This part of this module will deal with various types of health services and their implementation. Specifically, this will describe who's responsible for deciding how health services are established or modified. And we'll list some of the advantage and disadvantages of deciding upon which type of health services will be established. As with coordination, and all other aspects of humanitarian emergency preparedness, response, and recovery, the government is in charge of the overall response. However, many governments may not have sufficient capacity, and therefore will likely be supported by local NGOs and community-based organizations, as well as the international community. And this was discussed in the previous module on coordination. So if you are a minister of health and your country has just experienced a devastating earthquake that has killed over 10,000 people, what would you do to modify your existing health system? If you are in the same position but as opposed to a massive earthquake, 100,000 persons have just crossed your border fleeing conflict from a neighboring country. What would you do? These are very difficult questions and very context specific. Some key factors that governments and those that support them include the following, health system and personnel. How affected was the health system by this disaster? And how affected have the personnel been by, for example, the earthquake? It's not unusual to see health personnel have to leave because they have to take care of their personal situations. What is the capacity of the existing health system to address the consequences of the earthquake? Or to integrate a large number of refugees that have just crossed the border? Another big issue are medical supplies and equipment. Depending on the type of emergency and the expected epidemiological disease profile, including diseases of epidemic potential, which basically mean big epidemics. There may be a need for urgent supplies from beyond what exists in the country. For example, during the Ebola epidemic in Liberia, Sierra Leone, and Guinea, the health system was clearly overwhelmed. And there were limited supplies, and they were quickly exhausted. It was necessary for international support at a very large level, compared for example, to the many earthquakes that occur in China. Where for the most part, the government and its institutions have sufficient capacity to address them internally. Other important factors such as health financing and security will be discussed in following slides. For many decades, putting refugees or internally displaced persons into camps was the norm. It was easier to provide essential services, especially at the beginning of an emergency,. And many governments believed that it would be a more secure alternative. However, the policy has changed, at least internationally. As it has become clear that the so-called warehousing of refugees in camps for decades is not only harmful to the people that we are trying to support, but it's not sustainable, in the long run, for host governments or for the international community. For example, once again, let's look at Kenya and the Dadaab refugee camps that were established in 1991. And they are now together one of the largest cities in Kenya. They're a miserable place, where refugees are completely reliant, and have been for generations, on aid from the international community and from the Kenyan government. They live in a marginalized part of Kenya. They're not allowed the leave the camp. They're not allowed to work outside of the camp, and insecurity is rife. Particularly with the rise of Al-Shebab, a terrorist organization based primarily in Somalia. There are numerous advantages to out-of-camp settings. However, governments need to consider a variety of factors, particularly for refugees. Who are not citizens of their country compared to, for example, internally displaced persons who are. Before deciding if refugees and/or internally displaced persons should be integrated into existing health systems. The international community also has an influence in this area, particularly in health financing. Most humanitarian emergencies, whether natural disasters or man made, such as conflict, still occur in low income countries with limited health infrastructure, personnel, and financing. Besides the strain on existing health services when displaced persons come into a certain area and need these services, there's a tremendous amount of stress on the personnel, on the supplies and equipment needed. As well as the financing of healthcare, which is crucial to these governments. One particular important issue in humanitarian emergencies is the recommendation by WHO, many other agencies, as well as FEAR, that healthcare should be provided free of charge to affected populations. This also affects how local governments will provide care to their own population, who will be often using the same services as those displaced populations. Issues of equity among displaced persons and local populations is a recurring theme that needs to be carefully considered. One has to be very careful to say that refugees will be receiving free healthcare, while the surrounding communities, who may be also be very poor, will have to pay. Issues such as this and other equity issues need to be examined carefully. And win win situations need to be decided upon so that both the refugees and/or internally displaced persons, as well as the national populations, will benefit. Another important issue that often comes up is security. This relates to the decisions by governments