GAP GUIDANCE MATERIALS

Transcription

1 IASC Inter-Agency Standing Committee Global Health Cluster Subgroup on Management and Coordination GAP GUIDANCE MATERIALS Assisting the Health Sector Coordination Mechanism to Identify and Fill Gaps in the Humanitarian Response Version 1.0 for Field Testing October

2 Table of Contents Introduction COMMON GAPS AND ACTIONS AIMED AT FILLING THEM GAP IDENTIFICATION CHECKLIST PRIORITY SETTING LIST ACTION PLANNING GRID NOTE ON PROVIDER OF LAST RESORT ACKNOWLEDGEMENTS, ACRONYMS AND REFERENCES... 20

3 Introduction Identification and filling of gaps in the humanitarian health sector response is one of the core commitments of the Inter-Agency Standing Committee (IASC) Global Health Cluster 1. To assist the health coordination efforts in countries affected by and recovering from crises, the IASC Health Cluster has developed a series of Gap Guidance (GG) materials (see Box 1). The Health Cluster developed these materials following a review conducted in early 2007 of the humanitarian health response using 10 country case studies (2004-7) 2. Box 1: Introduction to the Gap Guidance (GG) materials Why would you use the GG materials? Who should use the GG materials? In what contexts can the GG materials be used? How should the GG materials be used? The Gap Guidance (GG) materials are designed to assist the health coordination mechanism to: Orient the humanitarian response towards the main causes of avoidable illness and death in a crisisaffected population Identify gaps in the health response from a sector-wide perspective Coordinate actions to fill the most important public health gaps in response The GG materials are designed to be used by the health sector coordination mechanism (the IASC Health Cluster where this has been activated), under the stewardship of the health sector lead. The GG materials are generic and can be used in a range of settings affected by emergencies, including acute-onset emergencies, chronic emergencies, and early recovery. The health sector coordination mechanism should adapt the materials according to the local context. The GG materials, adapted to the local context, can be used on an ongoing basis to focus the activities of the health sector on issues of public health importance to the affected population. The materials can be used in health coordination meetings under the stewardship of the lead agency to assist in orienting meetings towards action. The GG materials consist of five elements: Table of Common Gaps, Gap Identification Checklist. Priority-Setting List. Action Planning Grid. Note on Provider of Last Resort The Table of Common Gaps is a summary of common gaps reported from the health sector response to 10 crises over the past 3 years, actions aimed at filling them, and key reference materials. The Common Gaps have been summarized in the Gap Identification Checklist. The Gap Identification Checklist, adapted to the specific context, can be used to orient health sector coordination meetings towards action. For example, the Checklist might be used monthly in a stable situation, more frequently in an acute situation, and less frequently in early recovery. Listing the gaps identified in order of public health priority using the Priority-Setting List can help the health sector coordination mechanism organize the collective response of the health sector towards the most important causes of preventable illness and death in the affected population. Once the gaps have been ordered according to priority, then action planning can be conducted by the health sector coordination mechanism to fill these gaps using the Action Planning Guide, referring to the List of Common Gaps for examples of how gaps have been filled in other settings and for reference materials. Where important gaps persist, then the health sector may need to refer to the Note on Provider of Last Resort. Gap Guidance Materials 3

4 1 Common gaps and actions aimed at filling them A gap is usually identified as the difference between two points: the current situation and the desired situation, or benchmark 3. Benchmarks are a set of targets with defined indicators. Country case studies did not have benchmarks for the humanitarian health sector response. For the purpose of identifying gaps a set of benchmarks had to be assumed. In the absence of locally derived targets and indicators, global standards already in the public domain were therefore applied where available. In acute emergency response, The Sphere Project: Humanitarian Charter and Principles of Humanitarian Response 4, an interagency initiative to improve quality and accountability in humanitarian response provides one set of consensus benchmarks, supplemented by IASC guidance on gender 5, gender-based violence (GBV) 6, HIV/AIDS 7, and mental health and psychosocial support 8 in emergencies as well as interagency guidance on malaria control 9 and reproductive health 10 in emergencies or for refugee populations. The Millennium Development Goals (MDGs) 11 provide another set of benchmarks for early recovery. Using this approach, a generic list of the most common or important gaps in the humanitarian health response and proposed remedies for filling these gaps was generated, including a list of relevant international guidelines for developing interventions (Table 1). Table 1. Common or important gaps in the humanitarian health sector response and actions aimed at filling them based on a review of 10 country-case studies (2004-7) I. Information management and analysis Gap Examples Proposed remedies Reference materials 1 Needs assessment Sector-wide assessment of health needs of the affected population not comprehensive, inclusive or timely. Examples include: being conducted at central level, excluding the periphery 12 ; lacking gender- and age-based analysis of population needs 13 ; or being too slow to influence planning Poor representation of health actors in inter-sectoral emergency assessments 16. Conduct early epidemiological assessment 17 of the whole affected population, with data disaggregated by age and gender. Ensure that needs assessment process is gender sensitive, involving men and women from the affected community, male and female assessors and translators, and that needs are analysed by gender and age 5. Ensure that joint assessments are linked to an outcome eg funding mechanism or joint planning process and that the conduct of joint assessments does not replace or delay individual agency assessments used for programme design, monitoring and evaluation 14. IASC Rapid Health Assessment tool (forthcoming) IASC. Gender handbook in humanitarian action. IASC, Geneva, iasc/content/documents/subsidi/ tf_gender/iasc%2520gender% 2520Handbook%2520%2528Fe b% %2529.pdf UHCR. Tool for participatory assessment in operations. Geneva, org/publ/publ/450e963f2.html Ensure adequate representation of health agencies in early joint rapid assessments 16. Gap Guidance Materials 4

