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close this bookHandbook for Emergencies - Second Edition (UNHCR, 1999, 414 p.)
close this folder14. Health
View the document(introduction...)
View the documentOverview
View the documentIntroduction
View the documentHealth Assessment, Planning, Monitoring and Surveillance
View the documentMain Health Programmes
View the documentOrganization of Refugee Health Care
View the documentHuman Resources and Coordination
View the documentKey References
View the documentAnnexes

(introduction...)


Figure

Overview

Situation

It is well known from experience that emergencies result in excess loss of life (high mortality) and increased incidence of diseases (high morbidity). The diseases mainly responsible for high mortality and morbidity are measles, diarrhoeal diseases (including cholera), acute respiratory infections (pneumonia), malnutrition and malaria. The factors which increase the risk of disease and which should be addressed in any emergency response include an unfamiliar environment, poverty, insecurity, overcrowding, inadequate quantities and quality of water, poor environmental sanitation, inadequate shelter and inadequate food supply.

Objectives

· To promote the enjoyment of the highest attainable standards of physical and mental health1, and to prevent excess mortality and morbidity.

Principles of Response

· Priority should be given to a Primary Health Care (PHC) strategy focusing on the vital sectors of water, food, sanitation, shelter and physical planning. In addition, preventive and basic curative health services should be provided. The health of the majority of the refugees is more likely to be affected by these measures than by individual care;

· Refugee participation in the development and provision of health services is essential;

· Services provided for refugees should be at a level equivalent to that appropriate to host country nationals - i.e. there must be parity;

· The health programme should also be sustainable. It is sometimes better not to start activities which cannot be maintained, than to cease supporting activities which both implementing partners and beneficiaries have come to take for granted;

· The health services must be of a quality that ensures that programmes, providers and institutions respect patients' rights and comply with nationally and internationally accepted health standards and principles of medical ethics;

· Many countries will not have sufficient human and material resources to respond adequately to the extraordinary needs generated by an emergency. Experienced national and international NGOs should be mobilized to initiate urgent life saving measures. Rapid integration with the Ministry of Health (MOH) is essential;

· Health services should take into account the particular vulnerability of children under five years during emergencies. Priority should be given to immunizations, feeding programmes, oral rehydration therapy, Vitamin A prophylaxis, basic curative care and family health;

· Health services should also take into account the special needs of women who play a central role as primary health care providers and at the same time bear a disproportionate share of suffering and hardship;

· A UNHCR Health Coordinator should be appointed with responsibility for the health programme and for ensuring that nationally and internationally accepted standards and best practice are adhered to, in close coordination with the national health authorities and other organizations.

Action

· Assess the health and nutritional status of the population and identify the critical health risk factors in the environmental conditions;

· Establish priority needs, define the required activities to meet those needs and determine the required human, material and financial resources to perform these activities;

· In accordance with these activities, set up community-based health services and devise the appropriate organizational and coordination mechanisms both with the health partners and the other relevant sectors of assistance;

· Promote basic health education for the refugees and train refugee health workers;

· Monitor and evaluate the effectiveness of the services and adjust as necessary;

· Ensure that decisions about the health services are based on proper assessment and surveillance;

· Communicate information about the emergency situation and the health services for advocacy purposes.

1 International Covenant on Economic, Social and Cultural rights", 1996, Article 12.

Introduction

1. Good health, depending as it does on so many non-medical factors, is too big a subject to be left only to medical workers. This chapter is directed at non-specialist staff in the field. It does not pretend to give "medical answers" to health problems. It does however seek to show that proper assessment of problems, needs and resources, appropriate organization and coordination of public health and medical services based on a Primary Health Care (PHC) strategy are more important to the overall health status of refugees than curative medicine alone, see figure 1. These crucial organizational factors are often the responsibility of non-medical UNHCR staff.

2. In an emergency, many refugees will be exposed to insecurity, poor shelter, overcrowding, lack of sufficient safe water, inadequate sanitation, inadequate or inappropriate food supplies and a possible lack of immunity to the diseases of the new environment. Furthermore, on arrival, refugees may already be in a debilitated state from disease, malnutrition, hunger, fatigue, harassment, physical violence and grief. Poverty, powerlessness and social instability, conditions that often prevail for refugees, can also contribute to increased sexual violence and spread of sexually transmitted diseases including the Human Immuno-deficiency Virus (HIV).

3. The World Health Organization (WHO) has summarized the concept of Primary Health Care as follows: "PHC is essential health care made accessible to everyone in the country; it is given in a way acceptable to individuals, families, and the community, since it requires their full participation; health care provided at a cost the community and the country can afford. Though no single model is applicable everywhere, Primary Health Care should include the following: promotion of proper nutrition, an adequate supply of safe water, basic sanitation, reproductive and child care, including family planning, appropriate treatment for common diseases and injuries, immunization against major infectious diseases, prevention and control of locally endemic diseases, education about common health problems and what can be done to prevent and control them".

At the heart of such a strategy there is an emphasis on preventive, as against curative care alone.


Figure

Health Assessment, Planning, Monitoring and Surveillance

· An assessment of the health and nutritional status is an essential start to the provision of health services;

· This must be done by experts with experience of emergencies and, if possible, local knowledge;

· The factors affecting the health of the refugees must be identified and a surveillance and reporting system established.

Initial Assessment

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 surveys;

ii. Information collected during mass immunization campaigns;

iii. Mass health screening on arrival;

iv. Information collected by community health workers.

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 itself.

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 Response

Monitoring and Surveillance: The Health Information System

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 refugee population;

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 coverage;

v. Ensure that resources are targeted to the areas of greatest needs;

vi. Re-orient the programme as necessary.