of whether to have displaced persons in camps or integrated into their communities. It also relates to the concept of integration versus parallel health systems or education systems. Unlike in natural disasters, there can be important security issues related to persons displaced by conflict. We've seen this both in Kenya, where there have been concerns of al-Shabaab, the terrorist or group based in Somalia, coming over into Kenya. And/or some of the homegrown attacks that have occurred when you have hundreds of thousands, and in some cases millions, of refugees or internally displaced persons descend upon a country or specific district. Security is a major and recurring theme for governments when dealing with displaced persons. Specifically those displaced by conflict, whether refugees or internally displaced persons. Having hundreds of thousands, or in some cases, in the Syrian situation, millions, of persons integrated into cities and rural villages in a country is an issue that governments, in particular the Ministries of Interior, must take very seriously. However, as will be discussed in a future module, if integration of internally displaced persons and refugees into existing health systems can be done well. There should be a benefit for both effected populations as well as nationals. For example, referral hospitals can be improved, as both nationals and displaced persons will be using them. Another example would be the hiring of perhaps displaced persons, but also national healthcare workers. That should help the local economy but should also improve the quality and level of healthcare services available, again, to both displaced persons and national. Ultimately, if refugees or internally displaced persons are integrated into existing national systems, and if done well, in terms of financing, in terms of allowing these groups to work and pay for these services. Then existing health systems, the infrastructure, supplies, personnel, and ultimately the quality of health care should be improved for all populations. Referral systems are another important component of any health system. However referral, especially for secondary and tertiary care, can be very expensive. Therefore, clear standard operating procedures or SOPs should be created and communicated to ensure transparency and equity. Funds for humanitarian emergencies are often limited. Particularly for prolonged settings where there is less media interest and consequently, less money. Therefore, it is recommended that a public health approach is followed where primary health care, including preventive and curative services are prioritized. Emergency cases, particularly emergency obstetrical care, such as cesarean sections, should also be a priority for hospital referral care. Referral care is expensive, and obviously not all cases or patients can be referred. Therefore, a specified medical officer should be appointed to approve expensive referral care. Following the Iraqi civil war in the mid-2000s, where referral care became very complex, exceptional care committees, or ECCs, were developed for refugees in these surrounding countries. With Iraq and with Syria, these are middle-income countries. And much of our decisions, much of our protocols were developed for low-income countries. We were dealing with cancers, with renal dialysis, with coronary artery bypass. And we needed very clear and understandable rules of who would receive care and who would not. So these exceptional care committees were developed. For example, in Jordan, any patient with medical costs over a specified limit was referred to the exceptional care committee. The case was discussed by specialist doctors from that country, in this case Jordan, who took into account the prognosis, the cost, and specific socioeconomic and vulnerability issues of the patient an his or her family. Very difficult decisions were made in order to decide who would and who would not receive care. These decisions were communicated in an open and sensitive manner to the patients. And options, where he or she could possibly seek financial support from other sources, were provided when referral care was denied. Deciding upon referral care is very difficult for everyone involved. There is a lot of disappointment, and it can be quite heart rendering. However, if one takes a public health approach, it is important to use the limited amount of resources to help the most amount of people. And that's ultimately what we are trying to do with the exceptional care committee. To make sure that primary health care, preventive care, and certain emergency care is prioritized. And yes, there will be a certain amount of funds available for referral care. But they must be used in an open and clear way to help the most amount of people. Humanitarian emergencies also either increase certain illnesses or, in some cases, there are certain specific interventions that need to be provided. Due to the specific context and trauma that these people have suffered through. So although such illnesses that are listed above, such as mental health, sexual and gender-based violence, diseases of epidemic potential, and acute malnutrition and micronutrient deficiencies may occur in any setting. Experience has shown that they can be particularly acute during emergencies. And that interventions for these issues may not be sufficiently available in the countries for where these people have fled. For example, mental health. In many low and middle income countries, already there is sufficient health care workers to address mental health issues. But in emergencies, the stress of the situation can exacerbate existing conditions and cause new conditions. Particularly of concern is depression and post-traumatic stress disorder. During the past decade, mental health in emergencies has become recognized as a core issue. And it is now increasingly being addressed at both community and individual levels. However, much more still needs to be done in terms of training, intervention, and research in this area. Sexual and gender-based violence, or SGBV, has been recognized for decades as a very, very serious issue in emergencies. Women and children are often disproportionately affected by emergencies. And consequently are often more vulnerable to SGBV. However, we can not forget that men and boys are also survivors of sexual and gender-based violence. SGBV is a very sensitive issue in all communities, all over the world, and it is always under reported. Prevention and treatment of SGBV is recognized as a core issue in emergency response. However, it is not always sufficiently prioritized by all humanitarian actors. Furthermore, besides the health component of providing psychological support, post exposure prophylaxis for HIV, presumptive treatment for sexually transmitted infections, and the provision of emergency contraception. There are many protection sensitive interventions that the public health sector must also ensure occurs. These include ensuring that there are sufficient female health care workers to provide care for women and girls. These include ensuring that privacy for patients, being sensitive towards SGBV, and recognizing that most SGBV occurs through intimate partner violence, among other issues are addressed. Another important issue is diseases of epidemic potential. Overcrowding, lack of water, sanitation and hygiene promotion. Poor food nutrition, insufficient shelter, and health care and other factors increase the possibility of epidemics in emergencies. Common epidemics include measles, watery diarrhea, particularly cholera, bloody diarrhea, particularly Shigella, meningitis, and various types of hepatitis, to name a few. These are very common in humanitarian emergencies and must be addressed, primarily through vaccinations. Particularly for measles, which is essential at the beginning of an emergency. As well as the prioritization of water and sanitation activities, which are also core activities, together with the early implementation of a strong surveillance system. Which will allow for early detection and response to these diseases of epidemic potential. Note that acute malnutrition and micronutrient deficiencies will be discussed in a separate module. There are three durable solutions for refugees. The most common and largest is voluntary repatriation, where refugees return voluntarily to where they left when there is security. The second one's local integration. In some situations where host countries allow refugees to integrate and actually live there. And finally, the third one, and the least common, is resettlement to another country. So amongst the durable solutions, less than 1% of refugees, overall, are resettled. Therefore the chances of resettlement are extremely limited. Furthermore, medical resettlement is even rarer, as governments have limited space for this often costly type of resettlement. Other factors for resettlement come into play in deciding if and when someone will be medically resettled. These include key protection concerns beyond the medical aspect. As well as other family members that are already living in the country where this person could be resettled. Medical resettlement should not be considered the primary pathway for treating serious medical conditions. This will have to occur in the country where these people are residing. Referral and treatment in the country of asylum for refugees, therefore, still remains the most common and appropriate way of handling serious medical issues. Here are some of the main messages for this module. Following a disaster, a thorough assessment is critical at the start to provided health services in emergencies. Following a disaster, needs increase and resources are diminished. The nature of the disaster governs the type of services needed. Clinical services without public interventions are likely to be futile. The components of health services follow the World Health Organization's six building blocks. The essential services include communicable and non communicable diseases. Maternal, reproductive health, and child health. Injury prevention and treatment. And mental health services. The demand for services are generally predictable in a population. Other main messages include, as with leadership and coordination, the government is in charge of deciding what type of health services should be implemented in an emergency. However, many governments lack sufficient capacity, and are supported by local and international organizations. Minimum emergency standards, such as the Sphere standards, should be provided when feasible. Then levels of care should be similar to those at the national level. Whenever possible, health services should be integrated into national systems to improve services for both the affected persons and nationals. Certain health issues may occur specifically, or be exacerbated by, humanitarian emergency. And should therefore be specifically provided according to needs and context. And finally, medical resettlement to a third country is possible in a very limited number of situations. It is very rare. So that wraps up this module. Thank you very much for listening.