The accuracy of mortality reporting in displaced persons camps during the post-emergency phase

Inferring the impact of humanitarian responses on population mortality: methodological problems and proposals

Reducing excess population mortality caused by crises due to armed conflict and natural disasters is an existential aim of humanitarian assistance, but the extent to which these deaths are averted in different humanitarian responses is mostly unknown. This information gap arguably weakens governance and accountability. This paper considers methodological challenges involved in making inferences about humanitarian assistance's effect on excess mortality, and outlines proposed approaches. Three possible measurement questions, each of which contributes some inferential evidence, are presented: (1) whether mortality has remained within an acceptable range during the crisis (for which different direct estimation options are presented); (2) whether the humanitarian response is sufficiently appropriate and performant to avert excess mortality (a type of contribution analysis requiring in-depth audits of the design of humanitarian services and of their actual availability, coverage and quality); and (3) the actual extent to which humanitarian assistance has reduced excess deaths (potentially the most complex question to answer, requiring application of causal thinking and careful specification of the exposure, and for which either quasi-experimental statistical modelling approaches or a combination of verbal and social autopsy methods are proposed). The paper concludes by considering possible 'packages' of the above methods that could be implemented at different stages of a humanitarian response, and calls for investment in improved methods and actual measurement.

Integrated primary health care services in two protracted refugee camp settings at the Thai-Myanmar border 2000-2018: trends on mortality and incidence of infectious diseases

Aim:

This study aimed to assess the health outcome of four epidemic-prone infectious diseases, in the context of a Primary Health Care project implemented in a protracted refugee setting along the Thai–Myanmar border.

Background:

Refugees settled at the Thai–Myanmar border are fully dependent on support for health services, shelter, food, education, water, and sanitation. The Non-Governmental Organization Malteser International developed an integrated Primary Health Care program in close cooperation with trained camp residents over 25 years in the two settlements under its supervision. The project has been funded by the European Commission Civil Protection and Humanitarian Aid Operations (DG ECHO).

Methods:

This was a retrospective primary health care project evaluation. All-cause mortality; morbidity trends in malaria, lower respiratory tract infections (LRTIs), watery diarrhea, and dysentery; and health service utilization covering a time span of 18 years were assessed. Programmatic changes in the Primary Health Care (PHC) project and events with a potential effect on health of the target population were examined.

Findings:

Despite the continuous drain of trained health care workers, the volatile influx of refugees, and the isolated location of the two camps, the initial basic curative health care developed into an integrated and comprehensive PHC project including a SPHERE-compliant water, sanitation, and hygiene program. Malaria, LRTIs, watery diarrhea, and dysentery morbidity dropped twelve, three, two, and fivefold, respectively, over the 18-year period evaluated while the health services utilization dropped from 7.1 to 2.9 consultations per refugee/year. The international community may face situations where integration of refugees into the health services of the host country is not possible. In such a context, integrated and evidence-based PHC adequately funded and implemented by one health agency is an effective and relevant approach to reduce the infectious diseases burden under the constraints of semipermanent living conditions.

Public health information in crisis-affected populations: a review of methods and their use for advocacy and action

Valid and timely information about various domains of public health underpins the effectiveness of humanitarian public health interventions in crises. However, obstacles including insecurity, insufficient resources and skills for data collection and analysis, and absence of validated methods combine to hamper the quantity and quality of public health information available to humanitarian responders. This paper, the second in a Series of four papers, reviews available methods to collect public health data pertaining to different domains of health and health services in crisis settings, including population size and composition, exposure to armed attacks, sexual and gender-based violence, food security and feeding practices, nutritional status, physical and mental health outcomes, public health service availability, coverage and effectiveness, and mortality. The paper also quantifies the availability of a minimal essential set of information in large armed conflict and natural disaster crises since 2010: we show that information was available and timely only in a small minority of cases. On the basis of this observation, we propose an agenda for methodological research and steps required to improve on the current use of available methods. This proposition includes setting up a dedicated interagency service for public health information and epidemiology in crises.

