The Assessment Matrix
Introduction Analysis for decision makers The assessment matrix was developed in 2003 by the Inter-Agency Standing Committee (IASC) CAP Sub-Working Group, refined at a December 2003 workshop (attended by donors, UN agencies, the Red Cross, and NGOs), and polished thanks to additional inter-agency discussion in January 2004. The assessment matrix (and accompanying assessment framework) is work in progress: comments from teams or agencies using it would be welcome and can be sent to the IASC CAP SWG. The assessment matrix accompanies the one-page assessment framework and describes the categories and various elements of the framework in more detail. It is recommended that IASC Country Team sector coordination mechanisms discuss and fill in the relevant parts of the assessment matrix. (It is recognised that problems of access or lack of information might inhibit this process. It is also recognised that some issues might be more or less relevant in certain contexts.) Once completed, and under the guidance of the Humanitarian Coordinator (supported by the local OCHA Office), IASC Country Teams should analyse the situation establishing relevant causalities and interdependence between sectors. This should be summarised in the Common Humanitarian Action Plan (CHAP) and can be added as a two-page document in the Consolidated Appeal document. One copy of this matrix is to be filled out for each population group: Depending on the situation, a population group can be identified according to a geographic (i.e. “Huambo and its surroundings”, “the population of North Kivu”) or population group (i.e. “the IDPs”, “the refugees of Lukole camp”). Causality and interdependence The levels in the framework reflect a hierarchy of concerns. The framework was built up by looking at direct causes for excess mortality and morbidity, and underlying factors. Reality is much more complex than any causal pathway could reflect. Categories higher in the framework may influence categories mentioned further down in the framework, and often different areas may interact with each other. These interactions may differ in each context. To establish relevant insight into causalities and interdependence, when needs related to a specific category have been defined one should ask basic questions, including „What may have caused or contributed to these needs?‟ and „How does this need influence other areas of concern?‟. Judgements on severity and risks For each category to be assessed, the IASC CT is asked to make a judgement on its severity and risks. The level of severity (low, medium or high) is to be based on the health and nutrition status, and the extent to which affected populations have access to a specific service or commodity. This needs to be compared in relation to international standards and to be judged in the local context, i.e. what was „normal‟ and to what do people have access. As many of the categories reflect human rights, the situation within a category can be interpreted as the extent to which this right is fulfilled. In addition, the CT is asked to make a judgement and comment on the associated risks (low, medium, high), i.e. what are the consequences of this? For example, there can be increased short-term risk for diarrhoea when access to water is inadequate, and long term socio-economic consequences, for example when access to education is low. It is acknowledged that often the severity or risk related to any of the categories in the matrix can only be determined when analysed together with information from other categories. Finally, CTs may make an judgement of the overall severity of the crisis‟ humanitarian consequences should they wish to do so bearing in mind that a formula for doing so has yet to be elaborated. References to Sphere Many areas to be assessed are derived from the Sphere standards (The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response). The indicators that relate to these standards are helpful when determining the quality of services and/or levels of access that affected populations have in their current situation. The indicators represent helpful arguments to determine in a consistent
way what the humanitarian needs are, but they always need to be judged in the local context and compared to what was „normal‟ or to what people can realistically have access. The indicators can be found in the annex. For more details, see www.sphereproject.org or, preferably, use the Sphere Handbook alongside the matrix for the relevant sectors. Indeed, the handbook (which can be downloaded from the web site) includes guidance notes, which provide essential contextual information when using the standards and indicators. Capacities, Vulnerabilities and Gender These are cross-cutting issues that need to be considered when addressing each category of the framework. (When defining humanitarian needs, capacities are one facet of the same coin: i.e. needs exist when there is no local capacity to meet them.) They relate to national capacity (macro-level) and to capacity at the household/individual level (micro-level). Vulnerabilities need to be assessed in order to identify people who are more at risk than others and to understand why this is the case. Capacities and Vulnerabilities Analysis (CVA) is relevant to (a) improve targeting and prioritisation of needs; (b) support longer-term development programmes in addressing underlying vulnerabilities of the population; and (c) support and maximize local capacities and coping strategies in humanitarian response. To better understand humanitarian needs, these should be assessed simultaneously with capacities and vulnerabilities. There is a need for gender analysis supported by disaggregated information (e.g. by gender, age, disability, location, ethnicity, etc). Capacities and vulnerabilities are also included in the framework and matrix as a separate area to be assessed at the micro and macro level under the category, „Social, Economic and Cultural Context‟. Participation Participation is also an important cross-cutting issue when defining humanitarian needs. Wherever possible the assessments should be done in a participatory way, and the opinion of the affected population on their situation and how they perceive their needs should be taken into consideration. Participation is also addressed as a separate issue to allow analysis of the way affected populations and their representatives participate in ongoing humanitarian programmes, and/or to determine types of participation that may be most suitable in future operations. Thirdly, this would help to identify the best way population representatives can partake when formulating the CHAP. Generic points Quality control of information in the matrix: teams filling in the matrix should indicate the source of information; who collected the data; the methodology used (notably sampling) and the limits of this methodology; the specific population to which it relates; the time frame; and the context. Data are politically sensitive in many situations and there may be discrepancies between official and unofficial numbers (e.g. refugee counts, malnutrition rates, etc.). Often information is not available and/or available information may be unreliable. The difficulties of obtaining reliable quantitative data, especially in crisis situations, can include: problems of methodology; problems of access to affected populations making data collection impossible; problems of capacity (such surveys require time and money, and qualified staff); and lack of baseline data, and basic demographic data. ___________________________________________
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1. Demographics
(1) Group description: Legal status, geographic location, current situation of displacement or return, number of people missing, ethnicity, religion, etc. (2) Sex and age breakdown of the population groups (Data should be disaggregated by age and sex as far as is practical. As time and conditions allow, more detailed dis-aggregation should be sought, to detect further differences according to age (e.g. 0-11 months, 1-4 years, 5-14 years, 15-49 years, 50-59 years, 60+ years and sex) <5 years >5 years age group M F age group M F Total M F Group: Trends over time in size and composition: Sources (Census, estimates, official figures, etc.): (3) Description of access constraints to areas and/or populations (what and why):
2. Protection
Physical To what extent is there aggression against civilians, destruction, forced displacement, arbitrary arrests? Other issues to consider Genocidal acts, extra judicial executions, torture, violations of IHL, sex and gender based violence (see specific section below), lack of protection against crimes committed by non-state actors, refoulement, exposure of population to environment hazards, etc. Legal Pick out the key legal issues relating to the group or population of concern. Material Material protection relates to how aid, which is being provided, is being used. To what extent is aid used as part of the conflict?
Issues to consider Are women‟s and children‟s rights Other issues to consider adhered to? Level of destruction of housing, property Do people enjoy freedom of press? rights and their enforcement. Discrimination based in legislation; Availability of a specific legal framework to clarify the status and/or offer particular protection, assistance, or benefits for target group of the needs assessment; discrimination (of target group) observed in legal practice); access to police protection; access to administrative services; access to registration / documentation; access to courts; access to legal advise; and other observations concerning the legal status and protection situation. In addition, comment on the relevant protection and enforcement mechanisms: Judiciary, functioning (in different parts of the country), including measures taken to secure access to courts for displaced and (military) courts operational to address violations of IHL; Key security organs providing protection to civilians, including measures taken to provide security for the displaced; and Human rights institutions (ombudsmen, commissions, etc.)