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 1).

13. Only when the situation stabilizes can the system be made more comprehensive. Information on mortality and morbidity should be collected as follows:

Mortality

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.

Morbidity

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 centrally.

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 for malaria).

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 information changes.

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.

Mortality

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

deaths/10,000/day.

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

Average rate
in most developing
countries

0.5
deaths/10,000/day

Relief programme:
under control

<1.0
deaths/10,000/day

Relief programme:
very serious
situation

>1.0
deaths/10,000/day

Emergency:
out of control

>2.0
deaths/10,000/day

Major catastrophe

>5.0
deaths/10,000/day

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 1.

Main Health Programmes

· The main causes of death and diseases in emergency situations are measles, diarrhoeas (including cholera), acute respiratory infections, malnutrition and malaria (where prevalent). Priority should be placed on programmes to reduce the negative impact of these diseases;

· Other causes of morbidity include tuberculosis, meningitis, vector-borne diseases, sexually transmitted diseases including HIV/AIDS, pregnancy and obstetric3 complications, and childhood vaccine-preventable diseases;

· The emotional stress of displacement, often compounded by harassment, violence and grief suffered by the refugees will combine to deplete their physical and emotional reserves and reduce their natural resistance to diseases;

· Experience underlines the importance of meeting the reproductive health needs of refugees, and most particularly of women and adolescents;

· Early emphasis should be placed on correcting environmental factors which adversely affect health.

3 Obstetrics: the branch of medicine concerned with childbirth and the treatment of women before and after childbirth.

Curative care

26. The peak of curative medical care is at the early stage, when refugees are most vulnerable to their new environment with the health hazards it poses and before it has been possible to achieve any major public health improvements. Even though curative care alone will not meet the objective of reducing excess loss of lives, it will create confidence among the refugees towards the health services.

27. Appropriate diagnosis and treatment protocols of major diseases must be defined in accordance with national protocols, if they are suitable to the refugee context. There may be some exceptions to this rule, but implementation of refugee specific protocols should always be previously agreed upon with national authorities.

28. Remember to take into account deaths occurring outside the health care system. A commonly documented error, committed by even excellent clinicians who have become absorbed in a health facility, is to fail to notice that cemeteries are being filled by refugees dying in their shelters, without having been identified or referred to receive appropriate curative services.

Immunization

29. Measles has been documented as being responsible for excess loss of lives, particularly but not exclusively among children under five years of age.

Immunization against measles for young children is the only essential immunization in the early stages of an emergency.

UNHCR advocates the immunization of children from 6 months up to 12 or even 15 years (rather than the more usual 5 years) because of the increased risks from the living conditions in refugee emergencies.

30. The decision as to whether or not to undertake a measles vaccination campaign at the onset of an emergency should be the responsibility of an expert. The campaign should ideally be associated with, but not delayed by, distribution of Vitamin A. The decision will be based on the vaccination coverage reported in the country and area of origin and its reliability, and whether there has been a recent epidemic or vaccination campaign. If there is a need for a measles vaccination campaign, it should not be delayed until other vaccines are available, and it should have appropriate mechanisms to ensure new arrivals are vaccinated. The provision of vaccines should be discussed with UNICEF (see the MOU between UNICEF and UNHCR, Appendix 3).

31. There are strong reasons, both medical and organizational, not to have a mass immunization programme with all vaccines. The most common causes of disease and death in the emergency phase cannot be cured or prevented by immunizations (except measles). Mass immunization programmes require a large number of workers, and vaccines need careful handling and controlled, refrigerated conditions. Therefore undertaking such a campaign may represent a misuse of time and resources in an emergency.

32. As soon as the emergency has stabilized there should be a complete Expanded Programme of Immunization (EPI), which should form an integral part of the ongoing long-term health programme. A standard EPI includes diphtheria, pertusis and tetanus toxoid (DPT), oral polio (OPV), and BCG (Bacille Calmette-Guerin) vaccines as well as measles. However, there should not be a vaccination campaign against any of these (apart from measles), nor should there be a complete EPI, unless the following criteria are met: the population is expected to remain stable for at least 3 months; the operational capacity to administer vaccine is adequate, and the programme can be integrated into the national immunization programme within a reasonable length of time (see the MOU between UNICEF and UNHCR, Appendix 3).

33. It is essential that adequate immunization records be kept. At the very minimum, personal immunization (or "Road to Health") cards should be issued. In addition, an independent central register of all immunizations is desirable, to enable analysis of vaccination coverage.

Communicable Disease Control

· Emergency conditions, particularly overcrowding, poor sanitation etc. will facilitate the spread of communicable diseases;

· The aim is to prevent, detect, control and treat diseases;

· Refugees are at greatest risk if they are exposed to a disease against which they have not acquired immunity (e.g. measles, malaria etc.);

· Communicable disease outbreaks require an immediate on-the-spot expert investigation and close coordination of the response with the national authorities, WHO and partners as appropriate.

34. The main causes of death and morbidity among refugees in emergencies are:

i. Measles,

ii. Diarrhoeal diseases,

iii. Acute respiratory infections,

iv. Malaria (where prevalent).

Moreover, the interaction between malnutrition and infection, particularly among young children, contributes to increased rates of mortality.

Other communicable diseases - meningococcal meningitis4, tuberculosis, sexually transmitted diseases (STDs), hepatitis, typhoid fever, typhus and relapsing fever - have also been observed among refugee populations. However, the contribution of these illnesses to the overall burden of disease among refugees has been relatively small.

