08 STRENGTHENING CAPACITY FOR ACTION IN HUMANITARIAN AND FRAGILE SETTINGS


Implementation objectives for this ingredient:


Humanitarian and fragile settings as core business of national health and social systems

A core emphasis on neonatal survival and sexual and reproductive health in humanitarian and fragile settings

Emphasis on human rights

The worst mortality and morbidity rates for women, children and adolescents occur in humanitarian and fragile settings that are caused by, and create, breakdowns in governance, rule of law and support systems. Such settings can be a result of conflicts or natural disasters but can also stem from ongoing political crises and systematic weaknesses. These settings are characterized by destruction or absence of public infrastructure including health facilities, massive population displacement, insecurity and a collapse of the social contract. For example, hostilities may be actively directed at stigmatized populations, and governments may become hostile to displaced populations. And, while climate change threatens everyone, it has become increasingly evident that it brings differential impacts to women, children and adolescents. This requires specific actions putting women, children and adolescents at the centre of humanitarian response and climate change adaptation and mitigation strategies.

In response to these challenges, national health and social systems need to link development and humanitarian programming, seeing both as “core business”. This requires investments in preparedness, local systems building and service provision (including investment in civil society delivery), and community resilience. Governments should also consider how responses to emergencies might strengthen existing systems and/or build capacity where it does not exist, particularly in fragile settings.

A five year implementation plan is being developed for supporting implementation of the Global Strategy in humanitarian and fragile settings; a description is included in the resource  list below.

8.1 Humanitarian and fragile settings as core business of national health and social systems

Key steps for positioning humanitarian and fragile settings as core business of national health and social systems include:

  • integrating action in humanitarian and fragile settings into national strategies for health and other sectors, with a single planning, monitoring and accountability framework, with inputs from affected communities
  • ensuring clarity on jurisdiction and accountability between different ministries and sectors, clearly assigning overall leadership and roles, particularly during humanitarian emergencies
  • using assessment tools such as multi-hazard health sector risk assessment (including gender and conflict sensitivity analysis, risk of epidemics and pandemics, and climate-related risk) to understand vulnerabilities in health and social systems
  • using a risk-informed programming approach in country development plans, including risk assessments, risk mitigation, disaster planning and contingency funding
  • investing in the capacity to absorb shocks to build resilience, through simulations, preparedness and planning for reconfiguration of resources (e.g. workforce), with strategies for response to sudden reduction in capacities
  • acknowledging the potential impact of emergencies on proximal and distal health service coverage determinants and outcomes, such as diversion of resources, public security, communications infrastructure, geographic isolation, staff desertion and population movement
  • strengthening capacity and data availability to undertake situation analyses in emergencies
  • recognizing that capacity building and data strengthening should not only revolve around emergency preparedness, but should also include the perhaps limited but existing local, district and county health data systems.

8.2 A core emphasis on neonatal survival and sexual and reproductive health in humanitarian and fragile settings

The circumstances of humanitarian and fragile settings are marked by an absence of health workforce and services, significant constraints on service provision, and heightened risks of violence against women and children. Prioritization of health services to be scaled up is therefore essential. In particular, efforts to increase service delivery should maintain a core emphasis on neonatal survival and sexual and reproductive health by:

  • prioritizing provision of the Minimum Initial Service Package (MISP) for reproductive health in both national plans and systems as well as in the efforts of external partners in emergencies and crises
  • undertaking objective assessments of needs and vulnerabilities; addressing these through an integrated package of health, HIV/AIDS, nutrition and WASH services; and transitioning programmes responsibly across the emergency to development spectrum
  • ensuring the safety of health facilities and health worker safety as part of efforts to provide essential services.

