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Refugee Health and Nutrition

Executive Committee Meetings

Refugee Health and Nutrition

15 August 1997



1. This document is a follow-up to the paper entitled Refugee Health (EC/1995/SC.2/CRP.29), presented to the thirty-fifth meeting of the Sub-Committee on Administrative and Financial Matters of the Executive Committee of the High Commissioner's Programme. The 1995 paper reviewed the major challenges UNHCR faces in the fields of health and nutrition, and described the principles and objectives of refugee health and nutrition interventions. Their main objective can be described as prevention of disproportionate levels of mortality and morbidity.

2. In order to achieve this objective, UNHCR's main strategies have included:

(a) adoption of a multi-sectoral and preventive health approach;

(b) involvement of refugees in planning and implementation;

(c) meeting the specific needs of refugee children and refugee women;

(d) development of an appropriate health and nutrition information system; and

(e) ensuring coordination and complementarity.

This current paper will detail UNHCR's rationale and strategies adopted in order to meet these challenges and fulfil the objectives as described in the 1995 paper.

3. While efforts have been made to ensure the above strategies are translated into concrete activities, most refugee situations remain precarious, even after the emergency phase, and call for continued surveillance, and appropriate and timely action. Indeed, many factors contribute to the vast majority of refugees' not taking any significant control over their own lives, therefore often remaining dependent on international assistance.

4. Providing assistance to vulnerable groups is not always possible. There have been cases in which UNHCR has simply not had access to the refugees and has therefore not been able to put in place the programmes aimed at preventing a critical increase in premature deaths. An example of such a situation was in the Democratic Republic of the Congo when, from January to June 1997, too often most of the appropriate services could not be put in place. In April and May 1997 in particular, UNHCR was only able to carry out the minimal measures required for medical evacuation. Very high levels of mortality (10 to 15 times above acceptable standards) were documented, mainly due to malnutrition, malaria and diarrhoeal diseases.

5. There have also been emergency situations, such as the influx into the Kigoma camps in the United Republic of Tanzania, where malaria reached epidemic proportions between April and June 1997, with mortality rates as high as 8-10/10,000/day among the under-five (normal rate: £2/10,000/day). Also in Kigoma, the influx of refugees from Burundi and the Democratic Republic of the Congo was accompanied by a dramatic increase in the level of sexual violence, with one survey estimating that some 25 per cent of the female population over 12 years old had reported incidents since their departure from home or as camp residents.

6. Emergencies, however, are not the only settings in which a disproportionate number of lives can be at risk. Difficulties can also arise in long-standing refugee situations, as exemplified by the nutritional deficiencies and the cholera outbreaks in the refugee camps of Kenya at the end of 1996 and the beginning of 1997. Protein energy malnutrition (as defined by a weight/height (W/H) index below 80 per cent of the median W/H) has affected up to 25 per cent of the under-five population (the acceptable standard being < 5 per cent), and was accompanied by mortality rates at 4/10,000/day (normal rate: < 2/10,000/day).

7. Similarly, long standing displaced person situations, such as in the Caucasus, also present increased health risks to displaced populations. In this environment, local health services are generally overwhelmed and basic services, such as tuberculosis control or expanded immunization programmes, cannot be appropriately covered. Immunization coverage was reported to be as low as 25 per cent.

8. The emergence of such conditions after the situation has stabilized, confirms the need for continued technical support and control until a durable solution has been achieved. The role of the UNHCR Programme and Technical Support Section (PTSS) is to provide well integrated technical support to field operations through technical management and coordination in all sectors, including health and nutrition. Given that the range of operations in which UNHCR is involved is broad - from emergencies, care and maintenance or local integration, to repatriation and reintegration - there is a clear need to ensure that adequate and appropriate technical input capacity is available at the field level. This is being addressed through the following measures:

(a) Using internal resources: The deployment of technical staff to key operations through direct intervention by PTSS staff, technical consultants or calling forward of standby resources, and the presence of UNHCR Health Coordinators at field level in key operations.

(b) Using external resources: Drawing on and coordinating the activities of other actors (technically specialized organizations and technical partners), both in terms of work at the field level and in the establishment of mutually agreed-upon standards.