5 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 2 Target population Lack of clarity around population to be targeted by the humanitarian health response. For example, confusion between emergency affected population and population in need ; and targeting of areas of returning refugees, ignoring other areas that had been affected by the conflict and internal displacement 20. Lack of clear definition and quantification of vulnerable groups 2. Those less informed and less able to access services overlooked, particularly as moving towards early recovery Service delivery insufficiently sensitive to the needs of women, without strategies to address gender-based disadvantages 23. Clearly define the population targeted by humanitarian assistance, including all those affected by the humanitarian crisis, with a strategy for addressing unmet needs of other populations 19. Define and quantify vulnerable groups (those with fewer coping mechanisms to mitigate the risk of ill health consequences of the emergency) particularly where the affected population is large, diffuse, and difficult to access. Develop a strategy to address access for all, based on needs assessment, with indicators and targets of assistance to vulnerable groups 18. IASC. Operational guidelines on human rights and natural disasters. Geneva, content/documents/working/ OtherDocs/2006_IASC_ NaturalDisasterGuidelines.pdf IASC. Gender handbook in humanitarian action. IASC, Geneva, iasc/content/documents/subsidi/ tf_gender/iasc%2520gender% 2520Handbook%2520%2528Fe b% %2529.pdf 3 Benchmarks Lack of common key indicators, standards, benchmarks 24 and targets for the health sector response Benchmark the humanitarian health sector response as a whole 24, using common indicators and targets 13. The Sphere Project. Humanitarian Charter and Principles of Humanitarian Response, revised edition Geneva, UN Millennium Development Goals millenniumgoals/goals.html 4 Health information systems Lack of data for monitoring and planning including malnutrition, mortality 2, and morbidity 15. Health Information System inappropriate to the phase of the response. For example, continued use of sentinel site surveillance rather than population based data in the early recovery phase 25. Establish a common health information system coordinated by one agency aiming for timely complete reporting from all facilities. Put in place effective mortality data collection system (such as community-based mortality data collection using community health workers) 15. Conduct mortality survey where indicated 15. WHO. Communicable disease control in emergencies : A field manual. Geneva, ISBN_ pdf WHO. Recommended surveillance standards. Geneva, (document WHO/EMC/DIS/97.1). Implement population based Health Information System in early recovery (as appropriate) 25. Gap Guidance Materials 5

6 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 5 Monitoring Lack of monitoring of quality, outcomes or impact. Where monitoring does exist, focus is on coverage and inputs 24 (particularly health promotion), and not linked to follow-up mechanisms Evaluation No evaluation of the sector wide impact 24 of humanitarian health services from a population perspective. Formalise responsibility for monitoring of quality control to one agency, with adequate dedicated budget 24. Ensure monitoring includes access by vulnerable groups and on the basis of gender and age. Encourage peer review by publishing agency activities and outcomes using standard indicators (for example quarterly in a longstanding emergency) 26. Link programme funding mechanisms to performance 26. Conduct an Interagency Health Evaluation (formative or summative). The Sphere Project. Humanitarian Charter and Principles of Humanitarian Response, revised edition Geneva, index.htm Interagency Health and Nutrition Evaluations in Humanitarian Crises (IHE) Initiative. Guidelines for Implementing Interagency Health and Nutrition Evaluations in Humanitarian Crises (forthcoming). Gap Guidance Materials 6

7 1 Common gaps and actions aimed at filling them II. Coordination and strategic planning Gap Examples Proposed remedies Reference materials 1 Health sector coordination Ineffective health sector coordination mechanism, failing to include affected community, national and local governments, donor governments, multilateral agencies, national and international NGOs, academic institutions, military and the media, as well as the private sector and organised religion Poor coordination of plans and communication of activities between the capital and the field coordination mechanism Multiple coordination mechanisms operating simultaneously Meetings time-consuming, resulting in information sharing rather than action planning 15. Unclear distinction between health leadership roles of different UN agencies Inadequate inter-sectoral coordination Deploy authoritative lead with group facilitation skills 27 to act as dedicated coordinator with no additional implementation responsibilities 15 early in an acute crisis. Nominate field level coordinator(s) as well as central coordinator as indicated by the situation. Consider putting in place a decentralised Cluster approach with a Cluster lead agency in the field, conducting field level sector-wide planning which is then forwarded to central level for review and support 31. Orient meetings towards common actions; disseminate standards, guidelines and country planning documents (eg on CD) to partners 32. Establish interagency Letters of Understanding covering field operations to clarify agreed roles and responsibilities where confusion exists. Conduct regular inter-sectoral coordination meetings, ensuring attendance by sectoral representatives with decision making capacity. IASC. Guidance Note on using the Cluster Approach to Strengthen Humanitarian Response 24 November humanitarianreform/portals/1/ cluster%20approach%20page/ Introduction/ 2 Geographical coverage Considerable gaps in geographical coverage of health services due to: inaccessibility 33 ; insecurity 34 ; rapidly changing situation ; or new gaps appearing as the situation stabilizes and NGOs or donors review their exit strategies 29. Regularly update mapping of humanitarian activities 12, low technology tools (eg flip charts) may be more effective in the acute phase of an emergency 29. Continuously monitor the situation by the lead agency. Advocate with donors and partners to improve coverage where appropriate, avoiding stretching the capacity of partners resulting in decreased quality of existing partners IASC Health Cluster Mapping Tool (forthcoming) Gap Guidance Materials 7

