Purpose of assessment

The purpose of this type of rapid health assessment is to:

- assess the dynamics, magnitude, affected areas, and likely evolution of the emergency;

- assess the major health and nutritional impact of the emergency on the civilian population;

- identify groups and areas most at risk;

- assess existing response capacity and immediate needs in the health sector;

- identify short- and medium-term priorities for the delivery of health emergency response and recovery; and

- provide global indicators of life-threatening suffering to assist in mobilizing and managing humanitarian assistance.

Background

Complex emergencies are situations where “the cause of the emergency as well as the assistance to the afflicted are bound by intense levels of political considerations”.¹

¹ Coping with Major Emergencies - WHO Strategy and Approaches to Humanitarian Action. Geneva, World Health Organization, 1995 (unpublished document WHO/EHA/95.1; available on request from the Division of Emergency and Humanitarian Action, World Health Organization, 1211 Geneva 27, Switzerland),

Complex emergencies are characterized by varying degrees of instability and even collapse of national authority. This leads to loss of administrative control and to the inability to provide vital services and protection to the civilian population. One main feature of complex emergencies is the actual or potential generalized violence: against human beings, the environment, infrastructures, and property. Violence has a direct impact in terms of deaths, physical and psychological trauma, and disabilities. In conflicts characterized by rapidly shifting zones of combat, civilians often find themselves under crossfire. In many instances they become the primary targets of ethnic cleansing, murder, sexual violence, torture, and mutilation.

The other effects of conflict on public health are mediated by a variety of circumstances that include:

· Population displacement, with concentration in camps, public buildings or other settlements. This causes an increase in the risk of acute respiratory infections, diarrhoea and dysentery, measles and other epidemics. The dependence on food rations entails a parallel and interacting risk of malnutrition and micronutrient deficiencies (see Chapter 7 and Chapter 8).

· The loss of opportunities and instruments of production, food stocks, and purchasing power, usually accompanied by the destruction of the commercial network can result in diffuse food shortages. In an effort to cope, the population may resort to migration, on an even larger scale than that directly caused by violence (see Chapter 8).

· Armed attacks and landmines, in addition to targeting the civilian population, can damage key infrastructures, such as roads, water plants, communications, and even health facilities.

· The general economic crisis brought on by decreased production, loss of capital, and increased military expenditure, can force cuts in the budgets for the social sectors.

· Insecurity and military operations may restrict access to large areas of territory and constrain the delivery of health services, as well as general response and recovery operations.

As a result of population displacement, economic disruption and widespread violence, access to health care and other vital resources decrease just when hazards and vulnerabilities increase. The effects of acute respiratory infection (ARI), diarrhoea, measles, and other epidemics are compounded by the collapse of health services, programmes for immunization, and disease control.

The overall outcome is a generalized increase in the risk of illness and death that extends beyond the immediate area of conflict, and severe, acute, and chronic psychological traumas. All this must be addressed through emergency and long-term interventions.

A final, major consideration is that health needs will increase as soon as the conflict subsides. Cease-fire may be accompanied by such operations as repatriating refugees and demobilizing soldiers, who will need special health programmes in the quartering areas, and demining, which demands special provisions for medical evacuation.

The health infrastructures, weakened by war and economic crisis, will face new demands for curative care, and a major backlog of preventive measures which could not be implemented for long periods (e.g. measles immunization). Population movements will increase greatly, while previously cut-off areas will suddenly become accessible. The health sector will be required to re-establish coverage, since equitable access to services will play a major role in stabilizing the community and contributing to the peace process.

Conducting the assessment

The assessment can be carried out either at national level, as in preparing a consolidated appeal for humanitarian assistance, or at subnational, provincial, district or local levels. With some differences, the categories of data needed for each level of assessment are the same: in Box 5 on p. 85 there is a form which has recently been used for rapid health assessment at local level in Bosnia and Herzegovina, and that can be adapted to other situations.

As the background explains, complex emergencies usually involve population displacement and at least the risk of famine. Therefore, this protocol is to be used in conjunction with Chapter 7 and Chapter 8.