Does spending on refugees make a difference? A cross-sectional study of the association between refugee program spending and health outcomes in 70 sites in 17 countries

Background

Numerous simultaneous complex humanitarian emergencies strain the ability of local governments and the international community to respond, underscoring the importance of cost-effective use of limited resources. At the end of 2011, 42.5 million people were forcibly displaced, including 10.4 million refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR). UNHCR spent US$1.65 billion on refugee programs in 2011. We analyze the impact of aggregate-level UNHCR spending on mortality of refugee populations.

Methods

Using 2011 budget data, we calculated purchasing power parity adjusted spending, disaggregated by population planning groups (PPGs) and UNHCR Results Framework objectives. Monthly mortality reported to UNHCR’s Health Information System from 2011 to 2012 was used to calculate crude (CMR) and under-5 (U5MR) mortality rates, and expressed as ratios to country of asylum mortality. Log-linear regressions were performed to assess correlation between spending and mortality.

Results

Mortality data for 70 refugee sites representing 1.6 million refugees in 17 countries were matched to 20 PPGs. Median 2011 spending was $623.27 per person (constant 2011 US$). Median CMR was 2.4 deaths per 1,000 persons per year; median U5MR was 18.1 under-5 deaths per 1,000 live births per year. CMR was negatively correlated with total spending (p = 0.027), and spending for fair protection processes and documentation (p = 0.005), external relations (p = 0.034), logistics and operations support (p = 0.007), and for healthcare (p = 0.046). U5MR ratio was negatively correlated with total spending (p = 0.015), and spending for favorable protection environment (p = 0.024), fair protection processes and documentation (p = 0.003), basic needs and essential services (p = 0.027), and within basic needs, for healthcare services (p = 0.007).

Conclusion

Increased UNHCR spending on refugee populations is correlated with lower mortality, likely reflecting unique refugee vulnerabilities and dependence on aid. Future analyses using more granular data can further elucidate the health impact of humanitarian sector spending, thereby guiding policy choices.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-016-0095-4) contains supplementary material, which is available to authorized users.

Implementation and utilisation of community-based mortality surveillance: a case study from Chad

BACKGROUND

Prospective surveillance is a recognised approach for measuring death rates in humanitarian emergencies. However, there is limited evidence on how such surveillance should optimally be implemented and on how data are actually used by agencies. This case study investigates the implementation and utilisation of mortality surveillance data by Médecins Sans Frontières (MSF) in eastern Chad. We aimed to describe and analyse the community-based mortality surveillance system, trends in mortality data and the utilisation of these data to guide MSF's operational response.

METHODS

The case study included 5 MSF sites including 2 refugee camps and 3 camps for internally displaced persons (IDPs). Data were obtained through key informant interviews and systematic review of MSF operational reports from 2004-2008.

RESULTS

Mortality data were collected using community health workers (CHWs). Mortality generally decreased progressively. In Farchana and Breidjing refugee camps, crude death rates (CDR) decreased from 0.9 deaths per 10,000 person-days in 2004 to 0.2 in 2008 and from 0.7 to 0.1, respectively. In Gassire, Ade and Kerfi IDP camps, CDR decreased from 0.4 to 0.04, 0.3 to 0.04 and 1.0 to 0.3. Death rates among children under 5 years (U5DR) followed similar trends. CDR and U5DR crossed emergency thresholds in one site, Kerfi, where CDR rapidly rose to 2.1 and U5DR to 7.9 in July 2008 before rapidly decreasing to below emergency levels by September 2008.

DISCUSSION

Mortality data were used regularly to monitor population health status and on two occasions as a tool for advocacy. Lessons learned included the need for improved population estimates and standardized reporting procedures for improved data quality and dissemination; the importance of a simple and flexible model for data collection; and greater investment in supervising CHWs.

CONCLUSIONS

This model of community based mortality surveillance can be adapted and used by humanitarian agencies working in complex settings. Humanitarian organisations should however endeavour to disseminate routinely collected mortality data and improve utilisation of data for operational planning and evaluation. Accurate population estimation continues to be a challenge, limiting the accuracy of mortality estimates.