8 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 3 Financial Resources Inadequate resources to implement essential actions to minimise avoidable mortality and morbidity. In the acute phase, resource limitations exacerbated by inflexibility of emergency funding, and lack of transparency in disbursement to NGOs 24. Resource gaps often reported when moving from emergency to early recovery phase Advocate with donors and national governments for greater, more transparent resource allocation 36. Improve the evidence-base for advocacy such as through joint assessments or evaluations, and disseminate results 20. Encourage popular media coverage, for example by high profile personalities engaged as roving ambassadors 37. Avoid the introduction of user fees, which in most settings will not liberate adequate funds to improve quality and coverage and will disproportionately affect the poor Strengthening existing capacities Failure to link with existing capacities, including district and national authorities 18, local nongovernment and private sector 38. For example, a tented clinic was set up within walking distance of unsupported local health centre 19. Failure to involve communities in assessment, planning, monitoring and evaluation of interventions 32. For example, in one emergency international responders failed to recognize that most of the life-saving activity was conducted by local communities prior to the arrival of international support 18. In another emergency, beneficiary participation was limited to paying for labour 19. Develop local partnerships from the outset 18. Integrate humanitarian facilities with nearby local facilities 19. Invite a Ministry of Health representative as co-chair of the health cluster / health sector coordination mechanism 15. In early recovery, conduct district health management training 15. Strengthen linkages between community, community health workers, and health facilities 15. Take a human rights based approach to programming 39. IASC. Human rights guidance note for humanitarian coordinators. Geneva, org/iasc/content/products/docs/ IASC%20HR%20guidance%20 note%20for%20hcs%20 Final%20June% pdf Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP). Participation by Crisis-Affected Populations in Humanitarian Action: A Handbook for Practitioners. ODI, London, globalstudyparticipation.org/ index.htm Gap Guidance Materials 8

9 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 5 Implementation planning No implementation plan relevant to the phase of the response 25 (particularly structural rehabilitation 15 ) addressing the whole affected area 20. Implementation driven by agency capacities and mandates 36, availability of funds, and contextual opportunism, rather than needs 40 (eg inappropriate support to hospital capacity and tertiary care over primary care 23 ). Conduct a joint evidencebased prioritization exercise 15, identifying major causes of morbidity and mortality, prioritising preventive and curative health services to these causes 4. Agree on a minimum package of health services (including reproductive health) to be delivered by each level of health facility, appropriate to the phase of the emergency. Develop a common action plan 20 together with NGOs 15, affected community, and MOH, focused on health priorities, within the principles of primary health care, and, particularly in the early recovery phase, finding the balance between urgent service delivery needs and longer term system building 20. IASC. Health Cluster Strategic planning tool (forthcoming) MSF. Refugee health: an approach to emergency situations. Médecins Sans Frontières, Paris, en/refugee_health/rh1.pdf WHO. Analysing Disrupted Health Sectors. Geneva, techguidance/tools/disrupted_ sectors/en/index.html IAWG. Inter-Agency Field Manual for Reproductive Health in Refugee Situations. UNHCR/ UNFPA/WHO, Geneva, general%5ffieldtools/iafm_ menu.htm WHO. Guidelines for the use of foreign field hospitals in the aftermath of sudden impact disasters. WHO/PAHO, NY, ped/fieldhospitalsfolleto.pdf 6 Human Resources Insufficient numbers of trained local health staff and international staff Underpaid and demotivated local health workers 15. Lack of coordination regarding incentives for local health workers Disruption to local health services due to higher remuneration 27 or poaching 18 of local health staff. Ensure standards for recruitment, training and supervision of staff, local and international. Disseminate essential guidelines, and conduct short training courses, supervision and on-site training by agency staff 15. Advocate for improved incentives (remuneration and housing) for local staff in the short term 36, while developing longer term strategy with government for training local health personnel 26. In early recovery, conduct a knowledge, attitudes and practices survey of health personnel to understand more about absenteeism and health practice behaviour 15. Develop standard agreements and protocols 18 for incentives. Develop a human resources code of conduct 42. People in Aid. Code of Good Practice in the Management and Support of Aid Personnel. London, code/code-en.pdf Gap Guidance Materials 9