Information can be collected from existing documents, interviews, visits to the affected areas (see Chapters 1, 7, and 8). The information collected from NGOs, the United Nations, other international organizations, and the media will be particularly relevant in complex emergencies.

The rapid assessment consists of: describing the conflict, the affected area and the population, assessing the health outcome, the specific variables, and existing resources and additional immediate needs.

Describing the conflict, the affected area, and the population

To put health needs in perspective within the context of complex emergencies, information about the following is needed:

- duration of the conflict;
- state and progress of political negotiations (e.g. discussions for cease-fire);
- patterns of violence;
- accessible population;
- inaccessible population;
- inaccessible areas;
- occurrence of epidemics;
- occurrence of starvation; and
- general economic situation.

Assessing the health outcome

This is done by looking at crude and under-five mortality rates and causes, cause-specific morbidity and acute malnutrition rates, at least for the most severely affected areas or groups.

Assessing the variables

Information on the following points will help identify priorities and outline programmes for intervention in the short and medium term.

Violence and security

Information should be collected on:

- deaths and injuries from violence;

- deaths and injuries from landmines;

- occurrence of sexual violence;

- occurrence of torture;

- attacks on health personnel and response and recovery operators;

- attacks on health facilities; number and percentage of health facilities destroyed, closed or inaccessible;

- attacks on water systems;

- attacks on agriculture, food-processing, storage and distribution systems;

- attacks on response and recovery convoys;

- attacks on other lifeline systems: electricity, public transport, communications; and

- use of other inhumane weapons (e.g. biological and chemical).

Population displacement

Information should be collected on occurrence and numbers involved (see Chapter 7):

- internally displaced persons (IDPs);
- refugees in neighbouring countries;
- actual and expected movements (voluntary repatriations, foreseen returns);
- unaccompanied children;
- existence of IDP camps; and
- concentrations in urban areas (e.g. rates of urban growth).

Information should be collected on the loss of production, stocks of food, purchasing power and commerce (see Chapter 8).

Assessing local response capacity and immediate needs

Local response capacity and immediate needs should be assessed to determine the type and quality of external support required. As far as possible this information should be collected by province or district (see Chapter 7).

Health networks and programmes

The following information should be gathered on health networks and programmes:

- national health strategies addressing the emergency;
- percentage of working health facilities;
- geographical distribution of national health personnel (are they also displaced?);
- function of health information system (at least epidemiological and nutritional surveillance);
- availability and performance of primary health care services and programmes;
- capacities for surgery and trauma care;
- state of blood bank and transfusion safety;
- national and international organizations and NGOs: health projects and areas of coverage;
- military health assets (as far as possible, of all conflicting parties);
- sectoral coordination mechanisms;
- health training activities;
- salaries of national health personnel;
- share of state budget allocated to health; and
- international assistance to the health sector.

Environment and infrastructure

Information should be collected on the following:

- susceptibility to (history of) natural technological hazards;
- percentage of functioning water systems (urban, rural, IDP camps);
- percentage of working sanitation systems (urban, rural, IDP camps);
- state of roads, bridges, airports, etc.;
- percentage of buildings destroyed, public and private;
- presence of unexploded landmines and ordnance;
- geographical and climatic features; and
- prevalence of endemic diseases, vectors, etc.

Humanitarian assistance

The following points should be considered when assessing the humanitarian assistance being offered and planning for future provision of humanitarian assistance:

- composition of humanitarian assistance package (food and non-food);

- special humanitarian assistance programmes (demobilization, mine-awareness, and demining);

- access to the territory (road convoys, river and sea shipping, airlifts and airdrops, “humanitarian corridors”, “windows of peace”, etc.);

- patterns of aid distribution (i.e. by government, NGOs, the United Nations), timetable, coverage and logistic network;

- communication network;

- security requirements and assets;

- coordination mechanisms;

- procedures for international aid agreements;

- rights and authorizations for movements of people and goods (overflight, transit, landing);

- customs regulations, clearance, and waivers;

- mobilization of resources (projects, appeals, and donors’ response); and

- general budget for humanitarian assistance (at least data from latest appeal and, if possible, trends).

