health in emergencieshealth intelligence processes and products that lead to understanding of the...

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World HealthOrganization

HEALTH INEMERGENCIES

Issue No 15, December 2002

HEALTH INEMERGENCIES

Health intelligence in emergencies: which information and why?by Paul Ickx, Management Services for Health, AHSEP

In This Issue

HEALTH INTELLIGENCE IN EMERGENCIES 2

WORLD HEALTH NEWS 19

EHA REGIONAL CONTACTS 20

DECIDE

• Are the current levels of mortality and morbidity abovethe average for this area and this time of the year?

• Are the current levels of mortality, morbidity, nutrition,water, sanitation shelter and health care acceptableby international standards?

• Is a further increase in mortality expected in the nexttwo weeks?

ADVISE ACCORDINGLY

In mid-1999, almost 1,800 million people were living in countriesat severe risk of, affected by or emerging from armed conflicts.The “complexity” of these emergencies does not end when aformal cease fire is signed or political elections are held. On thecontrary, the transition is a particularly difficult and fragilesituation. For instance, in Afghanistan like in other post-conflictcountries, there is a patchwork of areas enjoying relativestability and others characterised by violence and insecurity. Inthis difficult environment, the challenge is to refocus internationalresources from emergency relief to development aid in order tosustain reconciliation and stability.

In situations of social and political instability, systems forroutine information are the first to collapse. A dilemmaconfronting humanitarian and development actors in Afghanistanand in other unstable countries, is that decisions need to bemade in the absence of health intelligence. The first, and mostdifficult decision concerns which priority health information isneeded, and how to monitor trends and support the shift inpriorities and resource allocation.

The health sectors in countries in post-conflict situations havesome common characteristics. Afghanistan is no exception (seeHealth in Emergencies issue 13: Countries in Transition). Theinternational community pledged earlier this year in Tokyo toprovide resources to rebuild the country. While the Ministry ofHealth (MoH) has built some credibility, many donors maintainfunding for relief-type interventions, and NGOs dominate actualservice delivery.

We will not expand on the intricacies of rebuilding a centralauthority in a country where previous central authorities havenever successfully penetrated local communities. It is howeverfelt that investment in health would help the peace process. Atthe same time donors seem to be more interested in infra-structural rehabilitation than in investing for systemsdevelopment and capacity building. Surveys and assessmentstend to reflect this bias.

NGOs most often need information for short-term relief-typeprojects. They will look for information that provides baseline

values for programmatic indicators. Several NGOs in Afghanistanundertook household surveys, often of good quality, but limitedto the project’s catchment area. Most program interventions areof too short a duration to demonstrate public health impact (i.e.change in mortality and morbidity), too local to benefit a largepart of the population, or pilot projects too expensive to bescaled up to regional or national scale.

International agencies, like UNICEF, WHO, UNFPA and othersare more interested in epidemiological data and proxy indicatorsthat reflect possible change in morbidity and mortality (e.g.vaccination coverage, service statistics, etc.). The informationlooked for is often more dictated by the global indicators of theagency than by the information gaps in the country. Theimmediate importance of the results of mortality surveys seemsmore directed towards creating a shock effect in the internationalcommunity with dismal figures, than providing new insightsinto disease specific mortality.

In a country like Afghanistan, with no real health infrastructure,with probably more than 60% of the population unable to accessthe most basic health services, one already knows that womenand children are the most vulnerable group, prone to diseasesthat are largely preventable and easily treated withunsophisticated means. For children those are the vaccinepreventable diseases, acute respiratory infections, and diarrhealdiseases. For women, pregnancy and childbirth related problemstake a heavy toll. For both groups, specific conditions will beexacerbated by chronic malnutrition and micro-nutrientdeficiencies. For all of these problems, interventions with proveneffectiveness exist. While program managers will want exactbaselines to measure impact, a government does not necessarilyneed exact proportions to know that these are priorities to beaddressed.

The Ministry of Health (MoH) is the prime stakeholder in thissituation and is interested in information, relating to a mediumterm plan for equitable health service provision and financing.

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HEALTH IN EMERGENCIES

WORLD HEALTH ORGANIZATION

Health information in emergencies:an overview of critical issues

The recent OCHA Symposium on Best Practices inHumanitarian Information Exchange concluded that the greatestchallenge is “creating a culture of information sharing thatpromotes the systematic collection, use and free flow of data,information and ideas, facilitates informed decision-making andbuilds trust and commitments among stakeholders”. Theconclusion is so general that few would object to it. However,reality is more complex. First, information and decisions inhumanitarian assistance are politically charged and involvedifficult compromises. Second, collecting and using informationin an effective way is difficult. This is particularly so inemergencies.

Does information support decision-making? Goodinformation is a necessary prerequisite to, but not a guaranteeof, rational decision-making. It is assumed that accurate, timelyand relevant data are gathered, processed and transmitted todecision makers, who then choose the “best” options.Uncertainty, complexity and competing pressures, however,disprove this linear model. The modern theories of decisionmaking stress that only in an ideal world does informationtranslate automatically into “sound” decisions. Decision makinginvolves political and personal values: “priority setting isultimately concerned with power relations and valuejudgements”1, and “any choice of output indicator as a basis fordecision-making, necessarily incorporates value judgements”2.In a heated environment with many players and conflictinginterests, a neutral use of information is impossible and decision-making can become messy. All humanitarian crises are politicaland the decision for an agency to engage is mainly based onpolitical grounds as well as on contextual information. Mortalityor morbidity indicators alone do not trigger action. They will becritical in guiding operations, monitoring the performance and indeciding when it is time to shift from an emergency to an ordinarymodus operandi. Furthermore, uncertainty and instability arecommon features of crisis, and it is difficult to factor them indecision making.

Types of uncertainty:

· Variation: cost, time and performance levels varyrandomly, but in a predictable range

· Foreseen uncertainty: a few known factors will influencethe project, but in unpredictable ways

· Unforeseen uncertainty: one or more major influencefactors cannot be predicted

· Chaos: unforeseen events completely invalidate theproject’s target, planning and approach

De Meyer A., Loch CH and Pich MT, 2002

Information can also be deliberately non-used: a frequent strategyin difficult contexts

3. Furthermore, the first requirement for an

early warning indicator to be of any value is for it to be discussedby decision-makers. But how realistically can a government incrisis be asked to discuss its mistakes or its own eventual demise?

Health IntelligenceProcesses and products that lead to understanding of thedeterminants of health and making decisions in any givencontext.

HEALTH INTELLIGENCE IN EMERGENCIESIts mandate is the establishment of successful public healthinterventions. These are interventions characterized by thefollowing: proven effectiveness, implemented on a large (national)scale, in a sustainable (some prefer the term affordable) mannerand in an equitable manner.

In Afghanistan most of the health information gathering untiltoday has focused on obtaining detailed baseline data forinterventions of proven effectiveness. This kind of informationgathering can be performed by expatriate public health experts,without active cooperation of a central health authority.However, information needed to ensure the other characteristicsof successful public health interventions can only be obtainedby recognizing the legitimacy of the central health authority inthese matters, no matter how limited that authority may bewhen it comes to actual implementation.

In Afghanistan, the MoH successfully engaged some of the majordonors on the health scene (USAID, EC, JICA), many of itsimplementing partners (UNICEF, WHO, UNFPA) and severalmajor national and international NGOs to undertake an inventoryof existing health services. This included the public sector, theNGO sector and the private sector. Between June and Septemberover 160 surveyors (all Afghan nationals) were trained andassigned to conduct the inventory of all health facilities inAfghanistan. They surveyed 1,038 health facilities in the 32provinces around the country. In addition, up to 2,915 healthworkers of different competence, living in the communitiesaround the health facilities and 1445 pharmaceutical outlets,located close to each facility were surveyed. Some of theinformation gathered focuses on rehabilitation of infrastructure.However, most of it focuses on identifying capacity gaps in thepublic and private health service’s ability to deliver the BasicPackage of Health Services.

The information obtained gives the MoH a clear picture of thecurrent health system, by showing the qualifications of the activehealth staff and identifying sources of support for the facilitiespresently delivering health services.

So far this picture shows the high inequity of distribution ofhealth services between provinces and between districts of thesame province. It has fed into an initiative to start thedevelopment of a decentralized health plan. The availableinformation will be reviewed province-by-province and used todraw up a plan that corresponds not only to the local needs, butalso relates to the resources that can be mobilized and the localcapacity to efficiently manage them.

Preliminary dissemination of the survey’s results by the centralMoH to the provincial health authorities, NGOs and donors,and the joint identification of implications for rational planninghas enhanced the credibility of the central MoH in its leadershiprole of tackling the issues of equity and sustainability, oftenlargely overlooked in post-emergency situations.



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Accuracy and comprehensiveness

Cost

: ca

pacities

nee

ded

&op

port

unities

lost

HEALTH INTELLIGENCE IN EMERGENCIES

Relationship between accuracy and the costof obtaining information

Adapted from Green A., 1999

We can conclude, therefore, with Sen4 that informational

exclusions are as important as information for making judgementsand that depending on the theory of ethics/justice that we(implicitly or explicitly) adopt, we will use one selectedinformational base and exclude another.

Paralysis by Analysis is a special case of non decision-making,due to the perceived lack of information5. It results from adesire for perfection but it can block necessary action. Forexample, where it is known that malaria is a major problem,estimating incidence rates does not need to be a precondition foranti-malaria activities. The opposite end of the spectrum isExtinction by Instinct

6: pressures to act or “field experience”,

force decisions with no systematic analysis, like undertaking arapid field assessment without obtaining previous securityclearance. In a crisis, it is usually the latter mechanism thatprevails: “action is always ahead of understanding”

7.

Sometimes, both mechanisms coexist; for example donors andNGOs take action while the national authorities decide to wait,or the opposite happens. Different perceptions of urgency,different biases and/or available resources and/or technicalcapacity can explain this lack of synchronisation.

Too little data or too much? In emergencies, the informationbase is generally weak and fragmented across different players;access and communication are difficult, and the collection andanalysis of data clash with other priorities. Some say that thestrongest indicator of a crisis is the lack of information, often inspite of a wealth of unused data. Even in a chronic emergencylike Afghanistan, health data, although incomplete, of variablequality and scattered among different players, were available.However, the capacity to compile them from different sources,judge their accuracy and make sense of them in a comprehensiveway

8seemed missing.

