|Handbook for Emergencies - Second Edition (UNHCR, 1999, 414 p.)|
· The health services must be developed with and not just for the refugees and in accordance with their needs and demands;
· The early appointment of a suitably experienced health coordinator to UNHCR's staff has proved essential. A reproductive health focal point should also be identified as early as possible;
· While the use and development of local expertise is preferable, it is often necessary to mobilize outside assistance in an emergency;
· The issue of staff salary and incentives should be discussed and solved from the outset;
· The Ministry of Health at all levels must be as closely involved as possible.
89. The refugees must be given responsibility for their own health. Outside health workers must understand the refugees' own concepts of health and disease. From the beginning, health services should be developed and operated with, rather than for, the refugees. If not, the services will be less effective, may be distrusted and poorly used, and are unlikely to be sustainable.
90. Preventive services should always be free. In most situations, other health services are also offered free of charge. While this may well be justified, it should not be considered as a policy as it is often based on paternalistic attitudes. The issue of cost-recovery or payment for services should be regularly analyzed and most particularly when refugees are integrated within the local population (which may have to pay for services) or when refugees are benefiting from local integration and sources of income.
91. As a general principle, the order of preference for selecting health personnel, in cooperation with the national authorities, is:
ii. Experienced nationals or residents;
Most emergencies will require some combination of these sources.
92. Strong emphasis should be placed on the training, supervision and upgrading of medical skills of selected refugees, particularly in their former roles within the community. When selecting refugees, care must be taken to include women who may not come forward as readily as men. Full account should be taken of the experience of the traditional healers and midwives. Refugees may seek traditional treatments and experience has demonstrated the advantages of encouraging traditional methods of health care which complement other organized health services.
93. An important consideration may be the government's attitude to foreign medical personnel, including, for example, recognized qualifications and permission to practice medicine.
94. The issue of staff salary and incentives should be addressed at the onset. All agencies and organizations involved in the refugee programme should adhere to the same standards. The determination of salaries and incentives should be based on the national (or country of origin) standards and due account should be taken of assistance (free food, water, shelter etc.) received by refugees. In principle, all staff performing work on a daily basis, with clearly identified responsibilities and strict working hours, should receive a salary or an incentive.
95. Special attention should be given to the recruitment of local staff. The salary or incentive offered to them should be in line with national standards. Very frequently, refugee emergencies attract national personnel (commonly referred to as "brain drain") at the expense of national services which can create serious tension.
The National Health Authorities
96. Early involvement of the host government's central, provincial, and district health services is essential. To the extent possible, services provided to refugees should be integrated with national services. It will be particularly important to ensure integration and compatibility with certain treatment protocols, immunization programmes, communicable disease control and surveillance practices. Promoting good health for the refugees is clearly in the interest of the local population. In addition, supporting existing structures will help ensure that health services for refugees are sustainable and are at a standard equivalent to that of the host country nationals.
UNHCR Health Coordinator
97. In major emergencies, (e.g. when there is a prevalence of epidemics, many partners, large numbers involved) UNHCR must ensure that a Refugee Health Coordinator is appointed. The Health Coordinator should be a key member of the UNHCR programme staff. The person should take the lead role in this sector, or play a key supporting role to the national institution which takes the lead role.
98. The Health Coordinator's primary responsibility will be to ensure that the level and quality of services provided adhere to nationally and internationally accepted standards and medical ethics.
Other main tasks and duties include:
i. Participating and facilitating the consultation process among all concerned parties in order to carry out an appropriate problem, needs and resources assessment;
ii. Participating in, and facilitating the creation of, health and nutrition committees with the Ministry of Health, other UN agencies and non-governmental organizations (NGOs) where coordination will take place to jointly identify priority activities, and to plan for their implementation by defining needed human, material and financial resources;
iii. Facilitating cooperation among all partners to ensure an appropriate implementation and monitoring of the programme as agreed upon at the coordination committee meetings;
iv. Setting up and participating in the implementation of an effective Health Information System;
v. Ensuring that joint protocols for medical treatment, staffing and training are established and that implementing partners adhere to them;
vi. Ensuring the identification of a qualified and experienced person to coordinate reproductive health activities at the start of the relief programme;
vii. Facilitating inter-sectoral coordination;
viii. Consolidate the reporting about the refugees' health and nutritional status;
ix. Assisting in setting up a medical evacuation plan for UNHCR staff.
99. Experience shows that it is in the first days and weeks of an emergency that excess mortality is recorded.
It is therefore vital that a UNHCR Health Coordinator is fielded immediately, at the very start of the emergency.