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Describe the extent of protection needs of this specific population (e.g. number and type of people/cases of abuse, exploitation, violence, violations of various human rights): Does any other type of information provide indications on needs related to protection? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)? Child Protection Estimated number of children part of the armed forces (dis-aggregated by gender and age): Proportion of child casualties during armed conflict: Proportion of children without primary care-givers (including separated and unaccompanied children):
Sexual Abuse and Exploitation Is sexual abuse and exploitation (as defined in the UN Secretary-General‟s Bulletin (ST/SCG/2003/13 of 9 October 2003) a problem in this country? (Rank on a scale of one to five.) 1. No reports of sexual abuse or sexual exploitation in the media or by community members either formally or informally to police, women's groups, churches, aid agencies, etc. 2. Occasional reports of sexual abuse and exploitation to above. 3. Many rumours of sexual abuse and sexual exploitation but no confirmation. 4. Many rumours and reports of sexual exploitation but few substantiated or confirmed cases. 5. Many confirmed or substantiated reports of sexual abuse and sexual exploitation CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the underlying causes of existing capacities and vulnerabilities?
Conclusion: Severity and associated risks for potential consequences. Low severity Medium severity High severity Low risk Medium risk High risk
3. Mortality
What information is available on the mortality rates of the affected population? (Crude mortality rate (CMR), Under 5 mortality rate (U-5MR), main causes of death or cause specific mortality rates (CSMR))
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Does any other information provide indications on the mortality situation? (For example, grave counts, number of orphanheaded households, reports of massacres, etc.)
What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups and/or locations? If so, why?
Conclusion: Severity and associated risks for potential consequences. Within normal range Increased but below the emergency threshold of double baseline rate Equal to or above the emergency threshold of double baseline rate Equal to or above the „emergency out of control‟ threshold of 4x the baseline rate Equal to or above catastrophic threshold of 10x baseline rate Low risk Medium risk High risk
4. Morbidity
Provide information on the morbidity pattern of the most important and/or life threatening diseases. What is the morbidity Describe the disease burden: What are the trends? What are the potential pattern? (List the most 1. Decreased disease burden evolutions? Are there risks Over what timeframe? common diseases in order 2. Normal, stable disease burden for outbreaks? of importance.) 3. Disease burden increased, above seasonal fluctuations 4. Endemic in the population, high risk for outbreak 5. Disease reached alert threshold 6. Confirmed epidemic 1. 2. 3. 4. 5. 6. Does any other information provide indications on the morbidity situation?
CVA/gender: using disaggregated data, are there any significant differences between and within groups and/or locations? If so, why?
Description of the HIV/AIDS situation (prevalence, who is at risk, why, etc.)
Conclusion: Severity and associated risks for potential consequences.
Low severity Medium severity High severity
Low risk Medium risk High risk
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Description of specific protection concerns (e.g. non-accidental injuries resulting from violence or landmines, sexual and gender based violence, stigmatisation, etc.) which may be related to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
5. Nutritional status
Provide a brief analysis of the recent trends in the prevalence of total, moderate, and severe malnutrition: What information is available on the nutritional status of the affected population? For example for children aged 6-59 months: Total malnutrition rate (<-2 Z scores WFH, or <80% median WFH, and/or oedema), Moderate malnutrition (-3 to <-2 scores WFH, or 70% to <80% median WFH), Severe malnutrition (<-3 Z scores WFH or <70% median WFH, and/or oedema) and/or micro-nutrient deficiencies
Does any other information provide indications on the nutritional situation (e.g. any cases of scurvy, pellagra, beriberi; whether vitamin A deficiency is a public health problem; trends in anaemia)?
What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? If so, why?
Conclusion: Severity and associated risks for potential consequences.
Low severity Medium severity High severity
Low risk Medium risk High risk
Description of specific protection concerns which affect malnutrition due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
6. Access to water
Description of the water distribution system available to each population group Small town system Borehole Hand dug well Gravity supply Spring catchment Rainwater River/lake/stream Other, specify Water supply - access and water quantity: To what extent do people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene? To what extent are public water points sufficiently close to households to enable use of the minimum Water supply – quality: Is the water palatable, and of sufficient quality to be drunk and used for personal and domestic hygiene without causing significant risk to health? Percentage of population that has access: Hand pump Hand pump Motorised Unprotected Protected % % % % % % % % Water supply - water use facilities and goods: Do people have adequate facilities and supplies to collect, store and use sufficient quantities of water for drinking, cooking and personal hygiene, and to ensure that drinking water remains safe until it is 6
water requirement?
consumed?
Using the indicators in the annex related to each Sphere standard as reference, describe the extent to which needs of this specific population are met (e.g. percentage and/or number of people with access to certain quantity and quality of water): Does any other type of information provide indications on needs related to water? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences. Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to have equal access to water due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
7. Sanitation and hygiene practices
Description of the excreta disposal systems available to each population group Piped sewage system Septic tanks Flush and pit latrines Dry pit latrines Compost latrines Other, please specify Excreta disposal access to and number of toilets. To what extent do people have adequate numbers of toilets, sufficiently close to their dwellings, to allow them rapid, safe and acceptable access at all times of the day and night? Excreta disposal design, construction and use of toilets To what extent are they sited, designed, constructed and maintained in such a way as to be comfortable, hygienic and safe to use? Vector control individual and family protection To what extent do people have the knowledge and the means to protect themselves from disease and nuisance vectors that are likely to represent a significant risk to health or wellbeing? Percentage of population that has access: % % % % % %
Solid waste management collection and disposal To what extent do people have an environment that is acceptably uncontaminated by solid waste, including medical waste, and have the means to dispose of their domestic waste conveniently and effectively? Using the indicators in the annex related to each Sphere standard as reference, describe the extent to which needs of this specific population are met (e.g. percentage and/or number of people with access to certain toilets or with knowledge of disease and nuisance vectors): Does any other type of information provide indications on needs related to sanitation and hygiene practises? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)? 7
Vector control physical, environmental and chemical protection measures To what extent are the numbers of disease vectors that pose a risk to people‟s health and nuisance vectors that pose a risk to people‟s well-being kept to an acceptable level?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences. Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to have equal access to sanitation and to practise safe hygiene due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
8. Availability and adequacy of shelter
Description of the shelter conditions Cement structure Stone structure Wooden structure Mud structure Straw buildings Tents Other, please specify Percentage of population that has access: % % % % % % %
Shelter and settlement Shelter and settlement Non-food items - clothing Non-food items - cooking covered living space standard -design and bedding and eating utensils To what extent do people have To what extent is the design of To what extent do the people To what extent does each sufficient covered space to the shelter acceptable to the have sufficient clothing, household have access to provide dignified affected population and blankets and bedding to cooking and eating utensils? accommodation; essential provides sufficient thermal ensure their dignity, safety and household activities can be comfort, fresh air and well being? satisfactorily undertaken, and protection from the climate to livelihood support activities ensure their dignity, health, can be pursued as required? safety and well-being? Using the indicators in the annex related to each Sphere standard as reference, describe the extent to which needs of this specific population are met (e.g. percentage and/or number of people living in a certain quality of shelter, possess sufficient clothing and cooking utensils): Does any other type of information provide indications on needs related to adequacy and availability of shelter or non-food items? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences. Low severity Medium severity High severity Low risk Medium risk High risk 8
Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to have equal access to appropriate shelter or non-food items due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
9. Healthy behaviours
Describe behaviour that influences health Health seeking: Time from onset of illness to seeking health care services, etc. Hygiene: People wash their hands after defecation and before eating and food preparation. Maintaining clean house and environment, etc. Food safety: safe storage of food in households; cooking or peeling all food before consumption, etc. Appropriate infant and young child feeding, e.g. exclusive breastfeeding for 6 months and introduction of safe, adequate and appropriate complementary foods from 6 months of age, etc. Describe the extent to which the needs of the affected population related to behaviour are met (e.g. percentage and/or number of people with behaviour that may be harmful to health): Does any other information provide indications on needs related to behaviour? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences. Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises healthy behaviour due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
10. a) Access to health and psycho-social services
Describe health and psycho-social services available: (e.g. the control of communicable diseases including prevention, diagnosis and case management, outbreak preparedness, detection, investigation and response, control of measles and HIV/AIDS; and the control of non-communicable diseases including injury, reproductive health, chronic diseases and mental and social aspects of health)
Health services: To what extent do people have access to health services that address the main causes of excess mortality and morbidity?
