GHC Review of evaluations country mission reports and ... · The objective of the document review was to provide the Global Health Cluster (GHC) with information on and analysis of

Review of Evaluations, Country Mission Reports

and Lessons Learned

Global Health Cluster

December 2011

Conducted by International Medical Corps on

behalf of the Global Health Cluster

ACRONYMS and ABBREVIATIONS 3W Who does What Where CCS Country Cooperation Strategy CO Country Officer (UN) CHC Country Health Cluster CI Core Indicators CLA Cluster Lead Agency DRC Democratic Republic of Congo DfID Department for International Development (British government aid) ECHO European Commission Humanitarian Office EHA Emergency Health Action ERC Emergency relief Coordinator EWARS Early Warning Alert and Response System GHC Global Health Cluster HC Health Cluster HCC Health Cluster Coordinator HeRAMS Health Resources Availability Mapping System HIS Health Information System HNTS Health and Nutrition Tracking Service HR Humanitarian Reform IASC Inter Agency Steering Committee ICCM Inter-cluster coordination mechanism IDP Internally Displaced Persons IRA Initial Rapid Assessment MOH Ministry of Health M&E Monitoring and Evaluation MSF Medecins sans Frontieres NGO Non Government Organisation NNGO National Non Government Organisation OCHA UN Office for the Coordination of Humanitarian Affairs oPt Palestinian Territories RO Regional Office TOR Terms of Reference UN United Nations WASH Water and Sanitation WHO World Health Organisation WR WHO Representative (Country Level)

2

Document Review for the Global Health Cluster I. Executive Summary The objective of this document review is to provide the Global Health Cluster (GHC) with information on and analysis of the work of the Cluster at global and country levels, based on existing documentation, to inform development of the 2012–2014 GHC strategic plan. The Global Health Cluster has been implemented in 28 countries since its inception in 2005. Key Findings Since the cluster system was initiated, notable advances in overall humanitarian response have taken place in the areas of better leadership, improved population coverage, and better identification of gaps and reduction of duplication in services. Partners of the Health Cluster at the country level are experiencing increased learning, sharing of better practices and interaction with other humanitarian partners, resulting in more cohesive sense of humanitarian identity.

Challenges remain in the effective rollout of the pattern of the Health Cluster’s response, and areas where the Ministry of Health (MOH) is underfunded and where health care systems or weak or fragile to non-existent, particularly at the local level. Coordination is particularly challenging when scores of aid agencies flood into emergency situations with varying skills and interest in participating with the Health Cluster. In conflict areas, humanitarian principles are bring threatened when relationships closely tied to missions, peacekeeping forces and entities involved in conflict. Inter-cluster coordination and collaboration still remains a gap in health operations. Cluster management can often be too process-oriented, not discussing strategic issues, resulting in poor management and facilitation of activities. Monitoring the effectiveness of the HC and partner adherence to relevant standards remains an operational gap. In the findings and evaluations of the Health Clusters (HC) and their performance, there were emerging themes in the areas of: need for effective leadership and coordination, timeliness of response (specifically with personnel), and adequacy of needs assessments and analysis (need to coordinate valid information gathering and dissemination). Overall, there was a clear trend: in emergencies in which there was strong leadership and experienced Health Cluster Coordination (HCC), the HC performed better in most of the functional areas. These findings indicate that improving leadership should be a priority recommendation for the Health Cluster. With improved leadership, overall function of the HC will improve and provide better service to partners and beneficiaries. Slowness of staff deployment to clusters was also an issue, which created problems within the humanitarian community and with negative response results. The

3

recommendations would be for the HCLA and partners to improve their surge capacity and to make better use of standby agreements with partners for experienced staff. The adequacy of needs assessments indicated that there was a clear need for timely and reliable information systems to inform the cluster and partners on where needs or gaps existed in health access or delivery. Some current tools are too burdensome and/or costly to apply, specifically the Initial Rapid Assessment used in Haiti. In addition, there was a lack of adequate analysis of existing information to optimally inform the process and partners. The recommendations indicate that a simplified rapid assessment tool should be adopted and analysis should be more robust. Awareness of tools and training is needed around other tools such as the Health Resources Services Mapping System. Better practice/lessons learned

Better practices for coordination within and outside HC include the HCC taking steps to ensure key UN players are knowledgeable about the HC and on board with them; outlining roles and responsibilities with these players; and having similar discussions with the MOH. Well functioning HCC’s have access to technical experts and whenever possible, have a staff member with information management skills on board. Appropriate links are made with the HCC and the WR, CO and OCHA. The HC works best when it can work through pre-established national and local relationships and structures. The WHO Representative (WR) can help facilitate contacts with ministries of health and disaster management authorities. When the Country Officer has kept the Who-What-Where (3W) list going prior to emergencies, it facilitates the HCC during the emergency. The HC should hold the first meeting early, being fully prepared, inviting all potential partners and have a clear agenda and time- frame, make work results-oriented, and establish an information sharing system. Ongoing orientation of newcomers to the Country Cooperation Strategy and engaging all Emergency Health Action colleagues helps to ensure involvement in the response.

In terms of needs assessment and monitoring, a better practice is to obtain and review baseline data, start monitoring early and for the Initial Rapid Assessment, build consensus and participation around the assessment process, not the tool itself. Use of the Early Warning Alert System for Communicable Diseases (EWARS) tool to define priorities for disease surveillance is best set into play after reviewing existing surveillance systems and engaging the MOH. Build consensus around monitoring and evaluation, including standards, with partners and the MOH, then widely disseminate the tools and mechanisms to collect the information. In emergency responses, depending on the context, the utilization of smaller experienced groups making strategic and technical decisions to guide the HCC has emerged. Monitoring the positive and negative impacts of health care aid is good practice. Equally important is to review who to best structure the provision of ‘free’ health services to avoid negative financial repercussions for private health care facilities. Contingency plans need to be kept updated, realistic, and tested with their implementation instructions widely disseminated. A monitoring tool developed during the Chadian emergency was cited as a good instrument to monitor the performance of the HC in other countries as well.