Others contend that often the problem is not the lack of data,but their excess9. Even where “easy” process indicators areavailable and appropriate10, expensive epidemiological data iscollected and analysed to measure the health impact ofprogrammes. Lists of notifiable diseases are often redundant, a“laundry list of most diseases known to mankind”11. Forexample, the Health Information and management system inAfghanistan, now under review, includes more than 30 diseases.

“Data do not speak for themselves”12

. They must be selected,processed and put into context to become intelligible and useful.The designers of information systems often disregard the factthat many decision-makers are generalists, for whom healthinformation is useful only if it is simple and complementsinformation from other sectors. Only if there is an intersectoralframe of reference, can decision-makers understand both theneeds in the field and each organization’s capacities and theneffectively coordinate with the partners.

How disaggregated should the information be? A crucialaspect confronting the designer of an information system is thelevel of aggregation of data at the different steps of the pathlinking the producer to the different users: the right information

should be transmitted to the right manager in the right amountand at the right time. This implies that management structure,data needs and flow must be analysed before designing anyinformation system.

It is common wisdom that information should be as disaggregatedas possible, and therefore analysed and used close to where it iscollected and action is needed. Decisions that are taken far awayfrom where the emergency unfolds are prone to errors, alsobecause contextual factors are missed. Aggregate informationcan hide the impact of the emergency on particular areas orgroups, or obscure inequalities in the response. Further, thetime for transmission of data from the periphery to the centrecan imply that response (e.g. to an outbreak) is implementedtoo late. On the other side, information at local level is usefulonly if capacities for decision and action are decentralised.Furthermore, the end user who sits in a western capital, and isrequested to make macro decisions on the allocation of resources,only needs aggregated information.

Timely or accurate information? In most emergencies,timeliness must take precedence over accuracy, and life-savingdecisions are taken on the basis of incomplete data. In fact, theopportunity costs incurred in improving information beforetaking urgent action are high as the graph shows.

An opportunity cost would be to delay the implementation ofand activity which could save lives just to improve accuracy ofdata which already indicates a health problem.

Also accuracy has a different weight in emergencies. Lack oftechnical skills and/or security conditions often impose the useof quick and dirty information. In unstable situations, precise

“much of the material remains unprocessed, or if processedunanalysed, or if analysed, not written up, or if written up,not read, of if read, not used or acted upon. Only a minusculeproportion, if any, of the findings affect policy, and they areusually a few simple totals”

Chambers R., 1983

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HEALTH INTELLIGENCE IN EMERGENCIESestimates can be a waste, “little more than an exercise in thequantification of misery”

13 : populations move, an outbreak can

flare up, the access to food can decrease, and the situation onthe ground may change by the time the findings of a survey areavailable. Provided that no strong biases are introduced, findingsfrom rapid assessments, which may not satisfy anepidemiologist, are acceptable for a health manager underpressure. They can, at least, help decide that more investigationis needed. “Precise quantification of incidence or prevalencerates rarely influences the choice of programmes offered by thehealth services”

14.

Does information support coordination? Another piece ofcommon wisdom is that good information helps coordination,and that good coordination improves information-sharing. Oneof the most-used definitions of coordination includes informationmanagement: “coordination is the systematic use of policyinstruments to deliver humanitarian assistance in a cohesiveand effective manner. Such instruments include strategicplanning, gathering data and managing information

15.

However, information use and coordination are processes thatare subordinate to the goal of achieving necessary changes

16.

They should not be regarded as positive outcomes per se. InAfghanistan, it was observed that “rather than information‘sharing’, there has been much information ‘airing’ in whichnews of projects, problems or opinions are spoken but nothingis systematically done with the information, either in terms ofcollection, analysis, dissemination or action”

17. Coordination

meetings can easily turn into political fora where no decision istaken, but simply information is used to provide its “owner”with a power position

18. In other cases, operational agencies,

which are used to rely on standard procedures, may not see theadded value of using and sharing information, and prefer tooperate “by the(ir) book” (e.g. establishing therapeutic feedingprogrammes, without waiting for evidence of malnutrition).

Conclusions

There are no universal prescriptions for improving informationmanagement in emergencies, because information needs andcapacity to use it vary from one crisis to another. There are,however, a few general hints that can help guide action andavoid frequent mistakes.

The lack of information is the best “piece of information”for making decisions in an emergency. The manager, at least,knows that (s)he has to investigate further, use all the sources,and all the available local intelligence. If the issue or thegeographical area on which no information is available areimportant, (s)he knows that something is wrong.

“Brand”, bad data should be not be used. In the scarcity ofdata, indicators attributable to an authoritative source are oftenused and reused, even if it they are known to be flawed or oflittle use. Uncritical use of brand sources can lead to the decisionof not looking for more useful information.

Information does not come for free, particularly in a crisis.The features of the information that is being sought (quality,

relevance, completeness, timeliness, accuracy) need to be relatedto the use of this information, the capacity of the decision makersto use it and the resources that are in place for implementingthose decisions. Restructuring information systems is a medium/long-term endeavour that should not divert energies from morepressing priorities. Too often, newcomers start new data gatheringschemes, bypassing existing systems. Instead, squeezing valuefrom existing data can often provide better returns.

Data out of context cannot produce information. Knowledgeof local context is critical to interpret data and produceinformation. Historical trends, seasonal variations, specific earlywarning signs are all important for understanding health dataand producing good intelligence.

Non-use and quality of information: a chicken and eggproblem which has a solution. Only using the information,triangulating it with other sources, checking its internalconsistency and comparing it with other standards allows theidentification of patterns of weaknesses in data, and theopportunity to improve it. Too often not using the informationbecause it is of low quality is a comfortable excuse for notprobing it. Dismissing available information as unreliable anduseless can become a self-fulfilling prophecy: sooner or laterthis information will become useless.For further information (including complete list of references)please contact A. Colombo at [email protected]

Endnotes1 Green A and Barker, 19882 Sandiford P, Annett H and Cibulskis R, 20023 Walt G, 19944 Sen A., 19995 Langley A,, 19956 ibid7 Pain A. and Goodhand J., 20028 WHO, 20029 Bertrand W.E., 198810 Garner P, 199711 Henderson D, 197812 Einstein A, quoted in Sauerborn R., 200013 Adeyi O and Husein K, 1989, quoted in Sandiford P (2)14 Sandiford (2)15 Minear L, Chelliah UBP, Crisp J, Mackinlay J and Weiss TG, 199216 Donini A, 199617 Bower H, 200218 Green A, 1999

Coverage and DisaggregationWhere does accuracy end?

Country

Province District

Village

Village

Village

District

Province

Province

District

District

District

District

VillageVillage

Village

Inaccessible

District ?

Coverage and DisaggregationWhere does accuracy end?

Country

Province DistrictDistrict

Village

Village

Village

DistrictDistrict

Province

Province

DistrictDistrict

DistrictDistrict

DistrictDistrict

DistrictDistrict

VillageVillage

Village

Inaccessible

DistrictDistrict ?



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The WHO Health System Framework: can it help in complex emergencies?


Health managers need a comprehensive view of the performanceof their service-delivery system in order to make informedchoices. This implies identifying and interpreting essentialknowledge from a range of formal and informal sources (e.g.routine information, research, the media, opinion polls, pressuregroups, etc.). Although there is no universal agreement on whatis “essential”, there is general consensus that decision-makersshould have reliable, up- to-date information on:

• current and future trends in health status and health systemperformance;

• important contextual factors and actors;• policy options, based on national and international evidence

and experiences.

This information, to be meaningful, needs to incorporate basiccriteria of quality for health statistics. For example, a figurequantifying an indicator needs to be valid and reliable at a certaindegree of confidence and be comparable across populations. Theapplication of these criteria for published health data constitutesa validation process that is carried on in consultation withcountries.

WHO has a long-term strategy to help countries monitor theirprogress and achievements in the development of health systems.The WHO Health System Framework1 provides a good standardapproach to the analysis of different aspects of performance:from the inputs absorbed by the health system, through itsfunctions (health services provision, resource generation, healthfinancing, stewardship) and achievements (e.g. effective coverageof health services provision), to its overall goals and efficiency. Anumber of core indicators are published in the annual WorldHealth Reports which can be accessed through the WHOCountries web page2,3 and others are being developed by WHO/EIP.

However, no country represents a homogeneous reality, in healthnor in other sectors: making the right choices at national leveldemands a comprehensive view of many, different sub-nationalrealities. To tackle this issue, many member countries suggestthat it would be useful to adapt the Health System Frameworkfor use at sub-national level. Thus, WHO is exploring ways toassess sub-national health systems performance in severalcountries. The focus is on using the data that are available andlow cost approaches to fill the gaps. Indeed, a wide array of dataexist in all countries: they may be incomplete, specific data maylack for some indicators, but at least estimates -priors- can beconstructed on the basis of related data from other sources.These sources include: routine activity reports, diseasenotifications and disease registers, surveillance systems, vitalregistration systems, household and facility surveys and periodicproject or programme assessments. Possible low cost approachesinclude:

• The use of national data to develop priors for sub-nationalareas

• The use of key informants as priors• Small sample survey techniques and item reduction strategies,

to shorten questionnaires.

Countries in complex emergency or in transition are extremeexamples of different and co-existing realities: a leopard skin ofareas, some relatively secure, well-serviced and well-known,others in total disarray and/or inaccessible. Health informationis fragmented and rarely presented in a systematic way. Especiallyscarce is information on how well the health systems functionand what resources exist to improve their performance. Verylittle can be consolidated in a meaningful picture of the country’soverall health status and health systems. When available, thisinformation is usually limited to describing how these systemswere structured and how they performed before the crisis.

The start of health sector recovery is a good time for membercountries to take a step back and consider what strategies aremore appropriate and cost-effective in different settings to collectinformation useful to decision makers. This requires in the firstinstance addressing the following questions:

• What information already exists and how useful is it?• What do decision-makers really need to know to make health

policy decisions that lead to better health and health systemperformance?

• Which are the available techniques for minimizing the effortand cost of filling important information gaps?

• How can findings be more effectively communicated todecision-makers and to the public. What factors enhance thechances of their use?