10 1 Common gaps and actions aimed at filling them III. Service delivery Gap Examples Proposed remedies Reference materials 1 Malnutrition Global acute malnutrition among children 6-59 months of age often excessive, including in longstanding emergencies and early recovery situations Health care for the malnourished not always in line with international standards, particularly routine malaria treatment in therapeutic feeding centres. For example, deaths due to malaria were very high in one therapeutic feeding centre 26. Promotion of breast feeding inadequate 43. Create linkages between the health sector and the nutrition coordination mechanism. Ensure adequate data for decision making on prevalence of malnutrition. Disseminate operational guidance to partners, together with nutrition partners, with focus on community based care (including community based therapeutic care and promotion of breast feeding). WHO. Management of severe malnutrition: a manual for physicians and other health workers. WHO, Geneva, WHO. The management of nutritional deficiency disease in major emergencies. Geneva, publications/2000/ pdf UNHCR/WFP. Guidelines for selective feeding programmes in emergency situations. Geneva, int/nutrition/publications/en/ selective_feeding_emergencies. pdf IFE Core Group. Infant and Young Child Feeding in Emergencies Operational Guidance for Emergency Relief Staff and Policy-Makers. Version 2.1 Feb Emergency Nutrition Network, Oxford, pool/files/ife/ops-guidance-2-1- english pdf Valid International. Community based therapeutic care, a field manual. Oxford, Gap Guidance Materials 10

11 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 2 Water-borne diseases Lack of prevention, hygiene promotion, and standardized clinical management of diarrhea, with linkages to water, sanitation and hygiene (WASH) activities Inadequate access to adequate quantities of safe water in many settings Create linkages between the health sector and the WASH sector coordination mechanism to ensure access to water meets minimum international standards, and to develop and disseminate standards and operational guidance on hygiene promotion and the management of diarrhea. WHO. Communicable disease control in emergencies : A field manual. WHO, Geneva, infectious-disease-news/ IDdocs/whocds200527/ ISBN_ pdf 3 Measles Measles vaccination coverage not in line with international standards 16 32, particularly in noncamp situations Outbreaks Lack of standard reporting and case definition, no real time analysis 15 and slow feedback 42. Delayed laboratory confirmation of outbreak 26. Slow response times 16 (greater than 48 hours). 5 Malaria Lack of standardized prevention and treatment of malaria 30, appropriate to the epidemiological setting and phase of response, and for special groups such as severely malnourished 26. Organise well monitored mass measles vaccination together with agencies and national authorities where indicated. Reinforce routine vaccination programme as indicated by phase of response. Appoint one agency to coordinate disease surveillance, outbreak detection and response. Plan for outbreak response, including identification of laboratories (local, national, international) for confirmation. Prompt establishment of Early Warning Alert and Response System 44. Establish contingency supply stock for emergency response 34. Develop and disseminate standards and operational guidelines, advocate for evidence-based treatment guidelines, and plan for additional support to drug and materials supply as necessary. WHO. Malaria control in complex emergencies: An interagency field handbook. WHO, Geneva, docs/ce_interagencyfhbook.pdf Gap Guidance Materials 11

12 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 6 Reproductive health incl. Obstetrics High maternal mortality 26 30, with limited access to emergency obstetric care and comprehensive reproductive health care Disseminate phase-specific minimum package of care among partners (including distribution of clean delivery kits to pregnant women in acute emergencies and promoting deliveries in a health facility with a trained practitioner in more stable settings). Appoint a dedicated reproductive health coordinator 45 or coordinating agency. Women s Commission for Refugee Women and Children. MISP fact sheet. NY, pdf and checklist IAWG. Inter-Agency Field Manual for Reproductive Health in Refugee Situations. UNHCR/ UNFPA/WHO, Geneva, general%5ffieldtools/iafm_ menu.htm 7 Gender Based Violence (GBV) Absent comprehensive effective inter-sectoral prevention and response to GBV 19. Ensure that the health sector participates in an inter-sectoral strategy for preventing and responding to GBV. Develop and disseminate standard operating procedures for GBV including standardized reporting, referral and clinical management 19, coordinated by dedicated reproductive health coordinator. IASC. Guidelines on GBV in Humanitarian Settings action sheet 8, health and community serviceshttp://www. humanitarianinfo.org/iasc/ content/documents/subsidi/ tf_gender/gbv/gbv%20 Guidelines%20AS8%20Health. pdf WHO/UNHCR/UNFPA Clinical Management of Survivors of Rape: Developing protocols for use with refugees and internally displaced persons (revised edition). WHO/UNHCR/UNFPA, Geneva, mngt_survivors_of_rape/ 8 HIV/AIDS and Sexually Transmitted Infections (STIs) Services for HIV/AIDS prevention and care neglected 13, inadequate 19 24, or not integrated into health service delivery 28. Lack of age- and genderappropriate prevention and treatment of STIs and HIV/AIDS, coordinated with other sectors 13. Waste disposal not always safe Blood transfusion not always safe 26. Initiate a community based minimum service package for STI and HIV prevention 23, sensitive to gender and age. Provide adequate supplies for prevention, diagnosis and treatment, including antiretroviral drugs where rolled out. Develop and disseminate standards and operational guidelines for implementation and monitoring of safe waste disposal and blood transfusion. IASC. Guidelines for HIV/AIDS Interventions in Emergency Settings, IASC, org/iasc/content/products/docs/ FinalGuidelines17Nov2003.pdf Gap Guidance Materials 12