(c) Capacity-building:

(i) Training: Development of technical training strategy/programmes, which include training of refugees and local health staff; and

(ii) Development and dissemination of technical policy, standards and guidelines.

(d) Integration: Emphasizing certain facets of health care until such concerns are integrated into refugee health programmes (such as with respect to reproductive health).


9. Support is provided to the field through the appointment of Health and Nutrition Coordinators in major operations, and through advisory and support missions from PTSS technical staff. As required, technical consultants are deployed to provide additional support and back-up in critical situations.

10. UNHCR Health Coordinators are technical advisers to UNHCR operations and ensure the suitability and cost-effectiveness of activities through their involvement in programme planning, implementation and monitoring. They also provide regular feedback and reporting on health and related sectors. The Coordinators play a key role in ensuring that internationally agreed upon standards are respected, liaising with national and regional authorities of the Ministry of Health, and coordinating the activities of UNHCR operational and implementing partners in the fields of health and nutrition. The effectiveness of UNHCR's technical coordination role was recognized in the Joint Evaluation of Emergency Assistance to Rwanda, issued in March 1996.

11. Technical and policy support is also provided through field missions undertaken by PTSS Headquarters technical staff, who perform needs identification and programme formulation, as well as evaluation missions. UNHCR maintains a small technical Health and Nutrition Team at Headquarters, which comprises two Medical Doctors, one Reproductive Health Officer (temporary), one Nutritionist and one Assistant Nutritionist.


12. Given the extraordinary human and material resources required to meet the needs of a mass influx or a major operation, a concerted effort is required on the part of a number of agencies. In order to respond in a cost-effective manner to the main health and nutrition needs of a refugee or displaced population, the activities of the various actors involved need to be well orchestrated. Effective coordination avoids gaps and unnecessary overlaps, and enables organizations from different backgrounds to adopt a complementary approach. Coordination at the field level encompasses the activities of implementing partners, initially the Government of the country of asylum, which has primary responsibility, and, complementing the Government's capacity, the NGOs which provide substantial resources and form the backbone of UNHCR assistance.

13. Also as part of its efforts to enhance collaboration and make optimal use of resources, UNHCR has signed Memoranda of Understanding (MOUs) with the Centers for Disease Control and Prevention (CDC) in Atlanta, UNICEF, UNFPA, WFP, and WHO. The MOU with WHO was revised in March 1997. It supersedes the previous MOU (December 1987) with WHO. These agreements set-out common objectives, standards and priorities, clarify roles and responsibilities, and create a mutually reinforcing network of support. They are intended to provide field offices with a set of potential roles and responsibilities which, according to the circumstances prevailing in each country, will then be translated into a field-based agreement.

14. Coordination is also achieved through working groups. The Inter-Agency Working Group on Reproductive Health and the Inter-Agency Food and Nutrition Working Group are two examples of such groups. These working groups are essential for providing updates on scientific progress and the review of operational issues of common concern. This is further expanded upon through the development of information-sharing sector-specific networks, the Emergency Nutrition Network (ENN) and CDCP being notable examples.


A. Establishment of Technical Guidelines and Standards

15. The establishment of field-oriented and refugee/displaced population-specific guidelines is a key element of UNHCR's strategy in promoting the adoption of commonly accepted standards. A series of guidelines on essential issues have been developed, or are being elaborated, in collaboration with sister organizations and NGOs. Most recent manuals include:

  • The Management of Nutrition in Major Emergencies
  • Guidelines for Drug Donations
  • Guidelines for HIV Interventions in Emergency Settings
  • Guidelines on TB Control in Refugee and Displaced Populations
  • Inter-Agency Field Manual on Reproductive Health in Refugee Situations
  • Inter-Agency Manual on Malaria Management and Control in Refugee Situations
  • Mental Health of Refugees
  • UNHCR Essential Drugs Manual
  • Vector and Pest Control in Refugee Situations

16. UNHCR has also developed its own Monitoring and Surveillance forms to facilitate the collection and analysis of data at the field level, so that decision-making is increasingly based on evidence. In accordance with the policy emphasis placed on refugee women and children, built-in indicators provide specific information on these groups, so as to improve the extent to which their needs are targeted and met.