When planning for reconstruction and recovery, decision-makersneed to quantify the differences in health system performancebefore and after an emergency, identify factors that influence itand articulate the most appropriate policies. There areconsiderably fewer systems-wide approaches that can be usedto inform more strategic decisions.For further information please contact M. Thieren at [email protected] orD. Egger at [email protected]

Endnotes1 Murray C. and Frenk J., 20002 www.who.int/country/en/3 w w w . w h o . i n t / h e a l t h - s y s t e m s - p e r f o r m a n c e / s p r g /

report_of_sprg_on_hspa.htm

K n o w le d g e s ta te s P r o c e s s a c t iv i t ie s

D E C IS IO N

J u d g m e n t

U n d e r s t a n d i n g

K n o w le d g e

In fo r m a t io n

D a ta

E v e n t s

A t t r ib u t in g v a lu e s

W e ig h in g o p t io n s

In te r p r e t a t i o n

A n a ly s is

O b s e r v a t io n &c o l le c t io n

S o r t i n g /S e le c t in g /A s s o c ia t in g

In t e l l i g e n c e

The knowledge-driven model ofdecision-making

Adapted from Van Lohuizen, 1986

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Health intelligence can be described as embracing two majorchapters of activities:

a) to identify, collect, integrate, analyse, and synthesizeinformation on the conditions under which healthproblems occur and how they can be prevented

b) to monitor events in the world and detect situationswhere preventative measures should be implemented.

The first activity seeks to build a “knowledge base” on why andunder what conditions health problems occur and how they canbe prevented. The second looks for the occurrence of theseconditions in the world so that preventative measures can beput in place. The former consists mostly of literature reviews,formal analyses and expert consultation; the latter implies theestablishment of early warning systems.

Both activities call for organized, systematic, formal mechanismsof identifying, collecting, analysing, and disseminating data.While these formal mechanisms are often described as the “healthintelligence system” there is an additional, frequently moreimportant but less well recognized source of health intelligence- the informal sources of information that often develop aroundthe formal mechanisms.

One important informal source that can develop around a formalmechanism are the authors identified in formal literature searches;they can frequently provide broader expertise. A second informalsource includes the participants in early warning systems whomay have access to information outside of their formalresponsibilities therein.

In both cases, sources that are part of a formal mechanismprovide information outside of the formal mechanisms. Howcan such informal sources be leveraged?

One method is to actively seek and involve informal sources -formalize the informal. A mechanism can be established forcontacting authors of publications, evaluating their potentialcontributions, and involving them in health intelligence; inessence establishing a network of experts for future consultation.The participants need to be briefed as broadly as possibleregarding the goals and scope of the health intelligence activityand on collaboration mechanisms. These can include formalconsultations, participation in health intelligence unit activities- reviews, analyses, etc. - and periodic information on relevantactivities and events. The main emphasis is on maintainingcontact with the sources so that if relevant information comesto light the participants will be more likely to share.

For participants in formal early warning systems, anunderstanding of the scope and goals of the health intelligenceactivity that is broader than their formal responsibilities isimportant. They will also need mechanisms for reporting datathat are outside of the normal channels and the authority to doso. On the receiving end, there must be mechanisms forprocessing data received outside the formal system - what todo, who to contact, what to pass on.

Information received through informal sources, while oftencrucial, arrives in an ad hoc fashion. It is important that the

Health intelligence: Formalizing informal mechanisms

Analysing Disrupted HealthSectors

In the wake of complex emergencies, when it comes to plan forhealth recovery, big mistakes are frequent and valuableopportunities are missed.

WHO’s departments of Emergency and Humanitarian Actionand Health Financing and Stewardship are working on a manualof how to carry out a review of a disrupted health sector, forreconstruction purposes. Dimensions to be studied include thegeneral country context, health status and needs, and a detailedreview of the health sector including: evolution, actors, structure,inputs, delivery processes/management systems, outputs,trends, policies, underlying patterns and priorities for action.

The manual is intended for public health professionals withsome field experience. It will be practical and action-oriented. Itwill discuss in detail how to collect, clean, validate, compile andmake sense of data, using real-life examples, discussing commonpatterns and pitfalls of analysis. The manual will includeexercises, annotated essential references, a glossary of definitions,concepts and indicators and examples of health sector profiles.Tables with figures will provide terms of comparison for variouswar-torn environments.

Work has started and is expected to continue during the first halfof 2003. Field testing is foreseen during the second half of theyear.For further information please contact A. Colombo [email protected]

mechanisms for dealing with it be as simple, clear and “light” aspossible. The intent is to cast as broad and “sensitive” a networkof informal sources rather than establish rigorous and “specific”system. The emphasis would be on briefs on unexpectedinformation rather than detailed confirmation of existing statesof affairs. At the receiving end, the follow-up should be onevaluation and synthesis rather than analysis. While informalreports can lead directly to action, more frequently they willtrigger further assessment and investigation.

Perhaps the most important features for leveraging informalsources is for key people to know that the intelligence unit: a) isinterested and b) will use the information. The interest can bepromoted through the early warning networks and the scientific/technical community. The previous use of the information canbe demonstrated by acting on information received outside ofFor further information please contact A. Burton [email protected]

If one takesa consistent preventative approach,

health intelligence should look atwhat keeps people alive and healthy,

rather than focus on what makes them sick.



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Emergency situations require simple, reactive systems formonitoring key indicators such as mortality and major epidemic-prone diseases. These systems, developed during the emergencyshould evolve into a national surveillance/early warning systemwhen the situation permits. During the last four years, the WHO/CSR team Lyon, has collaborated with various partners toestablish early warning systems in several complex emergencies.

In 1999, Albania faced a severe economic and social crisis. FromMarch to June, 442,000 Kosovar refugees arrived in Albania.More than half of them were hosted with Albanian families, therest being settled in camps and collective centres. The nationalsurveillance system, which included 73 diseases, was unpreparedto face this situation. An emergency system was set up to detectand control potential outbreaks among refugees.

The events under surveillance were those that constituted ahazard for outbreaks in the context of a refugee crisis (diarrhoeas,acute respiratory infection (ARI), scabies, measles andmeningitis). Every week health units caring for refugees reportedto the district epidemiologist new cases and deaths on a standardform which was transmitted to the National Institute of PublicHealth (IPH) in Tirana.

Standard analyses included computation of indicators such asnumbers of cases and deaths per week, number of units reporting,and number of districts reporting. The IPH prepared weeklyreports including a summary of the consultations for the week,the proportional morbidity, and specific comments.

After the detection of suspected cases of measles, an acceleratedimmunisation campaign was carried out among Kosovar andAlbanian children in Kukes and Has districts.

Clusters of suspected cases of diarrhoea with blood, hepatitis,and measles were detected in specific refugee settlements. Activecase finding and visits to the field were conducted to assess thesituation and to take appropriate control measures.

The high sensitivity of the syndrome-based surveillance systemled to several false alerts, but the system was designed tofacilitate early warning. Medical staff found the systemacceptable because of its simplicity: only diseases with thepotential for producing epidemics with high morbidity andmortality were monitored.

The development of epidemiologic instruments based on asyndrome approach led the WHO/CSR Lyon programme todevelop a system which can be rapidly implemented in varioussettings. In countries such as Serbia, which experienced severehealth emergencies, WHO/CSR Lyon helped national authoritiesestablish a national early warning system. In Iraq, WHO/CSRLyon is presently working to set up an early warning system,with the existing national surveillance system. The system isfocusing primarily on epidemic and emerging infectionsurveillance, but can easily evolve into a comprehensive earlywarning system.For further information please contact D. Buriot [email protected]

A surveillance system forcommunicable diseases


Why surveillance of risk factors ofnon-communicable diseases?

The risk factors of today are the diseases of tomorrow. The goalof Non-Communicable Disease (NCD) surveillance is to monitoremerging patterns and trends in major non communicable diseases,and to measure effectiveness of prevention interventions.Governments need up-to-date NCD information for analysis,planning and evaluating policies, preventive programs and healthservices. Many developing countries are seeking guidance inestablishing surveillance. WHO proposes to collect and reportinformation on some key NCD risk factors which are linked tomany chronic conditions. All of these risk factors are modifiable.

Filling the gaps in NCD risk factor surveillance:The WHO STEPwise approach

WHO has developed standardised materials and methods forNCD risk factor surveillance to allow countries to fill in theinformation gaps identified.

STEPS is the WHO recommended NCD surveillance tool. Itoffers one common approach to defining core variables forsurveys with the goal of achieving data compatibility over timewithin and between countries. STEPS offers an entry point forlow-and middle-income countries to get started in NCDactivities. It is a simplified 3 step approach providingstandardized materials and methods as part of technicalcollaboration with countries, especially those that lack resources.Once step 1 is in place, countries can build upon it.

Aggregate data on core risk factors will contribute to the WHOGlobal NCD InfoBase, currently under development. Thisdatabase is a resource that will hold up-to-date, country-level,risk-factor data for each of the 192 WHO member states.Summary profiles of available country-level data will be updatedcontinuously and published at regular intervals. The first SuRFReport (Surveillance of Risk Factors) is due at the end of 2002.For more information please contact R. Bonita at [email protected]

For scientists, linked to respectable statistical methods,complexities can be an unmanageable nightmare, for, ifthey simplify them until they are measurable, they destroythe complexities which are their strength

Toulmin & Chambers, 1989

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Collective violence and health: available informationOne of the groundbreaking aspects of theWorld HealthOrganization’s World report on violence and health is that itdraws together both the available findings, and data sources ofrelevance to all forms of violence. Beyond this, it organisesthese findings into a common ecological framework allowingone to consider both the prevention and the roots of violencewithin this framework.

What follows below are comments relating to data sources andfindings of relevance to one form of violence, namely, collectiveviolence. Collective violence is defined within the World reporton violence and health as ‘the instrumental use of violence bypeople who identify themselves as members of a group - whetherthis group is transitory or has a more permanent identity -against another group or set of individuals, in order to achievepolitical, economic or social objectives’.

The central problem with commenting on the public healthburden of collective violence is the lack of reliable data. Nationalreporting systems and assistance organisations in settingsaffected by collective violence are one source of information.They are complemented internationally by research institutesand organisations which gather data on conflicts, reported tortureor human rights abuses. A range of research institutes collect andanalyse data on the impact of conflicts and violence. TheStockholm International Peace Research Institute (SIPRI), hasannual reports on the impact of conflicts, and the Correlates ofWar Project of the University of Michigan is a well-knownsource on conflicts from the 19th century to the present day1.

Other data (e.g. on torture and human rights abuses) are gatheredby national human rights agencies and international NGOs:African rights, Amnesty International and Human Rights Watch;in The Netherlands, the interdisciplinary research programmeon root causes of human rights violations monitors deaths andother outcomes of abuses worldwide.

