3.3 Supporting health systems and infrastructure

The host country’s Ministry of Health (MOH) should lead the health sector response to any emergency, where possible. International assistance and resources should support the local MOH infrastructure and human capacity to assist with the extra burden of patients, and to repair damage to the health system and infrastructure caused by the emergency. When the MOH lacks the capacity to assume the leadership role of the health sector, a UN or other agency will often take on the responsibility for a temporary period of time.

All assistance provided by international NGOs should be provided in line with national health policies and systems. In cases where the health policies and systems are inadequate or have been destroyed due to the crisis (for example, in complex humanitarian emergencies characterised by state failure), international recovery and assistance efforts may include support to re-establish basic policies, systems and infrastructure, based on international best practices on the specific specialist areas of care.

The following key principles should be kept in mind when supporting national health systems:

• Health facility levels that should be considered and reviewed for capacity include a referral hospital, central health facility (health centre), peripheral health facilities (health posts) and home visits.
• These levels of capacity, as well as health standards and guidelines, should fall in line with the host country’s national policies.
• If policies are outdated, the MOH and other organisations supporting health should make revisions based on the most current evidence-based practice as shared by the Health Cluster and harmonizing with other existing internationally accepted guidelines.
• It is preferable that local staff and facilities should be used.
• Fees and lack of infrastructure such as laboratories, referral systems and other resources should be examined to determine if they hinder access or availability to health services.
• Any changes to any health systems or infrastructure, including upgrades to better accommodate those affected by an emergency, need to be made in collaboration with the MOH.

Local populations close to where response efforts are being made will also be affected, in particular with outbreaks of communicable diseases. It is essential that the local population is not overlooked and decisions about access and services need to be inclusive of the local population, including women and adolescent groups, as they may often have to rely on that same system to treat and prevent illnesses or mortality.

Surveillance is used to provide regular information for decision-making in an emergency.  Data collected for surveillance involves quantitative figures and analysis, which are used to determine the vulnerability of the crisis-affected community and sudden changes occurring in the area where the population is being hosted in the case of displaced populations. In an emergency response, the surveillance system should be standardised across authorities and organisations, with a designated agency collecting confidential epidemiological reports with supplementary data from health facilities and other agencies engaged in response. Any CARE health response should be coordinated and linked into this system.

The health surveillance system should provide an early warning component to track and respond to an illness, and manage any potential outbreak. Case fatality rates are aligned with particular illnesses and should not exceed the following prevalence for these identified illnesses:

• Cholera: 1% or lower
• Shigella (dysentery): 1% or lower
• Typhoid: 1% or lower.

As soon as an outbreak is identified-preferably within 24 hours of recognising the disease- appropriate control measures need to be put in place. Appropriate outbreak management requires the following:

• Staff and individuals engaged in first-line response for a medical threat or emergency should be ready to respond to an outbreak with an investigation and control plan that meets current protocols and standards.
• Health systems should be equipped with laboratories to respond to outbreaks quickly, as well as be able to diagnose and treat malaria and tuberculosis, and provide assistance for vector control.
• Stocks of essential drugs and contraceptive commodities should be readily available with methods for rapid procurement if necessary.
• Isolation sites should be available within the response site with transportation available to move specimens to laboratories locally, regionally, nationally or to another country to provide confirmation on the illness. 

Disaster and emergencies often lead to destruction or loss of critical health infrastructure and equipment, and depletion of medical supplies, including essential drugs. International humanitarian agencies are often requested to support the restoration or resupply of health infrastructure, equipment and supplies as part of the emergency response.

These responses are best managed by national health authorities with the support of the WHO and UNFPA, particularly the supply of essential drugs, equipment, and supplies related to sexual and reproductive health, e.g. emergency obstetric care, family planning/contraceptive needs. If the national and international health authorities are unable to fulfill these needs, there are times when it is appropriate for NGOs to consider supporting rehabilitation and reconstruction of health facilities, supply of basic health equipment, supplies and medications. For example, CARE has implemented this kind of response in the West Bank and Gaza, Iraq, Indonesia, and Syria among other places.

