Purpose

In emergency management, assessment means collecting subjective and objective information in order to measure damage and identify those basic needs of the affected population that require immediate response. The assessment is always meant to be rapid, as it must be performed in limited time, during or in the immediate aftermath of an emergency.

At the onset of a crisis, rapid assessment information will be used to recognize and quantify the emergency, and to readjust strategies and plans accordingly. Once a programme of assistance is under way, periodic assessments will assist evaluation of the effectiveness of response and recovery. In a wider perspective, rapid assessment will produce information for financial and political advocacy, public information, press releases, and case studies.

The information produced by the assessment is both an asset and a commodity. It must be used for vital decision-making, and for feedback along the different levels of the health sector. But this information can also be marketed to other sectors. Mutual exchange of information is the first step in effective coordination, and being recognized as a reliable source of information is the best way for an organization to assert its claim to a coordinating role.

The purpose of a rapid assessment is to:

- confirm the emergency;
- describe the type, impact and possible evolution of the emergency;
- measure its present and potential health impact;
- assess the adequacy of existing response capacity and immediate additional needs; and
- recommend priority action for immediate response.

Preparedness

If the rapid assessment is to be useful for guiding emergency health response, it must be clear in advance which individuals make the decisions on emergency interventions because they must receive the information and recommendations made by the rapid assessment team. Moreover, it is essential that responsibilities for each particular emergency health action are clearly defined at national, regional, and local levels. Ideally, the rapid assessment should be conducted as the cooperative effort of all organizations with responsibilities for emergency response.

While it is impossible to plan for all potential emergencies, the challenge for all health programmes is how best to make emergency preparedness a part of their current activities, to both strengthen existing services and prepare for emergency response. Emergency preparedness includes:

- policy development for preparedness, response and recovery;
- vulnerability assessment;
- emergency planning;
- training and education; and
- monitoring and evaluation.

Emergency plans should be prepared by the ministry of health for all anticipated emergencies. These plans should include a description of:

- management structure (emergency powers, control, command, communication, emergency coordination centres, and post-emergency review);

- organization roles (description by role, description by organization, description by sector and emergency operation centres);

- information management (alerting, emergency assessment, information processing, public information, reporting, and translation and interpreting);

- resource management (resource coordination, administration, financial procedures, external assistance);

- summary of vulnerability assessment;

- maps; and

- emergency contacts.

Provisions for the assessment should be part of these emergency plans. There should be clear mechanisms in place for incorporating the assessment findings in emergency decision-making.

Emergency health response does not always need to wait for the collection of data. Experience has shown that emergencies have specific, predictable patterns of impact on public health. Selected health responses can and should be planned in advance, ready to be carried out without awaiting the results of rapid health assessment.

An example of this is the higher risk of measles epidemics among children in displaced populations living in camps. In countries at increased risk of internal or cross-border displacements, the national programme of immunization should include strategies to prevent such outbreaks as part of preparedness planning. Another example applies to countries at increased risk of sudden-impact emergencies such as earthquakes: routine hospital management in these areas must include formulating mass casualty plans and holding regular emergency practice drills. In communities with chemical plants, formulating in advance standard treatment guidelines for chemical exposure makes prompt case management possible, should a chemical incident occur.

Preparedness checklist

These questions can be adapted for specific types of health emergencies. They can also provide a focus for health preparedness activities at regional, district, and community levels.

1. Is there a national health policy regarding emergency preparedness, response, and recovery? Is the policy being implemented?

2. Is there a person within the ministry of health in charge of promoting, developing, and coordinating emergency preparedness, response, and recovery activities?

3. What coordination in emergency preparedness activities exists between the health sector, civil defence, and key ministries (such as the ministry of the interior and the ministry of agriculture)?

4. What joint activities in emergency preparedness, response, and recovery are undertaken between the ministry of health, United Nations organizations, and nongovernmental organizations (NGOs)?

5. Are there operational plans for health response to natural, man-made or other emergencies?

6. Have mass casualty management plans been developed (both pre-hospital and hospital) at national level as well as for individual hospitals?

7. What health and nutrition surveillance measures have been taken for the early detection of health emergencies (high-risk seasons, geographical areas identified; early warning procedures in place; national reference laboratory established; surveillance system established and working)?