The validity of such data is imprecise. Most poor countries lackreliable health registration systems, making it particularly difficultto determine the proportions of deaths, disease and disabilitythat are related to conflicts. In addition, complex emergenciesinvariably disrupt existing surveillance and information systems.These caveats do not mean that one can say nothing about theglobal public health burden arising from collective violence, onlythat one needs to interpret available information with caution.Indeed, an increasingly rich body of literature examining bothcauses and consequences of collective violence is emerging andefforts have gone to considerable lengths to account fordeficiencies in available data sets.

Direct effects. It is perhaps best to consider these effects aseither arising directly or indirectly as a result of violence. Interms of direct health effects, the World Health Report 2001estimated that conflicts accounted for over 310,000 deaths during2000 with over half of these occurring in sub-Saharan Africa.Men aged 15-44 accounted for well over a third of mortality.

While estimation is difficult, it is likely that non-fatal injuriesrelated to conflict are substantial. A good source of primary datain this area is of course with the Military. Casualties among

armed forces are recorded according to prescribed proceduresand are likely to be fairly accurate. A review spanning the 20thcentury found that the ratio of people wounded to those killedduring conflicts range from 1.9 to 13.0 with an average of around3 people wounded for every individual killed2. The 1990 GlobalBurden of Disease estimated non-fatal outcomes attributable toconflict represented approximately the same global health burdenas fires and half that of road traffic injuries3.

Indirect effects. A wide variety of indirect effects arise from thedisruptive social changes accompanying collective violence.Collective violence typically creates population displacement,disrupts social infrastructure such as health care systems andhalts food production and distribution networks 4,5. Frequently,systems and infrastructures that are critical for the survival ofcivilian populations (lifelines) are specifically targeted in conflictsthrough attacks on health workers, and destruction of food andwater distribution complexes6,7. Research in these settings hasshown a significant reduction in indicators such as vaccinationstatus which accompany collective violence8.

While it is difficult to estimate with precision the burden ofhealth effects that are attributable to these changes, availableevidence suggests they are substantial. Crude mortality rates indisplaced populations have been reported at 5 to 12 times abovebaseline rates9, and were substantially higher among those fleeingthe Rwandan genocide who arrived in Goma10. The primarycauses of death in these circumstances are communicable diseasesand malnutrition. But over and above morbidity and mortalityrelated to communicable disease and malnutrition, a broad rangeof other health outcomes have been documented in populationsexposed to collective violence, including sequelae in the domainsof psychosocial, disability and reproductive health11. The riskof HIV/AIDS in Africa is thought to have increased considerablyas a result of civil wars12,13.

It also seems reasonable to expect that these indirect healtheffects would not be limited to the period during which violenceis occurring. A recent statistical assessment using cross sectionaldata indicates that the total disability adjusted life years lost in1999 due to the indirect effects of collective violence occurringbetween 1991 and 1997 was about the same as the number lostthrough direct effects of collective violence in 199914.For further information please contact D. Meddings [email protected]

Endnotes1 WHO, 2002 World report on violence and health at: www.who.int2 Coupland R. M. and Meddings DR., 19993 Murray CJL et al., 20024 Collier, 19995 Stewart F., 19936 Fitzsimmons DW, Whiteside AW., 19947 Toole MJ., 20008 Garfield RM, Frieden T, Vermund SH., 19879 Ghobarah H, Huth P, Russett B., 200110 Meddings DR, 200111 Meddings DR, 200112 Reid E., 199813 Epstein H., 200114 Ghobarah H., Huth P., Russett B., 2001



9

WHO continuously monitors disease outbreaks through theGlobal Outbreak Alert and Response Network. This Networkwas formally launched in April 2000 and links over 72 existingnetworks and institutions around the world, many of which areequipped to diagnose unusual agents and handle dangerouspathogens. It provides an operational framework to link theexpertise and skills needed to keep the international communityconstantly alert to the threat of outbreaks and ready to respond.

The Network has four main tasks:1. epidemic intelligence and detection,2. verification of rumours and reports,3. immediate alert,4. rapid response.

1. Epidemic intelligence and detection. The first task issystematically to gather global disease intelligence drawing on awide range of formal and informal sources. Formal reports ofsuspected outbreaks are received from ministries of health, WHOcountry offices and collaborating centres, government andmilitary laboratories, academic institutes, and non-governmentalorganizations. Of the informal sources, one of the most importantis a semi-automated electronic system that continuously scoursworld communications for rumours of unusual disease events.This is the Global Public Health Intelligence Network (GPHIN)computer application developed for WHO in partnership withHealth Canada in 1996. Other sources of information includenon-governmental organizations (NGOs).

2. Outbreak verification. Raw intelligence gleaned from allformal and informal sources is converted into meaningfulintelligence by the WHO Outbreak Alert and Response Team,which determines whether a reported disease event constitutesa cause for international concern. Each weekday morning, theteam meets to review incoming reports and rumours, assesstheir epidemiological significance and decide on the actionsneeded. A detailed report on suspected and verified outbreaks isdistributed electronically at the end of the day to a limited numberof WHO staff around the world. The combined system fordetection and verification is powerful, wide-ranging and highlyefficient. From July 1998 to August 2001, WHO verified 578outbreaks in 132 countries. (Please see “Rumors of Disease inthe Global Village: Outbreak Verification” available on the WHOweb site at www.who.int)

3. Real time alert. A network of electronically-interconnectedWHO member countries (192), disease experts, institutions,agencies, and laboratories is kept constantly informed ofrumoured and confirmed outbreaks. In addition, WHO maintainsand regularly updates an Outbreak Verification List, whichprovides a detailed status report on all currently verifiedoutbreaks. WHO also posts situation reports on verifiedoutbreaks on its web site, (Please see “Disease Outbreak News”available on the WHO web site at www.who.int).

4. Rapid response. When the Outbreak Alert and ResponseTeam determines that an international response is needed tocontain an outbreak, partners in the global Network providespecific support, including on-the-spot investigations,

confirmation of diagnosis, handling of dangerous (biosafety levelIV) pathogens, case detection, patient management, containment,and provision of logistics in the form of staff and supplies.Investigative teams are prepared to arrive at an outbreak sitewithin 24 hours. Since early 2000, WHO and the Network havelaunched effective international responses to outbreaks inAfghanistan, Bangladesh, Cote d’Ivoire, Egypt, Ethiopia, Gabon,Kosovo, Saudi Arabia, Sierra Leone, Sudan, Uganda and Yemen.For further information please contact M. Ryan at [email protected]


For further information please contact A. Colombo [email protected]

Surveys in emergencies: the use ofmortality and nutrition indicators

The measurement of mortality and wasting has been usedextensively for assessing the severity of an emergency, identifyingneeds, prioritising interventions, monitoring the impact and foradvocacy purposes. There are several advantages in the use ofthe two indicators: they provide a concise picture of the statusof a community, standard methods exist for collecting data, thesurveys are relatively quick and inexpensive, data analysis ismade easy by standard software packages and the interpretationis straightforward due to the existence of internationally acceptedcut-offs and threshold levels. There are, however, limitations.They include a limited validity and reliability due to samplingtechniques and the susceptibility to selection and informationbiases. Another constraint is the limited generalizability of thefindings of a survey. The area where a survey is conducted maybe chosen because it is safe enough for health workers toundertake the survey. This may imply that access to food,services, etc. is better. Sometimes an area is chosen becausemore information is available. But information is often associatedwith better overall conditions. On the contrary, an area may bechosen because it is known to be more severely affected. In thiscase the health status will be worse than in areas on the edge ofthe emergency.

Another problem has to do with the volatility which characterisesmost emergencies. While anthropometric data provide a staticpicture of the present nutritional situation (i.e. they are a cross-sectional, point prevalence estimate), mortality data are usuallycollected retrospectively and, therefore, represent an estimateof a past risk. As this is a dynamic measure, the outcome mayhave either improved, remained stable or worsened. This cancreate problems in the interpretation of mortality: in an emergencychanges in the determinants and mortality experience can bequick. From the response point of view, once the results of thesurvey become available, it may be too late for implementingeffective interventions.

Global Outbreak Alert and Response Network

Which information to collect ?Is the question clear?Why ask this question?

Where to find the information?What to do with the answers once we have them?

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Rapid health assessments inemergencies: an epidemic1 ofmethods?

Since the EPI cluster method was developed by WHO in 1981,a number of rapid techniques have been developed for healthmeasurement andprogramming. Theirrationale, to obtainquick information,and the need toovercome some ofthe shortcomings oft r a d i t i o n a lepidemiology in thefield, have beenpromptly recognisedas particularlyrelevant inemergencies2. WHO published in 1990 a booklet on rapid healthassessment (RHA)3, which contains standardised protocols, thatare disaster-specific and flexible (they can be adapted to localinformation needs). The protocols identify early warning eventsthat can accelerate the recognition of an emergency and theresponse. Since then, instruments for RHA have proliferated,with UN agencies and NGOs developing their own protocolsand tools (i.e. UNHCR, IFRC, MSF, UNICEF, OFDA, etc).The multiplicity of techniques for RHA (see table below) and ofdata-gathering and reporting tools is justified by different

information needs relating to: the type of disaster, the targetbeneficiaries, the local conditions in which agencies operate(security, access, etc), the composition of the assessment teamand its technical skills mix, etc.