4

In terms of training, learning and capacity building, the HC Guide and other tools developed by WHO are greatly appreciated by partners. While there is still minimal use of the Health Resources Services Mapping tool, NGOs expressed interest in applying it with the training assistance. HCC training has been valuable and should be part of broader training of other key players. Before choosing which tools, the HCC should first define the tasks. NGOs who brief (and debrief) staff for emergency response and about humanitarian reform and the HCC are better prepared for their job. Lastly, in terms of funding the HC, transparent allocation of pooled funds and HC decision-making in regards to those funds, is a good practice, developing trust with partners. Consolidated recommendations These are recommendations that emerged by thematic topic. More specific recommendations from the documentation are found in the report.

Health Cluster Leadership & Management 1. Define clear roles and responsibilities for UN entities, co-stewards vis-à-

vis the HC 2. Improve timely response to emergencies by ensuring the HCC roster staff

are deployed and funding is secured for the HCC team. 3. GHC develop working materials for the GHC and HC (decision-making

scale for the levels of emergencies, guidance for policy issues) 4. Develop surge capacities both for staffing the HC and assessments and

standby arrangements with other clusters/entities. 5. Ensure that in sudden-onset disasters that the IASC and HC build a cluster

compatible with local structures and actors.

Health Cluster Coordination 1. Provide dedicated qualified part-time or full-time coordinators for sub-

national HCs or levels where operational coordination takes place and include costs for sub-national facilitation and coordination in national cluster coordination budgets.

2. Identify appropriate partners in national and local authorities and strategies to strengthen their capacity and involve them in the cluster approach.

3. Integrate crosscutting issues in meetings, assessments, policies, tools, training, guidance, strategic planning and operations.

4. Linkages and coordination with other relevant sectors - Improve information sharing and management by and among clusters, e.g., by using simple and creative ways to free up meeting time, creating cluster-specific systems for identifying duplication, expanding “Who Does What Where” by including the status of projects; expanding cluster websites and using new technologies.

5

Policy Issues

1. Clarify staffing issues: Define roles and responsibilities of HCC with WR and the team composition for various levels of emergency; working with National authorities during the different phases of an emergency

2. Investigate opportunities for consistent funding mechanisms 3. Identify what to do when national standards are not compatible with

global standards, and how the HCC would go about meeting agreed upon standards.

Tools, guidance, technical assistance, and building capacity

1. Raise awareness of the range of tools (esp. IRA and HeRAMS) and guidance available to HCC partners and provide training to a targeted yet broader pool of trainees: depending on the context include; MOH, HCC partners and local organizations.

2. HCC should develop contingency plans with MOH and partners and integrate in overall strategic plan.

3. Establish and disseminate coherent framework for M&E, including agreed upon population-based indicators and benchmarks to partners (including local level), giving feedback to partners involved in the reporting system.

4. To increase accountability to affected populations, strengthen the role of clusters in using and promoting participatory approaches and using context-sensitive communication strategies and appropriate technologies.

5. To enhance the use of participatory methods among cluster members, facilitate training by NGOs experienced in applying these methods; facilitate exercises on participatory approaches; or promote participatory needs assessments through peer review processes.

6. Facilitate participation and capacity strengthening of national and local NGOs, including them in management and strategy development, drawing on the strength of clusters in creating inclusive fora and facilitating learning.

Additional Themes

1. GHC and HC work to develop more comprehensive response to Security and Access so that health care delivery and monitoring can continue to meet the population in need.

2. GHC define ways to improve documentation of emergency response through targeted evidence gathering, and research (i.e. quality control of procurement of pharmaceutical products, transition between relief and development, maternal and child mortality.) Specialized WHO offices could address such topics and support the analysis and recommendations that follow.

II. Background The objective of the document review was to provide the Global Health Cluster (GHC) with information on and analysis of the work of the Cluster at global and country levels, based on existing documentation, to inform development of the 2012–2014 GHC strategic plan. The terms of reference for the review are listed below.

Conduct a desk review of findings and recommendations of relevant evaluations, Cluster lessons learned workshops, donor and cluster agency mission reports, and other relevant literature related to the health cluster at global and field levels (Annex 1 is the bibliography of documents reviewed).

Identify and analyze common themes, trends, and lesson learned. Prioritize needs to strengthen at country level and the role of the global level in

the process. Produce a report for the GHC summarizing the review and analysis.

The Global Health Cluster has been implemented in 28 countries since its inception in 2005. This review covers available multi-cluster evaluations and Health Cluster documentation provided to the reviewer from seven countries (about 30 percent of the 28 countries): Chad, DRC, Haiti, occupied Palestine territory (oPt), Myanmar, Yemen, and Zimbabwe. UN entities (including WHO), donors, and nongovernmental organizations (NGOs) conducted the evaluations and wrote the UN Joint Mission evaluation reports. The reviewer consulted the Inter-Agency Standing Committee (IASC)/WHO Health Guide, as the issues and recommendations of a 4-year review outlined by core functions in the guide are still relevant today. A 2010 Health Cluster workshop yielded a set of priorities and recommendations for 2010. The progress of these recommendations and all previous recommendations should be addressed in a Global Health Cluster review workshop. The IASC Cluster Approach Evaluation 2nd Phase (April 2010) and individual country reports and Joint Missions for the Health Cluster identified the following accomplishments and challenges: Health Cluster advantages and accomplishments

Improved population coverage in some thematic areas Better identification of gaps and reduction of duplication Increased learning among humanitarian actors More predictable leadership Improved partnership between the UN and international humanitarian actors,

resulting in a more cohesive sense of humanitarian identity Improved planning and proposal quality for major funding appeals

Health Cluster challenges

2

Humanitarian principles threatened especially when members are financially dependent on cluster leads and where relationships are closely integrated with integrated UN missions, peacekeeping forces and entities involved in conflict.

