The Minimum standards in health action
The minimum standards in health action are a practical expression of the shared beliefs and commitments of humanitarian agencies and the common principles, rights and duties governing humanitarian action that are set out in the Humanitarian Charter. Founded on the principle of humanity, and reflected in international law, these principles include the right to life with dignity, the right to protection and security, and the right to receive humanitarian assistance on the basis of need.
Everyone has the right to health, as enshrined in a number of international
legal instruments. The right to health can be assured only if the population is
protected, if the professionals responsible for the health system are well trained
and committed to universal ethical principles and professional standards, if the
system in which they work is designed to meet minimum standards of need, and
if the state is willing and able to establish and secure these conditions of safety
and stability. In times of armed conflict, civilian hospitals and medical facilities
may in no circumstances be the object of attack, and health and medical staff
have the right to be protected. The carrying-out of acts or activities that jeopardise
the neutrality of health facilities, such as carrying arms, is prohibited.
The minimum standards in this chapter are not a full expression of the right to
health. However, the Sphere standards reflect the core content of the right to
health, especially during emergencies, and contribute to the progressive realisation
of this right globally.
The importance of health action in disasters
Access to healthcare is a critical determinant for survival in the initial stages of
disaster. Disasters almost always have significant impacts on the public health and
well-being of affected populations. The public health impacts may be described
as direct (e.g. death from violence and injury) or indirect (e.g. increased rates of
infectious diseases and/or malnutrition). These indirect health impacts are usually
related to factors such as inadequate quantity and quality of water, breakdowns in
sanitation, disruption of or reduced access to health services and deterioration of
food security. Lack of security, movement constraints, population displacement
and worsened living conditions (overcrowding and inadequate shelter) can also
pose public health threats. Climate change is potentially increasing vulnerability
and risk.
The primary goals of humanitarian response to humanitarian crises are to prevent
and reduce excess mortality and morbidity. The main aim is to maintain the crude
mortality rate (CMR) and under-5 mortality rate (U5MR) at, or reduce to, less
than double the baseline rate documented for the population prior to the disaster
(see table on baseline reference mortality data by region on page 311). Different
types of disaster are associated with differing scales and patterns of mortality
and morbidity (see table on public health impact of selected disasters opposite),
and the health needs of an affected population will therefore vary according to the
type and extent of the disaster.
The contribution from the health sector is to provide essential health services,
including preventive and promotive interventions that are effective in reducing
health risks. Essential health services are priority health interventions that are
effective in addressing the major causes of excess mortality and morbidity. The
implementation of essential health services must be supported by actions to
strengthen the health system. The way health interventions are planned, organised
and delivered in response to a disaster can either enhance or undermine the
existing health systems and their future recovery and development.
An analysis of the existing health system is needed to determine the system’s
level of performance and to identify the major constraints to the delivery of, and
access to, health services. In the early stages of a disaster, information may be
incomplete and important public health decisions may have to be made without
all of the relevant data being available. A multi-sectoral assessment should be
conducted as soon as possible. Better response is achieved through better preparedness. Preparedness is based includes contingency planning, stockpiling of equipment and supplies, establishment and/or maintenance of emergency services and stand-by arrangements,
communications, information management and coordination arrangements,
personnel training, community-level planning, drills and exercises. The enforcement
of building codes can dramatically reduce the number of deaths and serious
injuries associated with earthquakes and/or ensure that health facilities remain
functional after disasters.
Protection Principles & Core Standards
In order to meet the standards, all humanitarian agencies should be guided by the Protection Principles, even if they do not have a distinct protection mandate or specialist capacity in protection. The Principles are not ‘absolute’: it is recognised that circumstances may limit the extent to which agencies are able to fulfil them. Nevertheless, the Principles reflect universal
humanitarian concerns which should guide action at all times.
The Core Standards are essential process and personnel standards shared
by all sectors. The six core standards cover people-centred humanitarian response; coordination and collaboration; assessment; design and response; performance, transparency and learning; and aid worker performance. They provide a single reference point for approaches that underpin all other standards in the Handbook. Each technical chapter, therefore, requires the companion use of the Core Standards to help attain its own standards. In particular, to ensure the appropriateness and quality of any response, the participation of disasteraffected
people – including the groups and individuals most frequently at risk in disasters – should be maximised.