As a result, however, the comparability of findings from differentassessments in the same area suffers, as well as consolidatingthem into a broader picture. Also, reaching an early consensusbetween different agencies on what critical information to collectand how, often requires time-consuming negotiations andcompromises. There can be also political pressures to disprovethe emergency or underestimate its impact (e.g. when a choleraepidemic is suspected) or, conversely, to inflate the figures ofvictims or the extent of damage (e.g. to obtain more aid), whichcan influence where and how the needs assessment is carried outand how widely its findings are circulated. The overarchingdifficulty is, however, methodological and intrinsic to the RHAgoal. The need for quick information and the difficult fieldconditions prevent using formal epidemiological techniques:validity and precision must be sacrificed for sake of speed,simplicity and cost4. In order to compensate these losses, RHAshave to rely on extensive use of triangulation of different sources,combination of qualitative and quantitative methods andutilisation of proxy indicators. The limitations of RHA need tobe carefully considered when data are interpreted and filteredback to decision-makers: the dangers of erroneous conclusionscan delay or even block the response when it is badly needed or,conversely, can result in waste of precious resources6. Trainingin RHA is only a partial solution for overcoming these risks:making sense of poor data in the chaos of an emergency requiresfield experience and local knowledge of the context for identifying

trusty sources and interpretingfindings. This does not detract fromthe advantages of making availablestandard protocols and templates,like the one available at the WHO/EHA website (www.who.int/disasters/sitrep.cfm), which aims athelping field data gathering andreporting in a quick and standardizedway. Other efforts in this sense areunder way: WHO is in the final stageof producing two manuals (AnIntroduction to Management inEmergencies and an EmergencyManual for the Wester PacificRegion), which extensively coverRHA in emergencies.For further information (includingcomplete list of references) pleasecontact A. Colombo [email protected]

Endnotes1 Manderson l and Aaby P, 19922 Guha-Sapir D, 19913 WHO, 1990 revised in 19994 Anker M, 1991 and Macintyre K, 19995 Collins S, 2001

Type W h e n W h a t H o w

Rapidreconnaissance

Immediatelyafter a disaster:as soon as it ispossible to enterthe area

A q u ick,prelim inaryinspection of thedisaster area

• Satelliteimagery

• Overflights• M apping• D rive/w a lk

throughRapid Hea lthAssessm ents

A s soon as it ispossible to dosome work inthe area to thearea

A q u ick collectionof inform a tion toconfirm theemergency,measure the impact,identify healthneeds and guideresponse

• V isualinspection

• Consultat ion ofm edical records

• Interview ofkey informan ts

• Rapid surveys( M U A C , etc)

Surveys When thesituationstabilises andresponse hasbeen activated

A detailed study inw h ich inform a tionis system a ticallycollected in asam p le ofpopulation(morbidity,m o rtality, nutrition,K A P )

• Sampling(random )

• Interviewsand/ormeasurements

RHA: the rapid but structuredcollection of information to determinethe impact of an event, identify thebasic needs of the population thatrequire immediate response, anddefine the aspects and the areas onwhich more detailed investigationsshould focus. Both objective andsubjective information is considered

Ockwell, 2002




11


Epidemiological surveillance indisasters: a new PAHO publication

This guide responds to a need in the countries of the LatinAmerican region and the Caribbean to provide guidelines anddirectives to improve epidemiological surveillance in disastersituations, especially at the local level. The objectives of thebooklet are to orient the readers on the basic information needsfor epidemiological surveillance in disasters and to facilitate theempowerment of local health authorities.

The book is a practical tool; open, flexible and dynamic. It willbe enriched with new experiences both from national and locallevel, to ensure more efficient control and reduction of thenegative effects from disasters.

Currently available in Spanish only, with the title Vigilanciaepidemiológica Sanitaria en situaciones de desastre, Guía parael nivel local, the book can be obtained through WHO/PAHO [email protected]

Different information for differentpurposes

Complex emergencies are difficult and politically loaded contexts,where updated and thoroughly consistent information is essentialfor local, regional and global use. Clearance procedures anddelegations of authority must be established to guaranteetimeliness, accuracy and consistency. Different purposes requiredifferent characteristics of information. In general, and with alot of salt:

1. Information “for action” must be swift and compelling.On www.who.int/disasters, WHO proposes a template andinstructions for assessment/situation reports. Each countryhead of station/programme must have sufficient delegationof authority to clear and immediately circulate the situationreport among sister agencies in the field, and to regional andHQ offices.

2. Information “for services and image” must be swift andtechnically accurate; procedures must be arranged betweenfield and HQ (regional offices where this applies) in order toclear press releases, programme briefs and technical factsheets in a timely manner and respecting all areas ofcompetencies.

3. Information for “resources” must be timely, accurate andcomprehensive; a routine must be in place for monthlyprogress reports to be produced at field level and shared withHQ (regional offices where this applies) and donors.

Do biases matter in emergencies?Validity: the degree to which a measurement measures what itpurports to measure1

Precision: the quality of being sharply defined or stated (ibidem);the ability of a measurement to give a very similar result withrepeated measurements of the same thing2

Losses in precision are notan important issue in RapidHealth Assessments(RHA), where the mainobjective is to determine if there is an emergency and aresponse is urgently required: imprecise estimates do not changea course of action. Validity, instead, is crucial for guiding action.In fact, biases, that affect the validity of an assessment/study,may result in wrong decisions: at the worst, avoidable deaths orsuffering, at the best waste of resources.

RHAs seldom use random sampling techniques; therefore, theyare particularly susceptible to biases. On the other side, beingpredominantly descriptive (i.e. not aiming to draw causalinferences) they are protected from other biases that affectanalytical studies. A bias that is particularly relevant toassessments in emergencies is the survival bias, which occurswhen the crisis is so grave that no one remains alive or meets theeligibility criteria to be included in a survey. It has been allegedto play a role in underestimating the mortality in Somali refugeecamps in late 1980’s and, more recently, it was accounted for inthe IRC mortality studies in eastern Democratic Republic ofCongo. Dealing with biases is first of all a matter of being awareof them when planning the assessment, collecting the data andinterpreting the findings. The literature on bias is extensive;detailed catalogues of the kinds of bias that may be encounteredare provided by Sackett4 and Choi and Pak5. A selected choice ofthe most relevant types of biases in emergency assessments,derived from the above sources, is presented the followingsection.

Bias: deviations of results orinferences from the truth3

Selected biases· detection b.: caused by errors in methods of ascertainment,

diagnosis or verification of cases· generalisation b.: caused by errors in generalising study results

to people outside the study· migrator b.: migrants may differ systematically from

residents of an area (e.g. IDPS, refugees when compared toresidents)

· proxy respondent b.: for deceased cases, soliciting informationfrom proxies (e.g. family members) may result in differentialdata accuracy (e.g. in verbal autopsies)

· referral filter b.: due to referral from primary to secondary/tertiary care, the concentration of rare and/or more severecases may increase (e.g. most severe cases of malnutrition inspecialised hospitals)

· wrong sample size b.: too small samples can prove nothing;too large samples can prove anything

For further information and complete list of references, pleasecontact A.Colombo at [email protected]

Endnotes1 Last J, 20012 Jekel J, Emore JG and Katz DL, 19963 Last, see 14 Sackett Dl, Bias in analytical research; Journal of Chronic Diseases,

vol 32, 51-63, 19795 Choi BCH and Pak AWP, Bias, overview, in. Encyclopaedia of

biostatistics, Armitage P and Colton T eds, 331-38 1998

12




The UN inter-agency Geographic Information Support Team(GIST) has worked cooperatively since 1997, and has beeninstrumental in promoting the use of geographic data standardsand GIS technology in the collection and exchange of operationalinformation in support of humanitarian relief. The GIST is agroup of technical experts that includes geographic informationfocal points with humanitarian responsibilities.

The GIST seeks to enhance the use of geographic informationfrom the side of humanitarian agencies and donors by:

• Improving information flow and presentation• Providing a forum for geographic and geo-referenced

information and data exchange• Developing and promoting the use of techniques and standards

to enhance data and information coordination.

The overall objective of the initiative is to improve emergencypreparedness and response. The GIST promotes the use ofsimple, common standards in collecting and reportinghumanitarian related information – a concept known as SHARE(Structured Humanitarian Assistance Reporting).

The GIST has facilitated unprecedented cooperation in the faceof humanitarian emergencies. In late 1999 and early 2000, theGIST work in Kosovo was recognized as having a significantrole in supporting the collection, coordination and exchange ofinformation to strengthen humanitarian assistance. Morerecently, the GIST was the major actor in collecting data, andsatellite imagery to assist in the relief efforts in Afghanistan,Goma and the Democratic Republic of Congo.

With the technical support of the GIST and generous donorassistance several Humanitarian Information Centers (HICs)have been established in critical regions of the world (i.e.Afghanistan, occupied Palestinian territories, Goma, Eritrea, andSierra Leone).

With support from GIST members, Regional Resource Centers(RRC’s) continue to be developed. These offices, with a morepermanent and regional scope, focus their activities on data forpreparedness and rapid response. The GIST currently supportsthe Data Exchange Platform for the Horn of Africa (DEPHA),the Sierra Leone Information Centre (SLIS, covering the ManuRiver Union) and the Southern Africa Humanitarian InformationService (SAHIMS).

The GIST has a web site that contains public informationregarding its activities and a data exchange platform. Data areavailable to anyone with Internet access.

GIST is also focusing on the development of standarddeployment procedures for the HIC’s as well as the productionof several guidelines for field operations. The topics for theseguidelines include:

• Use of remote sensing in humanitarian operations• Humanitarian Information Centres (HIC)• The use of common standards - position and sectoral codes• Use of GIS for disaster response, a practical guide

These initiatives for information management and the relatedoperational concerns have led to greater realization of theimportance of information for humanitarian preparedness andresponse. The informal and highly practical manner in whichthe GIST operates allows for frank discussions, clearly developedgoals, and operational results.For further information please contact P. Recalde [email protected]

The Geographic Information Support Team (GIST)

Information to ensure the safety offield staff: The UN Approach

Information on the security situation in all countries in whichthe United Nations operates is collected and disseminated bythe Office of the United Nations Security Coordinator(UNSECOORD). In each country, the situation is assessed bya Security Management Team. The Designated Official forsecurity, usually the Resident Coordinator, chairs the SecurityManagement Team whose members include the representativesof the UN system agencies. The Team is best placed to assessthe security situation at country level and it is supported by theUN Field Security Coordination Officer: there are some 100 ofthem posted worldwide. The UN grades the security situationalong a scale of five levels or “phases”. The Designated Officialfor security has the authority to declare phases one(precautionary) and two (restricted movement). If the situationrequires it, the Designated Official may recommend declarationof phases three (relocation), four (emergency operations) andfive (evacuation), but it is the Secretary-General who ultimatelymakes the decision to declare these higher phases.

A monthly travel advisory, published by UNSECOORD,informs all agency security focal points and Designated Officialsof any changes in the situation. Within WHO, updates are sentto staff in Headquarters and to the security focal points in theregional offices.

In order to enhance knowledge of the current and prospectivesecurity situation in countries, UNSECOORD conducts periodicsecurity assessment missions to countries. UN systemorganizations are invited to participate in these missions andthe reports are made available to agency security focal pointsand the local Security Management Team.