Cluster management often too process-oriented resulting in poor management and facilitation of activities.

Cross-cutting issues and inter-cluster coordination are by-and-large ineffective Little evidence that clusters had developed mechanisms for monitoring adherence

and compliance to relevant standards. This is partly because the Cluster Lead Agency (CLA) do not understand their role as a “policing” one and perceive a conflict between a monitoring or even enforcement role and Partnership

III. Findings The document review found a number of common trends and issues in the HC’s response to disasters in Chad, the DRC, Haiti, Myanmar, the oPt, Yemen, and Zimbabwe. This section reviews those issues by Health Cluster (HC) core function and themes or issues in addition to the ten core functions, such as HC Coordination, Leadership and Management, Policy Issues, Local partnerships and Working with the MOH, HC tools, guidance and capacity building, HC response (gaps, timeliness), Linkages with other relevant sectors. The challenges, best practices and lessons learned presented here represent a reflection of what has been documented and experienced in various emergency contexts, and do not necessarily represent scientific, evidence-based research. Some reports mentioned better practices and recommendations that may not have been mentioned in other documents, however may have more global relevance for the Health Cluster. It should be noted that challenges remained in assigning weight of importance among the documents and biases reflected in select reports. A. Health Cluster Core Functions The IASC/WHO Health Cluster Guide outlines the 10 core functions of the Health Cluster. A number of UN Joint evaluation missions to the field assessed the HC emergency response according to some or most of these core functions. Challenges, recommendations, and best practices/lessons learned arising from the GHC’s core functions from the documents reviewed are summarized below. Annex 2 contains more detailed, country-specific information. FUNCTION I. Coordination mechanisms and inclusion of key actors within the Health Cluster and inter-cluster Challenges

Rapid deployment of additional staff to establish HC coordination capacity Poorly functioning roster for the Health Cluster Coordinator (HCC)

3

Bringing NGO capacity into the HC team for any of the functions The critical role of the WHO Representative (WR) in supporting HC functions at

the country level Declining HC attendance over time Need for support for the HC and Humanitarian Country Team from the

Emergency Relief Coordinator (ERC) and Global Coordinator (GC) to build a cluster system that is compatible with local coordination structures and does not exclude local actors

Recommendations for the GHC1

Work with the CLA to ensure it institutionalizes the cluster approach. Acknowledge the key role of WRs in supporting the HCC. Develop standards of practice (SOPs) for HC implementation and management. Decide on the level of decision-making depending on the scale of emergency. Ensure all GHC members (including donors) encourage country offices to support

the cluster approach. Ensure sustainable funding for the HCC team. Ensure that the HCC is deployed from a roster. Establish generic terms of reference (TOR) for roll out of country HC steering

committees for allocation of funds.

Better practice/lessons learned

HC organizes a meeting of the WR, HCC, and Country Officer (CO) to ensure they understand the role of the HC and their responsibilities. Having a similar discussion with ministries of health (MOH) in countries.2

Ensuring the HCC team includes information management (IM) capacity. Linking HC with the United Nations Office for the Coordination of Humanitarian

Affairs (OCHA), including sharing data and the preparatory workshop introducing clusters.3

FUNCTION II. Establishment of coordination with national authorities and other local actors Challenges

Insufficient authority of NGO and/or MOH representatives at meetings for decision-making on strategy, priorities, etc.

Difficulty of coordinating and managing massive influxes of international NGOs with varying capacity, professionalism, and resources

Need for information to flow back to those who provide it and to beneficiaries and between the capital and the field

1 HCC Lessons Learned Workshop, Geneva (2010) 2 IASC GHC Joint Country Mission to Yemen (April 2010) 3 Joint Country Missions to Myanmar, Chad, oPt, Haiti, and Yemen

4

Maintaining participation of implementing agencies throughout HC’s operation in country

Recommendations4

Define the human resource needs of the HCC team. Develop mechanisms to use the surge capacity of other clusters and partners, e.g.,

water, sanitation, and hygiene (WASH) and logistics. Create surge capacity for assessments within the GHC. Joint Missions visit countries in the early stages of major emergencies to ensure

effective HC implementation, identify areas of concern, and recommend actions for the CLA.

Improve coordination between “search and rescue” and “disaster medicine/post-operative care.”

Engage more strategically with key “non-cluster members” such as line ministries, the private sector, and national NGOs (NNGOs).

Ensure that in sudden onset disaster contexts, the ERC and GC support the HC and the Humanitarian Country Team in building a cluster system compatible with local coordination structures5.

Find a modus operandi for the cluster approach that does not exclude local actors. Work determinedly with other clusters that address an inter-related health

problem, such as WASH for cholera, Nutrition for acute malnutrition, host joint meetings.


Working through pre-established relations and structures to facilitate coordination6.

WR making contacts with ministries of health and disaster management authorities.

Being willing to be contacted and to meet new aid actors other than known friends and colleagues.