B. Training

(a) Training of refugees

17. UNHCR places high priority on training refugee health professionals, such as doctors, nurses, birth assistants and traditional healers. These health workers can serve the community both in exile and upon return to their country of origin. In the event of repatriation, the returning community can be assisted in their stabilization through the presence of trained health and nutrition staff. These can be employed by the local authorities and furnish valuable services based on their technical knowledge, as well as their familiarity with the population amongst whom they live.

(b) Training of local staff

18. Training is provided to national and/or regional health staff as part of the capacity-building strategy which UNHCR promotes. UNHCR is also promoting the participation of local organizations in the implementation of health services. Within this context, a training course for potential health coordinators was held in Nairobi, Kenya, in March 1997. Participants were selected from among national health staff working in refugee situations in developing countries of Africa, western Asia and Latin America. The workshop not only emphasized technical and coordination issues, but also matters more widely related to UNHCR operations. Workshop participants were given the necessary elements to function as UNHCR Health Coordinators, when required. A capacity-building training course on nutrition is also being prepared with the International Agricultural Centre in the Netherlands.

(c) Reproductive health: training video

19. As part of the on-going activities in the field of reproductive health, detailed separately below, UNHCR produced a training video on reproductive health in French and English. The aim of the video is to raise awareness of relief workers (not exclusively in the field of health) on reproductive health matters.

(d) External training courses

20. UNHCR technical staff are frequently invited to lecture or participate as resource persons in training courses organized by external bodies, such as NGOs, governmental and intergovernmental organizations and universities. Costs related to such participation are covered by the course organizers.


21. Special emphasis continues to be given to reproductive health and raising awareness of activities related to this issue. The ultimate aim is to integrate reproductive health activities into all UNHCR programmes, for example protection activities aimed at preventing sexual violence. The principle that reproductive health care should be available in all situations and be based on refugee, particularly women's, needs and expressed demands, with full respect for the various religious and ethical values and cultural backgrounds of the refugees, in conformity with universally recognized international human rights, should underlie all reproductive health activities.

22. UNHCR continues to spearhead the strengthening of reproductive health services to refugees under the auspices of the Inter-Agency Working Group (IAWG) on Reproductive Health in Refugee Situations. The IAWG, which has met twice since 1996, is a forum where the efforts to meet the goals and objectives set forth during the June 1995 Inter-Agency Symposium on Reproductive Health, where some 50 United Nations, government and non-governmental agencies were in attendance, and which set the objective to "integrate Reproductive Health activities into services delivered to refugee populations", can be consolidated. The Group comprises 28 United Nations, NGO and donor institutions. The main achievements of the IAWG to date include the following:

(a) A draft Inter-Agency Field Manual on Reproductive Health in Refugee Situations is currently being field-tested. A revised final version, based on field input, will be finalized by early 1998.

(b) A database has been established to keep track of reproductive health projects world-wide. Some 40 NGOs are implementing over 100 projects in 36 countries. Safe motherhood remains the best covered component. Sexual violence and reproductive health for young people, however, are the least covered areas.

(c) In order to improve timely provision of reproductive health materials and supplies in the early phases of an emergency, two initiatives are underway. The first is the inclusion of reproductive health materials and supplies in the revised New Emergency Health Kit. The second is the preparation of a number of reproductive health kits by UNFPA, to be made available in emergencies.

(d) A research agenda has been established and principal among its topics will be operational and qualitative research on sexual and gender based violence.

23. Furthermore, as part of the efforts to mainstream and integrate reproductive health activities within UNHCR, a reproductive health component has been introduced into the People-Oriented Planning (POP) training activities and into the training of community services staff. A section on reproductive health has also been added to various UNHCR documents, such as the Emergency Handbook and the Guidelines on Protection of Refugee Women.

24. In conclusion, this paper stresses the need for continued technical support in the health area during refugee situations, from the early emergency phase through the care and maintenance phases to repatriation and reintegration. It highlights the role of UNHCR's PTSS in providing a well integrated and coordinated package of technical support to field operations, which principally aims at ensuring the prevention of mortality and morbidity in refugee populations. It is paramount that this multifaceted package of technical support and services is provided in an adequate and timely manner, and effective coordination between all actors is achieved and maintained.