Vulnerabilities and capacities of disaster-affected
populations
This section is designed to be read in conjunction with, and to reinforce, the Core
Standards. It is important to understand that to be young or old, a woman, or a person with a
disability or HIV, does not, of itself, make a person vulnerable or at increased risk.
Rather it is the interplay of factors that does so: for example, someone who is over 70 years of age, lives alone and has poor health is likely to be more vulnerable than someone of a similar age and health status living within an extended family and with sufficient income. Similarly, a 3-year-old girl is much more vulnerable if she is unaccompanied than if she were living in the care of responsible parents. As the health action standards and key actions are implemented, a vulnerability and capacity analysis helps to ensure that a disaster response effort supports.
The minimum standards
1. Health systems
The World Health Organization (WHO) defines health systems as: “all the organizations,
institutions and resources that are devoted to producing health actions”. It includes the full range of players engaged in the provision, financing and management of health services, efforts to influence determinants of health as well as providing direct health services, and encompassing all levels: central, regional, district, community and household. The health system standards of Sphere are organised according to the WHO health system framework, consisting of six building blocks: leadership, human resources, drugs and medical supplies, health financing, health information management and service delivery. There are many interconnections and interactions between each of these functions and an action affecting one component can affect the others. These health system building blocks are the functions that are required to deliver essential health services. Health interventions during disaster response should be designed.
Health systems standard
1: Health service delivery : People have equal access to effective, safe and quality health services that are standardised and follow accepted protocols and guidelines.
Key actions:
a. Provide health services at the appropriate level of the health system. Levels
include household and community, clinic or health post, health centre and hospital
b. Adapt or establish standardised case management protocols for the most common diseases, taking account of national standards and guidelines Establish or strengthen a standardised system of triage at all health facilities to ensure those with emergency signs receive immediate treatment.
c. Initiate health education and promotion at community and health facility levels
d.Establish and follow safe and rational use of blood supply and blood products
e. Ensure that laboratory services are available and used when indicated
f. Avoid the establishment of alternative or parallel health services, including mobile clinics and field hospitals
g. Design health services in a manner that ensures patients’ rights to privacy, confidentiality and informed consent
h. Implement appropriate waste management procedures, safety measures
and infection control methods in health facilities
i. Dispose of dead bodies in a manner that is dignified, culturally appropriate and based on good public health practice
j. Establish or strengthen a standardised referral system and ensure it is utilised by all agencie
1. Level of care: Health facilities are categorised by level of care according to
their size and the services provided. The number and location of health facilities
required can vary from context to context. Health systems must also develop a process for continuity of care. This is best achieved by establishing an effective referral system, especially for life-saving interventions. The referral system should function 24 hours a day, seven days
a week.
2. National standards and guidelines: In general, agencies should adhere to
the health standards and guidelines of the country where the disaster response
is being implemented, including treatment protocols and essential medicines
lists. When they are outdated or do not reflect evidence-based practice, international
standards should be used as reference and the lead agency for the
health sector should support the Ministry of Health (MOH) to update them.
3. Health promotion: An active programme of community health promotion
should be initiated in consultation with local health authorities and community
representatives, ensuring a balanced representation of women and men. The
programme should provide information on the major health problems, health
risks, the availability and location of health services and behaviours that protect
and promote good health, and address and discourage harmful practices.
Public health messages and materials should utilise appropriate language
and media, be culturally sensitive and easy to understand. Schools and childfriendly
spaces are important venues for spreading information and reaching
out to children and parents
4. Utilisation rate of health services: There is no minimum threshold figure for
the use of health services, as this will vary from context to context. Among
stable rural and dispersed populations, utilisation rates should be at least 1 new
consultation/person/year. Among disaster-affected populations, an average of
2–4 new consultations/person/year may be expected. If the rate is lower than
expected, it may indicate inadequate access to health services. If the rate is
higher, it may suggest over-utilisation due to a specific public health problem or
under-estimation of the target population. In analysing utilisation rates, consideration
should ideally also be given to utilisation by sex, age, ethnic origin and
disability
5. Safe blood transfusion: Efforts should be coordinated with the national blood
transfusion service (BTS), if one exists. Collection of blood should only be from
voluntary non-remunerated blood donors. Good laboratory practice should
be established, including screening for transfusion-transmissible infections,
blood grouping, compatibility testing, blood component production and the
storage and transportation of blood products. Unnecessary transfusions can
be reduced through the effective clinical use of blood, including the use of
alternatives to transfusion (crystalloids and colloids), wherever possible. Appropriate
clinical staff should be trained to ensure the provision of safe blood and
its effective clinical use.