Holding the first HC meeting early, explaining the HCC; inviting all partners, have a clear agenda and time frame, making it work results oriented, establishing an information sharing system; proving the value added of the HCC and obtaining participant’s contact information.

Implementing opportunities for co-stewarding (co-lead), such as the NGO model implemented by Merlin in Myanmar.7

Modeling the close cooperation between cluster leads and the line ministry such

4 HCC Lessons Learned Workshop, Geneva (2010), Grunewald (2010) 5 Ensuring local compatibility with all emergency response is important, however more challenging in sudden onset emergencies. 6 Inter-Agency Real Time Evaluation Haiti (June 2010), IASC GHC Joint Country Mission to Yemen (April 2010) 7 Co-Stewarding the Health Cluster (2010)

5

as the example of the earthquake in Haiti.8

Maintain a dedicated HCC and ensure wide and inclusive participation of health players, involving NGOs and linking NGOs and the MOH, as the HC did in Zimbabwe, resulting in effective HC coordination with all players.9

FUNCTION III. Needs assessment and analysis, including identifying gaps in health response (emergency disease surveillance and early warning, health information) Challenges

Emergency operations should consider all aspects of response, positive and negative, and strategize accordingly to mitigate negative impacts (e.g., overburdening local staff who lack capacity, health economics, weak national health care systems).

Needs assessments need to be timely and rolling and include capacity assessment. IRA is too bulky and costly10 Health actions need to be timely (e.g., the process of meetings and decision

making were slower than the communication of the disease (cholera) in Haiti) Constraints should be analyzed proactively. Developing and agreeing upon joint assessments to reduce beneficiary survey

fatigue Many humanitarian agencies have strong internal policies on needs assessments

that are difficult to change through coordination Transparency, trust, protecting agency mandates, sharing information with others

Recommendations

Engage clusters in coordinating and improving needs assessments. Ensure integration of cross-cutting issues in assessments, policies, tools, training,

guidance, strategic planning and operations. Strengthen surge capacity through a roster of needs assessment experts. Include sex and age information in assessment questions. Consider HC instituting peer review to improve quality of needs assessments,

both the process and end products11 Support EWARS tool for use at national level, get financial request into CAP12


8 Inter-Agency Real Time Evaluation Haiti (June 2010) 9 Handzel (2009) 10 Joint Mission to oPt (June 2009), Inter-Agency Real Time Evaluation Haiti (June 2010) 11 Inter-Agency Real Time Evaluation Haiti (June 2010), IASC Cluster Approach Evaluation 2nd Phase (April 2010) 12 WASH Cluster evaluation summery (2009), Joint Mission to Chad (March 2011)

6

Orienting all newcomers on the WHO Country Cooperation Strategy (CCS) and ensure the CO and MOH are fully involved in the CCS.

Engaging all Emergency Health Action (EHA) colleagues in the CCS, especially in protracted emergencies.

Obtaining and review baseline data and monitoring indicators early. Building consensus and participation around the process, not the tool itself for

rapid assessments, agree to a small number of questions focusing on life-saving details, and allocate geographical areas.

Reviewing what surveillance systems exist, ensuring the MOH is involved in the early warning system, and defining priorities for disease surveillance if this has not already been done13.

FUNCTION IV. Strategy development, planning and filling gaps (community-based approaches, attention to priority cross-cutting issues, and filling gaps; operations research, innovation) Challenges

Promoting the strategic value of the health cluster and consulting partners on priorities (a strategic advisory group with good leadership and the right participation of key partners can address these issues)

Lack of consideration of operations issues in an urban context by the humanitarian community

Discussion of technical and policy issues is appreciated when done but criticized if not done.

Engaging community and beneficiaries in strategy implementation and monitoring of community-based approaches

Mobilizing technical expertise from the WHO country office Need for active participation of different technical work areas of the WHO

country office (the WR can provide appropriate political support for this) Recommendations

Promote community-based approaches with NGO and NNGOs, sharing best practices in HC meetings

Utilize community-generated indicators and involve them in monitoring the response


Separate the two key functions of a cluster: information sharing and strategy development technical guidance.

The lead agency, key cluster members, and in

13 Joint Mission Chad (March 2010), Joint Mission oPt (June 2009)

7

some cases the government meet as a “mini cluster” or “strategic advisory group” to decide on strategy and other key decisions.14

Strategically evaluate provision of free health services to avoid negative financial repercussions for private health care facilities.15

FUNCTION V. Contingency planning (and preparedness) In countries with frequent disasters such as Haiti, Indonesia, and Bangladesh among others, preparedness plans should have a national as well as local focus. Cluster lead agencies and NGOs, supported by donors, should quickly refill their medical stocks or have a stocks in country before to the emergency, as it happened in Haiti. Challenges Need to analyze both past and present context

Engaging local actors in planning

Recommendations HC in conjunction with the MOH should establish a sub-group to draft and submit contingency plan(s) for emergency preparedness to be designed by a bottom up approach (first based on field inputs, then aggregated at national level) Better practice/lessons learned

Keeping contingency plans updated, realistic, and tested.16 Developing and disseminating implementing instructions.