Information on security phases is for internal use – its purposebeing to enable the UN system organizations to effectivelymanage security and safety of staff. The security focal point inWHO is the Director, Security Coordination.For further information please contact M. Dam at [email protected]

“When it comes to living in an environment of deterioratingsocial service delivery systems which ultimately result incatastrophes, people’s tolerance levels tend to increase toaccept more episodes and interpret them as normal. Thelonger the situation continues the higher the tolerancelevel and the less likely another incident or event will beinterpreted as dangerous enough to trigger a response”

De Rooy C.and Shiawl T., 1996



13


Humanitarian Information CentersIn humanitarian crisis, centralized information management canfacilitate everybody’s task and end the isolation in whichdifferent actors often work.

In the past years Humanitarian Information Centers (HICs)have become a favoured approach to resolving informationmanagement problems in the field. In the same way as“coordination” and “information management” are umbrellaterms for a range of activities, a “Humanitarian InformationCentre” is an umbrella for implementing those activities. Mostof the HICs are interagency in nature: a HIC is normally aconvergence of many needs, not a single-issue office and thisseems to be one of the keys to its success.

The concept of HIC was not developed in isolation but in closeliaison with UN agencies, donors, private sector partners andcivil society: all those who are interested in informationmanagement in emergencies as well as during the reconstructionand rehabilitation stages. The HIC is by definition a non-permanent fixture: its role is to provide quick and critical surgecapacity to the UN country team and humanitarian community.National and regional information systems exist in most countrieswhere HICs are set up: the HIC will use, complement andreinforce the information products available with them. Oncethe emergency is over, the human and technical capacitiesdeveloped by the HIC, relevant equipment, etc. are shifted tolocal institutions.

As with any other humanitarian intervention, a needs assessmentis carried out before the HIC is set in place. An overall assessmentof the informational needs looks at the working environment,catalogues the existing information resources and analyses thecapacities of humanitarian actors. As a general rule, the HICwill be most useful in operational environments characterizedby :

• Rapid change• Multiple humanitarian actors with a high turnover in staff• Poor or degraded communications infrastructure• Limited prior exposure to humanitarian relief

The HIC will be evaluated on a number of levels, includinginformation needs in the community, quality of service providedto customers, resource management, services and products,coordination with other organizations, and marketing of the workof the HIC. This range of concerns highlights the fact that,while a HIC is a coherent entity, its work is inextricably linkedto the work of others and can only be judged in the context ofhow well it serves the needs of others.For further information please contact P. Recalde [email protected]

Health information: a glossary• Catchment area: the geographical area from which the users

of a particular health facility are drawn and to which thehealth information refers

• Coverage: a measure of the extent to which the servicesrendered cover the potential need for these services in acommunity

• Data: raw material -facts & figures, registered but not analysed• Decision Support Systems: systems which call for, order and

promote deliberation and analysis directly relevant tomanagement tasks where complexity and uncertainty makeit difficult to arrive at a reasoned response

• Geographical Information Systems (GIS): systems forcapturing, storing, checking, integrating, analysing anddisplaying data about the earth that is spatially referenced(usually they include a geo-referenced database andappropriate application systems)

• “Extinction by Instinct”: decisions made with no systematicanalysis due to pressures to act or wrong assumptions

• (Health) Information Systems: a set of components andprocedures organized with the objective of generatinginformation which will improve (health care) managementdecisions at all levels of the (health) systems

• Indicator: an indirect measure of an event/condition; variablethat indicates or shows a given situation, and thus can be usedto measure change; a way of seeing the big picture by lookingat a small piece of it. Proxy i.: indicator of something whichis, by its complex nature, inherently unmeasurable

• Information: analysed data, presented in a form that allowsdecision-making, exists only if it is transmitted and received

• Intelligence: processes and products that lead to understandingand making decisions in any given context

• Knowledge: information in context and for action.Something that all organisations possess and use to varyingdegrees. Its content can range from explicit knowledge, whichcan generally be expressed in the form of rules for decisionmaking, to tacit or intuitive knowledge, which is expressedthrough decision making and the exercise of judgement(absorption of the information, comparison with previousmental models, elaboration, understanding)

• Management Information System: a system that providesspecific information support to the decision-making processat each level of the organization

• Metadata: “data about data”, the background informationwhich describes the content, context, structure, quality, sourceand other characteristics of data

• Models: representations - abstractions from reality - of realprocesses, events, structures, expressed as systems of logical/mathematical relationships between variables

• “Paralysis by analysis”: non decision-making due to theapparent lack of sufficiently accurate information

• Surveillance: systematic ongoing collection, collation andanalysis of data and the timely dissemination of informationto those who need to know, so that action can be taken

• Survey: a study in which information is systematicallycollected, but in which the experimental method is not used

For further information (including complete list of references)please contact A. Colombo at colomboa@whoint

...definitions of system boundaries that exclude externalinfluences can only result in lack of knowledge...

Klinke and Renn, 2001

14




Challenges and strategies for health intelligence: A Regional Perspective

Country focus on health intelligenceThe WHO Department of Co-operation and Country Focus(CCO) is working on country intelligence in three ways:

1) WHO country presence: The Department has been requestedby the General Programme Management Group (GPMG) toprovide a summary view of WHO country presence. The idea isto provide an easily accessible summary for senior policy makersacross WHO. A first attempt to define information needs hasbeen completed, and sources within HQ have been used as muchas possible. A prototype database has been developed, and willbe further discussed with members of the GPMG and withWHO Representatives. Once standards for country informationhave been agreed, a mechanism for longer term maintenance willneed to be determined. This will draw on existing managementinformation systems and perhaps on more direct involvementof country teams.

2) Country documentation - WHO and Partners: CCO isdeveloping a small resource centre, gathering key non-technicalpolicy documents from WHO and partners that relate to specificcountries. They are being stored as a core documents, (e.g.UNDAF, CCA, World Bank and EU country documentation,both electronic and some hardcopy) and auxiliary documents(including briefing notes, UN workshop reports etc.) which arekept for a year.

3) Country Intelligence as part of the Country Focus Initiative:CCO is working with other parts of WHO to advocate for and,where possible, facilitate more effective country focusedinformation systems, whether it be for managerial or technicalpurposes. The aim is to have better, more integrated, flows ofinformation across the country, regional and headquarters levelsof the organization, particularly to ensure that country priorities,and development realities, are more accessible to all WHO staff.For further information please contact D. Hakobyan [email protected] or B. Fryatt at [email protected]

Reporting from the fieldCountry profile

Alert

Health Intelligence

SituationReport(s)

Where are we?

What’s happening?

What are the health aspects?

What are the relevant agencies doing?

What is WHO doing?

What else is needed?

Public health professionals often face the dilemma “Is thereenough health information to guide the decision makingprocess?” or “Is there too much or too little data?” and “Howbest to use data?”

In WHO Office for the Eastern Mediterranean Region (EMRO)these are daily questions, especially as complex emergencies arehigh on the agenda. The region counts five major, chronic crisesin Afghanistan, Sudan, Iraq, the occupied Palestine territory andSomalia. Over the past decade natural disasters have also affectedother countries: e.g. earthquakes in Egypt and Iran and floods inIran and Syria. In these environments, the scarcity of healthinformation represents a major challenge. Health informationsystems are very “thin on the ground”. They can often be weak,sometimes altogether absent and lacking functionality to clearlyidentify population needs. Baseline data are often nonexistentor out-dated. Even the registration of vital events is a luxury inparts of Afghanistan, Somalia and Sudan. More in general, limitedhuman and institutional resources hinder data analysis and “braindrain” entails a continuing loss of institutional memory incountries which are more vulnerable to crises.

These factors push EMRO to look into new strategic approachesfor health intelligence. Priority programs like Polio Eradication,Roll Back Malaria and Stop TB, can maintain field presence incomplex emergencies, thanks to the efforts of local and nationalauthorities, WHO and health partners. Through these initiativesand partnerships, WHO and Ministries of Health can enhancefield surveillance and operational monitoring for disease control.Success stories have been reported in Afghanistan and Somalia,where the Polio surveillance system also monitors measles andprovides alerts in the case of outbreaks. By extending surveillanceto neonatal tetanus, EPI coverage can also be assessed.

EMRO also bolsters health intelligence by becoming directlyinvolved in wider mechanisms for inter-sectoral coordination atcountry level. For instance, the UN has been establishingHumanitarian Information Centers (HIC) in many emergencieswith the objective to facilitate information exchange among thevarious stakeholders. WHO is part of the HIC and benefitsfrom its products.

In Afghanistan, a health geographic information system wasdeveloped by WHO working with the Afghanistan ManagementInformation System (AMIS). This system enables health sectorpartners to visualize health trends over a geographical area.Similarly, in the occupied Palestine territory, WHO hasestablished with its partners a health operations room (HealthInforum) to address the need for health and humanitarianinformation.

The changing dynamics of the Eastern Mediterranean Regionrequires data collection/analysis systems that address the “realtime” needs of populations living under difficult circumstances;systems that build upon existing national surveillance as well asrapid assessment techniques carried out at field level. Onlythen we can sufficiently answer the above-mentioned dilemmas.For further information please contact A. Musani [email protected]



15


Over the last months, the emergency situation inthe Palestinian territories has further deteriorated,mainly in the West Bank where the impact of theconflict has been most severe (Jenin, Nablus). Thisresulted in a dramatic shift in most programmestowards a humanitarian focus. One initiative,endorsed by the Local Aid Coordination Committeewas to create emergency “operations rooms” forhealth, shelter, water, food, electricity, andpsychosocial trauma.

WHO was requested to assume responsibility forthe health operations room, while the ItalianCooperation plays a leading role in the health sector.Health Inforum, (previously HART) aims tostrengthen coordination in support of thePalestinian health authorities and other partners,by collecting and sharing accurate, detailed and up-to-date health information about the humanitariansituation and the emergency response.

The main services delivered by Health Inforum are:• Regular reporting on the current humanitarian health situation

and the ongoing emergency response;• Networking to link Palestinian and international stakeholders

and service providers;• Making available resources and reference materials on best

practice in emergencies;• Providing health information for action-oriented decision-

making, through information collection, synthesis andanalysis, dissemination and feedback;

• Catalysing action in the health sector through the facilitationof coordination meetings and processes.