If considering this type of response, the following must be kept in mind:

• Ongoing provision of essential supplies for the health sector must be the responsibility of national authorities (with the support of WHO and UNFPA), and any support should aim to help responsible authorities restore this capacity as soon as possible.
• Procurement of health and medical supplies requires specialist expertise and should not be undertaken by general procurement staff without a specialist health or medical procurement advisor.
• Procurement or import of drugs must be consistent with national and international laws, including the country’s approved essential drugs list. Donor governments will often also have specific regulations governing the procurement of drugs.
• Rehabilitation or reconstruction of health and medical facilities also requires specialist expertise in health and medical design and construction.

WHO and UNICEF offer standardized, pre-packaged inter-agency emergency health kits that are designed to meet the primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate after math of a natural disaster or during an emergency. The IEHK 2011 consists of two different sets of medicines and medical devices, named a basic unit and a supplementary unit.

Basic unit contains: essential medicines and medical devices that can be used by primary health care workers with limited training. It contains oral and topical medicines, none of which are injectable.

Supplementary unit contains: essential medicines and medical devices for 10,000 people, and is used only by professional health workers or physicians. It does not contain any medicines or devices from the basic unit and can therefore only be used when these are available as well.

It should be noted that the basic and supplementary units are not intended to enable health care workers to treat rare diseases or major surgical cases. Nor is it intended for nor is designed for immunization or nutritional programs. IEHKs can be procured from UNICEF in country or through the UNICEF Supply Division in Denmark. Alternatively, they can be procured through IDA Foundation and WHO.

Specifically in relation to sexual and reproductive health (see section 3.6) UNFPA, UNICEF and USAID often provide stocks necessary for basic sexual and reproductive (SRH) services including the Minimum Initial Service Package (MISP). UNFPA offers standardized, pre-packaged emergency reproductive health kits (RH Kits) that contain enough essential medicines, supplies and equipment to meet the needs of displaced populations without medical facilities (or where medical facilities are disrupted during a crisis) for a three month period. They are intended for use during the initial phase of an emergency.

There are 12 RH kits in total. They are divided into3 different blocks according to population size and health service delivery level. They can be procured from UNFPA in country or through UNFPA’s Humanitarian Response Branch in Denmark.

To view how the kits correspond to the various components of the MISP, refer to the MISP cheat sheet. Refer toAnnex 8.5.3 for information on how to order RH kits if they are not available locally through UNFPA or whomever is responsible for coordinating RH activities.

 

It must be emphasized that, although supplying medicines and medical devices in standard pre-packaged kits is convenient early in an emergency, specific local needs must be assessed as soon as possible and further supplies must be ordered accordingly. Therefore, once basic reproductive health have been established, the reproductive health coordinator should assess reproductive health needs and reorder medicines, disposables and equipment based on consumption of these items, in order to ensure that the reproductive health program can be sustained. All efforts should be made to strengthen or develop a medical supplies logistics management information system. Re-ordering should be done through regular channels (via the national procurement system, nongovernmental organizations – NGOs – or other agencies) or through the UNFPA Procurement Services Branch in Denmark.

Health systems during emergencies also experience a significant decrease of available health workers in addition to having supplies and facilities issues. Many of the countries experiencing a humanitarian crisis are already wrestling with low resources, resulting in a weak health system with strained human resources for health. Emergencies exacerbate these shortages and compromise human and infrastructure safety, capacity and quality. Moreover, crises and emergencies can greatly increase the percentage of the population in need of immediate health care. A competent and capable workforce is necessary to implement essential health services during these time periods, including services for sexual and reproductive health.

 

Trained obstetric and gynaecologists are qualified human resources for providing comprehensive reproductive health services. These include being able to provide a full range of clinical services including Caesarean Section for complicated pregnancies, as well as other gynaecological surgeries required for saving women’s lives. Health facilities need to be fully equipped to provide this highest level of services. However, most of the maternal deaths occur due to a few frequently occurring complications, which if managed properly and in a timely manner can be prevented. Almost all of maternal deaths occur in low resource setting and in developing countries. Getting the right health care provider, especially skilled birth attendants, is a proven best practice for preventing excessive maternal deaths.