8. What preparedness steps have been taken by environmental health services?

9. Have facilities and areas been identified and designated as temporary settlements in the event of emergencies? What provisions have been made for health care? (Include details such as general or special health services, staffing, supplies, water, and sanitation.)

10. What training activities are devoted to emergency preparedness, response, and recovery in the health sector (at national, regional, and district levels) and what organizations are involved?

11. What resources are available to facilitate a rapid health response (e.g. an organized communications centre in the ministry of health, emergency budget, access to transport, and emergency medical supplies)?

12. Is there a system for updating information on the key human and material resources needed for an emergency health response (e.g. updated inventories of essential drugs, and four-wheel-drive vehicles)?

13. What opportunities exist to test emergency plans through, for example, simulation exercises and drills?

Organizational preparedness

The measures listed below are of particular concern to managers within the ministry of health. Such measures are essential components of health emergency preparedness and should be reflected in all the ministry’s technical programmes.

The following structures for emergency health response should be in place:

- a position in the ministry of health with overall authority and responsibility for emergency health response;

- executive structures at all levels, with clear responsibilities for emergency health response (e.g. emergency health committees at community, district, regional, and central levels);

- a clear chain of command from central to peripheral levels for emergency health management;

- working links at all levels between the ministry of health, national emergency response and recovery organizations, the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations High Commissioner for Refugees (UNHCR), the United Nations Development Programme (UNDP), the World Food Programme (WFP), NGOs, and bilateral and intergovernmental organizations involved in health and nutrition; and

- coordination with other sectors, such as health, lifelines, transport, police and investigation, and social welfare.

Prepare emergency plans for anticipated emergencies

It is important to identify emergencies likely to occur at national and subnational levels, and their probable health consequences. Simple emergency plans, prepared and approved within the ministry of health, should outline the administrative and technical responsibilities and procedures necessary for a timely response. These plans and procedures should then be distributed to the relevant organizations involved in emergency response.

Existing information and experience gained in past emergencies are useful in setting priorities. The following questions should be considered:

· Where were the high-risk areas in past health emergencies? Who are the populations at risk? Based on experience, when are the high-risk seasons?

· What is the likely health impact of a flood or epidemic of meningitis? (Consider the number of cases, hospital admissions, and deaths.)

Compile and update information for prompt response

· Establish procedures for communicating early signs of possible emergencies between health authorities, key ministries, national emergency response organizations, international organizations, and NGOs so that a prompt alert is signaled.

· Keep updated lists and maps of health facilities, with information on bed capacity and specialist services available.

· Keep an updated inventory of NGOs working in health in the country, and their areas of expertise and experience in emergencies.

· In areas at high risk for health emergencies, have detailed maps available showing airfields, access roads, health facilities, and major water sources.

Clarify areas of responsibility and accountability

· Clarify who is responsible for emergency health action at each administrative level.
· Determine which organization is responsible for:

- multi-organization coordination in an emergency (lead agency for the rapid assessment);
- clearance, storage, and transport of emergency items;
- directing technical health response; and
- other critical activities such as travel clearances.

Standardize approaches to international health assistance

· Clarify reporting channels or lines of accountability for international organizations and NGOs.

· Develop standard procedures for requesting external health assistance.

· Establish standard working procedures for the importation and expedited clearance of emergency health items and drugs.

Anticipate needs for budget, transport, and communications

· Establish procedures for accessing funds and resources in health emergencies.

· Identify emergency options for rapid surface and air transport of personnel and emergency health items.

· Set up procedures for rapid collection, transport, and analysis of laboratory specimens.

· Establish procedures for emergency communication with peripheral areas.

Deal with the technical aspects

Plans of action should be developed for the early detection of and response to anticipated health emergencies. A useful starting point is to review and map existing data on past emergencies to identify areas of greatest risk, and assess local response capacity. The rapid health assessment team or person should ask people from the ministry of health or provincial or district health services the following questions:

· What is the distribution of facilities, number of beds, number of specialist services, and seasonal access to the area and facilities?

· How many health workers are there in the area and what is their level of experience?

· What are the likely effects of specific emergencies on health services in the areas identified as high risk (e.g. consider the number of admissions and the outpatient attendance)?

· What is needed for a prompt emergency response (e.g. hospital staff trained in mass casualty management, experienced epidemiologist, improved radio communication, and training of clinicians for better diagnosis)?