13 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 9 Mental health and psychosocial support Stage specific planning 25 for mental health and psycho-social support disorganized 42 or absent, particularly for the management of alcohol dependence 26. Lack of community based approach to mental health 33. Define a global framework for mental health 42 early in the emergency response. In the emergency phase, actions should be mainly psychosocial 4, with community health workers delivering social support and psychological first aid 23. IASC. Guidelines on mental health and psycho social support in emergencies. Geneva, org/iasc/content/products/ docs/guidelines%20iasc%20 Mental%20Health%20 Psychosocial.pdf Médecins Sans Frontières (2005). Mental Health Guidelines. Amsterdam: MSF. mentalhealth/guidelines/msf_ mentalhealthguidelines.pdf 10 Forensics Socially and culturally inappropriate burial of corpses, mass graves 23. Disseminate standards and operational guidelines. Advocate with national authorities for culturally appropriate burial as indicated. Morgan, Oliver (ed). Management of dead bodies after disasters: a field manual for first responders. Washington, D.C: PAHO, DeadBodiesFieldManual.pdf. 11 Supply management Inadequate systems for procuring, storing, managing and distributing drugs and medical supplies 45. Drug supply not always assured 31. Inappropriate donation of drugs, medical supplies and breast milk substitutes Use kits in the emergency phase. Disseminate codes of practice and operational guidance 43 promptly to all actors by the coordination mechanism. UNFPA. Reproductive Health Kits for Crisis Situations, 3rd edition. UNFPA, Geneva, 2004, www. aidsandemergencies. org/rhkit_manual_en.pdf WHO. The Interagency Emergency Health Kit, WHO, Geneva, mrhealthkit.pdf UNHCR. Drug management manual UNHCR, Geneva, PUBL/43cf66132.pdf WHO. Guidelines for safe disposal of unwanted pharmaceuticals in and after emergencies, WHO, Geneva, 1999 (WHO/EDM/PAR/99.4) medicalwaste/unwantpharm.pdf WHO. Guidelines for drug donations, WHO, Geneva, 1999 (WHO/EDM/ PAR/99.4) hq/1999/who_edm_par_99.4.pdf WHO. International code on marketing of breast milk substitutes Gap publications/code_english.pdf Guidance Materials 13

14 1 Common gaps and actions aimed at filling them Gap Examples Proposed remedies Reference materials 12 Laboratory capacity Laboratory diagnosis inadequate for the phase of response, or inappropriately prioritised over life-saving activities. Routine laboratory services are rarely indicated in the early phases of an emergency 4 (although laboratories for confirmation of outbreaks will need to be identified). In early recovery, agree a minimum package of laboratory services, and develop and disseminate standards as appropriate. WHO. Communicable disease control in emergencies : A field manual. WHO, Geneva, infectious-disease-news/ IDdocs/whocds200527/ ISBN_ pdf 13 Referral mechanisms Limited access to life-saving secondary or tertiary care, lack of transport and communication, particularly for emergency obstetrics Unclear or disorganised referral mechanisms, including continuity of medical records and communication and support for patient support person/relative 35. Develop Standard Operating Procedures for referrals. Establish norms for referral facilities, transport and communication in longer standing emergencies and early recovery. Sphere. The Sphere Project: Humanitarian Charter and Principles of Humanitarian Response, revised edition 2004, The Sphere Project, Geneva, org/index.htm 14 Laboratory capacity Laboratory diagnosis inadequate for the phase of response, or inappropriately prioritised over life-saving activities. Routine laboratory services are rarely indicated in the early phases of an emergency 181 (although laboratories for confirmation of outbreaks will need to be identified). In early recovery, agree a minimum package of laboratory services, and develop and disseminate standards as appropriate. WHO. Communicable disease control in emergencies : A field manual. WHO, Geneva, infectious-disease-news/ IDdocs/whocds200527/ ISBN_ pdf 15 Referral mechanisms Limited access to life-saving secondary or tertiary care, lack of transport and communication, particularly for emergency obstetrics 182. Unclear or disorganised referral mechanisms, including continuity of medical records and communication and support for patient support person/ relative 183 Develop Standard Operating Procedures for referrals. Establish norms for referral facilities, transport and communication in longer standing emergencies and early recovery. Sphere. The Sphere Project: Humanitarian Charter and Principles of Humanitarian Response, revised edition 2004, The Sphere Project, Geneva, org/index.htm Gap Guidance Materials 14