4 See World Health Organization. Control of Epidemic Meningococcal Disease: WHO Practical Guidelines, 1995.

Diarrhoeal Diseases

35. Diarrhoeal diseases represent a major public health problem and acute epidemics of shigellosis (causing bloody diarrhoea dysentery) and cholera, have become common in refugee emergencies and have resulted in excess loss of lives. In risk areas, it is essential to set up appropriate preventive measures as soon as possible. These measures include:

i. Adequate supply of potable water and an appropriate sanitation system;

ii. Provision of soap and education on personal hygiene and water management;

iii. Promotion of food safety and breast-feeding;

iv. Reinforced home visiting and early case detection;

v. Identification of an area ("cholera management unit") to manage patients with cholera in case an epidemic occurs.

36. It is not possible to predict how a cholera outbreak will develop. If proper preventive measures are taken less than 1% of the population should be affected. Usually however, 1 to 3% are affected but in extreme cases it can be more-even as much as 10%.

37. To be prepared to respond quickly to an outbreak, the above preventive measures should be accompanied by the establishment of appropriate protocols on case management. These protocols should be based on National or WHO protocols and should be founded on rehydration therapy, continued feeding and appropriate antibiotics (especially for shigellosis5). In addition, there should be a reliable surveillance system for early detection of cholera cases, to follow trends and determine the effectiveness of specific interventions.

38. A significant amount of material, financial and experienced human resources are likely to be needed to respond to a cholera outbreak and reduce the case fatality rate.

39. To facilitate an immediate response, cholera kits can be obtained from the Supply and Transport Section at Headquarters at short notice. Each kit can cover the overall management of some 500 cases. No efficient vaccine to prevent cholera outbreaks is as yet available.

5 See World Health Organization. Guidelines for the control of Epidemics due to Shigella Dysenteriae Type 1, 1995.

Measles

40. WHO has classified refugees and displaced populations, especially in camps, as groups at highest risk for measles outbreaks. Indeed, this disease has been devastating in many refugee situations. Measles vaccination coverage should be as close as possible to 100%, if not, measures should be taken immediately to control the situation (see the MOU between UNICEF and UNHCR, Appendix 3, and paragraphs on immunization above).

Malaria

41. Malaria can also pose major problems. Its appropriate management and control is also a matter for experts and is based on the following:

i. Early case detection and appropriate treatment. It may be necessary to study drug resistance;

ii. Preventative treatment (chemoprophylaxis) particularly for pregnant women;

iii. Elimination of vector breeding sites;

iv. Vector control, including the distribution of insecticide-impregnated mosquito nets and periodic spraying, as indicated.

42. Chemical control measures such as spraying, or impregnated mosquito nets, may seem quite attractive but should only be taken upon expert advice as several factors must be considered such as: the habits of the refugees, seasonal variations, mosquito biting habits, transmission levels, national protocols about chemicals and registered lists of chemicals, and cost. Please see chapter 17 on environmental sanitation for guidance on vector control.

Acute Respiratory Infections

43. Pneumonia is the acute respiratory infection that has been documented as a cause for excess mortality, most particularly in the under five population. It is therefore essential to make sure that refugees are provided with adequate shelter and blankets as soon as possible. Health staff must be appropriately trained to diagnose and treat respiratory infections.

44. The more common diseases are outlined in table 2 below which illustrates the environmental impact on disease and indicates those improvements in living conditions which will bear directly on the health of the refugees.

Table 2 - Common diseases

Disease

Major contributing factors

Preventive measures

Diarrhoeal
diseases

Overcrowding, contamination of
water and food
Lack of hygiene

· adequate living space
· public health education
· distribution of soap
· good personal and food hygiene
· safe water supply and sanitation

Measles

Overcrowding
Low vaccination coverage

· minimum living space standards as defined in chapter
12 on site planning
· immunization of children with distribution of vitamin A.
Immunization from 6 months up to 12-15 years (rather
than the more usual 5 years) is recommended because
of the increased risks from living conditions

Acute
respiratory
infections

Poor housing
Lack of blankets and clothing
Smoke in living area

· minimum living space standards and
· proper shelter, adequate clothing, sufficient
blankets

Malaria

New environment with a strain to
which the refugees are not immune
Stagnant water which
becomes a breeding area for
mosquitoes

· destroying mosquito breeding places, larvae and
adult mosquitoes by spraying. However the success
of vector control is dependent on particular mosquito
habits and local experts must be consulted
· provision of mosquito nets
· drug prophylaxis (e.g. pregnant women according to
national protocols)

Meningococcal
meningitis

Overcrowding in areas where
disease is endemic (often has local
seasonal pattern)

· minimum living space standards
· immunization only after expert advice when
surveys suggest necessity

Tuberculosis

Overcrowding
Malnutrition
High HIV prevalence

· minimum living space standards (but where it is en-
demic it will remain a problem)
· immunization

Typhoid

Overcrowding
Poor personal hygiene
Contaminated water supply
Inadequate sanitation

· minimum living space standards
· safe water, proper sanitation
· good personal, food and public hygiene and public
health education
WHO does not recommend vaccination as it offers only
low, short-term individual protection and little or no pro-
tection against the spread of the disease

Worms
especially
hookworms

Overcrowding
Poor sanitation

· minimum living space standards
· proper sanitation, good personal hygiene
· wearing shoes

Scabies6

Overcrowding
Poor personal hygiene

· minimum living space standards
· enough water and soap for washing

Xerophthalmia
Vitamin A
deficiency

Inadequate diet
Following acute prolonged
infections, measles and
diarrhoea

· adequate dietary intake of vitamin A. If not available,
provide vitamin A fortified food. If this is not possible,
vitamin A supplements
· immunization against measles. Systematic prophylaxis
for children, every 4-6 months

Anaemia

Malaria, hookworm, poor
absorption or insufficient intake of
iron and folate

· prevention/treatment of contributory disease
· correction of diet including food fortification

Tetanus

Injuries to unimmunized
population
Poor obstetrical practice causes
neo-natal tetanus

· good first aid
· immunization of pregnant women and subsequent
general immunization within EPI
· training of midwives and clean ligatures, scissors,
razors, etc.