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Psycho-social services: To what extent do people have access to social and mental health services to reduce mental health morbidity, disability and social problems?
Using the indicators in the annex related to each Sphere standard as reference, describe the extent to which the needs of the affected population for these services are met (e.g. percentage and/or number of people with access to specific health and/or psycho-social services):
Does any other information provide indications on needs related to health and psychosocial services? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences. Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to have equal access to health and psychosocial services due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
10. b) Access to nutritional services
Describe nutritional services available (e.g. selective feeding programs, Nutritional Rehabilitation Units, community feeding programs, etc.) Moderate malnutrition: Severe malnutrition: To what extent is moderate malnutrition addressed? To what extent is severe malnutrition addressed? Using the indicators in the annex related to each Sphere standard as reference, describe the extent to which the needs of the affected population are met (e.g. percentage and/or number of people with access to specific nutritional services): Does any other information provide indications on needs related to nutritional services? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences.
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Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to have equal access to nutritional services due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or returnif population of concern has been defined other than in these terms, etc.)
11. Food intake
What information is available on the current and anticipated food intake of the affected population in terms of: Kcal per person per day (below nutritional standard/normal levels) Diversity of diet (% of staples in diet, % of total energy provided by protein and fat) Number of meals per day (below normal levels) Micronutrient composition Nutritional support The nutritional needs of the population are met. Using the indicators in the annex related to the Sphere standard as reference, describe the extent to which the nutritional needs of this specific population and particularly the at-risk groups are met (e.g. percentage and/or number of people at a certain level of caloric intake per day, and the composition of the diet): Does any other type of information provide indications on needs related to nutritional needs of the population? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)? CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Judgement of the severity and associated risks for potential consequences, including reasons why, based on duration and seasonality of shortages in food intake (also refer to underlying causes identified in food security analysis): Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to meet nutritional needs due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
12. Food security
What information is available on the current and anticipated levels of food security of the affected population in terms of availability, access and utilization: Production: % of food production compared to normal Income and Employment: Loss of jobs, drop in wages, % below poverty level population Markets: Rise in food prices and other essential commodities; functioning of markets (flows and price differentials) Coping strategies: Sale of productive assets, levels of indebtedness, distress migration, high-risk activities General Food Security To what extent do people have access to adequate and appropriate food and non-food items in a manner that Primary Production To what extent are primary production mechanisms protected and supported? Income and Employment Where income generation and employment are feasible livelihood strategies, to what extent do people have access Access to Markets To what extent is people‟s safe access to market goods and services as producers, consumers and traders 11
to appropriate income-earning protected and promoted? opportunities, which generate fair remuneration and contribute towards food security without jeopardising the resources on which livelihoods are based? Using the indicators in the annex related to each Sphere standard, as reference describe the extent to which people have access to adequate and appropriate food and non-food items that ensures their survival, prevents erosion of assets and upholds their dignity: ensures their survival, prevents erosion of assets and upholds their dignity? Does any other type of information provide indications on needs related to access to adequate and appropriate food items? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Judgement of the severity and associated risks for potential consequences, including reasons why, based on duration and seasonality of food insecurity (also refer to underlying causes for inadequate food utilization as identified in nutrition, health, water/sanitation analysis): Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the ability to have equal access to food and non-food items due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
13. Performance and quality of national or local health, nutrition and psycho-social services Describe the performance and quality of health, nutrition and psycho-social services
Primary health care To what extent are health, nutritional and psychosocial services based on primary health care principles?
Supporting national and local health systems To what extent are health, nutritional and psychosocial services designed to support existing national systems, structures and providers?
Clinical services To what extent do people have access to health and nutritional services that are standardised and follow accepted protocols and guidelines?
Health information systems To what extent are the design and development of health, nutritional and psychosocial services guided by the ongoing, coordinated collection, analysis and utilisation of relevant public health data?
Nutritional services – correction of Moderate Malnutrition What is the quality of programs correcting Moderate Malnutrition?
Nutritional services – correction of Severe Malnutrition What is the quality of programs correcting Severe Malnutrition?
Nutritional services – correction of Micronutrient Malnutrition What is the quality of programs correcting Micronutrient Malnutrition?
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Specific health programs. What is the quality of the specific health programs as described and prioritised under 10 of access to health services (e.g. the control of communicable diseases including prevention, diagnosis and case management, outbreak preparedness, detection, investigation and response, control of measles and HIV/AIDS; and the control of non-communicable diseases including injury, reproductive health and chronic diseases)?
Mental and social aspects of health What is the quality of programs addressing psychosocial problems?
Using the indicators in the annex related to each Sphere standard as reference, describe the extent to which the needs influencing performance and quality of these services are met: Does any other information provide indications on needs related to performance of health, nutrition and psychosocial services? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, is performance of health, nutrition and psychosocial services sensitive to identifying and responding to inequalities between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities?
Conclusion: Severity and associated risks for potential consequences. Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse and/or exploitation, which compromises the performance of health, nutritional and psychosocial services due to potential vulnerability factors (e.g. insecurity, discrimination, stigmatisation, gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
14. Education
If the formal education system is functioning estimate the following: Primary school enrolment as a percentage of corresponding age group: Secondary school enrolment as a percentage of corresponding age group: Specific educational information: Number of Institutions Male Students Female Students Teachers/Educators Pre-school Primary Secondary Tertiary/University Vocational training Formal Apprenticeships Literacy and Numeracy classes Other (please specify) Have communities or organizations established „child friendly spaces‟ ? How many individuals participate in these activities?
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Describe the extent to which education needs of this specific population are met (e.g. percentage and/or number of people enrolled in what type of education, student/teacher ratio, etc): Does any other type of information provide indications on needs related to quality and quantity of education? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
CVA/gender: using disaggregated data, are there any significant differences between and within groups? What are the aspects that make certain groups more vulnerable or give them particular capacities related to education? Conclusion: Severity and associated risks for potential consequences. Low severity Low risk Medium severity Medium risk High severity High risk Description of specific protection concerns, i.e. abuse by teachers, rebel attacks, exploitation, which compromises the ability to have equal access to education due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination and/or special needs relating to legal status or displacement , e.g. language barriers and religious freedom, etc.) Potable water on school compound Building condition Furniture Latrines Textbooks School supplies Yes __ No __
Good __ Little damage __ Extensive damage __ Destroyed/none __ Sufficient __ Adequate __ Few __ None __ Toilets exist __ Separate toilets for boys and girls __ Separate toilets for male and female teachers __ Easily available __ Difficult to find __ No textbooks __ Easily available __ Difficult to find __ No supplies __
15. Inequalities
Provide an overall assessment of the degree of marginalisation based on gender in the population group concerning their access to: Food Health Care Education Economic Activities Low Comments: The impact of humanitarian activities on the marginalisation of women, if present. Positive (reduced marginalisation) Comments: Provide an overall assessment of the degree of marginalisation based on age in the population group concerning their access to: Food Health Care Education Low Comments: The impact of humanitarian activities on the marginalisation of children, if present. Positive (reduced marginalisation) Comments: 14 Neutral (no impact) Negative (worsened marginalisation) Medium High Low Medium High Low Medium High Neutral (no impact) Negative (worsened marginalisation) Medium High Low Medium High Low Medium High Low Medium High
Provide an overall assessment of the degree of marginalisation of specific groups (based on ethnicity, geographic location, religion, political denomination, etc) concerning their access to: Food Health Care Education Low Comments: the impact of humanitarian activities on the marginalisation of the specific groups, if present. Positive (reduced marginalisation) Comments: Neutral (no impact) Negative (worsened marginalisation) Medium High Low Medium High Low Medium High
Describe the extent to which needs of the various groups (based on gender, age, ethnicity, etc) vary and the degree to which marginalisation/discrimination occurs, in their access to food, health care, education, economic activity, etc.: What are the aspects that make certain groups more vulnerable or give them particular capacities? Does any other type of information provide indications on variations and discrimination of specific groups? What are the trends? Over what time frame (including reference to the pre-crisis situation if possible or relevant)?
