Health Assessment, Planning, Monitoring and Surveillance
· An assessment of
the health and nutritional status is an essential start to the provision of
· This must be done
by experts with experience of emergencies and, if possible, local
· The factors
affecting the health of the refugees must be identified and a surveillance and
reporting system established.
4. First, information should be obtained on the number of
refugees2 segregated by age (percentage of children under five years
of age) and sex (male/female ratio). See chapter 11 on registration for more
information on estimating the total number of refugees.
Age/sex breakdown can be estimated from:
i. Information collected during
ii. Information collected during mass immunization
iii. Mass health screening on arrival;
iv. Information collected by community health
5. The aim of the initial health assessment is to identify basic
problems and needs and to establish priorities. It should be carried out by
people with appropriate qualifications and relevant experience. There are
obvious advantages in using national or locally-based personnel, but appropriate
outside expertise can be made available quickly and should be requested through
the Health and Community Development Section at Headquarters if necessary.
6. The priority should be to evaluate the incidence of the major
causes of excess mortality and morbidity - measles, diarrhoeas, pneumonia,
malaria and malnutrition.
7. Relevant information can be obtained from:
i. Direct observation;
ii. Reviewing baseline information regarding the
country/areas of origin and asylum;
iii. Analyzing records at health facilities and
interviewing health workers;
iv. Undertaking sample surveys (nutrition and
mortality). These must be done by experts;
v. Population estimation and registration (see
chapter 11 on population estimation and registration);
vi. Mass health and nutrition screening on arrival.
This should focus on: (i) nutrition screening through visual inspection and
measurement of the Mid Upper Arm Circumference ("MUAC"), (see chapter 15 on food
and nutrition), (ii) checking for communicable diseases and vaccination
coverage, and (iii) identifying patients in need of urgent referral. It is
usually impractical to try to provide treatment in the screening line
8. Figure 2 illustrates key management considerations for action
in light of the initial assessment.
2 Health experts sometimes call this
number "the denominator".
Figure 2 - Assessment and
Monitoring and Surveillance: The Health Information
9. From the earliest stages of an emergency, a health
information system should be put in place under the responsibility of the UNHCR
Health Coordinator. The health information system should be simple, reliable,
and action oriented, and its use will be essential to:
i. Quantify the health and nutritional status of the
ii. Follow trends in health status and monitor the
impact and outcomes of the relief programme;
iii. Detect epidemics;
iv. Evaluate programme effectiveness and service
v. Ensure that resources are targeted to the areas
of greatest needs;
vi. Re-orient the programme as
10. Annex 1 sets out the tables and forms for collecting
health-related information. However, to have a more comprehensive idea of the
situation, information regarding water, food, sanitation, shelter and
availability of soap should also be collected and analyzed (see the relevant
chapters on water, nutrition, sanitation, and physical planning).
11. The health information system should be kept simple. The
information to be collected should be adapted to suit the collectors'
qualifications. Overly detailed or complex reporting requirements will result in
non-compliance. In addition, only data that can and will be acted on should be
collected. Communication and exchange of views among all the actors in the
health information system are essential to secure the functioning of the system.
Only simple arrangements are effective in emergencies.
12. Health information in the initial stages of an emergency
should concentrate on:
i. Demography (see chapter 11 on registration, also
paragraph 4 above, and table 1 of Annex 1);
ii. Mortality and its causes (see tables 2.1 and 2.2
of Annex 1 and paragraph 14 below);
iii. Nutritional status (see Annexes 4 and 5 of
chapter 15 on food and nutrition);
iv. Morbidity (see below, and table 3.1 of Annex
13. Only when the situation stabilizes can the system be made
more comprehensive. Information on mortality and morbidity should be collected
14. Each health facility should keep a log of all patient deaths
with cause of death and relevant demographic information. This information
should be summarized in tables 2.1 and 2.2 of Annex 1, reported centrally and
consolidated with other data. Because many deaths occur outside the health-care
system, a community-based mortality surveillance system should also be
established. Such a system requires identifying sites which people are using as
cemeteries, employing grave watchers on a 24 hours basis, routinely issuing
burial shrouds, and using community informants. Deaths that occur outside
hospitals with unknown causes should be validated through verbal autopsy by
health workers specifically trained for this task.
15. Each health facility providing out-patient services
(including clinics for under five's and selective feeding programmes) should
keep daily records. These records should be in the form of a log book or tally
sheets at least, and should at least record the patient's name, age, sex,
clinical and laboratory diagnosis and treatment. This information should be
summarized in the forms set out as tables 3.1. in Annex 1 and reported
16. Diseases recorded in the health information system must have
a case definition (i.e. a standard description) which will guide health workers
in their diagnosis and ensure the consistency and validity of data. Where
possible, case definitions that rely on clinical signs and symptoms (e.g.
malaria) should be checked against a laboratory standard test (e.g. blood test
17. In addition, the patient should be issued a health record
card (or "Road to Health" card) on which the date, diagnosis, and treatment are
recorded. Every contact a patient has with the health-care system, whether for
curative or preventive services, should be noted on the health record card
retained by the patient.
18. The health information system should be periodically
assessed to determine its accuracy, completeness, simplicity, flexibility, and
timeliness. The way programme planners and key decision-makers use the
information should also be assessed. The system should evolve as the need for
19. Camp and centrally controlled monitoring of health and
nutritional status is essential if problems are to be identified in time to
allow preventive and/or corrective actions to be taken and to adjust resource
allocation. The refugees' health status should improve as public health services
start to function adequately and the refugees adjust to their new environment.
20. However, a vigilant surveillance system must be maintained.
Seasonal changes will affect health (for example temperature changes, and
especially the rainy season) so seasonal variations in the incidence of disease
will remain. The UNHCR Health Coordinator and her/his counterparts in the
government and other partners will be responsible for the quality of this
surveillance, the data required, who will interpret it and how to ensure action
on the results and feed-back to all actors.
21. The most important and specific indicators of the overall
status of the refugee population are the Crude Mortality Rate (CMR), for the
whole population and Under-5 Mortality Rate (U-5MR) for children under five
years of age. These indicators are of crucial importance to managers of the
operation and are also of great interest to the media, donors and relief
agencies. A priority for the health surveillance system is to produce reliable
information on death rates.
22. During the emergency phase, mortality rates should be
expressed as deaths/10,000 persons/day so that sudden changes can be detected.
Crude Mortality Rate is
This is calculated as follows:
23. The objective of the overall assistance programme in the
emergency phase should be to achieve CMR of <1/10,000/day and U-5MR of
<2/10,000/day as soon as possible. These rates still represent approximately
twice the "normal" CMR and U-5MR for non-displaced populations in most
developing nations and should not signal a relaxation of efforts.
24. Age and sex-specific mortality rates have to be collected
systematically and may indicate the need for targeted interventions. Table 1
below shows some benchmarks against which the daily Crude Mortality Rate (CMR)
can be compared. Under-5 Mortality Rate benchmarks are usually twice the CMR.
Table 1 - Crude Mortality Rate Benchmarks
out of control
Morbidity (incidence and types of disease)
25. Knowing the major causes of illness and the groups at
greatest risk helps efficient planning of intervention strategies and the most
effective use of resources. Morbidity incidence is the number of new cases of a
given disease among the population over a certain period of time, usually
expressed per 1,000. It is more useful to follow this than to keep a simple
tally of cases, as trends can be followed over time, or compared with other
situations. Morbidity incidence should be recorded as set out in Tables 3.1 and
3.2 in Annex