FUNCTION VI. Application of standards quality (encourage and monitor best practices in application; monitor; promote an enabling environment for implementation/ adoption of evidence-based practices) Challenges

Harmonizing international standards with national standards Balancing both acting as a policeman for standards and being a partner Reaching agreement on indicators and methods to collect them Implementation of standards while not undermining National health care system

Recommendations

Develop mechanisms for monitoring the quality of humanitarian response The HC should ensure more joint/common needs assessments, harmonized and

consolidated using the GHC core list of indicators

14 Inter-Agency RTE Haiti (June 2010), Joint Mission Chad (March 2011) and Handzel (2009) 15 Inter-Agency RTE Haiti (June 2010), Joint Mission Chad (March 2011) 16 IASC GHC Joint Country Mission to Yemen (April 2010)

8

Better practices/lessons learned

Build consensus with partners and MOH on standards. Widely disseminate set of standards and tools/mechanisms to collect them

FUNCTION VII. Training and capacity building (including emergency preparedness) The theme of training and capacity building emerged in every document as a key need, for the HC partners, MOH as well as local service providers. One of WHO’s strengths is the development and dissemination of health-related tools and guidance, and this was appreciated and noted in most documents. Nevertheless, to make these most effective in the HC setting, awareness raising about them, local availability, and training are needed on a more consistent basis. One example of a model of bringing capacity building down to the local level was developed in Myanmar. The HC developed field ‘hubs’ working through the local medical officers as the focal point for the field cluster, allowing relationships to be built using government structures as the conduit for health coordination, information flow and capacity building. Challenges

Need for CL regional and country offices to raise awareness of the role of the HC among the CLA, partners, and government

Inexplicit role of the MOH in the HC Limited thinking on strengthening capacity of health authorities to manage

emergencies Limited work on early recovery analysis No transition or exit strategies in place Affording time for training in the context of an emergency

Recommendations

WHO build the capacity of the MOH to develop a crisis preparedness and rapid response contingency plan.

Broaden participation in training on the Health Care Guide (e.g., co-stewards, government entities) an other HC trainings

Establish participatory approaches and consultation with the population and local institutions as a requirement, not viewed as a constraint to work

Provide specialized materials and training to aid agencies in specific technical areas.

Better practices/lessons learned

Country HCs defining tasks before choosing tools. Learning strategy with increased involvement of partners Humanitarian agencies briefing and debriefing deployed people, organizations,

and about the Health Cluster.

9

FUNCTION VIII. Monitoring and reporting The Health Cluster guides outlines monitoring the health cluster performance, as well as ongoing project monitoring, emphasizing joint and participatory monitoring on mutually agreed upon indicators. In a ten-country review of NGO participation in the health cluster, only 20% of the respondents reporting being involved in HC monitoring, citing the challenges to lack of use of standard indicators and cluster plans as well as a cluster-led framework for M&E17. Challenges Development of HC monitoring system

Indicators are established to measure progress and targets, but information is not systematically collected and analysed for monitoring at sector level.

Quality of data, lacking outcomes and impacts How the global level M&E system at global level links with the country health

cluster Monitoring the overall performance of the HC response Question of accountability when there is a co-steward agency and how best to

assess it Recommendations Development of HC monitoring system:

Establish coherent framework for M&E for health cluster activities, delimitating clear indicators and benchmarks

Disseminate monitoring plans and indicators to all parties involved, including local partners

Use population-based data instead of health-facility based reporting with a perspective of following-up the coverage of health services.

HC provide support for the analysis of data. Provide feedback to all partners reporting to the monitoring system.

Monitoring the overall performance of the HC response Review and disseminate a health cluster performance tool such as the one

developed and endorsed by the Joint Mission in Chad18 Better practices/lessons learned

Jointly designing a health monitoring system with partners Collecting only data needed Being gender-sensitive and incorporating cross-cutting indicators Starting the system early and not developing a too complex system

FUNCTION IX. Advocacy and resource mobilization, including reporting 17 Learning from NGO Experience of Participation in the Health Cluster (August 2010) 18 HC performance monitoring tool developed in Chad18

10

In most countries the Health Cluster has played the role of advocate for not only obtaining resources through the UN processes but also in terms of working with the MOH and advocating for partners to the MOH for a variety of causes. Challenges

Obtaining adequate funding for health cluster activities.

Transparency and trust of HC, partners, government

Who decides, who received resources allocation within HC Recommendations

Establish committees to make resource allocation decisions and peer review of proposals.

UN advocates for donor investments in building the capacity of a leadership cadre for large emergencies.

New information technologies such as Facebook, Twitter, and SMS can facilitate resource mobilization.

The CLA should ensure an agreed, transparent, rapid, and “light” system without heavy administrative requirements (e.g., the Central Emergency Response Fund, or CERF) for channeling funds to partners.


Transparent allocation of pooled funds and decision making FUNCTION X. Provider of last resort The documents reviewed indicated that this is the HC function least understood by partners. In large-scale disasters, most immediate needs are met by a plethora of humanitarian aid workers. The HC identifies critical health care gaps to be filled, either by the partners or by the Ministry of Health. WHO rarely implements programmes or is the provider of last resort, however does utilize whatever mechanisms possible to ensure critical health care needs are met. B. Common Themes This section covers common themes, issues, and best practices identified in the documents reviewed. They are broken down by four main topics: HC coordination, leadership and management; Policy Issues; Tools, guidance, technical support and building capacities; and miscellaneous themes.