Conclusion: Severity and associated risks for potential consequences. Low severity Medium severity High severity Low risk Medium risk High risk
16. Social, economic and cultural context & CVA
Describe briefly the social, economic and cultural context at community level (social stratification, classes, ethnic groups, political groups, linguistic and religious diversity, etc):
Using the CVA matrix of the CHAP, describe the key capacities and vulnerabilities at community level: Capacities Vulnerabilities Males Children Males Children Females Females Physical/Material What physical/material resources exist in the community? What are the access and control patterns for these resources? How do these patterns change in crisis? Social/Organizational What social/organizational institutions and relationships exist in the community? How does crisis impact these structures? How do these structures transform during crisis? What are the opportunities and challenges to people‟s capacities provided by this transformation?
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Motivational Attitudinal How does the community perceive the crisis? What are the capacities for coping strategies in the community? Conclusion: What are the key capacities and vulnerabilities relevant for priority setting and targeting, support to longer-term development programmes in addressing underlying vulnerabilities of the population, and support to and maximize local capacities and coping strategies for humanitarian response?
Description of specific protection concerns, i.e. abuse and/or exploitation, which influences capacity and vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.):
17. Participation
Describe briefly the existing forms of participation in the ongoing humanitarian programmes, e.g.: The most important reasons for participation: Who participates: With whom will we work? Stakeholder analysis, including issues of representation, and consideration of the humanitarian principles of impartiality, independence and neutrality How people participate: Practically non existent – people are not even informed of what is going to occur People are informed People participate by supplying information People are consulted in setting priorities but have no decision-making power People participate in implementation of responses by supplying materials/labour People are actively involved in the decision making process, monitoring and evaluations of the relief programmes CVA/gender: using disaggregated data, are there any significant differences in participation between and within groups?
Conclusion: What are the most appropriate approaches to participation in this particular context (with which potential partners, how, why)? Description of specific protection concerns, i.e. violence, abuse and/or exploitation, which compromises the ability of affected populations to participate, due to potential vulnerability factors (e.g. gender, age, disability, people living with HIV/AIDS, ethnicity, the risk of reinforcing the harmful power balance, discrimination related to citizenship, refugee or other legal status, or situation of displacement and/or return- if population of concern has been defined other than in these terms, etc.)
18. National context
Describe briefly the national context Political/Economic/Historical/Social Describe national (governmental and non-governmental) capacities and systems Ability of government to meet people‟s needs. Legal framework for addressing emergencies, displacement, etc. This includes: a) the International legal framework (accession to human rights and International Humanitarian Law instruments such as ICCPR, CESCR , CERD, CAT, CRC , CEDAW, Migrant Workers Convention, Geneva Conventions relative to the Protection of Civilian Persons in Time of War of 12 August 1949, Protocol I, Protocol II, 1951 Convention relating to the Status of Refugees, its 1967 Protocol, Convention relating to the Status of Stateless Persons, 1954, Convention on the Reduction of Statelessness, 1961 Protocol relating to the Status of Refugees, 1967, Accession to regional human rights instruments, etc.); b) the national protection framework and legislation (constitutional framework, declaration of a state of emergency, application of emergency legislation, minority protection legislation, anti-discrimination legislation, legislation related to registration or limitation of freedom of movement, 16
etc.); and c) the human rights situation in the country as addressed by specific resolutions of the UN General Assembly or Commission on Human Rights, group-specific protection consideration and challenges, in particular as reflected in observations and recommendations of treaty monitoring bodies and reports of special rapporteurs. National disaster preparedness & response plans, early warning systems, contingency planning, hazard resistant infrastructure, etc. Transport and communications infrastructure and access to populations of concern. Functioning of national government and ministries, at central and peripheral levels. Level and nature of participation of population of concern in national / local political and civic processes . Macro-economic indicators (e.g. poverty levels, GDP, etc.). Access to energy. Quality of infrastructure including status of roads, communication, etc. Environment, geography and climate. Natural and/or man-made hazards (e.g. annual flooding, droughts, earthquakes, pollution, etc.). Health system (financing, per capita health expenditure, human resource planning, health infrastructure, etc.). What is public opinion toward international assistance and presence, towards the government and toward the parties to the conflict? Aspects of the regional and international context that might affect the national context, e.g. instability, possible overflow of a conflict, cross-border tensions, potential population movements.
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ANNEX TO THE ASSESSMENT MATRIX
3. Mortality
The crude mortality rate (CMR) is maintained at, or reduced to, less than twice the baseline rate documented for the population prior to the disaster. The under-5 mortality rate (U5MR) is maintained at, or reduced to, less than twice the baseline rate documented for the population prior to the disaster.
Baseline reference mortality data by region CMR (deaths/ Region 10,000/day) Sub-Saharan Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean Central and Eastern European Region/ CIS and Baltic States Industrialised countries Developing countries Least developed countries World 0.44 0.16 0.25 0.19 0.16 0.30 0.25 0.25 0.38 0.25
CMR emergency threshold 0.9 0.3 0.5 0.4 0.3 0.6 0.5 0.5 0.8 0.5
U5MR (deaths/ 10,000 U5s/day) 1.14 0.36 0.59 0.24 0.19 0.20 0.04 0.53 1.03 0.48
U5MR emergency threshold 2.3 0.7 1.2 0.5 0.4 0.4 0.1 1.1 2.1 1.0
Further information on measuring mortality rates can be found under www.smartindicators.org
4. Morbidity
Incidence rates cannot fully reflect severity or true needs as it is influenced by access. Cause-specific mortality (including deaths in community) is therefore crucial as it may reflect those not being able to access health care. The trends and distribution of "clinic attendances or consultations" (stable, decreasing, increasing) of important diseases (major M&M or those with potential to cause major M&M e.g. epidemic-prone), with some alert thresholds for action, are important for priority setting. In some cases the actual number is also important, as whilst they do not indicate the true picture (i.e. they are often an underestimate), they will require priority action because they warn of potential morbidity and mortality to come. This is the case for some epidemic-prone diseases but also for non-accidental injury including rape (where both incidence and trend are important). Disease trends not only give an indication of severity, but they can also imply the needs of the population, e.g.: increasing level of diarrhoea (AWD or ABD) = basic human needs - safe water, adequate sanitation facilities (as specified by Sphere guidelines). increasing trend in malnutrition = need for regular, nutritious food. increasing trend in malaria cases = need for better shelter and planning, better protection against mosquito vectors, better quality curative health services (for case management). increasing respiratory infections = need for shelter (warm, ventilation, no overcrowding); need for clothing. cases of non-accidental injuries including rape = need for security, law and order, protection of civilians; need to advocate for human rights. one case of measles or pertussis = need for protection of children against vaccine-preventable disease; need for quality preventative health care. Confirmation of the existence of an outbreak: it is not always straight forward to determine whether an outbreak is present and clear definitions of outbreak thresholds do not exist for all diseases a. Diseases for which one case may indicate an outbreak: cholera, measles, yellow fever, Shigella, viral haemorrhagic fevers. b. Meningococcal meningitis: for populations above 30,000, 15 cases/100,000 persons/week in one week indicates an outbreak; however, with high outbreak risk (i.e. no outbreak for 3+ years and vaccination coverage <80%), this threshold is reduced to 10 cases/100,000/week. In populations of less than 30,000, an incidence of five cases in one week or a doubling of cases over a three-week period confirms an outbreak. c. Malaria: less specific definitions exist. However, an increase in the number of cases above what is expected for the time of year among a defined population in a defined area may indicate an outbreak.