There is a consensus that Health Inforum activities have beensuccessful in linking the emergency with the long term approach

Health information exchange in the occupied Palestinian territory

The Integrated Disease Surveillance and Response (IDSR)(www.cdc.gov/idsr) is a strategy of the African Regional officeof WHO that aims to improve the availability and use ofsurveillance and laboratory data to control priority infectiousdiseases that are the leading causes of death, disability and illnessin Africa. The strategy is intended to improve the ability ofdistricts to detect and respond to outbreaks of priority infectiousdiseases with available and effective interventions.

Surveillance is not limited to communicable diseases: manycountries are monitoring nutrition, HIV/AIDS, etc. The SouthernAfrica Humanitarian Crisis shows how important the availabilityof key health data is for informing decisions and improvingcoordination for relief. Since maintaining effective surveillancesystems is time-consuming and costly, avoiding duplicationbetween different components becomes crucial. In Malawi, atdistrict level, reporting of unusual cases or deaths according tostandard case definitions is part of IDSR. This is a continuousprocess. Nutritional surveillance has two components: one is

surveillance/monitoring through NRUs (nutritional rehabilitationunits) and under-five clinics. The second component isintermittent field surveys. These employ standard populationsampling methods and collection of anthropometric data.

Since the processes for disease surveillance and for nutritionalsurveillance are fairly distinct, we do not expect to fully integratethe two. However, surveillance data for epidemic-prone diseasesand for nutritional status must be harmonized at the districtlevel. Some of the same issues arise for HIV/AIDS surveillance.This is done primarily through sentinel sites, but the informationfor HIV burden, nutritional status and communicable diseaseincidence must all be considered together when planninginterventions, especially in the emergency context. At thenational level in Malawi, all of this information comes togetherat the level of the Planning Department, where the HealthManagement Information System (HMIS) is based.For further information, please contact B. Aldis (WHORepresentative in Malawi) at [email protected]

Integrating different surveillancesystems

EHA’s web site provides information on what is happening inemergency situations (health situation reports, epidemiological

surveillance, needs assessments, etc.) and what to do about it (technical guidance).

www.who.int/disasters

and supporting an effective coordination between the MoH andother partners including donors, health service providers, majorsupply transporters, etc. Thanks to its services, Health is widelyviewed as the most active and well-coordinated sector in thePalestinian territories. Health Inforum serves the informationneeds of the health community in the emergency phase andbeyond. It is a sustainable, long-term support for health policy,planning and action in the Palestinian territories.For further information please contact A. Manenti [email protected] or access the Health Inforum web site athttp://hart.itcoop-jer.org

Coordination / Operations Room

Health Inforum Team

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ÈTools

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-Daily health news-Urgent Requests-Electronically GIS Maps forHealth Services-Electronically health library•Biweekly Newsletter•Medical supplies distribution•Donors and international organizations database•Dialogue forum

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Field intelligence

16



Measuring humanitarian needs inthe Southern Africa crisis

Most humanitarian crises are defined as such because of theseverity of the situation in terms of excess mortality andmorbidity, increased levels of malnutrition, and/or human rightsviolations. This evidence base combined with that of insufficientnational capacity to cope with these demands, then triggers andguides international humanitarian responses. The crisis insouthern Africa is different because the response seems to havebeen determined by a prediction of significant food shortages tocome, rather than by the gravity of the situation at the time ofthe assessment. The food aid seems to have prevented thesituation from getting out of control.

Analyses of underlying causes and compounding factors, forexample in Malawi and Zimbabwe, were available early thisyear. HIV/AIDS was mentioned in the first appeals as animportant factor increasing vulnerabilities and underminingcoping capacities of societies and families. Figures of less than40% access to health services and alarm about this percentagedecreasing further (even while morbidity was expected toincrease), was already available to decision makers.

However the predominant response was, and continues to befilling the predicted food deficit. The international communityis slow in addressing the underlying causes or taking a longerterm perspective. It is widely acknowledged that food is also apriority to people living with HIV/AIDS, enabling them to livelonger and to be less susceptible to diseases. This then allowsthem to work longer, raise their children, and avoid other copingmechanisms (e.g. prostitution) which increase the risk of thespread of HIV. Considering that HIV/AIDS will be a seriousundermining factor in the coming decades, the approach throughwhich families achieve their food security and remain healthyfor as long as possible, requires more sustained and multi-sectoralsolutions.

To address this from the health sector, both development andhumanitarian actors need to come together and design a robuststrategy that will provide for adequate strengthening of the healthsystem. The low and decreasing access to basic health services,or the low coverage capacity of the nutritional rehabilitationunits, already fall far short of the SPHERE standards. Althoughthis may not qualify as a sudden crisis, it can be seen as adevelopment failure. Treatment of ‘normal’ morbidity is alreadyundermined, while additionally there is the increasing diseaseburden due to opportunistic infection among people living withHIV/AIDS. The recent report from the Commission on Macro-economics and Health indicates that resources required toadequately strengthen the health system are substantially greaterthan what is currently available.WHO is supporting an ODI study on needs assessment practiceand its influence on resource allocation. A WHO staff member wasrecently seconded to the team that went to look into the southernAfrica crisis. The full case study report is expected during thecoming weeks.

For further information, please contact A.Griekspoor [email protected]


Early Warning of communicablediseases in emergencies:an experience from Sudan

Within the context of OLS (Operation Lifeline Sudan),WHOcollaborates with UNICEF and more than 40 NGOs, operatingan Early Warning and Response Network (EWARN) in southSudan. EWARN is based on 21 teams, supported by communityleaders and linked by radios, and a network of laboratories staffedby 29 technicians. Laboratory quality control is assured by theAfrican Medical and Research Foundation (AMREF) and theKenya Medical Research Institute. The system benefits fromthe experience, structure and means of the Polio Eradicationprogramme. The surveillance system covers the followingdiseases/syndromes: diarrhoea (acute bloody or watery),measles, acute flaccid paralysis, suspected meningitis, relapsingfever, suspected malaria and haemorrhagic fever. Training is animportant component of the programme: over the last 3 years,175 health workers have been trained in clinical and laboratoryaspects of outbreaks, 446 have been briefed on the programmeand more than 200 community members have been trained forsupporting the EWARN staff.

In 2002, 40 rumours of outbreaks were reported, of which 40per cent were confirmed as false alarms. In 33% of reportedoutbreaks, response was ensured in less than one week, in 23%between 1-2 weeks and in the remaining cases in more than 2weeks.

A review, undertaken in 2001, concluded that EWARN, byimproving early detection of outbreaks and rapid response,provides a valuable service to the population as well to thepartner agencies operating in south Sudan.For further information please contact A. Sow [email protected]

DISASTERManifestations

Immediate causes

Underlying causes

Socio-economical Vulnerabilities and

Capacities

Structural causes

Primary Vulnerabilities

Infra-structural causes

Development, Disaster

Prevention and

Preparedness Planning

Contingency Planning and

Early Warning

Emergency Response

Information for

Information for

Information for

Natural Hazards Man-made Hazards

Governance

Economy Society

Culture

EnvironmentPopulation

The disaster development continuum: analysisof the causal chain and use of information



17

Tools for assessment

Assessments along the Life Cycle of Emergencies

Assessing levels of risk for extreme events, their impact onhealth care delivery systems and health status and the prioritiesfor recovery and reconstruction are critical for guiding emergencypreparedness, response and reconstruction. Various tools areused by the Ministries of Health and agencies involved inhumanitarian assistance. A synoptic analysis of these tools wouldbe helpful for improving their standardisation, the comparabilityof their results and facilitating coordination of humanitarianactions.

WHO/EHA is developing a catalogue of available tools forinformation management. This catalogue includes:

1. Tools for mitigation and preparedness2. Standard operational procedures for readiness and crisis

management3. Reconstruction

The matrix below aims to help identify the main focus,determinants, indicators and available tools for assessment before,during and after an emergency.

The assessment of the determinants and impact of emergencieson health is the subject of an international conference that WHOis in the process of organising for 2003 (see Health inEmergencies: issue 14). Any feedback to the matrix andcatalogue, and more in general to this issue of Health inEmergencies will help to develop the conference agenda andaddress participant concerns and interests.For further information please contact A. Loretti [email protected]


ACTIVITY/PHASE

WHAT are we assessing ? DETERMINANTS INDICATORS INSTRUMENTS

Mitigation

Preparedness

The Levels of Risk :⇒ Priorities for the health

sector in Mitigation andPreparedness

⇒ Levels of preparedness

• Natural and historicalenvironment

• Geopolitics and global economy• Types and levels of

vulnerability• Types and magnitude of

hazards• Levels of local/national

capacities

• Historic data: epidemics,endemic diseases

• Presence of vectors• Economic and other

demographic indicators• Coverage by/access to health

services• Quality of baseline

information and informationsystems

• Agencies' country profiles• CCA ( Country Common

Assessment)• Early Warning Systems• Lifelines assessment• Contingency plans• Capacity/ Vulnerability assessment• UN Development Assistance

Framework (UNDAF) andCommon Humanitarian ActionPlan (CHAP)

• Hazard assessment• WHO Health System

frameworkResponse The Needs for Survival :

⇒ Priority health needs⇒ Operational priorities

for the delivery of relief⇒ Interfering hazards

The Performance ofRelief:⇒ Relevance of objectives⇒ Fulfilment of objectives⇒ Cost-effectiveness⇒ Impact, Connectedness

& Sustainability

• Water and environment• Accessibility• Population movements• Levels of local/national

capacities• Levels of international interest

and capacities• Level and degree of integration

("co-ordination") of externalcapacities

• Geopolitics and global economy• Media coverage• Flow and quality of external

resources

• Crude Mortality rates• Acute Malnutrition rate• Various sets of Health data• Notification of epidemics• Coverage by activity• Concentration by activity• Cost by activity• Investment and recurrent

costs• Pledges versus requirements

• Rapid Health Assessment Protocols

• Consolidated Appeal process(CAP)

• Menu of health indicators forhumanitarian coordination

• Local Planning techniques• WHO Core Commitments in

Emergencies• Humanitarian Supply Management System (SUMA)• Logistic support System (LSS)

Rehabilitation

Recovery

Reconstruction

Prevention

The Feasibility andSustainability ofRecovery⇒ State of Health care

delivery systems.⇒ State of complementary

systems⇒ Donors' attitudes

Analysis:• Geopolitics and global economy• Patterns of displacement

temporary or permanent)• Stability: economic, social,

political• Levels of local/national

capacities• Inter-sectoral recovery plans• Donors' interests

• Historic data• Reports of violence,

disturbances, etc• Levels of employment,

salaries• Investment and recurrent

costs• Pledges versus requirements

• Guidelines for "Assessment for Health Recovery" ( work in progress with WHO/EHA)• WHO Health System

framework

18




Monitoring vital needs in an emergency

Menu of health information for monitoring the needs and for coordination of activities

Health District / Region of ............................ Date..........