1. HC Coordination & Leadership & Management

11

i. Coordination Most of the coordination issues were highlighted under Functions I and II in the Health Cluster Core Functions section in this report. For the topic of coordination with Ministries of Health, there arose a number of suggestions for active engagement with them, starting with having the ideal situation being that WHO and MOH’s have pre-emergency established relationships and if not, having the WR or a UN representative make introductions. Engaging the MOH in HC meetings, planning, activities and monitoring is important to not only draw upon local experience and contextual knowledge but also build capacity for the transition to longer-term health care delivery. Cautionary notes were raised in least two Joint Missions about setting up parallel systems and the need to sort out the relationship between the HC and the MOH. In Myanmar, the two health monitoring systems were eventually merged and in the oPt , the HC was not initially supported by the MOH as they felt they should retain authority over their health care system.19

ii. Coordination with other clusters linked to health

The seven countries reviewed noted infrequent coordination with WASH, nutrition, and food clusters, which was also found in the Cluster-wide evaluation.20 These clusters should be more interconnected in the overall cluster approach, as each component relates to health. Merlin mentioned that lack of integration of clusters (apart from the Nutrition Cluster) in Somali relief operations led to duplication, weak leadership and participation, weak decision-making, lack of information sharing, and poor accountability.21 Points raised for improving cluster linkages included:

proactively increasing communication with relevant partners, the HC can seek to incorporate joint assessments, indicators and

monitoring with clusters linked to health, Link joint plans and funding appeals where is makes sense.

In Chad, the MOH collected nutrition information, however didn’t share it with the health cluster. WHO hired a nutritionist to incorporate nutrition data from the MOH into the national epidemiological surveillance system22. In DRC, the Needs Analysis Framework is used by OCHA to score the severity of needs and rank the provinces and districts for prioritization, with

19 Joint missions to Myanmar and oPt (2008, 2009 respectively) 20 IASC Cluster Approach Evaluation 2ND Phase (April 2010) 21 Merlin Co-stewarding Review 2007–2010 22 Joint WHO-ECHO Review Mission Chad (March 2011)

12

indicators for population movement, protection, nutrition, food security and health. Data on epidemics is systematically collected, shared between stakeholders (including OCHA) and used to coordinate a joint response, There is however, ‘passive’ sharing of information between clusters.23

iii. Management issues

Three sub-topics emerged in the document reviews: the cluster approach, overall HC management, and information management. a. Cluster approach

The IASC HC guide describes the purpose of the HC as follows: “The country-level Health Cluster (or existing sector coordination group adopting the cluster approach) should serve as a mechanism for participating organizations to work together in partnership to harmonize efforts and use available resources efficiently within the framework of agreed objectives, priorities and strategies, for the benefit of the affected population(s). This includes avoiding gaps and/or overlap in the international humanitarian health response and resources (human and financial).”

The following themes regarding the cluster approach emerged from the documents:

The need for better understanding of and training on the HC model, and humanitarian reform

The need to involve affected populations and NNGOs, routinely cited as an element for successful humanitarian assistance but rarely achieved (few examples were found in multi-cluster evaluations24 )

The need to include the pre-existing emergency situation as well as development structures and do more preparedness and contingency planning25

b. Cluster management The IASC Joint Country Mission to Yemen made the following (more HC country generic) recommendations for improving HC management26 :

Use multiple channels for advocacy and resource mobilization, highlight key health issues, and use national and international media more effectively.

Advocate with OCHA to review current inter-cluster coordination mechanisms (ICCM). The ICCM is effective for information sharing on

23 Final DRC Joint Mission DRC ( Feb 2011) 24 IASC Cluster Approach Evaluation 2nd Phase (2010), Inter‐Agency RTE Haiti (June 2010) 25 Health Cluster LL Workshop , Geneva (2010) 26 IASC Global Health Cluster Joint Mission Yemen. (April/May 2010)

13

security and resource mobilization issues but does not effectively address programmatic linkages between clusters.

The MOH and donors were asked to encourage non-participating agencies such as UNHCR and ICRC to work with the HC to ensure greater complementarities. Participation in the HC will in no way compromise respective mandates or independence.

The HC workshop and at least one other document added the following recommendations:

Develop SOPs on cluster management and make training targeted, more inclusive, and managed at the local level rather than by headquarters.

Conflict of interest for the agency versus cluster role with WHO and resulting comprise in agency’s mandates

Clarify the domain of the HC (preparedness/response/recovery) and link to preparedness and recovery for a more successful response.

c. Information management

Information management and sharing are still problematic in a number of country HCs, with lack of information and agency reluctance to share. Information should be used for action and not only reporting. Lack of information flow from the national level to sub-levels and lack of timely information to partners and beneficiaries in local languages were cited frequently in documents reviewed. To address lack of information transparency, the documents made the following recommendations:

Give (analysed) information back to those who provide it (in raw form), transparently and in a form they can understand.

Improve meeting management by:

-Preparing for meetings with agendas and inputs/suggestions from participants, announcing meetings in advance, including scheduling, via email and phone; and having translators present. -Facilitating meetings to include strategic thinking, not only process and information dissemination and encourage continual attendance by appropriate decision makers. -Disseminating minutes on time, widely, and in hard copy as well as through email to selected partners and follow up on actionable items.

2. Policy Issues There arose a series of policy issues that should be discussed at the HC level:

Lack of clarity around roles and responsibilities of HCC versus WR Need to establish predictable funding mechanisms and the make up of HC

14

teams for various scales of emergency (and funding implications). Define how to work with national authorities during the different phases of an

emergency, including how to ensure partners and governments meet standards.

Identify what to do when national standards are not compatible with global standards.

The inter-agency real time evaluation 3 months after the Haiti earthquake and the emergency response in Chad found the “free aid paradigm,” particularly free health care, problematic27. This will likely be an issue in strongly privatized health sectors. The humanitarian community and GHC should review and research the impacts of the paradigm and consider future policy and program decisions to mitigate negative impacts (as was done for Food for Work)28.

