3.1 Establish service delivery structures
Humanitarian emergencies raise major challenges to CAH health service delivery (Box 11). Many of these challenges affect everyone in some way. But many challenges will disproportionately affect children of different ages or different capacities. These include loss of: birthing services for newborns and adolescent mothers; integrated management of neonatal and childhood illness (IMNCI) for young children, supply chains for those with chronic conditions, and safe streets for older children and adolescents.
Health service delivery structures often require major changes in order to effectively and efficiently respond to the new, different and rapidly changing health needs of the population (and children and adolescents in particular) in the evolving situation. This may include different scopes of practice and new services (e.g. outreach) as well as modification of existing methods of health service delivery (Box 12).
Box 11 Challenges to the delivery of child and adolescent health services
Service disruption and facility destruction
Break down of essential health promotion and prevention services (e.g. immunization, nutrition advice, breastfeeding support and vector control) and treatment activities (e.g. IMNCI and integrated community case management). Disruption of supply chains. Loss of health care providers and reduced affordability of essential services. Reduced access to essential services (water and power), sanitation and hygiene, and food. Damaged roads, difficult transport.
Population movements
Mobile populations. Crowded living environments. Loss of livelihoods. Rapid population increase in semi-urban areas (many displaced people will move into urban areas, rather than into refugee camps).
Competing priorities
New health issues (e.g. injury and epidemic disease) and displaced populations overwhelming existing health structures and programmes and causing neglect of other essential services.
Lack of safety
Threats to the security and safety of affected populations and health care workers and hence impaired access to and delivery of essential health services. Impaired access because of restrictions on mobility (e.g. curfews).Box 12 Levels of health service delivery
These are the general features of the different levels of health service delivery and the potential role they can play during emergencies. This is only a guide – the exact structure of health service delivery and the roles of those providing services will vary between places and over time.
1. Household and community
Care is provided to children, adolescents and families in the community, including camps and informal settlements for displaced people. Care providers may include community health workers, traditional birth attendants, outreach workers, or other trained health workers. Providers should be linked to nearby primary care facilities for referral and other support. Providers typically provide a narrow selection of health promotion and preventative services (e.g. safe birth kits and advice, nutrition advice and contraception), and basic treatment (e.g. first aid and community case management). Outreach workers and teams often have a particularly important role during humanitarian emergencies.
2. Clinics/primary care facilities
Care is provided to children, adolescents and families at small health facilities, including mobile clinics and temporary camp clinics. Care providers may include nurses, midwives, health assistants and sometimes doctors. They typically provide a range of outpatient services (e.g. IMNCI, vaccinations, nutrition services and treatment of common conditions) and link to hospitals for referral and support.
3. Hospitals/secondary and tertiary health facilities
Care is provided to children, adolescents and families at established hospitals, including camp hospitals and therapeutic feeding centres. Care providers include the full range of medical, nursing and allied health professions, varying by size of facility. They typically provide a range of inpatient and outpatient services, linking to other hospitals and primary care facilities; they often run outreach services.
Key actions – health service structure
Adapted from the Sphere Health Standards (1)
- The health cluster/sector lead coordinates the implementation of priority health services, in collaboration with government departments and other health partners. The RMNCAH/CAH working group has an important role in advocating for CAH priorities and ensuring that the interests of all children and adolescents are protected.
- Review the levels of service delivery identified by the needs assessment (Box 12) and consider how the prioritized health services and activities can be most effectively delivered in your context. Adapt and improve the existing system.
- Engage the community to design health services relevant to their needs and with access acceptable to the affected population. Involve young people and women in decisions about CAH health services. Incorporate accountability processes (section 1.2.2).
- Identify threats to and opportunities for reaching the population affected (Box 11). Consider the different needs and capacities of urban versus rural populations and children at high risk (Box 8). Develop strategies to include them.
- Consider additional services to reach populations in need. Establish temporary health outposts within, or very close to, affected communities. Provide mobile services. Deploy community workers to visit pregnant women, children and families in their homes. Provide clean delivery kits and essential newborn kits to promote safe delivery when access to a health facility is not possible.
- Strengthen, or establish, referral pathways to ensure that pregnant women, children and adolescents have access to essential services.
- Establish or strengthen a protocol for triage at health facilities to ensure those with emergency presentations receive immediate treatment and stabilization care during transport when referred. Use WHO emergency triage, assessment and treatment (35).
- Address referrals between levels of care and services. Include referrals between sectors (e.g. nutrition, education and child protection).
- Assess risk of violence against health facilities, workers and patients. Create a prevention and response plan. Make health facilities weapon-free. Use locally recognized symbols to identify health facilities (e.g. red cross or red crescent).
- Provide health care that guarantees patients’ rights to dignity, privacy, confidentiality, safety and informed consent. Give special consideration to those who may need assistance (e.g. children, people with certain impairments, people with certain mental illnesses and unaccompanied minors).
- Use or adapt standardized protocols for health care, case management and rational drug use. Use national standards, if available, or refer to international guidelines (see WHO and Médecins Sans Frontières guidelines in resources and tools).
- Provide safe health care and services. Use appropriate infection prevention and control measures. Employ appropriate use (rational drug use) and safe management of medicines, laboratories and technology.
- Manage and bury dead people in a safe, dignified and culturally appropriate manner, based on good public health practice (36).
Key indicators – health service structures
- The RMNCAH/CAH working group and partners have worked with the health cluster lead to review service delivery capacity and develop a plan.
- Availability of health facilities
- One community health unit per 1000 population
- One health facility per 10 000 population
- Five health facilities with basic emergency obstetric and newborn care per 500 000 population
- One health facility with comprehensive emergency obstetric and newborn care per 500 000 population
- Ten inpatient beds per 10 000 population
- Proportion of health care facilities using triage and referral systems.
- Proportion of the population within 5 km of a health facility.
8 Increasingly, most people affected by emergencies are in urban settings with unique risks (e.g. large populations, many services and much of the infrastructure affected by the crisis) and opportunities (e.g. existing infrastructure, hospitals and health services, technology and communication).
9 See also the priority CAH actions in Annex 3.
10 Particular aspects of nurturing care are covered in other sections (e.g. child safety and protection, nutrition and food security). See UNICEF’s Early childhood development in emergencies: integrated programme guide (42) for more details.
11 Logistics cluster (https://logcluster.org/).
12 For more information, see UNICEF supply catalogue (https://supply.unicef.org/), or contact UNICEF: countrysupport@unicef.org, psid@unicef.org.
13 See tools and resources at the end of this section for lists and medicines and medical devices.