In addition to Obstetricians and gynaecologists, other providers like general practitioners, mid-wives, nurses, clinical officers and health assistants can also provide good quality reproductive health services. During a humanitarian emergency, these providers who are trained in sexual and reproductive health skills can provide valuable health services to prevent maternal and neonatal deaths. As far as possible, during an emergency every effort should be made to hire trained providers who can provide good quality sexual and reproductive health services.

 

At the onset of a crisis, it is essential to find providers who are well trained in SRH skills to initiate quality service delivery as quickly as possible. There is very little scope for introducing training for providers at this stage. Once the situation has stabilized and the emergency response is better resourced, more in-depth training can occur to increase the workforce and include more local workforce to assist in efforts to meet demand for services. High intensity refresher training in sexual and reproductive health care can be organized to cover skills with discreet modules of basic emergency obstetric care (BEmOC), contraceptive counselling, and other basic integrated SRHR services. High intensity refresher training for long acting reversible contraceptive (LARC) methods can also be conducted to meet the demand for these services. Ensuring a competent health workforce for SRHR services is essential for preventing and reducing high maternal mortality and morbidity in humanitarian settings. For example, ensuring skilled birth attendants (SBA) to assist in births is considered best practices to reduce maternal mortality and morbidity. For SRHR program design and training needs COs can contact the SRHR global team for assistance. Ref to contact information at the beginning of the Health and SRHR section.

 

Supporting Access to Family Planning and Post-Abortion Care Initiative (SAF-PAC) 

The ongoing Supporting Access to Family Planning and Post-Abortion Care (SAFPAC) initiative led by CARE, is an example of programming that addresses the strains on health infrastructure and workforce in crisis situations. Since its beginning in 2011, the project has provided contraceptives, including long-acting reversible contraceptives (LARCs), to refugees, internally displaced persons, and conflict-affected resident populations in Chad, the Democratic Republic of the Congo (DRC), Djibouti, Mali, and Pakistan.

Implementation
SAFPAC’s strategy focuses on 4 broad interventions drawn from public health best practices in more stable settings: competency-based training for providers, improved supply chain management, regular supervision, and community mobilization to influence attitudes and norms related to family planning. The approach promotes sustainability by establishing in-country training centers to build capacity in clinical skills training and supervision of new providers. In addition, monthly supervision using simple checklists has improved program and service quality, particularly with infection prevention procedures and stock management. We have generally instituted a “pull” system to manage commodities and other supplies, whereby health facilities place resupply orders as needed based on actual consumption patterns and stock-alert thresholds. Finally, reaching the community with mobilization efforts appropriate to the cultural context has been integral to meeting unmet family planning needs rapidly in these crisis-affected settings. Despite the constraints in crisis-affected countries, such as travel difficulties due to security issues, in our experience, we have been able to extend access to a range of contraceptive methods, including long-acting reversible contraceptives, in such settings using best practice approaches established in more stable environments.

Results
Between July 2011 and December 2013, the initiative reached 52,616 new users of modern contraceptive methods across the 5 countries (catchment population of 698,053 women of reproductive age), 61% of whom chose long-acting methods of implants or intrauterine devices. The percentage of new users choosing LARCs varied by country: 78% in the DRC, 72% in Chad, and 51% in Mali, but only 29% in Pakistan. In Djibouti, those methods were not offered in the country through SAFPAC during the period discussed here. In Chad, the DRC, and Mali, implants have been the most popular LARC method, while in Pakistan the IUD has been more popular. Use of IUDs, however, has comprised a larger share of the method mix over time in all 4 of these countries. These results to date suggest that it is feasible to work with the public sector in fragile, crisis-affected states to deliver a wide range of quality family planning services, to do so rapidly, and to see a dramatic increase in the percentage of users choosing long-acting reversible methods.

Adapted from  “Delivery High Quality Family Planning Services in Crisis Affected Settings” article series published in Global Health: Science and Practice (GHSP). Training Materials