Hepatitis

Lack of hygiene
Contamination of food and water

· safe water supply
· effective sanitation
· safe blood transfusions

STD's/HIV

Loss of social organization
Poor transfusion practices
Lack of information

· test syphilis during pregnancy
· test all blood before transfusion
· ensure adherence to universal precautions
· health
· availability of condoms
· treat partners

6 Scabies: skin disease caused by burrowing mites

Reproductive Health7

7 See: United Nations High Commissioner for Refugees. An Inter-agency Field Manual on Reproductive Health in Refugee Situations, 1995.
UNFPA have developed a set of reproductive health kits which can be used as part of a programme to deal with reproductive health problems and the Health and Nutrition Unit or the Supplies and Transport Section at Headquarters should be contacted for details.

45. Reproductive health care in refugee situations should be provided by adequately trained and supervised staff and should be guided by the following principle:

Reproductive health care should be available in all Situations and be based on refugee, particularly women's, needs and expressed demands. The various religious, ethical values and cultural backgrounds of the refugees should be respected, in conformity with universally recognized international human rights.

46. The provision of quality reproductive health services requires a collaborative effort by a number of sectors (health, community services, protection, education) and organizations, which should provide reproductive health services based on their mandates.

47. While resources should not be diverted from addressing the problems of the major killers (measles, diarrhoeal diseases, acute respiratory infections and malaria), there are some aspects of reproductive health which must also be dealt with in the initial phase of an emergency. The major objectives of reproductive health care in an emergency are to:

i. Prevent and manage the consequences of sexual violence;

ii. Decrease HIV transmission by respecting universal precautions8 and guaranteeing the availability of free condoms;

iii. Prevent excess neonatal and maternal morbidity and mortality by providing clean home delivery kits, ensuring clean and safe deliveries at health facilities and managing emergency obstetric complications by establishing a referral system;

iv. Plan for provision of comprehensive reproductive health services, integrated into Primary Health Care, as soon as possible;

v. Identify a person responsible to coordinate reproductive health activities under the responsibility of the overall health coordinator.

48. As soon as feasible, when the situation has stabilized, comprehensive reproductive health services based on the needs of refugees should be put in place. These services should be integrated within the primary health care system and should address the following aspects:

8 "Universal precautions" means procedures and practices by health workers to limit transmission of disease.

Safe Motherhood

49. This should cover antenatal care, delivery care and postnatal care. All pregnant women should receive antenatal care services during pregnancy. All deliveries should be accompanied by a trained health care provider. A referral system to manage obstetric emergencies should be put in place. Within the first 4-6 weeks, mothers and their new babies should visit the health services and receive nutritional supplements, counselling on child spacing, and education about breast-feeding and infant care.

Prevention and Response to Sexual Violence

Please refer to chapter 10 on community services.

Sexually Transmitted Diseases including HIV/AIDS9

50. Experience shows that HIV spreads fastest in conditions of poverty and social instability - conditions which typify refugee emergencies. The priority should be on preventing HIV transmission: ensure there is respect for universal precautions and work closely with the community to promote HIV prevention strategies including condom education and distribution. Where blood transfusions are provided, ensure they are safe. Treatment of sexually transmitted diseases should be a routine part of the health services and should include appropriate follow up of partners.

Mandatory HIV testing in refugee circumstances, with the single exception of testing blood for transfusion, is not justified, and WHO has determined that, as a matter of policy, such testing should not be pursued.

9 United Nations High Commissioner for Refugees, UNAIDS and WHO. Guidelines for HIV Interventions in Emergency Settings, 1996.

Family Planning

51. Family planning services should be initiated as soon as feasible. Ensure that the refugees are informed and understand their free choice in the matter.

Other Reproductive Health Concerns

52. Women who have complications such as spontaneous or unsafe abortion should be cared for by the referral system.

53. Programmes to eradicate harmful traditional practices including female genital mutilation should be implemented once the situation has stabilized. It is crucial to work closely with the refugee community in tackling this issue10. Culturally appropriate sanitary supplies should be distributed to women as soon as possible. Inadequate sanitary protection may prevent women from collecting material assistance.

10 See IOM/FOM (83/97: 90/97), Policies on Harmful Traditional Practices, UNHCR, 1997.

Reproductive Health and Young People

54. Health workers should pay particular attention to meeting the reproductive health needs of young people as they may be at greater risk and have more limited access to appropriate services.

55. It is important to ensure that sufficient female health workers are trained in reproductive health in order to provide culturally appropriate health services including education in the community and at the health facilities. At least some of these health workers should be recruited from among the refugee community.

Tuberculosis control11

56. The prevalence of Tuberculosis (TB) has significantly increased in recent years worldwide, but a TB control programme is not a priority in the early stages of an emergency when mortality and malnutrition rates are very high.

57. Expert advice and involvement of the National TB control programme (often supported by WHO) are needed before starting a TB programme. Bad planning and poor implementation could result in more harm than good.

58. To increase the chances of success, TB programmes should only be started in stable situations, when Directly Observed Therapy12 can be implemented, when funds, drugs, reliable laboratory services and trained staff are available.

