Overview

Health interventions in crisis response aim to reduce mortality, morbidity, and the human suffering of crisis affected individuals by ensuring access to and availability of life-saving health care, as well as at the same time supporting the recovery and rebuilding of resilient health systems.

Key Considerations

Global Health References for Crisis Response

The following Global Health References (GHR) outline the minimum standards necessary for more effective health programming in response to crisis. Compliance with these global standards enables IOM staff to accurately map humanitarian gaps, track project progress and performance, evaluate impact and ensure accountability internally as well as to affected populations. The GHR provide a set of indicators and related measurement strategies that are essential components to the strengthening of health system capacities and coordination with partners. For the purpose of this Internal Guidance, the following are recognized GHR to incorporate into health programming in response to crisis.

1. Health Resource Availability Mapping System (HeRAMS)

Health Resource Availability Mapping System (HeRAMS) is a standardized tool used by the Health Cluster during an acute crisis to measure the availability of health system resources in an affected region. The HeRAMS enables both a baseline assessment on the impact of a crisis as well as monitor the changes in resource availability throughout the crisis and beyond. The sub-sectors of HeRAMS include:

• General Clinical Services
• Child Health
• Communicable Diseases
• Sexual and Reproductive Health
• Non-communicable Diseases, Injuries, and Mental Health
• Environmental Health

The response domains, with their respective essential services, are imperative to save lives, reduce morbidity and suffering in times of crisis. IOM's health programming in response to crisis therefore needs to address all sub-sectors comprehensively, whether their essential services are provided by IOM directly or through the identification of partnerships.

Another key component of HeRAMS is the articulation of the each sub-sector and its essential services within the three different levels of care. This allows for more effective referral systems and coordination of care between community care, primary care, and secondary and tertiary care. IOM's programming should address each level of care and its associated services and identify partners to fill in the gaps.

2. WHO Health System Building Blocks (HSBB)

A Health System (HS) consists of all the organizations, institutions, resources and people whose primary purpose is to improve health. IOM's health assistance during a crisis response aims to support and reinforce a crisis-affected HS. Crises can magnify pre-existing problems within a HS as well as create new ones, often previously hidden. Even during the most acute response to a crisis, HS strengthening needs to be the ultimate goal of IOM's health programming. The WHO Health System Building Blocks (HSBB) framework is used to monitor health system strengthening through the identification of key inputs and immediate outcomes in the subsequent areas:

• Service Delivery
• Health Workforce
• Health Information
• Medical Products, Vaccines, and Technologies
• Health Financing
• Leadership and Governance
• Community**

**Community was a building block in the previous version of the HSBB framework. Within health response to crisis, this building block is re-inserted, notably in consideration to the framework for Accountability to Affected Populations.

It is important for IOM to keep in mind the HSBB at all stages of health programming in response to crisis. Direct service delivery and capacity building need to address all seven HSBB, whether activities are implemented by IOM directly or through the identification of partnerships.

Relevance to IOM’s Emergency Operations

Health Support is part of IOM's Humanitarian Mandate, and is recognized by the Migration Crisis Operational Framework (MCOF) as one of the 15 sectors of assistance to address before, during, and after crises. As such, health response is frequently part of IOM's larger multi-sectoral humanitarian assistance, although it can also be delivered as a stand-alone intervention. Notwithstanding, coordination within IOM and with other sectors of assistance is critical. Health response in times of crisis aims to alleviate suffering, save lives, and protect human dignity while also upholding IOM's commitment to humanitarian principles, as stated in IOM's Humanitarian Policy - Principles for Humanitarian Action (PHA) and protection mainstreaming.

MCOF Objective of Response: To provide comprehensive health-care and prevention services during the crisis and throughout the movement process at the pre-departure stage, during travel and transit, and upon return based on existing health systems and evidence-based needs assessments.

Since its establishment, IOM's health activities have evolved and expanded in response to the changing needs of migrants as well as the contexts in which migration occurs. The adoption of the resolution Health of Migrants by the 61st World Health Assembly in 2008 (WHA 61.17)¹ signified a shift in global policy and an increased focus by global actors on prioritizing the migration health agenda. Recognized as a partner of the WHO and a member of the Inter-Agency Standing Committee's (IASC) Global Health Cluster (GHC), IOM is increasingly a key player in health service delivery in response to crises and public health emergencies, as well as in supporting health system recovery and resilience.

Coordination

As an active member of the GHC, IOM is also a member of the Health Cluster in many countries affected by crisis, both at the national as well as sub-national levels. In being so, IOM actively participates in Health Cluster and other humanitarian coordination activities and initiatives, takes part in joint needs assessments, and participates in the Humanitarian Programme Cycle (HPC) - particularly in the development of Humanitarian Needs Overview and strategic response plans.

IOM staff in the field should ensure active participation within the Health Cluster at the country level. This participation should be reflected throughout the planning and implementation of IOM's emergency health programmes which should be in line with the overall Health Cluster strategy in country.