3. Tools, guidance, technical support and building capacities

Some of the recommendations for tools and guidance from earlier Joint Agency evaluation missions, such as Myanmar (2008) were followed. Most tools were developed or finalized in 2009, and additional tools were developed for specific countries, but there is still a need for modification of some tools and guidance in the following areas:

TOR and guidance for co-stewards agencies Mechanisms to assess cluster performance Revision of the GHC Guide, IRA

Simpler, shorter, less redundant guides and assessment tools are needed that are quick to use, adaptable to the context, and accessible to partners through training. One such problematic tool from the Initial Rapid Assessment (RINAH)29 in Haiti. Information from these tools is often assessed and distributed long after the fact and no longer reflects reality. The challenge is the HC’s desire to do simpler assessments while donors require more complex assessments to determine emergency assistance funding. Many of the following recommendations for improvement of tools are guides are drawn from the 2010 HCC workshop:

Health Cluster Guide

Focus more on partners, including government, and brand the guide accordingly.

Involve partners in the distribution and planned revision of the guide.

27 Inter‐Agency RTE Haiti (2010) Joint Mission to Chad ((March 2011) 28 HC and evaluators awareness needed around the position paper ‘Removing user fees for primary health care services during humanitarian crises’ 24 March 2010. 29 RINAH Costs 3 million dollars, 12‐page questionnaire taking 3 hours to complete, team of 128 persons, and 23 helicopter flights (Grunewald 2010).

15

Include information on both acute and chronic emergencies. Work with other clusters to develop common core content for all

cluster guides. Train ministries of health, co-steward agencies, and key partners in the

guide.

Health Cluster tools Review the use of the GHC tools in countries where they have been

used.

Define the process and resource needs to implement the GHC tools. Identify and build links between the GHC tools and other tools

developed by partners and other clusters. Work with donors to adopt a standard format (with core indicators) for

country implementation/reporting.

Building capacities and learning modalities Define a learning strategy that includes key participants (e.g., WRs,

NGOs and partners, HCCs); defines and develops competencies; enhances the sustainability of learning through follow-up, refresher training, and coaching; and measures the impact of learning programs and activities.

Continue HCC training by the GHC and CLA, including refresher training for active HCCs, including a focus on inter-cluster issues.

Hold annual HCC lessons learned workshops with increased participation of NGOs and donors.

Make full use of learning opportunities provided by other UN, NGO, and donor organizations.

Use partners as resource partners when organizing events. Pre -and post-deployment CLA regional and country offices should prepare pre-deployment

briefing packages and mechanisms for HCC team members. The GHC should develop standard procedures for post-deployment

debriefing of HCC The RO to provide HCC training as a prerequisite for deployment. Aid agencies should give staff cultural, contextual, and program

orientation before deployment, including instruction in Sphere and humanitarian principles.

4. Additional Themes i. Security and access

Most countries in this review had encountered security and access issues. In Haiti

16

aid workers questioned the declared UN security phase (3), which hampered access to populations, and felt security was not analyzed thoroughly.30 Security and access were given as reasons not to use participatory approaches in eastern Chad and the DRC. In Chad the HC found a national NGO to take over services from Médecins Sans Frontières (MSF), which had to leave for security reasons. In the oPt, a needs assessment was restricted for security reasons, although the team focused on priority health needs and service delivery rather than systems, which were more political. Aid agencies with inconsistent access to the oPt worked from the protection angle to deliver aid. Health clusters in the oPt and Myanmar were commended for their joint decisions, strategic discussions, and guidance in light of the security situation. NGOs and NNGOs that could obtain access provided health information when the UN could not.31 This was seen as another reason to develop local partnerships.

ii. Research and evidence gathering, innovation, vaccines, pharmaceuticals, supply chain

Customary WHO functions that were not mentioned in the various reports included; research and evidence gathering, health care innovations, vaccination coverage, cold chain supply, and pharmaceuticals. The medical supply side of health interventions was rarely mentioned except in the DRC, where the co-steward agency (Merlin) worked with NGOs to adhere to national health policies and not use its own. The mission review team in one country suggested more strategic rather than operational discussions for the HC in the capital, as this could be coordinated closer to operations. The sub-clusters could bring thematic topics to the national cluster for policy advice. Topics could include quality control of procurement of pharmaceutical products, transition between relief and development, and maternal and child mortality. Relevant WHO specialized areas of work could address such technical topics and support the analysis and recommendations that follow.

30 Inter-Agency RTE Haiti (June 2010) 31 IASC Cluster Approach Evaluation 2ND Phase (April 2010)

17

IV. Consolidated Recommendations By Thematic Issue

Health Cluster Leadership & Management 1. Define clear roles and responsibilities for UN entities, co-stewards vis-à-

vis the HC 2. Improve timely response to emergencies by ensuring the HCC roster staff

are deployed and funding is secured for the HCC team. 3. GHC develop working materials for the GHC and HC (decision-making

scale for the levels of emergencies, guidance for policy issues) 4. Develop surge capacities both for staffing the HC and assessments and

standby arrangements with other clusters/entities. 5. Ensure that in sudden-onset disasters that the IASC and HC build a cluster

compatible with local structures and actors.

Health Cluster Coordination 1. Provide dedicated qualified part-time or full-time coordinators for sub-

national HCs or levels where operational coordination takes place and include costs for sub-national facilitation and coordination in national cluster coordination budgets.

2. Identify appropriate partners in national and local authorities and strategies to strengthen their capacity and involve them in the cluster approach.

3. Integrate crosscutting issues in meetings, assessments, policies, tools, training, guidance, strategic planning and operations.

4. Linkages and coordination with other relevant sectors - Improve information sharing and management by and among clusters, e.g., by using simple and creative ways to free up meeting time, creating cluster-specific systems for identifying duplication, expanding “Who Does What Where” by including the status of projects; expanding cluster websites and using new technologies.