11 World Health Organization and United Nations High Commissioner for Refugees. Guidelines for Tuberculosis Control in Refugees and Displaced Populations, 1996.

12 Directly Observed Therapy is where the health worker is able to observe the treatment including that the medication is taken correctly.

Mental Health13

59. The psychosocial needs of refugees have often been neglected or even forgotten. However, health services should aim to promote the highest standard of both physical and mental health. It is easy to recognize that there is a heavy burden placed upon refugees from, for example, physical violence, grief and bereavement, fear and stress, an uncertain future and a sense of powerlessness.

60. Experience in identifying and dealing with the psychosocial problems of refugees (including Post Traumatic Stress Disorders) is limited, even so the following general guidance can be given. Any programme dealing with mental health must be community-based with the refugees themselves playing a major role. The programme must be based on a solid knowledge and understanding of the refugees' cultural background and integrated with the other services provided to refugees, and, from the outset, its long term sustainability must be ensured.

13 World Health Organization and United Nations High Commissioner for Refugees. Manual of Mental Health of Refugees, 1996.

Capacity building

Health Education

61. The importance of health education is widely recognized. However, there are significant difficulties in persuading those most at risk to change long-established habits.

In the emergency phase, the priority topics should be those directly related to the immediate public health problems.

62. Health education should therefore focus on the disposal of human excreta and refuse, water management and personal hygiene. Many governments and organizations produce simple health education materials that may be useful. Trained refugee teachers and respected elders are likely to be more effective than outsiders in communicating the basic principles and practices of health to their own people. At a later stage, information, education and communication should also be a major tool for the prevention and reduction of sexually transmitted diseases including HIV.

Training

63. As suggested by the definition of "emergency", extraordinary mobilization of resources, including human, will be needed to cope with the situation. Annex 2 sets out a suggested structure of the health service and numbers and qualifications of staff needed. Full staff support including community health workers, and health workers, doctors and nurses at health centres, health posts and clinics, with the necessary qualifications and experience, will not be instantly available.

Training will therefore be a cornerstone of an effective health and relief programme.

64. Training activities must be well targeted to meet the objective of the programme, and this is dependent on definition of roles and responsibilities among various levels of health care and identifying the necessary qualifications. Training must be part of the main health programme.

Medical supplies

65. There must be a policy on essential drugs. The aim of the policy will be to ensure a supply of safe, effective and affordable drugs to meet priority needs of the refugees. The Health and Community Development Section and the Supply and Transport Section at Headquarters issued an essential drugs list which is used to order drugs for UNHCR operations.

66. In order to foster the appropriate use of drugs, standard treatment protocols should be established. This will help rationalize prescription habits among the various partners and organize training activities. Protocols are usually based on national standards.

67. In the early stage of an emergency, it is often useful to resort to pre-packaged emergency health kits. The best known is the New Emergency Health Kit which has been developed through collaboration among many agencies (WHO, UNICEF, MSF, ICRC, UNHCR and others). The contents of the kit are intended to cover the needs of 10,000 people for 3 months during an emergency. The kit can be obtained at short notice through the Supply and Transport Section at Headquarters and can be used at the community level of health care and at health centres. The emergency health kit should only be used in the early stage of an emergency and not relied on for longer term needs.

68. As soon as possible, arrangements should be made for a regular supply of appropriate quantities of essential drugs from the UNHCR essential drugs list. The requests should be based on epidemiological surveillance and disease patterns. The Supply and Transport Section can also provide support for the purchase of drugs and their transport to the field.

69. It is of utmost importance to establish a system to monitor drug consumption. In major operations, a full time pharmacist may be needed to work with UNHCR. Over-prescription of medicines by health workers following pressure by refugees is not uncommon in refugee emergencies.

70. Donations of unsolicited drugs are often a problem during emergencies. A number of agencies (UNDP, UNHCR UNICEF, WHO, MSF and others) have jointly developed guidelines on drug donations14 that provide donors and users with a list of drugs and supplies which can be sent to emergency situations. This is to help ensure that personnel in the field do not waste time sorting out "useless" donations (small quantities of mixed drugs, free samples, expired medicines, inappropriate vaccines, and drugs identified only by brand names or in an unfamiliar language). UNHCR's policy is that overseas medical supplies should be sent only in response to a specific request or after expert clearance. The WHO Representative, local diplomatic missions and all others concerned should be briefed accordingly.

14 WHO, Guidelines for Drug Donations, May 1996.

Laboratory Services

71. Refugees are often remote from laboratory facilities. However, very simple laboratory services at the site level are usually adequate.

72. Reference laboratory services are required for epidemic management and control, (e.g., meningitis, shigellosis, cholera, hemoragic and relapsing fevers, high malarial endemicity, hepatitis etc.) to confirm/clarify diagnosis and perform antibiotic sensitivity. This should be discussed with the national authorities and WHO. Where blood transfusions are provided, laboratory services will be absolutely essential to test all blood for HIV before transfusion.

Organization of Refugee Health Care

· There is no single model for organizing health services in refugee situations, but it is usually structured on three levels: community health posts and clinics, health centres, and referral hospitals;

· It is of the utmost importance to ensure good communication and feed-back between the various levels of health care;

· Priority should be given to using host country health facilities as referral centres and support should be agreed upon and provided to the facilities (see MOU between WHO and UNHCR, Appendix 3).

Introduction

73. The three levels of health care are summarized in Annex 2. The first level is at the community level with health posts, clinics and outreach services. At the second level is a health centre with basic facilities for out and in-patients departments, dressing and injections, a pharmacy, and a basic laboratory. At the third level is a referral hospital for emergency obstetric care and surgery, management of very complicated cases, performance of laboratory tests etc. Referral hospitals are usually national facilities at the district, regional or national level.