· Where are the gaps (in technical expertise, material supplies, emergency logistics, communication, and managerial skills)?

Establish early warning procedures

· Define the early signs that would signal an “emergency alert”. Can or could they be detected early through improved surveillance and reporting?

· Develop guidelines to help health personnel at all levels recognize and report these signs.

· Intensify surveillance for specific epidemic diseases during high-risk transmission periods.

Preparedness for rapid assessment

An important function of emergency planning is to identify in advance those warning signals which indicate that a rapid health assessment is needed. Alerts for these signals should also be determined, as shown in Table 1.

These alerts should be related to local conditions and expected seasonal variations. Ideally they will be triggered by ongoing activities such as epidemiological and nutritional surveillance.

Although all of the following seven measures are not always feasible, they are very desirable if the assessment is to be carried out rapidly.

1. Lines of authority within the ministry of health should be defined and clearly stated.

2. Organizational networks and partnerships should be maintained for mobilizing personnel and resources for the rapid assessment.

3. National, subnational, and district maps of high-risk areas, showing settlements, water sources, main transport routes, and health facilities, should be developed, kept updated, and made easily available.

4. Data collection forms, specimen containers, and other items essential for specific types of field assessments should be kept at the national and subnational levels.

5. Reference laboratories and special shipment procedures for rapid analysis of specimens should be identified in advance.

6. Communication channels between the assessment team, local authorities, decision-makers, and participating organizations should be agreed upon and kept open.

7. Qualified personnel should be identified in advance for rapid health assessment in specific types of emergencies.

Preparedness provides an opportunity to identify local skilled individuals as potential assessors in different types of emergencies, and to highlight gaps in technical expertise in advance. Although a rapid health assessment is usually best undertaken by a team, the composition of the group will vary according to the type of emergency.

Table 1. Warning signals of emergencies

Warning signal	Alert
An increase in hospitals reporting cases of meningococcal meningitis	Give alert for a meningitis outbreak
Above-expected seasonal levels of the disease in one district
Rising prices of staple cereals, and migration of people into an area that is expected to have a major crop failure at harvest time	Give famine alert
Increasing hospital admissions with signs of irritation of the eyes, skin, and mucous membranes in a community near a chemical plant	Give alert for a chemical accident

For instance, it is more important that a nutritionist participate in assessing a refugee influx than a meningitis outbreak. However, an individual skilled in epidemiology or public health should be a member of every assessment team.

Planning the assessment

This section contains information on: time and distance factors in emergencies, final preparations, the assessment itself, the best working practices, and common sources of error.

The seven preparedness measures listed in the previous section can also serve as a checklist for planning a rapid health assessment when an emergency is reported or rumoured.

Considering time and distance factors

Rapid assessment time-frame requirements and opportunities vary with the type of event and the accessibility of the affected area. In general, the following holds true:

· Rapid-onset emergencies, such as earthquakes and chemical accidents, require the most immediate assessment, in a matter of hours after the impact.

· Epidemics, floods and sudden displacements of population should be assessed at the latest within two to four days.

· In the case of suspected famine, where the onset is usually slower and an adequate investigation requires sampling the population, the assessment may take somewhat longer.

· In some situations, logistic or security considerations (e.g. in complex emergencies) may reduce the time available for conducting the assessment at field level to a few hours.

Distance or difficult access to the affected area, or both, can delay the initial assessment. If several areas have been affected, or the emergency is thought to have had widespread impact, several small assessment teams may be needed. In almost all situations, the initial rapid assessment should be followed by a more thorough and focused one. In particular, when the effectiveness of emergency response is being evaluated, it is necessary to collect baseline information through surveys that use probability sampling of the population.

Making the final preparations

The final preparations include: determining what information to gather, coordinating different organizations, selecting team members, identifying the team leader and assigning tasks, and making administrative arrangements.

Determining what information to gather

The two most important criteria for deciding what information to collect in a rapid assessment are its usefulness for timely decision-making and its public health importance.

Coordinating different organizations

Members of the rapid health assessment team should contact as many as possible of the organizations delivering emergency response, to coordinate activities and avoid duplicating efforts. Coordination and pooling of resources can produce a more complete and rapid assessment.