Operations

Putting Global Health References into Practice

IOM's health response to crisis is guided by well-established Global Health References. These references delineate the scope of sound emergency health programming required to support the realization of the ultimate life-saving goal of humanitarian assistance. Compliance to global standards of operations is also critical to ensure the equitable delivery of the highest attainable quality of health care during emergencies. Partners of the GHC are expected to follow these standards in their operations.

The two most important references used in IOM's emergency health operations are: 1) the Health Resource Availability Mapping System (HeRAMS) Health Cluster Response Domains, and 2) the World Health Organization (WHO) Health System Framework for Action. HeRAMS is a standardized tool used by the Health Cluster during crises to conduct baseline assessments on the impact of a crisis and monitor the changes in resource availability throughout the crisis and beyond. HeRAMS delineate the different response domains of the Health Cluster, each of which are associated with specific measurement indicators. The WHO Health System Framework for Action describe the different 'building blocks' that make up a health system (Health System Building Blocks - HSBB). The HSBB framework is used to monitor health system strengthening through the identification of key inputs and immediate outcomes within a health system.

Both the HeRAMS tool and the HSBB framework are global references that outline the minimum standards necessary for more effective health response to crisis. Compliance with these global standards enables IOM to accurately map humanitarian health gaps, track the progress of its response, evaluate impact, and ensure accountability internally as well as to affected populations.

Refer to the Key Considerations below for a more detailed explanation of HeRAMS and HSBB.

1. HeRAMS Health Cluster Response Domains and HSBB

The following matrix incorporates the HeRAMS seven domains of response and HSBB seven building blocks into one tool to guide IOM staff to maintain both paradigms throughout all stages of the health response to crisis. The matrix can be used during the needs assessment, project response planning, monitoring and evaluation, in order to not miss a critical sector of the health response while still striving towards overall health system strengthening. A key input to the matrix is the identification of actors involved across the sub-sectors and the different HSBB. The actors include IOM as well as National Health System (NHS) entities such as the Ministry of Health (MOH) and other health partners including Non-Government Organizations (NGOs), Civil Society Organizations (CSOs) and the private sector.

HeRAMS Response Division Domains and HSBB Matrix

Scope and utilization of the matrix

• Needs Assessment: The matrix serves to detect gaps in domains of health response across the seven HSBB, allowing for subsequent prioritization of response, development of interventions and identification of potential partnerships, whether with actors already in place or new ones.

• Response Planning: The matrix should be completed with IOM proposed activities for each response domain across the HSBB, as identified and prioritized in the needs assessment. If the intervention does not address all domains and/or building blocks, partnerships with national entities such as MOH and other health actors need to be identified to fill in the gaps.
• Monitoring and Evaluation: The evolution of the content of the matrix illustrates the progress made from the needs assessment stage, throughout response implementation, and ultimately its impact on health system strengthening, and the growth of national partnerships.

Trigger Questions to Aid in Matrix Completion

• HeRAMS Health Cluster Response Domains

• Health System Building Blocks (HSBB)

2. Levels of Care

During all stages of the intervention, it is essential to distinguish the levels of care in which the HeRAMS response domains and their essential services are available during a crisis. Coordination between the four levels of care, community care, primary care, and secondary and tertiary care, enables more effective monitoring of the health situation. IOM health response must link the different levels of care through the incorporation of partners and other actors to provide the most comprehensive and effective health support possible.

3. Gender Mainstreaming

It is vital that a thorough gender analysis is carried out in the health needs assessment. Response planning consequently needs to properly address the specific needs of women, men, boys and girls as analyzed in the needs assessment. Subsequent response activities must take into consideration the specific gender dynamics of the affected populations. Monitoring and evaluation need to be based on indicators that are properly engendered. These indicators need to be well articulated at the output, outcome, and impact levels; all key data must be disaggregated by sex and age to the extent possible.

The IASC has developed Guidelines for integrating Gender-based Violence Interventions into Humanitarian Action. The Health Thematic Area Guide can be accessed online and in the Gender Mainstreaming entry.

4. Protection Mainstreaming

The health implications of protection violations need to be addressed throughout all stages of health response to crisis. A comprehensive understanding of protection violations and their potential health implications needs to be part of the initial needs assessment. This will help inform how IOM's health response can both prevent occurrence and reoccurrence of protection violations as well as respond to their health implications. Response activities should articulate how health services will contribute to response and prevention efforts stemming from protection violation. Services dealing with management of protection violations, notably violence, include emergency contraception, clinical management of rape, and trauma care. In many settings, men and boys are just as susceptible to gender-based violence as women and girls. Practitioners need to be prepared to respond to both circumstances in culturally-sensitive ways. Another essential component of protection mainstreaming into the health response is building capacity of personnel on the prevention and management of the health implications of protection violations - notably violence.

Area of IOM's Health Response to Crises

Primary Health Care Provision and Community Health Revitalization: From the onset of a disaster and through the early recovery transition period following the crisis, primary health infrastructure can be reestablished; the health needs of crisis-affected populations and their host communities can be met by a variety of external and provisional health services. This includes the provision of mobile clinics, temporary health posts, or transitional clinics, depending on the situation.