74. The refugees must have easy access to appropriate treatment. If the local national health facilities cannot be strengthened to meet the needs, alternative arrangements will be required. Unless treatment is provided at the right level, the hospitals or health centres will be swamped by refugees demanding treatment for simple conditions. Thus, a community-based health service is required that both identifies those in need of health care and ensures that this is provided at the appropriate level. Close coordination with community services is essential.

Community Level Health Care

75. Whether refugees are in camps or spontaneously settled among local villages, community level services are essential.

Community-level health care must be the mainstay of health services from the very beginning of the emergency.

76. This means basic health care is to be delivered at the community level in a decentralized manner with two components: (i) a peripheral clinic/health post and (ii) outreach services delivered by Community Health Workers (CHWs) and Traditional Birth Attendants (TBAs). TBAs might be recruited among traditional midwives in the community. In order to be effective, CHWs and TBAs must be trained, supported and closely supervised. The role of CHWs and TBAs includes:

i. home visiting, identification and referral of sick people and malnourished children;

ii. identification of pregnant women and referral for antenatal, delivery and post natal care;

iii. basic health education;

iv. data-gathering for the health information system (deaths and their causes and the incidence of major communicable diseases);

v. responding to the needs of refugees who have been sexually assaulted.

As a guide, 1 CHW per 1,000 population and 1 TBA per 3,000 population should be the goal. Ideally, 50% of those trained should be women as same sex care is often preferred.

77. The clinic or health post will cater for the needs of approximately 5,000 refugees in crowded conditions but otherwise in reasonably good health. This should be a simple building with facilities for consultation, basic curative care (drugs from the New Emergency Health Kit), oral rehydration therapy, clinical procedures such as dressings (but not injections because of the risks of HIV transmission), a small lock-up pharmacy, simple equipment and sterilization facilities (electricity may not be available), data collection (log books to record patients and activities). Water and sanitation are essential in all health facilities.

The Health Centre

78. In support of the clinics/health posts, there should be a health centre for each refugee settlement (approximately 10,000 to 20,000 people). Very large settlements may require more than one. The health centre should be able to handle all but the most complicated medical, obstetric and surgical cases. More facilities should be available than at the clinics, including basic laboratory services, a central pharmacy and some beds for in-patients, in the range of one per 2,000 to 5,000 refugees. The health centre should collect and consolidate health information from the various clinics and health posts. The health centre should also organize the main health programmes (EPI, reproductive health, tuberculosis) and the supervision and training of staff (at both first and second level).

79. An indication of the number and qualifications of health staff required is given in Annex 2.

Referral Services

80. The health centre must be able to refer patients to hospitals for treatment. Referral hospitals should provide emergency obstetric and surgical care, treatment for severe diseases, laboratory and x-ray services as well as supply and support for nationally controlled programmes (TB, leprosy, HIV/AIDS).

81. Only a small proportion of patients will require referral services. These services will usually be organized in national health facilities at the district, regional or national level, and ideally, referral should be made to the nearest national hospital. This has obvious advantages, not least the fact that the infrastructure already exists.

The programme should compensate the national referral structures for services provided to refugees.

82. The hospital(s) should be expanded or supported as necessary, for example with tents and additional health personnel as well as some financial and/or material support (drugs, supplies, food). Care must be taken not to swamp the local hospital. Close and direct coordination with the district or regional medical officer is essential.

83. An agreement should be signed between the parties, under the aegis of the Ministry of Health, which clarifies the conditions of assistance including cost per patient per treatment and in kind support (food and drugs). A written agreement is essential to avoid controversies.

84. It is only in certain circumstances that special refugee hospitals will need to be established, but generally this should be avoided. They should only be established when the needs cannot be met by existing or strengthened national hospitals, for example when refugee numbers are very large (much larger than the local population), when the nearest national hospitals are too far away, or for security reasons. The Supply and Transport Section and the Health and Community Development Section should be consulted prior to establishing or acquiring refugee specific field hospitals.

85. Whatever arrangements are made for hospital treatment and referral, there must be suitable transport to and from the referral hospitals. Facilities at the hospital must also provide for the needs of relatives and allow parents to be with young children.

86. Arrangements for referral must be such that only those patients specifically referred from the health centres are attended, with no refugees presenting themselves directly to the hospital.

87. Refugee emergencies are not usually characterized by large numbers of injured persons. However, when this is the case, there may be an initial requirement for the rapid deployment of a surgical unit which is normally quickly available. Pre-packaged (expensive) surgical kits can be obtained through Supply and Transport Section at short notice.

88. The UNHCR Health Coordinator should ensure that there is a system to record referrals and subsequent treatment and follow-up of the patients.

Human Resources and Coordination

· 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.

The Refugees

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.

Staffing Needs

91. As a general principle, the order of preference for selecting health personnel, in cooperation with the national authorities, is:

i. Refugees;

ii. Experienced nationals or residents;

iii. Outsiders.

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.

Key References

An Inter-agency Field Manual on Reproductive Health in Refugee Situations, 1995. United Nations High Commissioner for Refugees, Geneva. To be updated in 1999.

Essential Drugs Manual: Guidelines for the Use of Drugs in Refugee Settings and UNHCR List of Essential Drugs, Geneva, 1989.

Famine-affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues, July 24, 1992/Vol.41/No. RR-13. The Centers for Disease Control, (CDC).

Guidelines for Tuberculosis Control in Refugees and Displaced Populations, 1996 World Health Organization and United Nations High Commissioner for Refugees.

