newly arrived 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 camp and out-of-camp settings. To tailor its interventions more efficiently to emergency situations, UNHCR recommends the use of SPHERE standards during emergency operations.
- 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 acess 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 and/or the cost of services, may harm relations between refugees and host populations.
Failure to provide adequate health and nutrition services at the transit centre may generate a number of risks, for example:
- The security of transit centres may be 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
Decision points with respect to transit centres:
- Transit centres are rest stations that need to provide food, basic health care and nutrition services, and water and sanitation facilities.
- Ensure standby vehicle are available for emergency referrals.
- Ensure there is capacity to provide first aid care on the road (en route).
- Make sure that patients continue to receive medication.
- Make arrangements to assist individuals who have serious medical conditions or specific needs
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 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.
Transit centres are normally part of an overall operation that includes camps and out-of-camp settings. Managing a transit centre is therefore one element in the operational response. Public health interventions in transit centres focus on the following priorities:
- Establish strong co-ordination to ensure the response covers all needs, and that referrals across services as well as individual follow-up are assured.
- Measles and polio vaccination of all children between 6 months and 15 years of age, Vitamin A supplements, and deworming.
- Health screening (triage) for serious medical conditions and referral to a nearby public hospital.
- Assessments of nutrition status; screening for acute malnutrition, where indicated (please refer to the Entry on nutrition in transit centres).
- Ensure referral to a nearby health centre or establish temporary health post for consultations for acute illness and for consultations for people with chronic diseases for continued medication, including people on antiretroviral treatment.
- Provision of a minimum initial service package (MISP) for reproductive health (RH), where no RH services are available or accessible.
- Referral for emergency obstetric neonatal care and SGBV.
- Refugees with specific needs, who require assistance to access or use health services should be supported and prioritised.
- Apply the age gender and diversity (AGD) perspective and use community-based approaches in assessment and response.
Key management considerations
The efficient implementation of public health measures hinges on the efficiency of 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.
UNHCR should ensure that the public health situation in transit centres is monitored and that relevant stakeholders receive regular reports, and can therefore respond rapidly if the situation changes. The Basic Indicator Report format should be used for reporting.
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 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, national 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.
- Parallel services especially in transit centres and camps may have to be set up with support of partners; however ensure a strong linkage to the national health services and the Ministry of health.
DPSM/PH Section at: