Minimum standards in post-emergency phase

Summary of online published paper¹

In the acute phase of complex humanitarian emergencies, assessment data on service delivery and health outcomes for interventions are increasingly being gathered to develop an evidence base for policies. However, for the post-emergency phase, there has been little equivalent study and no comprehensive programme guidelines currently exist. A recent study aimed to identify associations between agespecific mortality and health indicators in displaced people in post-emergency phase camps, and to define the programme and policy implications of these data. It was hoped that the findings would initiate a dialogue on minimum standards for displaced people during the post-emergency phase of complex humanitarian emergencies.

Between 1998 and 2000, the study team obtained and analysed retrospective mortality data for the previous three months in 51 post-emergency phase camps in seven countries. The team also completed field trips of 6-8 weeks duration to the following countries: Azerbaijan, Ethiopia, Myanmar, Nepal, Tanzania, Thailand, and Uganda. Inclusion criteria for camps were: displaced people residing in the camp during the post-emergency phase, less than 5% change in population size during the 3 months prior to data collection, camp population at least partly dependent on outside organisations for food aid and health care, and functioning healthinformation system.

Multivariate regression analysis was carried out using 18 independent variables that affect crude mortality rates (CMRs) and mortality rates in children younger than 5 years (U5MRs) in complex emergencies. The results were compared with recommended emergency phase minimum indicators.

The main findings were that recently established camps had higher CMRs and U5MRs, and fewer local health workers per person, than did camps that had been longer established. Camps that were close to the border or region of conflict, or had longer travel times to referral hospitals, had higher CMRs than did those located further away or with shorter travel times. Camps with less water per person and high rates of diarrhoea had higher U5MRs than did those with more water and lower rates of diarrhoea.

The results support some policies and programmes that are already being implemented, such as provision of a minimum quantity of water and an emphasis on diarrhoeal disease prevention and treatment. Sphere recommendations include at least 15 L of water per person daily for drinking, cooking, and personal and domestic hygiene during the emergency phase of a complex humanitarian emergency. However, in the post-emergency phase, displaced people need water for more than just survival as they return to aspects of settled lifestyles, such as agriculture, livestock care, and building. In this study, provision of more than 20 L per person daily of water was associated with lower mortality rates in children. Hence the minimum standard for water supply may need to be higher than 20 L in the post-emergency phase.

The study also identified factors whose importance has not been sufficiently prioritised in guidelines and standards, such as the number of local health-care workers per person and the distance that camps are situated from a border or area of conflict.

A consensus between international humanitarian organisations, taking into account budgetary constraints, will be necessary to establish optimum staff levels in post-emergency camps. Current Sphere recommendations should be reassessed, since it is likely that more health workers are needed in an emergency, than in a post-emergency phase camp.

The authors recommend that programmes in complex emergencies should focus on indicators proven to be associated with mortality. Humanitarian organisations often provide similar services in the emergency and post-emergency phases of complex humanitarian emergencies, despite increasing evidence and consensus that needs differ between these phases.

Research is needed to establish evidencebased policies and programmes with the objective of reducing mortality in displaced people living in postemergency phase camps. Sphere standards describe indicators and minimum standards for the emergency phase of complex humanitarian emergencies, but a comprehensive and practical set of minimum standards for key indicators needs to be developed for displaced people in post-emergency phase camps.

¹Spiegel P, Sheik M, Gotway-Crawford C, Salama P (2002). Health programmes and policies associated with decreased mortality in displaced people in post-emergency phase camps: a retrospective study. The Lancet. Published online November 19, 2002. http://image.thelancet.com/extras/01art11089web.pdf