15 2 Gap Identification Checklist Health sector coordination mechanism may find it useful to apply the list of common or important gaps reported from other situations (Table 1) to their specific situation in a systematic way, such as using a checklist. An example of such a checklist is given below. The benchmarks are taken from existing standards as outlined above. Where no consensus standards exist, the benchmark has been approximated (indicated with an asterisk). A mix of different types of benchmarks has been included inputs, process, outputs, and outcomes that refer to different levels of the response information management, planning, and service delivery. These benchmarks, and the checklist, need to be adapted by the health sector coordination mechanism to the specific situation. Sample checklist: Common or important gaps in the humanitarian health sector response Element Benchmark Gap? I. Information management and analysis 1. Needs assessment Assessment of needs according to gender, age and diversity 4 2. Target population Target population including vulnerable groups defined and quantified 4 3. Benchmarks Benchmarks established for the humanitarian health sector response 4 4. Health information systems CMR - Emergency: <twice baseline (<1/10,000/day if unknown) 4 Early recovery: Within host country or regional norms 11 U5MR - Emergency: <twice baseline (<2/10,000/day if unknown) 4 Early recovery: Within host country or regional norms 11 Global Acute Malnutrition (children 6-59 months) - Emergency: prevalence <10%; 4 Early recovery: prevalence within host country / regional norms 11 Common health information system with coordinating authority and at least 80%* of facilities timely complete reporting 4 5. Monitoring Regular systematic monitoring of health sector performance 4 6. Evaluation Plans for sector-wide evaluation 46 II. Coordination and strategic planning 1. Health sector coordination Functioning health sector coordinating mechanism involving UN agencies, NGOs, CBOs, health authorities, donors, and community members, including between the centre and the field, and with other sectors 4 2. Geographical coverage 80%* of the target population has access to functioning primary health service within one hours walk 4 Gap Guidance Materials 15

16 2 Gap Identification Checklist Element Benchmark Gap? 3. Financial resources 80%* humanitarian health funds available 4. Strengthening existing capacities 5. Implementation planning Community participation in health services planning, delivery, monitoring and evaluation 4 Joint evidence-based implementation planning exercise* 6. Human resources No shortfalls of trained health staff delivering services in the field 4 III. Service delivery 1. Malnutrition Emergency: >50% (rural), 70% (urban) and 90% (camp) of the estimated population under five years of age with global acute malnutrition is covered by targeted supplementary feeding programmes 4 2. Water-borne diseases Access to adequate quantities of safe water. Emergency: 15 lpppd 4 Early recovery: Proportion of population with access within host country or regional norms (37% sub-saharan Africa, 50% developing countries) Measles vaccination Measles vaccination coverage. Emergency: 95% 6 months to 15 years 4 Early recovery: 95% months Outbreaks Outbreak investigation within 24 hours, and response within 48 hours 4 5. Malaria (for endemic areas) 6. Reproductive health incl obstetrics No stock ruptures of artemesinin-based combination treatments 9 60% households with at least one insecticide treated net or treated with indoor residual spraying in malaria endemic area 9 Emergency: 100% expected obstetric complications are treated Early recovery: Proportion of deliveries in a health facility/by qualified personnel within host country or regional norms (56% developing countries) Gender-based Violence (GBV) 100% facilities have standard operating procedures for GBV 6 8. HIV/AIDS and Sexually Transmitted Infections (STIs) 9. Mental health and psycho-social support 100% blood transfusions screened for HIV and Hepatitis B 7 100% facilities apply syndromic approach to treating STIs 7 100% health facilities have safe disposal of medical waste 7 1 condom distributed / person / month 7 No stock ruptures of ARVs (where implemented) 7 Early recovery: 100% Health programmes are linked to an inter-sectoral community-based psycho-social support programme Forensics No examples of inappropriate disposal of dead bodies Supply management Laboratory capacity Referral mechanisms No examples of inappropriate donations of medicines and supplies (including breast milk substitutes) 4 100% health facilities with supply management QA systems 4 Early recovery: Proportion of higher level health facilities with routine laboratory diagnostic capacity for the most important causes of illness within host country / regional norms* Early recovery: Access to referral to higher level facility (including emergency obstetric care) within host country / regional norms* Gap Guidance Materials 16

17 3 Priority Setting List Once gaps are identified, they can be prioritised according to the public health importance (the greatest contribution to preventable illness and death). The health sector coordination mechanism may find it useful to list the most important gaps using the template below. List: The most important gaps in order of public health priority Gap Guidance Materials 17

18 4 Action Planning Grid Once the key gaps have been identified, action planning can be conducted together with all partners in the humanitarian health sector, including representatives of the affected community The health sector coordination mechanism may find it useful to refer to examples of actions to fill gaps that have been proposed in other settings, as well as reference documents, outlined in the generic list of gaps above (Table 1). Outcomes should include targets and indicators that are Specific, Measurable, Attainable, Relevant, and Timebound (SMART). Grid: Plan the response 48* Gap Response Aim Objective Target population Activities Resources Outputs Outcomes (targets and indicators) Time frame Responsible agency Gap Guidance Materials 18