Gender and international crisis response: do we have the data, and does it matter?

For more than a decade the humanitarian community has been mandated to mainstream gender in its response to crises. One element of this mandate is a repeated call for sex-disaggregated data to help guide the response. This study examines available analyses, assessments and academic literature to gain insights into whether sex-disaggregated data are generated, accessible and utilised, and appraised what can be learned from existing data. It finds that there is a gap between policy and practice. Evaluations of humanitarian responses rarely refer to data by sex, and there seems to be little accountability to do so. Yet existing data yield important information, pointing at practical, locally-specific measures to reduce the vulnerability of both males and females. This complements population-level studies noting the tendency for higher female mortality. The study discusses some possible obstacles for the generation of data and hopes to spur debate on how to overcome them.

Substance use among populations displaced by conflict: a literature review

This paper reviews the literature on substance use among populations displaced by conflict. Of the 17 publications presenting primary data retained for review, all consider populations in or recovering from protracted conflict, the majority (10) in non-camp settings. Most studies (10) offer prevalence estimates, suggesting that substance use (such as of alcohol, opiates, or minor tranquilizers) is common in some displaced settings. Five describe harmful consequences of substance use among displaced populations (such as HIV transmission, tuberculosis treatment failure, gender-based violence, and economic problems). Three studies suggest risk factors for substance use problems (such as gender, trauma-related conditions, pre-displacement substance use, and socio-economic factors); two examine qualitatively the gendered nature of alcohol-related harm and its links with gender-based violence. One study examines an intervention. The evidence base is weak. Findings are used to develop a conceptual framework emphasizing the risk environment to inform further research, to encourage debate among researchers and practitioners, and to enable the development of interventions.

A new method to estimate mortality in crisis-affected and resource-poor settings: validation study

BACKGROUND

Data on mortality rates are crucial to guide health interventions in crisis-affected and resource-poor settings. The methods currently available to collect mortality data in such settings feature important methodological limitations. We developed and validated a new method to provide near real-time mortality estimates in such settings.

METHODS

We selected four study sites: Kabul, Afghanistan; Mae La refugee camp, Thailand; Chiradzulu District, Malawi; and Lugufu and Mtabila refugee camps, Tanzania. We recorded information about all deaths in a 60-day period by asking key community informants and decedents' next of kin to refer interviewers to bereaved households. We used the total number of deaths and population estimates to calculate mortality rates for 60- and 30-day periods. For validation we compared these rates with a best estimate of mortality using capture-recapture analysis with two further independent lists of deaths.

RESULTS

The population covered by the new method was 76 ,476 persons in Kabul, 43,794 in Mae La camp, 54,418 in Chiradzulu District and 80,136 in the Tanzania camps. The informant method showed moderate sensitivity (55.0% in Kabul, 64.0% in Mae La, 72.5% in Chiradzulu and 67.7% in Tanzania), but performed better than the active surveillance system in the Tanzania refugee camps.

CONCLUSIONS

The informant method currently features moderate sensitivity for accurately assessing mortality, but warrants further development, particularly considering its advantages over current options (ease of implementation and analysis and near-real estimates of mortality rates). Strategies should be tested to improve the performance of the informant method.

Cross-sectional survey methods to assess retrospectively mortality in humanitarian emergencies

Since the rates and causes of mortality are critical indicators of the overall health of a population, it is important to evaluate mortality even where no complete vital statistics reporting exists. Such settings include humanitarian emergencies. Experience in cross-sectional survey methods to assess retrospectively crude, age-specific, and maternal mortality in stable settings has been gained over the past 40 years, and methods appropriate to humanitarian emergencies have been developed. In humanitarian emergencies, crude and age-specific mortality can be gauged using methods based on the enumeration of individuals resident in randomly selected households-frequently referred to as a household census. Under-five mortality can also be assessed through a modified prior birth history method in which a representative sample of reproductive-aged women are questioned about dates of child births and deaths. Maternal mortality can be appraised via the initial identification of maternal deaths in the study population and a subsequent investigation to determine the cause of each death.