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5. Nutritional status
Key indicators for micronutrient deficiencies There are no cases of scurvy, pellagra, beriberi or riboflavin deficiency. Rates of xerophthalmia and iodine deficiency disorders are not of public health significance. Further information on measuring Acute Malnutrition can be found in Appendix 5 of the food section of the Sphere handbook. Among others, this gives indications how to measure malnutrition among older children, adolescents, adults, older people and disabled people. Additional information on measuring malnutrition rates can be found under www.smartindicators.org
6. Access to water
Water supply standard 1: access and water quantity All people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene. Public water points are sufficiently close to households to enable use of the minimum water requirement. Key indicators (to be read in conjunction with the guidance notes) Average water use for drinking, cooking and personal hygiene in any household is at least 15 litres per person per day (see guidance notes 1-8). The maximum distance from any household to the nearest water point is 500 metres (see guidance notes 1, 2, 5 and 8). Queuing time at a water source is no more than 15 minutes (see guidance note 7). It takes no more than three minutes to fill a 20-litre container (see guidance notes 7-8). Water sources and systems are maintained such that appropriate quantities of water are available consistently or on a regular basis (see guidance notes 2 and 8).
Water supply standard 2: water quality Water is palatable, and of sufficient quality to be drunk and used for personal and domestic hygiene without causing significant risk to health. Key indicators (to be read in conjunction with the guidance notes) A sanitary survey indicates a low risk of faecal contamination (see guidance note 1). There are no faecal coliforms per 100ml at the point of delivery (see guidance note 2). People drink water from a protected or treated source in preference to other readily available water sources (see guidance note 3). Steps are taken to minimise post-delivery contamination (see guidance note 4). For piped water supplies, or for all water supplies at times of risk or presence of diarrhoea epidemic, water is treated with a disinfectant so that there is a free chlorine residual at the tap of 0.5mg per litre and turbidity is below 5 NTU (see guidance notes 5, 7 and 8). No negative health effect is detected due to short-term use of water contaminated by chemical (including carry-over of treatment chemicals) or radiological sources, and assessment shows no significant probability of such an effect (see guidance note 6).
Water supply standard 3: water use facilities and goods People have adequate facilities and supplies to collect, store and use sufficient quantities of water for drinking, cooking and personal hygiene, and to ensure that drinking water remains safe until it is consumed. Key indicators (to be read in conjunction with the guidance notes) Each household has at least two clean water collecting containers of 10-20 litres, plus enough clean water storage containers to ensure there is always water in the household (see guidance note 1). Water collection and storage containers have narrow necks and/or covers, or other safe means of storage, drawing and handling, and are demonstrably used (see guidance note 1). There is at least 250g of soap available for personal hygiene per person per month. Where communal bathing facilities are necessary, there are sufficient bathing cubicles available, with separate cubicles for males and females, and they are used appropriately and equitably (see guidance note 2). Where communal laundry facilities are necessary, there is at least one washing basin per 100 people, and private laundering areas are available for women to wash and dry undergarments and sanitary cloths. The participation of all vulnerable groups is actively encouraged in deciding the location and construction of bathing facilities and/or the production and distribution of soap, and/or the use and promotion of suitable alternatives (see guidance note 2).
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7. Sanitation and hygiene practices
Excreta disposal standard 1: access to, and numbers of, toilets People have adequate numbers of toilets, sufficiently close to their dwellings, to allow them rapid, safe and acceptable access at all times of the day and night. Key indicators (to be read in conjunction with the guidance notes) A maximum of 20 people use each toilet (see guidance notes 1-4). Use of toilets is arranged by household(s) and/or segregated by sex (see guidance notes 3-5). Separate toilets for women and men are available in public places (markets, distribution centres, health centres, etc. (see guidance note 3). Shared or public toilets are cleaned and maintained in such a way that they are used by all intended users (see guidance notes 3-5). Toilets are no more than 50 metres from dwellings (see guidance note 5). Toilets are used in the most hygienic way and children‟s faeces are disposed of immediately and hygienically (see guidance note 6).
Excreta disposal standard 2: design, construction and use of toilets Toilets are sited, designed, constructed and maintained in such a way as to be comfortable, hygienic and safe to use. Key indicators (to be read in conjunction with the guidance notes) Users (especially women) have been consulted and approve of the location and design of the toilet (see guidance notes 13). Toilets are designed, built and located to have the following features: – they are designed in such a way that they can be used by all sections of the population, including children, older people, pregnant women and physically and mentally disabled people (see guidance note 1); – they are sited in such a way as to minimise threats to users, especially women and girls, throughout the day and night (see guidance note 2); – they are sufficiently easy to keep clean to invite use and do not present a health hazard; – they provide a degree of privacy in line with the norms of the users; – they allow for the disposal of women‟s sanitary protection, or provide women with the necessary privacy for washing and drying sanitary protection cloths (see guidance note 4); – they minimise fly and mosquito breeding (see guidance note 7). All toilets constructed that use water for flushing and/or a hygienic seal have an adequate and regular supply of water (see guidance notes 1 and 3). Pit latrines and soakaways (for most soils) are at least 30 metres from any groundwater source and the bottom of any latrine is at least 1.5 metres above the water table. Drainage or spillage from defecation systems must not run towards any surface water source or shallow groundwater source (see guidance note 5). People wash their hands after defecation and before eating and food preparation (see guidance note 6). People are provided with tools and materials for constructing, maintaining and cleaning their own toilets if appropriate (see guidance note 7).
Vector control standard 1: individual and family protection All disaster-affected people have the knowledge and the means to protect themselves from disease and nuisance vectors that are likely to represent a significant risk to health or well-being. Key indicators (to be read in conjunction with the guidance notes) All populations at risk from vector-borne disease understand the modes of transmission and possible methods of prevention (see guidance notes 1-5). All populations have access to shelters that do not harbour or encourage the growth of vector populations and are protected by appropriate vector control measures. People avoid exposure to mosquitoes during peak biting times by using all non-harmful means available to them. Special attention is paid to protection of high-risk groups such as pregnant and feeding mothers, babies, infants, older people and the sick (see guidance note 3). People with treated mosquito nets use them effectively (see guidance note 3). Control of human body lice is carried out where louse-borne typhus or relapsing fever is a threat (see guidance note 4). Bedding and clothing are aired and washed regularly (see guidance note 4). Food is protected at all times from contamination by vectors such as flies, insects and rodents.
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Vector control standard 2: physical, environmental and chemical protection measures The numbers of disease vectors that pose a risk to people‟s health and nuisance vectors that pose a risk to people‟s well-being are kept to an acceptable level. Key indicators (to be read in conjunction with the guidance notes) Displaced populations are settled in locations that minimise their exposure to mosquitoes (see guidance note 1). Vector breeding and resting sites are modified where practicable (see guidance notes 2-4). Intensive fly control is carried out in high-density settlements when there is a risk or the presence of a diarrhoea epidemic. The population density of mosquitoes is kept low enough to avoid the risk of excessive transmission levels and infection (see guidance note 4). People infected with malaria are diagnosed early and receive treatment (see guidance note 5).
Solid waste management standard 1: collection and disposal People have an environment that is acceptably uncontaminated by solid waste, including medical waste, and have the means to dispose of their domestic waste conveniently and effectively. Key indicators (to be read in conjunction with the guidance notes) People from the affected population are involved in the design and implementation of the solid waste programme. Household waste is put in containers daily for regular collection, burnt or buried in a specified refuse pit. All households have access to a refuse container and/or are no more than 100 metres from a communal refuse pit. At least one 100-litre refuse container is available per 10 families, where domestic refuse is not buried on-site. Refuse is removed from the settlement before it becomes a nuisance or a health risk (see guidance notes 1, 2 and 6). Medical wastes are separated and disposed of separately and there is a correctly designed, constructed and operated pit, or incinerator with a deep ash pit, within the boundaries of each health facility (see guidance notes 3 and 6). There are no contaminated or dangerous medical wastes (needles, glass, dressings, drugs, etc.) at any time in living areas or public spaces (see guidance note 3). There are clearly marked and appropriately fenced refuse pits, bins or specified areas at public places, such as markets and slaughtering areas, with a regular collection system in place (see guidance note 4). Final disposal of solid waste is carried out in such a place and in such a way as to avoid creating health and environmental problems for the local and affected populations (see guidance notes 5-6).
8. Availability and adequacy of shelter
Shelter and settlement standard 3: covered living space People have sufficient covered space to provide dignified accommodation. Essential household activities can be satisfactorily undertaken, and livelihood support activities can be pursued as required. Key indicators (to be read in conjunction with the guidance notes) The initial covered floor area per person is at least 3.5m 2 (see guidance notes 1-3). The covered area enables safe separation and privacy between the sexes, between different age groups and between separate families within a given household as required (see guidance notes 4-5). Essential household activities can be carried out within the shelter (see guidance notes 6 and 8). Key livelihood support activities are accommodated where possible (see guidance notes 7-8).
Shelter and settlement standard 4: design The design of the shelter is acceptable to the affected population and provides sufficient thermal comfort, fresh air and protection from the climate to ensure their dignity, health, safety and well-being. Key indicators (to be read in conjunction with the guidance notes) The design of the shelter and the materials used are familiar where possible and culturally and socially acceptable (see guidance note 1). The repair of existing damaged shelters or the upgrading of initial shelter solutions constructed by the disaster-affected population is prioritised (see guidance note 2). Alternative materials required to provide temporary shelter are durable, practical and acceptable to the affected population (see guidance note 3). The type of construction, materials used and the sizing and positioning of openings provides optimal thermal comfort and ventilation (see guidance notes 4-7). 21
Access to water supply sources and sanitation facilities, and the appropriate provision of rainwater harvesting, water storage, drainage and solid waste management, complement the construction of shelters (see guidance note 8). Vector control measures are incorporated into the design and materials are selected to minimise health hazards (see guidance note 9).
Non-food items standard 1: clothing and bedding The people affected by the disaster have sufficient clothing, blankets and bedding to ensure their dignity, safety and well-being. Key indicators (to be read in conjunction with the guidance notes) Women, girls, men and boys have at least one full set of clothing in the correct size, appropriate to the culture, season and climate. Infants and children up to two years old also have a blanket of a minimum 100cmx70cm (see guidance notes 1-4). People have access to a combination of blankets, bedding or sleeping mats to provide thermal comfort and to enable separate sleeping arrangements as required (see guidance notes 2-4). Those individuals most at risk have additional clothing and bedding to meet their needs (see guidance note 5). Culturally appropriate burial cloth is available when needed.
Non-food items standard 3: cooking and eating utensils Each disaster-affected household has access to cooking and eating utensils. Key indicators (to be read in conjunction with the guidance notes) Each household has access to a large-sized cooking pot with handle and a pan to act as a lid; a medium-sized cooking pot with handle and lid; a basin for food preparation or serving; a kitchen knife; and two wooden serving spoons (see guidance note 1). Each household has access to two 10- to 20-litre water collection vessels with a lid or cap (20-litre jerry can with a screw cap or 10- litre bucket with lid), plus additional water or food storage vessels (see guidance notes 1-2). Each person has access to a dished plate, a metal spoon and a mug or drinking vessel (see guidance notes 1-4).
9. Healthy behaviours
Key indicators in: Health seeking behaviour Time from onset of illness to seeking health care services. Hygiene Wash your hands after going to the toilet. Maintaining a clean house and environment (including sweeping floors inside and outside, food or other scraps should not be lying on the ground - which may invite disease-carrying vectors). Food safety Wash your hands before handling food and often during food preparation. Wash and sanitise all surfaces and equipment used for food preparation. Protect kitchen areas and food from insects, pests and other animals. Separate raw meat, poultry and seafood from other foods. Use separate equipment and utensils such as knives and cutting boards for handling raw foods. Store foods in containers to avoid contact between raw and prepared foods. Cook food thoroughly, especially meat, poultry, eggs and seafood. Bring foods like soups and stews to boiling to make sure that they have reached 70°C. Reheat cooked food thoroughly. Do not leave cooked food at room temperature for more than 2 hours. Refrigerate promptly all cooked and perishable food (preferably below 5°C). Keep cooked food piping hot (more than 60°C) prior to serving. Do not store food too long even in the refrigerator. Do not thaw frozen food at room temperature. Use safe water or treat it to make it safe. Select fresh and wholesome foods. Choose foods processed for food safety, such as pasteurised milk. Wash fruits and vegetables, especially if eaten raw. Do not use food beyond its expiry date. Cook or peel all food before consumption. Appropriate infant and young child feeding Exclusive breastfeeding for infants under 6 months of age or, in exceptional cases, have access to an adequate amount of an appropriate breast milk substitute. 22
A nutritionally adequate breast-milk substitute, fed by cup, should be available for infants who do not have access to breast milk. Introduction of safe, adequate and appropriate complementary foods from 6 months of age. Infants born into populations affected by emergencies should normally be breastfed. The use of infant-feeding bottles and artificial teats in emergency settings should be actively discouraged. The preparation and feeding of complementary foods for older infants and young children should be done frequently and in a clean environment.
10. Access to health, psycho-social and nutrition services
Health systems and infrastructure standard 1: prioritising health services All people have access to health services that are prioritised to address the main causes of excess mortality and morbidity. Key indicators (to be read in conjunction with the guidance notes) The major causes of mortality and morbidity are identified, documented and monitored. Priority health services include the most appropriate and effective programmes to reduce excess morbidity and mortality. All members of the community, including vulnerable groups, have access to priority health programmes. Local health authorities and community members participate in the design and implementation of priority health programmes. There is active collaboration with other sectors in the design and implementation of priority health programmes, including water and sanitation, food security, nutrition, shelter and protection. Access to psychosocial services: mental and social aspects of health People have access to social and mental health services to reduce mental health morbidity, disability and social problems. Key social indicators (to be read in conjunction with the guidance notes): During the acute disaster phase, the emphasis should be on social programmes. People have access to an ongoing, reliable flow of credible information on the disaster and associated relief efforts. Normal cultural and religious events are maintained or re- established (including grieving rituals conducted by relevant spiritual and religious practitioners). People are able to conduct funeral ceremonies. As soon as resources permit, children and adolescents have access to formal or informal schooling and to normal recreational activities. Adults and adolescents are able to participate in concrete, purposeful, common interest activities, such as emergency relief activities. Isolated persons, such as separated or orphaned children, child combatants, widows and widowers, older people or others without their families, have access to activities that facilitate their inclusion in social networks. When necessary, a tracing service is established to reunite people and families. Where people are displaced, shelter is organised with the aim of keeping family members and communities together. The community is consulted regarding decisions on where to locate religious places, schools, water points and sanitation facilities. The design of settlements for displaced people includes recreational and cultural space. Key psychological and psychiatric programme indicators (to be read in conjunction with the guidance notes) Individuals experiencing acute mental distress after exposure to traumatic stressors have access to psychological first aid at health service facilities and in the community. Care for urgent psychiatric complaints is available through the primary health care system. Essential psychiatric medications, consistent with the essential drug list, are available at primary care facilities. Individuals with pre-existing psychiatric disorders continue to receive relevant treatment, and harmful, sudden discontinuation of medications is avoided. Basic needs of patients in custodial psychiatric hospitals are addressed. If the disaster becomes protracted, plans are initiated to provide a more comprehensive range of community-based psychological programmes for the post-disaster phase. Access to nutritional services: Correction of malnutrition standard 1: moderate malnutrition Moderate malnutrition is addressed. Key indicators (to be read in conjunction with the guidance notes) From the outset, clearly defined and agreed objectives and criteria for set-up and closure of the programme are established. Coverage is >50% in rural areas, >70% in urban areas and >90% in a camp situation. More than 90% of the target population is within <1 day‟s return walk (including time for treatment) of the distribution centre for dry ration supplementary feeding programmes and no more than 1 hour‟s walk for on-site supplementary feeding programmes. Supplementary feeding is based on the distribution of dry take-home rations unless there is a clear rationale for on-site feeding. Correction of malnutrition standard 2: severe malnutrition Severe malnutrition is addressed. 23
Key indicators (to be read in conjunction with the guidance notes)
From the outset, clearly defined and agreed criteria for set-up and closure of the programme are established. Coverage is >50% in rural areas, >70% in urban areas and >90% in camp situations.