100. The quickest and most practical way to deploy a Health Coordinator is usually to send UNHCR staff or consultants. Headquarters should be consulted immediately on this. At a later stage, posts can be created or staff seconded from other UN agencies (UNICEF or WHO), or from the Ministry of Health.
Other Specialized Staff
101. The need for specialized staff should be carefully assessed by the UNHCR Health Coordinator or by the Health and Community Development Section at Headquarters. Such specialists include epidemiologists, specialists in public, reproductive and mental health, nutrition, tropical medicine, paediatrics, midwifery, pharmacy etc.
Experienced personnel with the right personality are more important than highly trained Specialists, whose skills are often inappropriate.
102. Familiarity with the local culture, patterns of disease and the public health services and previous experience in emergencies are as important as an advanced knowledge of medicine and medical techniques.
Role of the UN and Specialized Agencies
103. WHO. The World Health Organization works directly with the Ministry of Health in almost every country in the world. The response to the health needs of the refugees and surrounding local populations should be closely coordinated with WHO. Details of this collaboration are described in the WHO and UNHCR Memorandum of Understanding, Appendix 3.
104. UNICEF. Collaboration with UNICEF in emergencies will focus on supply of measles vaccines and delivery/midwifery kits, as well as on health education (see Memorandum of Understanding between UNICEF and UNHCR for more details, Appendix 3)
105. UNFPA. Collaboration with UNFPA focuses on reproductive health matters and demography and there is a Memorandum of Understanding between UNFPA and UNHCR which details this collaboration, Appendix 3.
106. UNAIDS. UNAIDS is an inter-agency mechanism created in 1995 to support national HIV/AIDS programmes. Refugee health services must be integrated in these national programmes.
107. Through a standby arrangement with UNHCR, the Centre for Disease Control and Prevention (CDC Atlanta, USA) can supply, at short notice, experts for rapid health and nutritional assessment, improvement of epidemic preparedness and response in emergencies and set up Health Information Systems. Deployments are usually limited from four to eight weeks and can be arranged upon request through the Health and Community Development Section at Headquarters.
Role of NGOs
108. Operational and implementing partners are essential collaborators for UNHCR. All collaborators in the emergency health programme must be brought together to form health sub-committees at the central and field level as appropriate. Initially, these committees may have to meet daily or at least weekly, usually under the chairpersonship of a representative of the Ministry of Health, supported by the UNHCR Health Coordinator. Ideally, members of the committee should have been identified at the contingency planning stage.
109. Activities of the health sub-committee include: allocation of tasks, exchange and pooling of information on health activities and with other sectors (e.g. food, water, sanitation etc.), setting up jointly agreed protocols for medical procedures, staffing levels and training, and problem-solving in general.
110. In emergencies, urgent outside assistance in the health sector is almost invariably necessary. This is because the immediate and specialized attention needed represents a burden that existing local structures are not designed to bear. District health services will almost never have the needed reserve capacity in terms of staff at all levels, infrastructure, medical supplies and technical expertise. This capacity can be developed over time, with the support from the central government and other UN agencies.
111. NGOs (international, regional or national) must be chosen with care and this is usually done by the government of the country of asylum. However, it is also the responsibility of UNHCR to advise the government on which organizations have proven competence in emergencies. Some agencies have experience in long-term situations but less in emergencies; others may be too narrow in focus, preferring to do purely curative work to the exclusion of public health, prevention, sanitation etc.
112. Small NGOs, especially those created in response to a specific situation, should first demonstrate appropriate competence before being engaged in the emergency phase.
The number of agencies involved should be kept to a minimum.
113. During the early stages of an emergency it is essential that the numbers of NGOs involved should be kept to the minimum necessary, and that those chosen should be professional, capable of deploying experienced personnel and with proven past experience in collaborating with both governments and UNHCR in the effective management of an emergency.
Organization of Response
114. A possible hierarchy of health services is outlined in Annex 2. It is based on a large-scale emergency involving a great number of health staff, both national and international. A smaller emergency will require fewer levels of organization. Note that the numbers and qualification of staff suggested is no more than an indication. Actual needs will depend on the health problems, the degree of isolation of the area and so on.
115. Once the pattern of disease and overall needs have been determined, situation-specific guidelines on standard procedures for health workers should be prepared, based on national or internationally recognized standards. These should cover all aspects of the services, including such subjects as basic principles, how the services are to be organized, including any selective feeding programmes, standardized treatment protocols, drug lists and supply, vaccination and reporting. The guidelines should be prepared by the UNHCR Health Coordinator in consultation with all concerned, issued under the aegis of the Ministry of Health if possible, and reviewed periodically, for example by a health coordination sub-committee. At least part of the guidelines should be translated into the language of the community health workers.
All organizations providing health care to the refugees should be involved in the preparation and required to observe standard guidelines.