Guidelines for HIV Interventions in Emergency Settings, 1996 United Nations High Commissioner for Refugees, UNAIDS and WHO, Geneva.

Manual of Mental Health of Refugees, 1996 World Health Organization and United Nations High Commissioner for Refugees.

Sexual Violence against Refugees, Guidelines on Prevention and Response, 1995 United Nations High Commissioner for Refugees, Geneva.

UNHCR, IOMIFOM (83/97; 90/97), Policies on Harmful Traditional Practices, 1997 United Nations High Commissioner for Refugees, Geneva.

Vector and Pest Control in Refugee Situations, April, 1997 United Nations High Commissioner for Refugees, Geneva.

Annexes

Annex 1 - Health Information System

In the early stages of an emergency it is essential to collect information on a weekly or monthly basis for the following tables:

Table Number

Table Description

1

Demographic information

2.1 A and B, 2.2

Crude Mortality Rate and Under five years old Mortality Rate
Cause-specific-mortality

3.1

Morbidity Incidence

  1. and 4.2 (set out in Annexes 4
  2. and 5 of chapter 15 on nutrition)
  1. Nutrition, Supplementary and Therapeutic Feeding Programmes
  1. 5.2
  1. Main causes of discharge/deaths in In-Patients Departments
  1. 7.1
  1. Deliveries: Birth (Total births and birth rate only)
  1. 7.4
  1. Cholera/Meningitis/Hepatitis/Micro-nutrients deficiencies

Collection of the information required for the other tables should be progressively introduced as the situation stabilizes.

In order to detect problems and to monitor the impact of any health programme, it is necessary to collect information over time so as to follow trends. The tables below are designed to allow tabulation of information on a weekly or monthly basis. Graphical presentation of the same information will make it easier to detect trends. The tables may need to be adjusted to reflect the needs of actual situations.

1. Demographic Information

Table 1 - Population

Camp/area
Names

Male
under 5 years

Female
under 5 years

Male
over 5 years

Female
over 5 years

Total
Population

Total

Sources of demographic information: registration Estimate Government Other

% of total population which is under 5 =

% of total population which is female =

Note: demographic information does not necessarily have to be reported in a table format. The denominator used for calculation of rates could differ from the official working figure and this should be clarified.

2. Mortality

2.1 Mortality rates

Mortality rates (segregated by age and sex) should be given per 10,000 per day

A. Crude Mortality Rate: CMR

Table 2.1 A

Camp/area
Names

Male

Female

Total

Number
of deaths

Death
Rate

Number of
deaths

Death
Rate

Number of
deaths

Death
Rate

Total

B. Under five years old mortality rates (U-5 MR)

Table 2.1 B

Camp/area
Names

Male

Female

Total

Number
of deaths

Death
Rate

Number of
deaths

Death
Rate

Number of
deaths

Death
Rate

Total

Female / Male ratio:

A graph line (to show trends) for CMR and U-5 MR could be attached.

2.2 Cause-specific mortality

Tables 2.2 (2.2 A for total population and 2.2 B for under-five population).

Male

Female

Total

Number
of deaths

% of the total
number
of deaths

Number
of deaths

% of the total
number
of deaths

Number
of deaths

% of the total
number
of deaths

Malaria

Pneumonia

Watery
diarrhoea

Bloody
diarrhoea

Measles

Meningitis

Cholera

Maternal
death (2.2 A only)

Peri/neo
natal

Malnutrition


Total

100%

100%

100%

From table 2.2 A and 2.2 B, pie charts could be attached to the report.

The list of diseases is provided as an indication.

Comments on mortality:

3. Morbidity

3.1 Incidence (Number of new cases per 1,000 of the population for the period)

Tables 3.1 (3.1A for total population and 3.1B for under-five population).

Male

Female

Total

Malaria

Pneumonia

Watery diarrhoea

Bloody diarrhoea

Measles

Meningitis

STDs

The list of diseases is provided as an indication.

3.2 Out-Patient Department (OPD) consultations

Table 3.2 Number of consultations per refugee per year.*

Camp Names

Male

Female

Total

Average

* from the total number of OPD consultations per camp, extrapolate to define the number of consultations per refugee per year. As an example: 10,000 consultations in one month in a camp of 30,000. 10,000 × 12 = 120,000 / 30,000 = 4 consultations/refugee/year.

Comments on morbidity:

4. Nutrition

4.1 Supplementary Feeding Programme Monthly Report

This table is contained in Annex 4 of chapter 15 on nutrition.

4.2 Therapeutic Feeding Programme Monthly Report

This table is contained in Annex 5 of the chapter 15 on nutrition.

4.3 Food basket monitoring

See chapter 15 on food and nutrition. If undertaken, please specify by whom and the results.

Comments on nutrition:

5. In-Patients Department (IPD) Activities

5.1 Activities

Table 5.1 (per week or month)

Hospital Name

Hospital Name

Hospital Name

A. No. of patients end
last week/month

B. No of patients
admitted

C. No. of patients end
week/month (A+B-D)

D. No. Discharged
of which:

D.1 authorized

%

D.2 unauthorized

%

D.3 deaths

%

D.4 transferred

%

No. of beds

Average length
of stay (No. Of days)

Occupancy rate

%

5.2 Main Causes of discharge/deaths in IPDs

Table 5.2 (per week or month).