11. Food Intake
General nutritional support standard 1: The nutritional needs of the population are met. Key Indicators (to be read in conjunction with the guidance notes) There is access to a range of foods – staples (cereals or tuber), pulses or animal products and fat sources that meet nutritional requirements. The following estimates for average nutritional requirements should be used, as adjusted for each population: 2,100 kcals per person per day 10 – 12 % of total energy provided by protein 17% of total energy providing by fat
There is access to a range of foods – staple (cereal or tuber), pulses (or animal products) and fat sources – that meet nutritional requirements. There is access to vitamin A-, C- and iron-rich or fortified foods or appropriate supplements. There is access to iodised salt for the majority (>90%) of households. There is access to additional sources of niacin (e.g. pulses, nuts, dried fish) if the staple is maize or sorghum. There is access to additional sources of thiamine (e.g. pulses, nuts, eggs) if the staple is polished rice. There is access to adequate sources of riboflavin where people are dependent on a very limited diet. Levels of moderate and severe malnutrition are stable at, or declining to, acceptable levels.
12. Food Security
General Food Security – people have access to adequate and appropriate food and non-food items in a manner that ensures their survival, prevents erosion of assets and upholds their dignity. Primary Production – Primary production mechanisms are protected and supported Income and Employment – Where income generation and employment are feasible livelihood strategies, people have access to appropriate income-earning opportunities, which generate fair remuneration and contribute towards food security without jeopardising the resources on which livelihoods are based. Access to Markets – People‟s safe access to market goods and services as producers, consumers and traders is protected and promoted. An explanation of how the disaster/crisis has affected the food security/ livelihood/ economic situation of people in different areas and/or population subgroups; the underlying causes of their food insecurity; the pre-crisis baseline, the present situation; recent trends and current expectations (the prognosis for the coming months). This should include specific information in relation to: Is food available, in the locality, the country and (where appropriate) neighbouring countries? Are food sources adequate, e.g. households‟ own production, market purchases, food aid, other safety nets, gifts, hunting, gathering, etc., and the relative importance of each? Have income and/or assets been affected (including entitlements from social networks/political allegiances)? What are the effect on debt burden (distinguishing debts for consumption and for production) and the implications of defaulting on repayments? To what extent people are able to meet their essential non-food requirements/obligations (including rent, energy/fuel, water, shelter, health care, school fees, etc.), in particular highlight items that are essential for future food security (e.g. keeping livestock alive for pastoralists)? If available, how has the balance between household income and expenditures changed? Are population groups engaged in detrimental trade-offs (at household level) between food and non-food needs and provisions? Are current coping/survival strategies undermining people‟s health and livelihoods and are they sustainable? What opportunities are available to people to enhance their food security and what are their capacities to exploit those opportunities? What seasonal considerations are relevant to people‟s food security? To what extent is food security affected by the macro-economic situation and fiscal and other policies? To what extent is market failure contributing to food insecurity? What is the potential for markets to help address food insecurity, for example can private food market flows offset a national or local food shortfall? 24
What is the potential for adverse effects on markets and producers of food and non-food programmes?
13. Performance and quality of health, psycho-social and nutrition services
Health systems and infrastructure standard 4: primary health care Health services are based on relevant primary health care principles. Key indicators (to be read in conjunction with the guidance notes) All people have access to health information that allows them to protect and promote their own health and well-being (see guidance note 1). Health services are provided at the appropriate level of the health system: household/community, peripheral health facilities, central health facilities, referral hospital (see guidance note 2). A standardised referral system is established by the lead health authority and utilised by health agencies. Suitable transportation is organised for patients to reach the referral facility. Health services and programmes are based on scientifically sound methods and are evidence-based, whenever possible.
Health services and programmes utilise appropriate technology, and are socially and culturally acceptable.
Health systems and infrastructure standard 2: supporting national and local health systems Health services are designed to support existing health systems, structures and providers. Key indicators (to be read in conjunction with the guidance notes) Representatives of the Ministry of Health lead the health sector response, whenever possible. When the Ministry of Health lacks the necessary capacity, an alternate agency with the requisite capacity is identified to take the lead in the health sector. Local health facilities are supported and strengthened by responding agencies. Local health workers are supported and integrated into health services, taking account of gender and ethnic balance. Health services incorporate or adapt the existing national standards and guidelines of the disaster-affected or host country. No alternate or parallel health facilities and services are established, including foreign field hospitals, unless local capacities are exceeded or the population does not have ready access to existing services. The lead health authority is consulted on this issue. Health systems and infrastructure standard 5: clinical services People have access to clinical services that are standardised and follow accepted protocols and guidelines. Key indicators (to be read in conjunction with the guidance notes) The number, level and location of health facilities are appropriate to meet the needs of the population. The number, skills and gender/ethnic balance of staff at each health facility are appropriate to meet the needs of the population. Adequate staffing levels are achieved so that clinicians are not required to consistently consult on more than 50 patients per day. If this threshold is regularly exceeded, additional clinical staff are recruited. Utilisation rates at health facilities are monitored and corrective measures taken if there is over- or under-utilisation. Standardised case management protocols are established by the lead health authority, and adhered to by health agencies. A standardised essential drug list is established by the lead health authority, and adhered to by health agencies. Clinical staff are trained and supervised in the use of the protocols and the essential drug list. People have access to a consistent supply of essential drugs through a standardised drug management system that follows accepted guidelines. Drug donations are accepted only if they follow internationally recognised guidelines. Donations that do not follow these guidelines are not used and are disposed of safely. Bodies of the deceased are disposed of in a manner that is dignified, culturally appropriate and is based on good public health practice. Health systems and infrastructure standard 6: health information systems The design and development of health services are guided by the ongoing, coordinated collection, analysis and utilisation of relevant public health data. Key indicators (to be read in conjunction with the guidance notes) A standardised health information system (HIS) is implemented by all health agencies to routinely collect relevant data on demographics, mortality, morbidity and health services. A designated HIS coordinating agency (or agencies) is identified to organise and supervise the system. Health facilities and agencies submit surveillance data to the designated HIS coordinating agency on a regular basis. The frequency of these reports will vary according to the context, e.g. daily, weekly, monthly. A regular epidemiological report, including analysis and interpretation of the data, is produced by the HIS coordinating agency and shared with all relevant agencies, decision-makers and the community. The frequency of the report will vary according to the context, e.g. daily, weekly, monthly. Agencies take adequate precautions for the protection of data to guarantee the rights and safety of individuals and/or populations. 25
The HIS includes an early warning component to ensure timely detection of and response to infectious disease outbreaks. Supplementary data from other relevant sources are consistently used to interpret surveillance data and to guide decisionmaking.
Performance of nutritional services: correction of moderate malnutrition Moderate malnutrition is addressed. Key indicators (to be read in conjunction with the guidance notes) The proportion of exits from targeted supplementary feeding programmes who have died is <3%, recovered is >75% and defaulted is <15%. Admission of individuals is based on assessment against internationally accepted anthropometric criteria. Targeted supplementary feeding programmes are linked to any existing health structure and protocols are followed to identify health problems and refer accordingly. Monitoring systems are in place. Performance of nutritional services: correction of severe malnutrition Severe malnutrition is addressed. Key indicators (to be read in conjunction with the guidance notes) The proportion of exits from therapeutic care who have died is <10%, recovered is >75% and defaulted is <15%. Discharge criteria include non-anthropometric indices such as good appetite and the absence of diarrhoea, fever, parasitic infestation and other untreated illness. Mean weight gain is >8g per kg per person per day. Nutritional and medical care is provided according to internationally recognised therapeutic care protocols. As much attention is attached to breastfeeding and psychosocial support, hygiene and community outreach as to clinical care. There should be a minimum of one feeding assistant for 10 in-patients. Constraints to caring for malnourished individuals and affected family members should be identified and addressed. Performance of nutritional services: correction of micronutrient malnutrition Micronutrient deficiencies are addressed. Key indicators (to be read in conjunction with the guidance notes) All clinical cases of deficiency diseases are treated according to WHO micronutrient supplementation protocols. Procedures are established to respond efficiently to micronutrient deficiencies to which the population may be at risk. Health staff are trained in how to identify and treat micronutrient deficiencies to which the population is most at risk. Performance – specific health programs See related standards and indictors (pg. 273-294) in the Sphere handbook. Control of non-communicable diseases standard 3: mental and social aspects of health People have access to social and mental health services to reduce mental health morbidity, disability and social problems. Information: access to information is not only a human right but it also reduces unnecessary public anxiety and distress. Information should be provided on the nature and scale of the disaster and on efforts to establish physical safety for the population. Moreover, the population should be informed on the specific types of relief activities being undertaken by the government, local authorities and aid organisations, and their location. Information should be disseminated according to principles of risk communication i.e. it should be uncomplicated (understandable to local 12-year-olds) and empathic (showing understanding of the situation of the disaster survivor). Burials: families should have the option to see the body of a loved one to say goodbye, when culturally appropriate. Unceremonious disposal of bodies of the deceased should be avoided (see Health systems and infrastructure standard 5, guidance note 8 on page 269). Psychological first aid: whether among the general population or among aid workers, acute distress following exposure to traumatic stressors is best managed following the principles of psychological first aid. This entails basic, non-intrusive pragmatic care with a focus on listening but not forcing talk; assessing needs and ensuring that basic needs are met; encouraging but not forcing company from significant others; and protecting from further harm. This type of first aid can be taught quickly to both volunteers and professionals. Health workers are cautioned to avoid widespread prescription of benzodiazepines because of the risk of dependence. Care for urgent psychiatric complaints: psychiatric conditions requiring urgent care include dangerousness to self or others, psychoses, severe depression and mania. Community-based psychological programmes: these should be based on an assessment of existing services and an understanding of the socio-cultural context. They should include use of functional, cultural coping mechanisms of individuals and communities to help them regain control over their circumstances. Collaboration with community leaders and indigenous healers is recommended when feasible. Community- based self-help groups should be encouraged. Community workers should be trained and supervised to assist health workers with heavy caseloads and to conduct outreach activities to facilitate care for vulnerable and minority groups. 26
16. Social, Economic and Cultural context: capacities and vulnerabilities analysis
Physical/Material All of the listed categories will be different for women and for men. While women and men suffer material deprivation during crisis, they always have some resources left. These resources serve as capacities on which agencies can build. The following questions should be answered through this section of the CVA What physical/material resources exist in the community? What are the access and control patterns for these resources? How do these patterns change in crisis? Physical/Material Health and disability Livelihoods/ Vocational skills Livestock Access to markets Transport Staple crops Housing Technologies Water supply Food supply Access to capital or other assets Relative poverty and wealth Features of land, climate, environment Capacities Males Vulnerabilities Males Children
Females
Children
Females
Social/Organizational Gender analysis in this category is crucial, to understand women‟s and men‟s different roles in decision-making, as well as access to resources and social systems of exchange. Divisions on the basis of gender, race, ethnicity, class, caste or religion can weaken the social fabric, increasing a group‟s vulnerability. Social organisations usually are disrupted in crisis, creating both chaos and opportunities for social change, e.g., around gender roles. The following questions should be answered through this section of the CVA What social/organizational institutions and relationships exist in the community? How does crisis impact these structures? How do these structures transform during crisis? What are the opportunities and challenges to people‟s capacities provided by this transformation? Social/Organizational Family structures Kinship groups, clans Formal social and political organizations Informal social gatherings Divisions of : gender, race, ethnicity class caste religion Social capital (systems of support and power) Education Systems for distributing goods and services Capacities Males Vulnerabilities Males Children
Females
Children
Females
Motivational Attitudinal This category includes cultural and psychological factors based on traditional views, the people‟s history of crisis, their expectation of emergency relief assistance, and their coping strategies. When people feel victimized and dependent; they may become fatalistic and passive, and suffer a decrease in their coping strategies. Their vulnerabilities can also be increased by inappropriate relief that does not build on their capacities. Some of the relevant questions to ask may be: 27
How does the community perceive the crisis? What are the capacities for coping strategies in the community? Capacities Males Vulnerabilities Males Children *
Motivational Attitudinal Psycho social profile History of crisis Expectation of emergency Relief Existing coping strategy Cultural and psychological Factors Change in power structures and relations
Females
Children *
Females
*Note: In the matrix the columns on children can be further broken down into different age groups but for the purpose of this training exercise we will only keep it limited to the broad category of children under 15 years of age.
17. Participation
Participation is something that differs from one situation to the next. While forms of participation can be described (see matrix) and these descriptions indicate increasing levels of participation, what is “bad”, “acceptable”, or “good”, will depend on the context (security, political situations, nature and impact of the crisis), the population characteristics (capacity to participate, the will, etc.), and on the capacity and expertise of an agency. If people‟s participation endangers them, it is better not to insist on it! Questions that must be asked to understand types / kinds of participation are: Participation, why? To gain access to certain areas? For security reasons? To reduce costs? To improve understanding of and response to a certain situation? Out of respect of the rights of the population for self determination? Participation by whom? Local NGOs? Government representatives? Community-based organisations? Individual members of the affected population? Work with ministries, or with CBOs, why, why not? To determine with whom agencies can work, a stakeholders‟ analysis (including issues of representation and consideration of the humanitarian principles of impartiality, independence and neutrality) needs to be done. Participation, what? Consultation? In decision-making? Supply in labour or kind? Support to existing programmes designed by the local population? A big constraint to genuine participation is that the relationship between agencies and affected populations are fraught with biases. People with experience in aid know what agencies provide and therefore what to ask for and the balance of power between resource provider and resource seeker makes it difficult for genuine concerns to be heard. Developing participation requires flexibility, and often requires one to be ready to step away from one‟s priorities, models, and standards, and be open to local specificities. For further reading on participation, see chapter 1 in ALNAP‟s „Practitioners handbook: participation by crisis affected populations in humanitarian action‟, www.alnap.org
25 January 2004
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