6. Laboratory services: The most common communicable diseases can be
diagnosed clinically (e.g. diarrhoea, acute respiratory infections) or with the
assistance of rapid diagnostic tests or microscopy (e.g. malaria). Laboratory
testing is most useful for confirming the cause of a suspected outbreak, testing
for culture and antibiotic sensitivity to assist case management decisions (e.g.
dysentery) and selecting vaccines where mass immunisation may be indicated
(e.g. meningococcal meningitis). For certain non-communicable diseases,
such as diabetes, laboratory testing is essential for diagnosis and treatment.
7. Mobile clinics: During some disasters, it may be necessary to operate
mobile clinics in order to meet the needs of isolated or mobile populations
who have limited access to healthcare. Mobile clinics have also been proven
crucial in increasing access to treatment in outbreaks where a large number
of cases are expected, such as malaria outbreaks. Mobile clinics should be
introduced only after consultation with the lead agency for the health sector
and with local authorities
8. Field hospitals: Occasionally, field hospitals may be the only way to provide healthcare when existing hospitals are severely damaged or destroyed. However, it is usually more effective to provide resources to existing hospitals so that they can start working again or cope with the extra load. It may be appropriate to deploy a field hospital for the immediate care of traumatic
injuries (first 48 hours), secondary care of traumatic injuries and routine surgical and obstetrical emergencies (days 3–15) or as a temporary facility to substitute for a damaged local hospital until it is reconstructed. Because field hospitals are highly visible, there is often substantial political pressure from donor governments to deploy them. However, it is important to make
the decision to deploy field hospitals based solely on need and value added.
9. Patients’ rights: Health facilities and services should be designed in a
manner that ensures privacy and confidentiality. Informed consent should be
sought from patients (or their guardians if they are not competent to do so),
prior to medical or surgical procedures. Health staff should understand that
patients have a right to know what each procedure involves, as well as its
expected benefits, potential risks, costs and duration.
10. Infection control in healthcare settings and patient safety: For an effective
response during disasters, continuing infection prevention and control (IPC), programmes should be enforced at both national and peripheral levels, and at the various healthcare facility levels. Such an IPC programme at a healthcare facility should include:-- defined IPC policies (e.g. routine and additional infection control measures to address potential threats), -- qualified, dedicated technical staff (IPC team) to run infection control programme with a defined scope, function and responsibility. -- early warning surveillance system for detection of communicable disease outbreaks, -- defined budget for activities (e.g. training of staff) and supplies in response to an emergency, -- reinforced standard precautions and additional specific precautions defined for an epidemic disease, -- administrative controls (e.g. isolation policies) and environmental and engineering, controls (e.g. improving environmental ventilation), -- personal protective equipment used, -- IPC practices monitored and recommendations reviewed regularly.
11. Healthcare waste: Hazardous waste generated in healthcare facilities can be segregated into infectious non-sharp waste, sharps and non-infectious common wastes. Poor management of healthcare waste potentially exposes health staff, cleaners, waste handlers, patients and others in the community
to infections such as HIV and hepatitis B and C. Proper separation at the point of origin of the waste through to final category specific disposal procedures must be implemented in order to minimise the risk of infection. The personnel assigned to handle healthcare waste should be properly trained and should
wear protective equipment (gloves and boots are minimum requirements). Treatment should be done according to the type of waste: for example, infectious non-sharp waste as well as sharps should be either disposed of in protected pits or incinerated.
12. Handling the remains of the dead: When disasters result in high mortality,
the management of a large number of dead bodies will be required. Burial of
large numbers of human remains in mass graves is often based on the false
belief that they represent a health risk if not buried or burned immediately. In
only a few special cases (e.g. deaths resulting from cholera or haemorrhagic
fevers) do human remains pose health risks and require specific precautions.
Bodies should not be disposed of unceremoniously in mass graves.
People should have the opportunity to identify their family members and
to conduct culturally appropriate funerals. Mass burial may be a barrier to
obtaining death certificates necessary for making legal claims. When those
being buried are victims of violence, forensic issues should be considered
Health systems standard 2: Human resources
Health services are provided by trained and competent health workforces who have an adequate mix of knowledge and skills to meet the health needs of the population.