Evaluating integrated healthcare for refugees and hosts in an African context

This paper argues on ethical and practical grounds for more widespread use of an integrated approach to refugee healthcare, and proposes a basic model of assessment for integrated systems. A defining element of an integrated approach is an equal ability by refugee and host nationals to access the same healthcare resources from the same providers. This differs fundamentally from parallel care, currently the predominant practice in Africa. The authors put forward a general model for evaluation of integrated healthcare with four criteria: (1) improved health outcomes for both hosts and refugees, (2) increased social integration, (3) increased equitable use of healthcare resources, and (4) no undermining of protection. Historical examples of integrated care in Ethiopia and Uganda are examined in light of these criteria to illustrate how this evaluative model would generate evidence currently lacking in debates on the merit of integrated healthcare.

Users' guides to the medical literature: how to use an article about mortality in a humanitarian emergency

The accurate interpretation of mortality surveys in humanitarian crises is useful for both public health responses and security responses. Recent examples suggest that few medical personnel and researchers can accurately interpret the validity of a mortality survey in these settings. Using an example of a mortality survey from the Democratic Republic of Congo (DRC), we demonstrate important methodological considerations that readers should keep in mind when reading a mortality survey to determine the validity of the study and the applicability of the findings to their settings.

Documenting mortality in crises: what keeps us from doing better

Francesco Checchi and Les Roberts discuss how mortality among crisis-affected populations is currently documented, barriers to better documentation, and how these barriers might be overcome.

Knowledge, attitude, and practice (KAP) of HIV prevention and HIV infection risks among Congolese refugees in Tanzania

Little is known about HIV infection risks and risk behaviours of refugees living in resource-scarce post-emergency phase camps in Africa. Our study at Nyarugusu Camp in Tanzania, covering systematically selected refugees (n = 1140) and refugees living with HIV/AIDS (PLWHA) (n = 182), revealed that the level of HIV risk of systematically selected refugees increased after displacement, particularly regarding the number having transactional sex for money or gifts, while radio broadcast messages are perceived to promote a base of risk awareness within the refugee community. While condoms are yet to be widely used in the camp, some refugees having transactional sex tended to undertake their own health initiatives such as using a condom, under the influence of peer refugee health workers, particularly health information team (HIT) members. Nevertheless, PLWHA were less faithful to one partner and had more non-regular sexual partners than the HIV-negative group. Our study revealed that community-based outreach by refugee health workers is conducive to risk behaviour prevention in the post-emergency camp setting. It is recommended to increase the optimal use of "radio broadcast messages" and "HIT," which can act as agents to reach out to wider populations, and to strengthen the focus on safer sex education for PLWHA; the aim being to achieve dual risk reduction for both refugees living with and without HIV/AIDS.

Conflict-related mortality: an analysis of 37 datasets

Mortality rates are among the main indicators of the human impact of armed conflict and many surveys have assessed this impact both for targeting and evaluating humanitarian aid programmes. Almost no epidemiological analysis such as calculating relative risk was performed nor were reference values clearly described. Here the aim is to review published mortality rates for a better understanding of age-specific mortality in armed conflict. Published mortality rates from conflict situations were collected and pre-conflict reference rates composed. We calculated the relative risk of dying in conflict compared to pre-conflict for children under 5 and people older than five years old. Although limited by reporting inadequacies, the results confirm the high vulnerability of children < 5 but identify a higher relative risk of dying among the > or = 5 year olds. Although not entirely new, this observation is not fully understood. Further systematic epidemiological research is needed to estimate and understand the impact of armed conflict on mortality.

HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action

Conflict, displacement, food insecurity and poverty make affected populations more vulnerable to HIV transmission. However, the common assumption that this vulnerability necessarily translates into more HIV infections and consequently fuels the HIV/AIDS epidemic is not supported by data. Whether or not conflict and displacement affect HIV transmission depends upon numerous competing and interacting factors. This paper explores and explains the epidemiology of HIV/AIDS in conflict and addresses the unique characteristics that must be addressed when planning and implementing HIV/AIDS interventions among populations affected by conflict as compared with those in resource-poor settings. These include targeting at-risk groups, protection, programming strategies, coordination and integration and monitoring and evaluation. Areas for future HIV/AIDS operational research in conflict are discussed.

Refugee participation in health relief services during the post-emergency phase in Tanzania

INTRODUCTION

While community participation in health activities has been examined extensively after Alma-Ata, few studies have focused on beneficiary participation in health services in a humanitarian disaster relief programme. This research scrutinized refugee participation in encamped health services, explored its achievement, and identified the further needs of refugees in pursuit of enhanced health services in the camp.

METHODS

The study was performed at Lugufu Camp, Tanzania, where a health information team (HIT) of Congolese refugees actively participated in health services. Structured questionnaires were used for this cross-sectional observational study, covering three types of respondents: i.e. (1) systematically selected refugee community members (n=576); (2) all HIT members (n=48); and all Tanzanian health staff in charge of preventive health (n=17). Additional information was also collected through focus group discussions.

RESULTS

HIT refugees used their own health initiatives, which resulted in a growth of self-confidence. There was an evidence of benefits, especially in promoting health education, affirmed by an almost established consensus among the refugee community, Tanzanian health staff and HIT members themselves. However, refugee community members who did not know any HIT members had less positive health-seeking behaviours than those who knew one or more HIT members, thus showing a need for further dissemination of HIT services.

CONCLUSIONS

Participation in the health services led the HIT refugees to regain the sense that they could contribute to solving peers' health problems with their own knowledge and services, and by working together as a team. Beneficiary participation is a dynamic process that heightened responsibility and health consciousness, along with a concomitant gain in power over their destiny.

Health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study

BACKGROUND

An estimated 35 million people have been displaced by complex humanitarian emergencies. International humanitarian organisations define policies and provide basic health and nutrition programmes to displaced people in postemergency phase camps. However, many policies and programmes are not based on supporting data. We aimed to identify associations between age-specific mortality and health indicators in displaced people in postemergency phase camps and to define the programme and policy implications of these data.

METHODS

In 1998-2000, we obtained and analysed retrospective mortality data for the previous 3 months in 51 postemergency phase camps in seven countries. We did multivariate regression with 18 independent variables that affect crude mortality rates (CMRs) and mortality rates in children younger than 5 years (<5 MRs) in complex emergencies. We compared these results with recommended emergency phase minimum indicators.

FINDINGS

Recently established camps had higher CMRs and <5 MRs and fewer local health workers per person than did camps that had been established earlier. Camps that were close to the border or region of conflict or had longer travel times to referral hospitals had higher CMRs than did those located further away or with shorter travel times, and camps with less water per person and high rates of diarrhoea had higher <5 MRs than did those with more water and lower rates of diarrhoea. Distance to border or area of conflict, water quantity, and the number of local health workers per person exceeded the minimum indicators recommended in the emergency phase.

INTERPRETATION

Health and nutrition policies and programmes for displaced people in postemergency phase camps should be evidence-based. Programmes in complex emergencies should focus on indicators proven to be associated with mortality. Minimum indicators should be developed for programmes targeting displaced people in postemergency phase camps.

Emerging issues and future needs in humanitarian assistance

During the past two decades, there has been tremendous investment in the ability to intervene in disaster settings, and significant barriers remain to providing appropriate services to populations affected by natural and man-made calamities. Many of the barriers to providing effective assistance exist within the NGO community, and illustrate emerging needs for international agencies. These emerging needs include improving methods of recipient participation to promote the local health system, developing improved methods for quality assurance, enhancing options for personnel development, and addressing long-term needs of reconstruction and rehabilitation. Relief agencies face challenges on all levels to develop sound practices in providing humanitarian assistance that can lead to long-term benefits to populations affected by disaster.