|Handbook for Emergencies - Second Edition (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR), 1999, 414 p.)|
· 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).
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.
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.