Key actions:
a. Review staffing levels and capacity as a key component of the baseline health assessment.
b. Address imbalances in the number of staff, their mix of skills and gender and/
or ethnic ratios where possible
c. Support local health workers and integrate them fully into health services,
taking account of their competence
d. Ensure adequate ancillary workers for support functions in each health
facility.
e. Train clinical staff in the use of clinical protocols and guidelines
f. Provide supportive supervision to staff on a regular basis to ensure their compliance with standards and guidelines, including provision of feedback.
g. Standardise training programmes and prioritise them according to key health
needs and competence gaps.
e. Ensure fair and reliable remuneration for all health workers, agreed between
all agencies and in collaboration with the national health authorities.
f. Ensure a safe working environment, including basic hygiene and protection for all health workers.
Key indicators:
There are at least 22 qualified health workers (medical doctors, nurses and midwifes)/10,000 population:
-- at least one medical doctor/50,000 population
-- at least one qualified nurse/10,000 population
-- at least one midwife/10,000 population.
1. There is at least one Community Health Worker (CHW)/1,000 population,
one supervisor/10 home visitors and one senior supervisor.
2. Clinicians are not required to consult more than 50 patients a day consistently.
If this threshold is regularly exceeded, additional clinical staff are recruited
1. Staffing levels: The health workforce includes a wide range of health workers
including medical doctors, nurses, midwives, clinical officers or physician assistants, lab technicians, pharmacists, CHWs, etc., as well as management and support staff. There is no consensus about an optimal level of health workers for a population and this can vary from context to context. However, there is correlation between the availability of health workers and coverage of health interventions. For example, the presence of just one female health
worker or one representative of a marginalised ethnic group on a staff may significantly increase the access of women or people from minority groups to health services. Imbalance in staffing must be addressed through the redeployment and/or recruitment of health workers to areas where there are critical gaps in relation to health needs
2. Training and supervision of staff: Health workers should have the proper
training, skills and supervisory support for their level of responsibility. Agencies have an obligation to train and supervise staff to ensure that their knowledge is up-to-date. Training and supervision will be high priorities especially where staff have not received continuing education or where new protocols are introduced. As far as possible, training programmes should be standardised and prioritised according to key health needs and competence gaps identified through supervision. Records should be maintained of who has been trained in what by whom, when and where.
Health systems standard 3: Drugs and medical supplies
People have access to a consistent supply of essential medicines and consumables.
Key actions:
1. Review the existing lists of essential medicines of the disaster-affected country early in the response to determine their appropriateness
2.Establish and endorse a standardised essential medicines and medical equipment list that contains items appropriate for the health needs and the competence level of health workers
3. Establish or adapt an effective medicines management system
4. Ensure essential medicines for the treatment of common illnesses are available.
5. Accept donations of medicine only if they follow internationally recognised guidelines. Do not use donations that do not follow these guidelines and dispose of them safely
Guidance notes
1. Essential medicines list: Most countries have an established essential medicines list. This document should be reviewed, when necessary, in consultation with the lead health authority early in the disaster response to determine its appropriateness. Occasionally, alterations to essential medicines lists may be necessary, e.g. if there is evidence of resistance to recommended antimicrobials. If an updated list does not already exist, guidelines established by WHO should be followed, e.g. the WHO Model Lists of Essential Medicines. The use of standard pre-packaged kits should be limited to the early phases of a disaster.
2. Medical equipment: Care should be taken in defining a list of the necessary equipment available at different healthcare levels. This should also be linked to the required competency of the staff.
3. Drug management: Health agencies need to establish an effective system of drug management. The goal of such a system is to ensure the efficient, cost-effective and rational use of quality medicines, storage and correct disposal of expired medicines. This system should be based on the four key elements of the medicines management cycle: selection, procurement,
distribution and use.
4. Tracer products: These include a list of essential or key medicines that are selected to regularly evaluate the functioning of the drug management system. The items to be selected as tracer products should be relevant to local public health priorities and should be available at all times at the health facilities. Examples include amoxicillin and paracetamol.
Health systems standard 4: Health financing
People have access to free primary healthcare services for the duration of the disaster.