1. Vital needs Essential and complementary data Available?yes/no

Howoften?

Fromwhere?

OVERVIEW • N . of population• …

1.1.SECURITY

• N . of vict ims of deliberate violence (new cases)• …

1.2. WATER

• N . of cases of diarrhoea• …

1.3.FOOD

• N . of cases of wasting and stunting• …

1.4.SHELTER &SANITATION

• Shelters/environment condit ions• …

1.5.SOAP, BUCKETSAND PANS

• N . of cases of diarrhoea• …

1.6.HEALTH CARE

• State of infrastructures and equipment• State of supply of drugs and material• State of personnel• N . of outpatients• N . of immunizations per antigen and age-group• N . of MCH activit ies• N . of cases of measles, cholera, dysentery and meningit is• State of strategic stocks for epidemics• N . of cases of ARI, malaria and STDs• N . of cases of tuberculosis under treatment• Availabil i ty of condoms• Referral system: state of functioning and accessibil i ty

2 . SUPPORTATCITIVITIES2.1.INFORMATION

• Functioning of epidemiological and nutrit ional surveil lancesystems

• …2.2.LOGISTICS &C O M M U N ICATION

• State of reception, distribution and storage system o f medicalmaterials

• …2.3.COORDINATION

• Periodicity of coordination meetings• …

2.4.TRAINING

• Training activit ies organised by the health centres or theagencies

• …2.5.RESOURCEMOBILISATION

• List of health projects submitted for f inancing• …

The ultimate goal of humanitarian assistance is to reduce theburden of avoidable death and illness in a population affectedby an emergency, through life-saving interventions. The keyword is “avoidable” due to the situation, which implies that anemergency generally results in extra morbidity/mortality incomparison to the “normal” (background levels) of ill-health.Relief interventions aim to reduce or prevent this excess burden,while developmental actions target the underlying, normal, ill-health. This is to emphasize that the excess morbidity, disabilityand mortality are due not only to the lack of essential publichealth/medical actions, but mainly to the shortage of essentialgoods (water, food, shelter, security, etc) for meeting vital needs,as well as to the inability to mitigate the effects of the

determinants (biological, social, political, or economic).

Since most emergencies impact on all aspects of a community(social and economic), health interventions not linked with otherinterventions can, in the long run, fail to meet health needs, notleast to achieve the ultimate humanitarian goal. As a bareminimum, relief agencies need access, security (both for themand for their beneficiaries), resources and capacities to deliveran effective humanitarian assistance taking into account thevarious stakeholders in an area. Verifying which informationrelated to all vital needs is available is the first step for identifyinggaps, deciding how best to fill them and programming reliefinterventions. The following menu can help address this issue.

NOTE: For the complete menu of indicators please contact A. Loretti at [email protected]



19

Sudan: from a complex emergencyto a complex peace

Since independence in 1956, Sudan has known longer periods ofwar than peace. Natural disasters are common: droughts arecyclical, and floods are recurrent. Overall the health status ispoor, as the available health indicators and the vulnerability toepidemics show. War has drained resources away from socialinfrastructure. The human capital has been decapitated. Copingmechanisms of the population have been stretched to the limits.The consequences have been dramatic: some two million peoplehave died because of the conflict. The country has the largestpopulation of IDPs – an estimated four million - in the world.The health sector has limited resources, both human and financial,to respond to the needs

There are, however signs of hope. Since 1999 the country isexporting oil. The recent peace protocol signed in Machakos inJuly and the truce agreed on October 15th have generated newoptimism. Diplomatic pressures on both parties to reach asettlement are mounting. With prospects of peace, the return ofmillions of IDPs and refugees to their home areas and an increasedinflux of aid to help address humanitarian needs, rehabilitationneeds, and sustain reconciliation are no longer a dream. The newcontext of peace will bring opportunities, in terms of securityand peace dividend. At the same time, the transition will presentenormous challenges. With peace, hidden humanitarian needs ofthose populations that are presently inacessible will emerge.Demands and expectations will rise also for longer-terms needs,such as those related to the rehabilitation of social sectors, inboth Government and opposition areas.

Acknowledging lessons learned in other transitional contexts,which point to the need for enhancing preparedness, WHO hasstarted developing a post-conflict strategic framework. Thisprocess aims to improve WHO’s performance, making its agendaof work more consistent with needs, through a re-alignment ofpriorities and re-allocation of resources.

For further details see: www.who.int/disasters/repo/8301.pdfFor further information please contact A. Colombo [email protected]

SUMA Lumba: Victory to SUMAThe SUpply MAnagement training held in Gambia closed withAfrican voices singing. UNICEF organized the second RegionalSupply Logistic Workshop in Gambia from 27 October to 1November. The 46 participants represented 25 countries fromWest and Central Africa as well as delegates from UNICEFCopenhagen. The objective of the workshop was to improvecapacity in planning and management of emergency supplies.

UNICEF had invited experts from FUNDESUMA to provide athree day training course on SUMA. This inter-regionalcollaboration is part of Logistic Support System, an Inter-Agency initiative between different UN agencies includingOCHA, WFP, UNICEF, PAHO and WHO.

The participants concluded that the Warehouse module is veryuseful for every day use, and that the program is good buttraining is needed at country level. The song SUMA Lumba(Victory to SUMA) spontaneously sang as a thank you to thetrainers, indicated the enthusiasm of the participants after theirfirst contact with SUMA.For further information please contact E. Pluut at [email protected]

Health Library for Disasters - 2003Version

The Pan American Health Organization and WHO are preparingto update the CD-ROM “Health Library for Disasters”, forrelease in early 2003.

Participating agencies include UNAIDS, UNHCR, UNICEF,the ICRC, the SPHERE Project, and ODI. New publicationsrange from Public Health and Chemical Incidents to ClinicalManagement of Survivors of Rape.

Some of the new features of the HELID 2003 are:• Self-copy feature for transfer of the CD-ROM to a hard disk• Each book can be extracted to a zip-file.• When “open”, each book will identify the languages in which

it is available (i.e. English, French and Spanish)

WHO also aims to increase the user friendliness of the CD-ROM based on feedback from the field.For more information please contact: E. Pluut at [email protected]

GLOBAL NEWS

SUMA to be available in RussianA Russian expert worked with FUNDESUMA Costa Rica at thetranslation of the SUpply MAnagement (SUMA) into Russian.This Cyrillic translation of SUMA will include the software, thepractice manuals as well as the users manuals of the Central,Field Unit and Warehouse module.

In addition the Logistical Management of Emergency Supplies(MISE) manual will be available in Cyrillic early in 2003.For more information please contact: [email protected]

H.E.L.P. in Japan 2003Health Emergencies in Large Population is a course comprisedof two modules focusing on public health activitiesinternational humanitarian law, human rights and the ethicalresponsibilities of health professionals. It will be offered inJapan for the first time from March 10 - 28For further information please visit the web site at:www.jrckicn.ac.jp/~japanhelp/index.htm

20



CONTACTSDepartment of Emergency andHumanitarian ActionWorld Health Organization20 avenue Appia1211 Geneva 27, SwitzerlandPhone: (41 22) 791 2752/2727/2987Fax: (41 22) 791 48 44email: [email protected]/disasers

Regional Office for the Western Pacific(WPRO)Division of Health Sector Development(DHS)PO Box 29321099 Manila, PhilippinesPhone: (632) 528 80 01Fax: (632) 521 10 36 or 536 02 79email: [email protected]

Regional Office for Europe (EURO)Emergency and Humanitarian Action(EHA)8, Scherfigsvej2100 Copenhagen O, DenmarkPhone: (45) 39 17 17 17Fax: (45) 39 17 18 18email: [email protected]/emergencies

Regional Office for the EasternMediterranean (EMRO)Coordination, Resource Mobilizationand Emergency Relief (CMR)WHO Post OfficeAbdul Razzak Al Sanhouri Street,(opposite Children's Library)Nasr CityCairo 11371EgyptPhone: (202) 276 5025Fax: (202) 670 24 92email: [email protected]

Regional Office for the Americas(AMRO)/Pan American Health Organization(PAHO)Emergency Preparedness Programme(PED)525, 23rd Street, NWWashington, DC 20037, USAPhone : (202) 974 3399or (202) 974 3520Fax: (202) 775 4578email: [email protected]/disasters

Regional Office for South-East Asia(SEARO)Emergency and Humanitarian Action,Sustainable Development and HealthyEnvironment (SDE)World Health HouseIndraprastha EstateMahatma Gandhi RoadNew Delhi 110002, IndiaPhone: (91 11) 337 0804Fax: (91 11) 337 8438email: [email protected] [email protected]/emergency

If you are interested in receiving Health In Emergencies electronically oradding your organisation to our mailing list, please contact [email protected]

Season’s Greetings from theDepartment of Emergency and Humanitarian Action

Regional Office for Africa (AFRO)Emergency and Humanitarian Action(EHA)BP 06BrazzavilleRepublic of CongoPhone: (1 321) 953 9314Fax: (1 321) 95 39 501email:[email protected] [email protected]/eha/index.html

Health in Emergencies is a newsletter of the Department of Emergency and Humanitarian Actionof the World Health Organization (WHO). This newsletter is not a formal publication of WHO. Allrights are reserved by the Organization. The document may, however, be freely reviewed, abstracted,reproduced or translated in part or whole, but not for sale or for use in conjunction with commercialpurposes. The presentation of maps contained herein does not imply the expression of any opinionwhatsoever on the part of WHO concerning the legal status of any country, territory, city or areas orof its authorities, or concerning the delineation of its frontiers or boundaries. The views expressedin this newsletter do not necessarily reflect those of WHO.

Production of this newsletter has been made possible by the support of the Italian Government andthe British Government (DFID).

Correspondence and inquiries for subscription should be addressed to:

The Editor

The Department of Emergency and Humanitarian ActionWorld Health Organization

20 Avenue Appia, 1211 Geneva, Switzerland

Phone: (41 22 ) 791 4037, Fax: (41 22) 791 4844

email: [email protected]

Chief Editor: Dr Alessandro Loretti

Editors: Mrs Ellen Egan and Dr. Alessandro Colombo

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