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Humanitarian Charter and Minimum Standards in Humanitarian Response

Health systems standard 1: Health service delivery

People have equal access to effective, safe and quality health services that are standardised and follow accepted protocols and guidelines.

Key actions (to be read in conjunction with the guidance notes)

Key indicators (to be read in conjunction with the guidance notes)

(see guidance note 1).

Guidance notes

  1. Level of care: Health facilities are categorised by level of care according to their size and the services provided. The number and location of health facilities required can vary from context to context.

    Health systems must also develop a process for continuity of care. This is best achieved by establishing an effective referral system, especially for life-saving interventions. The referral system should function 24 hours a day, seven days a week.
  2. National standards and guidelines: In general, agencies should adhere to the health standards and guidelines of the country where the disaster response is being implemented, including treatment protocols and essential medicines lists. When they are outdated or do not reflect evidence-based practice, international standards should be used as reference and the lead agency for the health sector should support the Ministry of Health (MOH) to update them.
  3. Health promotion: An active programme of community health promotion should be initiated in consultation with local health authorities and community representatives, and ensuring a balanced representation of women and men. The programme should provide information on the major health problems, health risks, the availability and location of health services andbehaviours that protect and promote good health, and address and discourage harmful practices. Public health messages and materials should utilise appropriate language and media, be culturally sensitive and easy to understand. Schools and child-friendly spaces are important venues for spreading information and reaching out to children and parents (see INEE Minimum Standards for Education – access and learning environment standard 3).
  4. Utilisation rate of health services: There is no minimum threshold figure for the use of health services, as this will vary from context to context. Among stable rural and dispersed populations, utilisation rates should be at least 1 new consultation/person/year. Among disaster-affected populations, an average of 2–4 new consultations/person/year may be expected. If the rate is lower than expected, it may indicate inadequate access to health services. If the rate is higher, it may suggest over-utilisation due to a specific public health problem or under-estimation of the target population.In analysing utilisation rates, consideration should ideally also be given to utilisation by sex, age, ethnic origin and disability (see Appendix 3: Formulas for calculating key health indicators).
  5. Safe blood transfusion: Efforts should be coordinated with the national blood transfusion service (BTS), if one exists. Collection of blood should only be from voluntary non-remunerated blood donors. Good laboratory practice should be established, including screening for transfusion-transmissible infections, blood grouping, compatibility testing, blood component production and the storage and transportation of blood products. Unnecessary transfusions can be reduced through the effective clinical use of blood, including the use of alternatives to transfusion (crystalloids and colloids), wherever possible. Appropriate clinical staff should be trained to ensure the provision of safe blood and its effective clinical use.
  6. Laboratory services: The most common communicable diseases can be diagnosed clinically (e.g. diarrhoea, acute respiratory infections) or with the assistance of rapid diagnostic tests or microscopy (e.g. malaria). Laboratory testing is most useful for confirming the cause of a suspected outbreak, testing for culture and antibiotic sensitivity to assist case management decisions (e.g. dysentery) and selecting vaccines where mass immunisation may be indicated (e.g. meningococcal meningitis). For certain non-communicable diseases, such as diabetes, laboratory testing is essential for diagnosis and treatment
  7.  Mobile clinics: During some disasters, it may be necessary to operate mobile clinics in order to meet the needs of isolated or mobile populationswho have limited access to healthcare. Mobile clinics have also been proven crucial in increasing access to treatment in outbreaks where a large number of cases are expected, such as malaria outbreaks. Mobile clinics should be introduced only after consultation with the lead agency for the health sector and with local authorities (see Health systems standard 6).
  8. Field hospitals: Occasionally, field hospitals may be the only way to provide healthcare when existing hospitals are severely damaged or destroyed. However, it is usually more effective to provide resources to existing hospitals so that they can start working again or cope with the extra load. It may be appropriate to deploy a field hospital for the immediate care of traumatic injuries (first 48 hours), secondary care of traumatic injuries and routine surgical and obstetrical emergencies (days 3–15) or as a temporary facility to substitute for a damaged local hospital until it is reconstructed. Because field hospitals are highly visible, there is often substantial political pressure from donor governments to deploy them. However, it is important to make the decision to deploy field hospitals based solely on need and value added.
  9. Patients’ rights: Health facilities and services should be designed in a manner that ensures privacy and confidentiality. Informed consent should be sought from patients (or their guardians if they are not competent to do so), prior to medical or surgical procedures. Health staff should understand that patientshave a right to know what each procedure involves, as well as its expected benefits, potential risks, costs and duration.
  10. Infection control in healthcare settings and patient safety: For an effective response during disasters, continuing infection prevention and control (IPC) programmes should be enforced at both national and peripheral levels, and at the various healthcare facility levels. Such an IPC programme at a healthcare facility should include:
    • defined IPC policies (e.g. routine and additional infection control measures to address potential threats)
    • qualified, dedicated technical staff (IPC team) to run infection control programme with a defined scope, function and responsibility
    • early warning surveillance system for detection of communicable disease outbreaks
    • defined budget for activities (e.g. training of staff) and supplies in response to an emergency
    • reinforced standard precautions and additional specific precautions defined for an epidemic disease
    • administrative controls (e.g. isolation policies) and environmental and engineering controls (e.g. improving environmental ventilation)
    • personal protective equipment used
    • IPC practices monitored and recommendations reviewedregularly.
    1. Healthcare waste: Hazardous waste generated in healthcare facilities can be segregated into infectious non-sharp waste, sharps and non-infectious common wastes. Poor management of healthcare waste potentially exposes health staff, cleaners, waste handlers, patients and others in the community to infections such as HIV, hepatitis B and C. Proper separation at the point of origin of the waste through to final category specific disposal procedures must be implemented in order to minimise the risk of infection. The personnel assigned to handle healthcare waste should be properly trained and should wear protective equipment (gloves and boots are minimum requirements). Treatment should be done according to the type of waste: for example, infectious non-sharp waste as well as sharps should either be disposed of in protected pits or incinerated.
    2. Handling the remains of the dead: When disasters result in high mortality, the management of a large number of dead bodies will be required. Burial of large numbers of human remains in mass graves is often based on the false belief that they represent a health risk if not buried or burned immediately. In only a few special cases (e.g. deaths resulting from cholera or haemorrhagic fevers) do human remains pose health risks and require specific precautions.Bodies should not be disposed of unceremoniously in mass graves. People should have the opportunity to identify their family members and to conduct culturally appropriate funerals. Mass burial may be a barrier to obtaining death certificates necessary for making legal claims. When those being buried are victims of violence, forensic issues should be considered (see Shelter and settlement standard 2, guidance note 3).