Presenting results

Consolidate the information and present a report that provides the following:

- a brief description, including the percentage of the population and territory directly affected by the conflict;

- selected indicators, to show the emergency’s direct impact (e.g. mortality rates, number of displaced, extent of malnutrition, damage to infrastructure and economy);

- indicators showing the secondary impact of the emergency (e.g. increase in risk of illness and death by epidemic or endemic diseases or both);

- data on the damage suffered by the health sector (percentage of lost infrastructure and personnel, disruption of primary health care programmes, priority shortages in drugs or vaccines); and

- the coverage, constraints and coordination of response and recovery operations.

In the report, try to describe worst-case and best-case scenarios for the next 6-12 months. What will be the health priorities if the conflict continues or if a cease-fire or peace is reached? Make recommendations, highlighting:

- immediate and medium-term priorities for action in the health sector, and needs, as arising from the above; and

- the best approaches and strategies considering the situation and current humanitarian action.

During a complex emergency, the situation can change very rapidly. Therefore, it is necessary to be cautious about long-term assumptions, to carry out planned actions quickly, before the situation changes, and to report on the situation and actions at frequent intervals.

Box 5. Sample form for rapid health assessment in complex emergencies Area: __________________________ Surrounding towns: __________ Date: _________________ Assessor: ___________________________ Background Total population - current: ____________________ pre-war: ________ Age and sex distribution: · population under five years · other vulnerable groups? Weather - current: _______ projected: ___________________________ Who is in charge?______________________ Food and agriculture What are people eating now?______________________ Source(s) of food: ______________________________ Date of last air drop:__________________________ How is air drop, humanitarian aid distributed? ____________________ Does it reach those most in need? _____________________ Market availability (and prices), include black market if possible: _____________ _________________________________________________________________ _________________________________________________________________ Visual assessment of livestock: ________________________________________ Assessment of cooking fuel: __________________________________________ Any seeds available for planting: _______________________________________ Overall assessment of food availability and needs - include timeframe for seeds, etc. Health and nutrition Who is in charge?___________________________ What health services exist?____________________ Assessment of damage to health infrastructure: What public health programmes (vaccination, etc.) currently operate? Assessment of recent mortality (rates and causes): __________________________________________________________________ Assessment of recent morbidity (rates and causes): __________________________________________________________________ Evidence of epidemics: _______________________________________________ (specifically check for measles, hepatitis, diarrhoea) Current staff: _________________________________ Current drug supplies:___________________________ Current medical supplies: ________________________ Evidence of malnutrition: ________________________ Evidence of micronutrient deficiencies: _____________ Particularly vulnerable groups: ____________________ Overall health assessment - include priorities for assistance: Water and sanitation Who is in charge? ____________________________ Normal sources of water: ___________________ Current sources - for drinking: ___________________ for washing, etc.: ____________________________ Estimates of current quantities provided: ____________ Is water tested or treated in any way? ___________ If so, how? ___________________________________ Assessment of damage to water system: ___________________ Assessment of damage to sewer system: ___________________ Changes in water supply expected due to seasonal variation: _________________ Assessment of solid waste disposal: _________________ Problems with rat control:_________________________ Overall assessment: water supplies are adequate or inadequate; safe or unsafe? Priorities for assistance: _______________________________________ Shelter and household function Who is in charge? _____________________________________ Assessment of damage to housing: ________________________ Availability of construction materials, plastic, etc.: _____________ What type of clothing are people wearing?__________________ Availability of blankets, sleeping bags, etc.: _________________ Impact of upcoming weather or season: __________________ Logistics and security Who is in charge?_____________________________________ Possible routes for humanitarian assistance: ______________ Assessment of roads and bridges, etc.: _________________ Availability of local storage facilities: _______________ Security___________________________________________ - checkpoints:_____________________________ - local security: ____________________________ Overall assessment: ______________________ Overall: Top priorities, constraints, etc.