Key actions:
1. Identify and mobilise financial resources for providing free health services at the point of delivery to the affected population for the duration of the disaster
2. Where user fees are charged through the government system, make arrangements for their abolition or temporary suspension for the duration of the disaster response
3. Provide financial and technical support to the health system to cover any financial gaps created by the abolition and/or suspension of user fees and to cope with the increased demand for health services
Health financing: The cost of providing essential health services varies
according to the context. Such a context includes the existing health system,
the population affected by the disaster and the specific health needs determined
by the disaster. According to the WHO Commission on Macroeconomics
and Health, providing a minimum package of essential health
services would require expenditure of at least US$ 40/person/year in lowincome
countries (2008 figures). Providing health services in disaster settings
is likely to incur higher costs than in stable settings.
2. User fees refer to direct payments by beneficiaries at the point of service
delivery. User fees impede access to healthcare and result in poor and vulnerable
people not always seeking appropriate healthcare when it is needed.
A basic humanitarian principle is that services and goods provided by aid agencies should be free of charge to recipients. In contexts where this is not possible, providing members of the affected population with cash and/or vouchers can be considered to enable access to health services Removal of user fees must be accompanied by other measures to support the health system to compensate for the revenue forgone and increase use (e.g. paying incentives to health staff, providing additional supplies of medicine). The ccessibility and quality of services must be monitored after the removal of user fees.
Health systems standard 5: Health information management
The design and delivery of health services are guided by the collection, analysis, interpretation and utilisation of relevant public health data.
1. Health information system: A surveillance system should build upon the
existing HIS whenever possible. In some disasters, a new or parallel HIS
may be required. This is determined by an assessment of the performance
and adequacy of the existing HIS and the information needs for the current
disaster. During the disaster response, health data should include, but not be
limited to, the following:
-- deaths recorded by health facilities including under-5 deaths
-- proportional mortality
-- cause-specific mortality
-- incidence rates for most common morbidities
-- proportional morbidity
-- health facility utilisation rate
-- number of consultations/clinician/day.
2. Sources of data: The interpretation and use of health facility data need to take into account the source of the information and its limitations. The use of supplemental data for decision-making is essential in a comprehensive HIS, for example estimates of prevalence of diseases or information on healthseeking
behaviour. Other sources of data that may improve the analysis include population-based surveys, laboratory reports and quality of service measurements. Surveys and assessment must follow internationally recognised
quality criteria and use standardized tools and protocols and, where possible, be submitted to a peer-review process.
3. Disaggregation of data: Data should be disaggregated by sex, age, vulnerability of particular individuals, affected and host populations, and context (e.g. camp versus non-camp situation) as far as is practical to guide decisionmaking. Detailed disaggregation may be difficult during the early stages of an emergency. However, mortality and morbidity data should at least be disaggregated for children under 5 years old. As time and conditions allow, more detailed disaggregation should be sought to help detect potential inequalities and vulnerable people
4. Confidentiality: Adequate precautions should be taken to protect the safety
of the individual, as well as the data itself. Staff members should never share patient information with anyone not directly involved in the patient’s care without the patient’s permission. Special consideration should be given to persons with intellectual, mental or sensory impairment, which may compromise their ability to give informed consent. Data that relate to injury caused by torture or other human rights violations including sexual assault must be treated with the utmost care. Consideration may be given to passing on this information to appropriate actors or institutions if the individual gives their informed consent
Health systems standard 6: Leadership and coordination
People have access to health services that are coordinated across agencies and sectors to achieve maximum impact
1. Lead health agency: The Ministry of Health should be the lead health agency and be responsible for leading the health sector response. In some situations, the MOH may lack capacity or willingness to assume the leadership role in an effective and impartial manner. In this situation, WHO, as a lead
agency for the global health cluster, will generally take on this responsibility. On occasion, when both the MOH and WHO lack capacity, another agency may be required to coordinate activities. The lead health agency should ensure that responding health agencies coordinate with local health authorities
and that they support the capacities of local health systems
2. Health sector strategy: An important responsibility of the lead health agency is to develop an overall strategy for the emergency response within the health sector. Ideally, a document should be produced that specifies health sector priorities and objectives and outlines the strategies for achieving them. This
document should be developed after consultation with relevant agencies and community representatives ensuring as inclusive a process as possible.
3. Coordination meetings should be action-oriented and provide a forum in which information is shared, priorities are identified and monitored, common health strategies are developed and adapted, specific tasks are allocated and standardised protocols and interventions are agreed upon. They should be used to ensure that all health partners use common denominators and other relevant figures, tools, guidelines and standards, whenever possible. Meetings should be held more frequently at the beginning of the disaster.