8.3 Emphasis on human rights

Human rights and the use of human rights principles and approaches are at the heart of the Global Strategy. Humanitarian and fragile settings require particular attention to human rights including:

  • Focusing on respect and the delivery of services and interventions without coercion, violence or discrimination in accordance with international human rights law
  • Taking into account the specific needs and rights of different sex and age groups
  • Anticipating, preventing and responding to the major threats to health and wellbeing that often worsen in humanitarian and fragile settings, such as gender-based violence
  • Protecting the safety of affected groups in humanitarian and fragile settings during the collection of data and advocacy efforts and ensuring confidentiality.

CASE
STUDY

Prioritizing humanitarian settings:

Turning disaster into an opportunity for resilient quality improvement in essential intrapartum and newborn care (EINC) services in the Philippines

Being affected by 20 major typhoons every year, flash flooding, volcanoes and earthquakes, the Philippines is considered the third most disaster-prone country in the world. In November 2013, Super Typhoon Haiyan hit parts of the Philippines affecting over 18 million people and causing infrastructural damage of an estimated US$1.5 billion. The hardest hit geographic areas belonged to the most deprived regions in the country with 40% of children living in poverty. Rapid assessments conducted 16 weeks following the typhoon revealed that health services infrastructure, logistics and human resources were severely impacted. In addition, existing service standards and provider skills were inadequate. Re-establishment of health services for mothers and children, particularly primary and secondary care for obstetric emergency, was identified as a top priority by the Department of Health (equivalent to the Ministry of Health).

In a first stage, emergency stakeholders conducted a multi-stage vulnerability analysis to identify priority areas for the humanitarian response. Based on preliminary data from the Philippines National Disaster Risk Reduction and Management Council and the United Nations Office for the Coordination of Humanitarian Affairs, 120 most affected cities and municipalities were identified. Criteria used included 1) 95% and above affected population, 2) category of typhoon signal and 3) highest potential for storm surge. In a second stage, additional data such as poverty incidence were analysed and a simple index and weighted averages to fine-tune area prioritization created. In a third stage, the status of existing and planned interventions across five sectors namely health, nutrition, education, child protection, and water, sanitation and hygiene, were categorized into high, medium and low convergence areas (high – all 5 sectors present; medium – 4 sectors; and low – less than 4 sectors).

In a fourth and final stage, the top 40 priority municipalities covering all high and some of the medium and low convergence areas were identified based on cumulative affected populations that would yield optimal coverage in relation to strategic response plan targets.

With technical support from the Philippines-based non-governmental organization Kalusugan ng Mag-Ina, UNICEF provided Essential Intrapartum and Newborn Care (EINC) trainings, Training of Trainers (TOTs), Cascade Quality Assurance workshops and supervisory visits in 40 priority municipalities. While trainings were based on updated guidelines endorsed by the World Health Organization for utilization in post-disaster areas, the content of each training session was tailored to the local context, taking into account gaps identified in previous rapid assessments. Gaps identified included Breastfeeding, Kangaroo Mother Care, Infant and Young Child Feeding in Emergencies, Basic Newborn Resuscitation, administration of magnesium sulfate, and postnatal care of mother and newborn.

In addition, two independent post-training evaluations were undertaken comprising of field visits to 56 facilities in the target areas. These evaluations revealed that 1) key commodities were now readily available at health facilities (e.g., magnesium sulfate from 38% to 94%, bag and masks from 0% to 88%-100% across the regions) and 2) service standards (partograph use, delivery room temperature and delivery records) had substantially improved. Dramatic increases in antenatal steroid use and Kangaroo Mother Care were also observed and recorded. Less progress was observed for handwashing, companion of choice during labor, BCG birth doses and monitoring of postnatal care.

This experience shows that post-disaster settings can provide opportunities to strengthen health systems and make them more resilient for future emergencies. The rapid restoration of EINC was a key entry point to quality improvement and health systems strengthening in this post-disaster setting.

Source: Castillo MS, Corsino MS, Calibo A, Zeck W, Capili D, Andrade L, Reyes KV, Alfonso LC, Ponferrada MB, Silvestre MA (under review) Turning disaster into an opportunity for quality improvement in essential intrapartum and newborn care (EINC) services in the Philippines.
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