Selecting team members

The rapid health assessment should be performed by a multidisciplinary team of qualified personnel, representing an appropriate range of expertise. For example, a team to assess the health needs of a refugee population should include an individual from each of the following fields: public health and epidemiology, nutrition, logistics, and environmental health.

The following criteria should be taken into account in selecting team members:

- familiarity with the region or population affected;

- knowledge of and experience with the type of emergency being assessed;

- personal qualities, such as endurance, motivation, and personal health, the capacity for teamwork, and local acceptability for team members recruited abroad;

- analytical skills, particularly the ability to see trends and patterns; and

- the capacity to make correct decisions in unstructured situations on the basis of relatively sparse data.

Identifying the team leader and assigning tasks

One team leader must be identified to coordinate technical preparations for the field assessment, such as delegating responsibilities among members, ensuring consistency in approach and use of questionnaires, and preparing laboratory supplies and other equipment.

Making administrative arrangements

These include:

- obtaining travel and security clearances;

- organizing transportation and other logistics (e.g. vehicles, fuel, and, in some cases, camping equipment, food, and beverages);

- setting up the communications system and informing the authorities in the affected area of the assessment’s timetable;

- organizing other equipment, such as computers, height boards, scales, and checklists; and

- ensuring safety and security of team members from violence, infection or other hazards in the emergency-affected area.

Conducting the assessment

The steps for carrying out the assessment are: collecting data, analysing them, presenting results and conclusions, and monitoring.

Always take into consideration the following questions:

· How feasible is it to collect this information, given available personnel and resources?

· Is it worth the cost?

· How reliably do the data reflect the situation of the entire population affected by the emergency, i.e. how representative are they?

Collecting the data

Emergencies are often chaotic, and data collection during a rapid health assessment may not proceed in a step-by-step, logical fashion. Yet the plan for data collection and analysis must be systematic. In addition, the limitations of the various sources of information must be borne in mind during data collection and analysis. There are four main methods of collecting data:

- review of existing information;
- visual inspection of the affected area;
- interviews with key informants; and
- rapid surveys.

Review of existing information

Review baseline health and other information at national and regional levels from government, international, bilateral, and NGO sources about the following:

- the geographical and environmental characteristics of the affected area;

- administrative and political divisions of the affected area;

- the size, composition, and prior health and nutritional condition of the population affected by the emergency;

- health services and programmes functioning before the emergency; and

- resources already allocated, procured or requested for the emergency response operation.

Even official data sources are subject to limitations. For example, census data may underestimate certain subgroups or the population as a whole. In addition, morbidity surveillance data may represent an incomplete picture because diseases are routinely under-reported and the extent of under-reporting often varies.

Visual inspection of the affected area

When travel is undertaken by air, useful preliminary observations of the affected area can be made before landing. These may include a gross estimate of the extent of the disaster-affected area (e.g. the extent of flooding or of storm damage), mass population movements, condition of infrastructure (e.g. roads and railways), and of the environment.

A walk through the emergency-affected area may give you a general idea of the adequacy of shelter, food availability, environmental factors (such as drainage and vector breeding), other potential hazards, and the status of the population. The age and sex distribution and size of the population should be estimated.

During the observation, the affected area should be roughly mapped. Such maps should indicate the extent of the area affected, the distribution of the population, and the location of resources, including medical facilities, water sources, food distribution points, and temporary shelters.

Even careful observation may result in a biased impression. If the area visited is more or less severely hit than the rest, the observer may think the overall condition of the entire affected area is better or worse than it is. In addition, the most severely affected persons are often the least visible; injured or sick persons are more likely to be inside shelters and less accessible to visitors.

Interviewing key informants

Conduct interviews with key personnel in the area and with persons from every sector of the affected population:

- clan, village, and community leaders;

- area administrators or other government officials, teachers;

- health workers (including traditional birth attendants and healers);

- personnel from local and international emergency response organizations, including United Nations bodies working in the area; and

- individuals in the affected population.

The information collected from these interviews should include:

- the interviewees’ perception of the event (cause and dynamics);
- pre-emergency conditions in the affected area;
- geographical distribution and size of the affected population;
- age and sex distribution of the population and average household size;
- adequacy of security and prevalence of violence;
- current morbidity and death rates and causes;
- current food supplies, recent food distribution, and future food needs;
- current supply and quality of water;
- current adequacy of sanitation;
- other priority needs of the affected population, such as shelter and clothing;
- current status of transport, fuel, communication, and other logistic necessities; and
- current resources available in the affected community, including medical equipment, drugs, and personnel.