19 5 Note on Provider of Last Resort There may be situations in which an important gap in the response has been identified but there is no provider willing or able to fill this gap. In this situation (particularly where the IASC Health Cluster has been rolled out), the sector lead may need to act as the provider. The Inter-Agency Standing Committee (IASC) Guidance Note on using the Cluster Approach to Strengthen Humanitarian Response 24 November 2006 states that sector leads are responsible for acting as the provider of last resort (subject to access, security and availability of funding) to meet agreed priority needs 49. In extreme situations, therefore, where 1. the Health Cluster agrees that there is an important life-threatening gap in the Health sector response, and 2. one or more of the agreed benchmarks for the health sector response as a whole are not being met, and 3. evidence suggests that a significant proportion of the target population is at risk of avoidable death if the gap is not filled urgently, then the sector lead should act as provider of last resort. Gap Guidance Materials 19

20 Acknowledgements, Acronyms and References Acknowledgements These materials were prepared by Nadine Ezard for the IASC Global Health Cluster subgroup on Coordination and Management, supervised by Linda Doull from Merlin with support from Robin Nandy from UNICEF. The group would like to thank the country offices and field staff who assisted in the field visits, as well as those who completed the questionnaires and who were interviewed by telephone. Acronyms CAR CBO CMR DRC GBV HAC IASC INGO Lppd MDGs MOH NGO NNGO OCHA POLR QA RH SC STI UN UNICEF U5MR WASH WHO Central African Republic Community Based Organisation Crude mortality rate Democratic Republic of the Congo Gender Based Violence Health Action in Crisis Inter-agency Standing Committee International Non-Governmental Organisation litres per person per day Millennium Development Goals Ministry of Health Non-Governmental Organisation National Non-Governmental Organisation United Nations Office for the Coordination of Humanitarian Affairs Provider of Last Resort Quality Assurance Reproductive Health Save the Children Sexually Transmitted Infection United Nations United Nations Children s Fund Under five mortality rate Water, Sanitation and Hygiene World Health Organization References 1. WHO. Inter-Agency Standing Committee Global Health Cluster Core Commitments. healthcluster/health_cluster_commitments/en/ index.html accessed June Case study countries were: current (2007) humanitarian response in CAR, Chad, DR Congo, Lebanon, Liberia, Mozambique, Uganda, Somalia; and historical casestudies of the tsunami response in Banda Aceh, Indonesia (2004) and the earthquake response in Pakistan (2005). Methods used were a review of available literature (published articles, reports and agency documents), key informant interviews of agency staff members, and field visits to selected sites. For more information on methods and findings see Ezard N, Health Cluster Guidance on Identifying and Filling Gaps in the Health Sector: Final report on the process of achieving the results of the constancy Wardrope J, McCormick S. Strategy to develop everyday operational management. Emerg. Med. J. 2001;18; The Sphere Project: Humanitarian Charter and Principles of Humanitarian Response, revised edition Geneva. 5. IASC. Gender handbook in humanitarian action. Geneva, IASC. Guidelines on GBV in Humanitarian Settings. Geneva, IASC. Guidelines for HIV/AIDS Interventions in Emergency Settings. Geneva, IASC. Guidelines on mental health and psycho social support in emergencies. Geneva, WHO. Malaria control in complex emergencies: An interagency field handbook. Geneva, IAWG Inter-Agency Field Manual for Reproductive Health in Refugee Situations. UNHCR/UNFPA/WHO, UN Millenium Development Goals un.org/millenniumgoals/goals.html 12. IASC. Interim Self-Assessment of efforts to implement the cluster approach at the field level, Annex 3, Liberia, in-country self Gap Guidance Materials 20