Health Referrals: To facilitate linkages between the different levels of health services - and notably access of crisis-affected populations and their surrounding communities to adequate secondary and tertiary health care services during crisis and post-crisis recovery periods and to reduce undue congestion of hospitals - IOM provides an adequate environment in strengthening health referral mechanisms to and from secondary and tertiary health care facilities, assisted hospital discharge, and assisted returns with transportation and communications support. In so doing, operational relief is provided to reduce the strain on functioning health care facilities during and after crisis events.

Medical Evacuation and Rehabilitation: In severe circumstances during emergencies or in post-emergency phases where there are overwhelming needs for urgent and complex medical care, some patients may require local, regional or international medical evacuation in order to access adequate life-saving medical care. In these cases IOM initiates medical evacuation programmes in collaboration with interested governments and partners and contributes to in-country capacity and enhancement of national health infrastructure, skills development, and targeted projects that serve to address gaps in health service delivery.

Travel Health Assistance: Travel and movements of populations may pose health risks to both the people traveling and the hosting or receiving communities. IOM has a responsibility to ensure that people traveling under the auspices of the Organization travel in a safe and dignified manner, are fit to travel, receive appropriate assistance through medical escorts to final destination when necessary, and do not become a hazard to other travelers, personnel or receiving communities. The Transport Assistance for Affected Populations entry for more information.

Health, Border and Mobility Management: IOM's approach to responding to public health emergencies, disease outbreaks, and preparing for future health threats is particularly anchored upon human mobility - notably through the Health, Border, and Mobility Management (HBMM) framework. The summary of the components within the HBMM framework are shown in the below figure. HBMM has the ultimate goal of improving prevention, detection and response to the spread of infectious diseases and other health threats along the mobility continuum (at origin, transit, destination and return points) and its spaces of vulnerability, with particular focus on border areas. At the core of HBMM is the understanding that mobility is a continuum that extends beyond the physical or regulated border areas, such as the official Points of Entry (or PoEs, as articulated within IHR, 2005), to include pathways and spaces of vulnerability. Grounded on this understanding, the scope of HBMM ranges from collection and analysis of information on mobility patterns, to disease surveillance and health threat response mechanisms at spaces of vulnerability along mobility pathways. HBMM, therefore, ultimately contributes to health system strengthening that is sensitive to mobility dynamics, notably at the primary health care level.

Health within other humanitarian interventions

Camp Management and Displacement Tracking: As the co-lead of the Camp Coordination and Camp Management (CCCM) Cluster, IOM strives to facilitate the effective and equitable provision of assistance and protection in camps and camp-like settings for displaced persons and migrants in transition. Recognizing IOM's key role in camp management, it is vital that public health dimensions such as public health risk assessments and monitoring are systematically integrated into existing camp-based operational practices as well as included within the information collection process of the Displacement Tracking Matrix (DTM).

Shelter and NFI: The incorporation of first aid kits into IOM's Non-Food Item (NFI) responses supports existing health promotion practices and promotes self-sufficiency and self-management for the affected populations.

Water, Sanitation and Hygiene (WASH): In addition to ensuring adequate access to clean water, sanitation, and safe waste management in times of crisis, IOM has the capacity to incorporate health promotion and disease prevention activities as well as capacity building support for the affected communities within its WASH programming.

Transport Assistance for Affected Populations: Travel and movements of populations may pose health risks to both the people traveling and the hosting or receiving communities. IOM has a responsibility to ensure that people traveling under the auspices of the Organization travel in a safe and dignified manner, are fit to travel, receive appropriate assistance through medical escorts to final destination when necessary, and do not become a hazard to other travelers, personnel or receiving communities. In severe circumstances during emergencies or in post-emergency phases where there are overwhelming needs for urgent and complex medical care, some patients may require local, regional or international medical evacuation in order to access adequate, life-saving medical care.

Psychosocial Support: IOM also directly implements mental health support and psychosocial interventions to immediately address the needs of crisis affected populations. Services include the deployment of mobile psychosocial teams to provide psychosocial counselling, the setup of referral mechanisms and the provision of basic psychosocial training, including psychological first aid training, for humanitarian workers in accordance with Do No Harm principles.

Prevention of Gender based Violence: Health services are often the first point of contact for survivors of gender based violence (GBV). IOM aims to ensure that survivors have safe access to health facilities and health care workers who are trained to provide quality health care and psychosocial support, as per the standard of the Minimum Initial Service Package (MISP). IOM Health teams work alongside Protection teams to guarantee that appropriate referral pathways are in place for referrals for legal and other services that can support survivors and mitigate and prevent further harm and suffering caused by GBV.

IOM HBMM Framework

HBMM Activity Linkages

Contacts

For additional support and guidance on Health in Emergencies contact the Migration Health Division (MHD): mhddpt@iom.int.