Concerns expressed by the people interviewed can be further investigated during the rapid health assessment. For example, if health workers report an outbreak of cholera in the emergency-affected area, this should be confirmed or refuted immediately by the assessment team.

The interview with key personnel should be used for planning the establishment of a surveillance system monitoring morbidity, mortality, and nutritional status.

Assessment personnel should always keep in mind that information derived from interviews is coloured by the interviewees’ perceptions. These perceptions are subject to the same biases mentioned above regarding visits to the affected area. Moreover, informants may intentionally exaggerate the extent of damage, injury or illness to solicit emergency assistance for the population they represent.

Rapid surveys

Because surveys take more time and resources, they should be reserved for data which are essential but may not be available from other sources. Such data could include:

- sex and age distribution of the affected population;

- average family size;

- number of persons in vulnerable groups, such as unaccompanied children, single women, households headed by women, and destitute elders;

- recent death rates;

- recent rates of health conditions that are specific to the type of emergency, such as diarrhoea, traumatic injuries, burns, and respiratory distress;

- nutritional status;

- vaccination coverage among children;

- state of housing; and

- access to health care, food, water, and shelter.

For a more complete description of survey techniques for rapid health assessment, see Annex 1.

Analysing the data

The data collected during the rapid assessment must be analysed quickly and thoroughly, and the results made available to decision-makers as soon as possible to derive the greatest benefit from the information.

The analysis should use standard techniques to ensure its comparability to assessments conducted in other situations, and to subsequent assessments that will be carried out during the current emergency. For example, standard case definitions for diseases should be used.

The analysis should be as specific as possible to ensure the best targeting for interventions. Data should be disaggregated and treated separately, according to administrative area, period, and type of population, to get specific estimates. The sources of data should always be specified, and an attempt made to assess their reliability.

Presenting results and conclusions

The presentation of the results and conclusions of the rapid assessment should have the following characteristics.

· It should be clear. Decision-makers or staff of local, national, and international organizations whose action depends on the results of the rapid assessment may have little training in interpreting health and epidemiological data. User-friendly language should be used; graphs can help make complex data and trends more easily understood.

· It should be standardized. The results should be presented in widely recognized formats so that they can be compared with other assessments. For example, the prevalence of moderate and severe malnutrition should be expressed as a percentage of the target population. In an emergency due to sudden population displacement, mortality should be calculated as the number of deaths per 10000 people per day.

· It should give clear indication of the highest priority needs and how to address them. Chronic or pre-existing conditions and needs should be distinguished from the new ones related to the emergency. The members of the rapid assessment team should arrive at clear recommendations for implementing organizations. For a suggested standard report format, see page 85.

· It should be widely distributed. Copies of the report should be distributed to all organizations involved in the emergency response operations.

Monitoring

The rapid health assessment should be only the first step in collecting data. Ongoing data collection is necessary to evaluate the effect of health programmes implemented before or as a result of the rapid assessment. For example, after recent death or morbidity rates are calculated from data derived from a survey conducted during the rapid assessment, a surveillance system should be established, or reestablished, to monitor future trends.

Developing the best working practices

Ensuring good team work

· International personnel should ensure that national staff participate in the assessment. Likewise, national personnel should include local or district staff in the exercise.

· At field level, introduce yourself and outline quickly the objectives and the method of the assessment. Do not intimidate your interlocutors with unheard-of United Nations or NGO names and abbreviations. Carry visiting cards.

· Explain what you are doing and why. The best way not to be an “emergency tourist” is to discuss on the spot your preliminary conclusions and give new ideas and hints on what you are going to do with the information gathered. Leave behind a copy of your questionnaire as a contribution or as a start-up for a local information system.

· If part of a multisectoral or multi-organizational team:

- work together at developing and readjusting case definitions and methods;

- share your questionnaire forms and familiarize yourself with those of other sectors (if the team has to split up to cover more ground in less time, any member should be able to collect data on any issue); and

- reserve half an hour every day for mutual debriefing.