Hospital Name:

Hospital Name:

Hospital Name:

Number
of cases

Number
of deaths

Number
of cases

Number
of deaths

Number
of cases

Number
of deaths

Malaria

Pneumonia

Watery
diarrhoea

Bloody
diarrhoea

Meningitis

Measles

Comments on IPDs:

6. Referral System

6.1 Total number of patients transferred for admission and where:

6.2 Causes of transfer

Table 6.2

Camp Name:

Camp Name:

Camp Name:

Number
of cases

% of the
total

Number
of cases

% of the
total

Number
of cases

% of the
total

Obstetrics

Surgery

Paediatrics

Internal
medicine

Blood
transfusion

Total

Comments:

7. Main Health Programmes
7.1 Reproductive Health
7.1.1 Safe motherhood

a. Deliveries: Birth

Table 7.1.1

Camp names

Number

Crude Birth Rate*

Total A:
a1 + a2 + a3

· a1: total # and % of birth in health centre or hospital:

· a2: total # and % of birth assisted by a Trained Birth Attendant (but outside health centre or hospital):

· a3: total # and % of other births (i.e. A - (a1 + a2):

· total number and % of complicated deliveries:

· total # of cases of neonatal tetanus:

· total # and % of deliveries with adequate Tetanus Toxoid (TT) coverage:

b. Ante-natal care (ANC)

· total # of expected pregnancies per year:

· total # of new ANC consultations (last 3 months) and % compared to expected:

· % of women with three ANC visits at delivery:

· are supplements given to pregnant women? specify criteria and supplements provided:

· RPR test (syphilis test): % of positive tests:

c. Other information

· maternal mortality: # and incidence per 100,000 live birth per year:

· Peri/neonatal mortality: # and incidence per 1,000 live birth per year:

· # of abortions and % per number of pregnancies:

· low birth weight (below 2.5 kg): provide # and percentage per total number of births:

· # and percentage of total number of births having a post-natal consultation:

7.1.2 Sexual and gender based violence

· # of cases of sexual and gender based violence per month (incidence per 10,000):

· is there any special programme for Female Genital Mutilation (where prevalent)? if yes, give brief description:

7.1.3 STDs including HIV / AIDS

· enforcement of universal precautions:

· % of blood tested for HIV before transfusion:

· % of HIV positive among blood tested:

· distribution of condoms, # and percentage of acceptance:

7.1.4 Family Planning (every three months)

· number of new acceptors in last three months, per method:

· total # and % of acceptors per method:

7.1.5 Adolescents

Is there any special programme for adolescents? if yes, give a brief description:

Comments on reproductive health:

7.2 Extended Programme of Immunizations (EPI)

· measles vaccination coverage:

· other antigens coverage:

· are there any vaccine preventable diseases prevalent in the camps?:

· comments:

7.3 Tuberculosis (every three months and not usually during the emergency phase)

· expected number of new cases per year (i.e. prevalence in country of origin):

· treatment protocols:

Table 7.3

January-March

April-June

July-September

October-Dec.

A. No. under treatment
at beginning

B. No. of new cases

C. No. of discharged
of which:

C.1 cured

%

C.2 defaulters

%

C.3 deaths

%

C.4 transferred

%

Total at end of period:
A+B-C

7.4 Cholera/Meningitis/Hepatitis/Micronutrients deficiencies etc.

On daily, weekly and/or monthly basis: number of cases, number of deaths and attack rate (cumulative) and Case Fatality Rate (cumulative). Graphic representation could be attached to the report.

7.5 Mental health

Provide a description of the mental health programme.

7.6 Training activities

Provide a description of training activities which have taken place during the reporting period: type of training, by whom, to whom, etc.

7.7 Laboratory activities

8. Information on other vital sectors

· availability of potable water: # litres per person per day

· availability of functioning latrines per # of persons

· % of population with adequate shelter

· quantity of soap available per person per month

· specify vector control activities

Annex 2 - Possible organisation of health services in a major emergency Number of births in a year

Unit/Location

Level

Health staff

Outline of major responsibilities

· Health Coordinating Committee
with all partners, this may be
decentralised as appropriate
· Refugee Health Unit (with
Ministry of Health if possible or
as part of UNHCR programme
team)

Capital/national level

· UNHCR Health Coordinator or
Health professionals,
Nutritionist, Pharmacist, Health
Administrator

· Planning and monitoring pro-
grammes
· Preparation and dissemination of
guidelines on standard procedures
· Overall coordination and supervision
· Procurement and supply of drugs and
equipment

3rd level

Regional/district Hospital

Regional or district level

· If necessary: say, 1 doctor,
2 nurses to help existing staff
(plus material support if
required, especially food and
drugs)
· Cost per patient or per treat-
ment could also be negotiated
with the hospital

· Complicated obstetric cases and
surgical emergencies on referral from
settlement
· Reference laboratory

2nd level

Health Centre (with limited beds
for overnight stay, as guidance:
1 bed per 2,000 to 5,000 refugees)

Each refugee settlement
of about 30,000

· As guidance: 2 doctors, 6-8
nurses, 1 midwife
· About 10 health workers
(1 health worker per 50 - 70
consultations per day)

· Supervision of settlement health
services including training health
workers and any selective feeding
programmes
· Treatment of patients not handled
at 1st level
· Security, distribution and use of drugs
· Basic laboratory
· Referral to third level

1st level

1 Health Post or clinic

Section level approximately
5,000 refugees

· As guidance, 1 nurse (from
above) and 2-3 refugee or
national health workers per
section

· Section level services, both preventative and basic curative care
· Supervision of outreach services

The community

Outreach services (organized by
section of, say 1 Community
Health Worker per 1,000 and
1 traditional birth attendant per
3,000 refugees)

· Refugee Community Health
Workers

· Identification of public and
individual health and nutritional
problems
· Referring sick patients to health post
· Home visiting
· Basic surveillance of mortality and
birth