21 References assessment 26 October OCHA, NY, IASC. Interim Self-Assessment of efforts to implement the cluster approach at the field level, Annex 4, Somalia, in-country self assessment 30 October OCHA, NY, De Ville C, de Goyet C, Meriniere L. The role of needs assessment in the tsunami response. Tsunami Evaluation Coalition (TEC), London, Heffinck J, Yao M, Vandam S. Mission report : Joint evaluation on WHO HAC in Uganda in the context of the Health Action in Crises Three Years Program. Evaluation by joint team DG ECHO-WHO WHO, Geneva, Ezard N. IASC Global Health Cluster, subgroup on Management and Coordination, Consultancy on Identifying and Filling gaps in the Health Sector Field trip to Somalia Health Coordination Mechanism, 2-7 May Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over the past decade. Lancet (2004): 364; Scheper B, Parakrama A, Patel S. Impact of the tsunami response on local and national capacities. Tsunami Evaluation Coalition (TEC), London, Michael M, Pearson N, Daliam A. Interagency Health Evaluation : Humanitarian Oasis in a parched health sector: Refugees and host populations in eastern and southern Chad, conducted February Interagency Health and Nutrition Evaluations in Humanitarian Crises Initiative/UNHCR, Geneva, Sondorp E, Msuya C. Liberia Interagency Health Evaluation September 2005 Final report. Interagency Health and Nutrition Evaluations in Humanitarian Crises Initiative Working Group /UNHCR, Geneva, ICMH. Interim report of a meeting on public health impact of the tsunami. International Centre for Migration and Health (ICMH), Geneva, Cosgrave J. Synthesis Report: Expanded Summary. Joint evaluation of the International Response to the Indian Ocean Tsunami. Tsunami Evaluation Coalition (TEC), London, WHO. Draft report of the Health Aspects of the tsunami Disaster in Asia WHO Conference Phuket Thailand 4-6 May 2005, Draft 7. Geneva, Cosgrave J, Gonçalves C, Martyris D, Polastro R, Sikumba-Dils M. Inter-agency real-time evaluation of the response to the February 2007 floods and cyclone in Mozambique May 2007 Draft final version to be presented for endorsement of the Recommendations at the IASC Working Group meeting June. 25. Perez L, Annuziata G, Vandam S, Heffinck J. Mission report: Joint evaluation of WHO Tsunami Response operations in Sri Lanka and Indonesia (Banda Aceh) in the context of the Health Action in Crises Three Years Program (TYP) Evaluation by joint team ECHO-WHO 3/04/05 14/04/05. WHO, Geneva, Pearson N. Chad a country in Crisis. Report of the follow-up visit, interagency health and nutrition evaluation. Jan Interagency Health and Nutrition Evaluations in Humanitarian Crises Initiative/UNHCR, Geneva, IASC. Real time evaluation cluster approach Pakistan Earthquake; Final Draft, Application of the IASC Cluster Approach in the South Asia Earthquake. Islamabad, Pakistan, Feb OCHA, New York, IASC. Interim Self-Assessment of efforts to implement the cluster approach at the field level, Annex 5, Uganda, in-country self assessment October OCHA, New York, Interview with Paula Sansom, MERLIN, 15 March 2007, referring to eastern DRC 2007 and Pakistan IASC. Interim Self-Assessment of efforts to implement the cluster approach at the field level, Annex 2, DRC, in-country self assessment October OCHA, New York, Interview with Navaratnasamy Paranietharan (WHO Somalia) 10 April 2007, referring to Somalia. 32. Ezard N. IASC Global Health Cluster, subgroup on Management and Coordination, Consultancy on Identifying and Filling gaps in the Health Sector, Field visit to Northern Uganda, May Interview with Khalid Shabib 22 March 2007, referring to Pakistan Christian Itama (WHO Chad) in response to questionnaire, May 2007 Gap Guidance Materials 21

22 References 35. Interview with Lizzie Berryman (Save the Children, UK), 29 March, referring to Lebanon and Pakistan Interview with Olushayo Olu (WHO-HAC/ Uganda), March , referring to Uganda Eli Ramamonjisoa (UNICEF CAR), response to Questionnaire, May Interview with Guiseppe Annunziata (WHO) 15 April 2006, referring to Lebanon IASC. Human rights guidance note for humanitarian coordinators humanitarianinfo.org/iasc/content/products/ docs/iasc%20hr%20guidance%20note%20 for%20hcs%20final%20june% pdf accessed 26 July Flint M, Goyder H. Funding the tsunami response. Tsunami Evaluation Coalition (TEC), London, p8 41. Bechir Aounen (UNICEF) referring to Chad, response to questionnaire, May Bagole D, Heffinck J, Vandam S. Mission report :Joint evaluation on WHO emergency response operations in Pakistan in the context of the Health Action in Crises Three Years Program (TYP). Evaluation by joint team DG ECHO DFID WHO WHO, Geneva, McLaine A, Corbett C. Infant feeding in emergencies: Experiences from Indonesia and Lebanon. Field Exchange, Dec accessed March Lucia Linares (WHO Mozambique) and Alissair Rady (WHO Lebanon) in response to questionnaire, May Pomatto V, Schuftan C. ECHO Review of Quality Assurance (QA) Mechanisms for Medicines and Medical Supplies in Humanitarian Aid - Concept Paper. GFE, Aachen, Interagency Health and Nutrition Evaluations in Humanitarian Crises Initiative/UNHCR. Guidelines for implementing interagency health and nutrition evaluations in humanitarian crises version 1.0. Geneva (forthcoming) 47. Women s Commission for Refugee Women and Children. Minimal Initial Service Package (MISP) for reproductive health in crisis situations. A distance learning module. NY, Can be calculated as: number of direct obstetric complications treated in emergency obstetric care facilities in the catchment area/ number of expected direct obstetric complications in a population x100. Number of expected complications is 15%. Number of deliveries calculated from crude birth rate or, where not available, estimated from total number of pregnancies, approximately 4% of total population at any one time for developing country (i.e. 0.6% of total population). 48. adapted from Stimson G, Fitch C, Rhodes T, Keetley K. The Rapid Assessment and Response Guide on Injecting Drug Use (IDU- RAR) draft Geneva: WHO 49. IASC Guidance Note on using the Cluster Approach to Strengthen Humanitarian Response 24 November 2006 p15 ocha.unog.ch/humanitarianreform/portals/1/ cluster%20approach%20page/introduction/ ASCGUIDANCENOTECLUSTERAPPROACH. pdf accessed 10/06/2007 Gap Guidance Materials 22