Making the best of available information

· In emergencies, hard data may appear unattainable. But cross-matching data can provide an idea of the overall quality of information. Likewise, by contacting as many sources as possible, you may be able to put together an unexpected quantity of secondary data.

· The lack (or poor quality) of information is in itself information. A sector or area that does not report is one that has a problem.

· Inaccessibility may be the greatest constraint to the assessment. Try to quantify how much of the situation is actually reflected by your data, defining the accessible areas, the “grey zones” and the “black holes” on the map.

· The situation may change quickly. Collect the most recent data and continue monitoring after the rapid assessment. Circulate and discuss preliminary conclusions while processing the final report.

· Keep a record of geographical distances between major points, such as organizations’ offices, warehouses, and water sources. This will assist in planning emergency response.

· Carry with you reference values (e.g. cut-off values for death rates and standard nutritional requirements) for on-the-spot evaluation and preliminary planning. (Annex 2 carries a list of reference values that have proved useful in Africa and that can be adapted for other regions.)

· Keep separate notes of factual observations and personal impressions; if you have a personal computer, record them daily.

Being a good citizen

· Before leaving the capital or provincial headquarters, offer to carry mail, newspapers, or a reasonable amount of supplies to the field stations; carry with you some small luxury, such as fruit or a newspaper, to leave behind.

· Realize that emergency response field-workers labour under heavy workloads and difficult living conditions and that they will stay behind, while you come and go. Pose your questions in a non-threatening way, show appreciation for the good being done, and express criticism constructively.

· If, in the field, you find relevant documents (e.g. registers and reports), copy the information. Never take away the originals with you.

· Be ready to assist in medical evacuations from the field, making room for sick or wounded in your vehicle or plane.

Reviewing common sources of error

Common sources of error may be logistic, organizational, or technical.

Logistic

· Transportation and fuel are insufficient for the assessment.

· Communications between field, regional, and national levels are inadequate: the authorities in charge of the area(s) targeted for assessment are not informed on time and are not ready to assist the team.

Organizational

· A lead organization is not designated, the responsibilities of the various organizations are not well defined, and a team leader is not appointed.

· Key decision-makers and potential donors are either not informed that an assessment is being undertaken, or feel pressured to respond to political demands before the findings are known - resulting in inappropriate assistance.

· The assessment is conducted too late or it takes too long.

· Information is collected that is not needed for the planning of the emergency response.

Technical

· Specialists with appropriate skills and experience are not involved in the assessment.

· Programmes that could be implemented immediately, on the basis of past experience, are unnecessarily delayed until the assessment is complete.

· Assessment conclusions are based on data that do not represent the true needs of the affected population (e.g. from non-representative surveys).

· Information received from field-workers and official interviews is taken at face value, without cross-checking all sources.

· A surveillance system is developed too slowly, thus preventing monitoring and evaluation of the emergency response programme.

Presenting the results of the assessment

The following format can be adapted for presenting the results of the assessment in different situations.

· Reason for emergency (type of actual or imminent hazard):

- onset and evolution;
- additional hazards.

· Description of the affected area (add at least a sketch map).

· Description of the affected population:

- number, estimated breakdown by age, sex, and special risk or vulnerability factors;
- estimated total number of deaths and injuries.

· Impact, in terms of mortality and morbidity:

- daily crude mortality (number of deaths for the day per 10000 population);
- other indicators, such as malnutrition rates, losses in vital infrastructures, financial losses and other socioeconomic data can be used.

· Existing response capacity (in terms of human and material resources):

- local, subnational, and national capacity;
- international organizations (bilateral, nongovernmental, and intergovernmental);
- overall authority and national focal point;
- distribution of tasks and responsibilities;
- coordination mechanisms;
- logistics, communications, and administrative support.

· Additional requirements:

- immediate vital needs of the affected populations;
- immediate and medium-term needs for national capacity-building;
- implementation, monitoring, and evaluation mechanisms.

· Recommendations. Indicate the following:

- priority actions by projects;
- responsible office (national focal point and national and international partners);
- time frame;
- breakdown of requirements by projects (estimated costs).

An annex should illustrate the timetable of the assessment, give a summary of the methods used and list the sources. It will also include maps and a copy of the questionnaires used and the background documents that may have been collected in the field.