Policy Issues

1. Clarify staffing issues: Define roles and responsibilities of HCC with WR and the team composition for various levels of emergency; working with National authorities during the different phases of an emergency

2. Investigate opportunities for consistent funding mechanisms 3. Identify what to do when national standards are not compatible with

global standards, and how the HCC would go about meeting agreed upon standards.

Tools, guidance, technical assistance, and building capacity

1. Raise awareness of the range of tools (esp. IRA and HeRAMS) and guidance available to HCC partners and provide training to a targeted yet

18

broader pool of trainees: depending on the context include; MOH, HCC partners and local organizations.

2. HCC should develop contingency plans with MOH and partners and integrate in overall strategic plan.

3. Establish and disseminate coherent framework for M&E, including agreed upon population-based indicators and benchmarks to partners (including local level), giving feedback to partners involved in the reporting system.

4. To increase accountability to affected populations, strengthen the role of clusters in using and promoting participatory approaches and using context-sensitive communication strategies and appropriate technologies.

5. To enhance the use of participatory methods among cluster members, facilitate training by NGOs experienced in applying these methods; facilitate exercises on participatory approaches; or promote participatory needs assessments through peer review processes.

6. Facilitate participation and capacity strengthening of national and local NGOs, including them in management and strategy development, drawing on the strength of clusters in creating inclusive fora and facilitating learning.

Additional Themes

1. GHC and HC work to develop more comprehensive response to Security and Access so that health care delivery and monitoring can continue to meet the population in need.

2. GHC define ways to improve documentation of emergency response through targeted evidence gathering, and research (i.e. quality control of procurement of pharmaceutical products, transition between relief and development, maternal and child mortality.) Specialized WHO offices could address such topics and support the analysis and recommendations that follow.

19

ANNEX I Bibliography Co-stewarding the Health Cluster: An NGO Perspective. Merlin Internal review of Co-Stewarding Activities 2007-2010. Circa 2010. Evaluation of WASH Cholera Response to 2008-09 in Zimbabwe. Draft. Dr. T. Handzel, Centers for Disease Control and Prevention, 3 August, 2009. Feedback from donors and partners on health cluster performance. Summary of internal documents. Various dates.

Health Cluster Coordinator Lessons Learned Workshop. Workshop Report Geneva. Switzerland, co-facilitator Timothy Foster, 7-8 June 2010. (includes Power point Presentation) Health Cluster Guide: A practical guide for country-level for Implementation of the Health Cluster. Global Health Cluster, IASC and WHO. 2009. The Health Response In Haiti After The Earthquake: Some Food For Thought. By Francois Grunewald Groupe URD, 9 June 2010.

IASC Cluster Approach Evaluation 2ND Phase Cluster Approach Evaluation 2 Synthesis report. URD and GPPi. By J. Streets, et.al. April 2010.

IASC Global Health Cluster Joint Country Mission to Yemen. 30 April- 7 May 2010 Annex 1 Yemen recommendation summary draft DATE. May 2010 Annex 2 Mission TOR DATE. May 2010 Annex_3_ IASC Global Health Cluster Draft Report. Global Health Cluster Workshop 2 May 2010. Annex 4 Field trip to Harad. May 2010 Annex 5 Matrix for a Profile of the HC Yemen. May 2010

Inter-agency Real time evaluation 3 months after the earthquake. By F. Grunewald, F. , A. Binder, and Y. Georges (National Consultant) A URD and GPPi, June 14th 2010.

Joint ECHO-DFID-WHO Reviews Feedback Spreadsheet. Internal document. Dr. A. Griekspoor. 2010 Joint Evaluation of the Health Cluster in Zimbabwe WHO / DG ECHO / DFID R. Kessler (DFID), K. Kalambay (WHO) JP. Mustin (DG ECHO), J. Heffinck (DG ECHO), 7th – 12th March, 2010. Joint WHO-ECHO Review Mission on the performance of the health cluster in Chad, including the role of WHO as lead agency. Final Report, 15 March 2011.

20

Joint WHO/ECHO/SIDA review mission, on the performance of the health cluster in the Democratic Republic of Congo including the role of WHO as lead agency. 17-23 October 2010. Final report. 15 February 2011.

Learning from NGO experience of Participation in the Health Cluster. ECHO Project-Effective NGO participation in Humanitarian Coordination Mechanisms. By Vivienne Forsythe. Merlin. Supported by ECHO. August 2010. Merged Recommendations. Internal document. Circa 2010.

Mission Report: Joint Field Mission to Study WHO Disaster Preparedness and Response in the Context of the Health Cluster Response in the occupied Palestinian territory, by Joint Team DG ECHO, DFID, AECID, WHO: Dr J. Heffinck (DG ECHO), R. Lavy (DFID)R. Escudero (AECID) D. McArdle (WHO HAC). 1-5 June 2009 Mission Report: Joint Field Mission to Study WHO Disaster Preparedness and Response in the Context of the Health Cluster Response to Cyclone Nargis in MYANMAR by Joint Team DG ECHO, DFID, MERLIN, WHO: Dr J. Heffinck (DG ECHO), W. Van Hattum (DG ECHO), R. Lavy (DFID), Y-K. Creac'h (MERLIN), Dr. R. Ofrin (WHO SEARO), D. McArdle (WHO HAC). 2-7 November 2008. Summary of WASH Cluster Cholera Response Lessons learnt. Author unknown. circa 2009.

21

ANNEX II (insert file: Seven Country Feedback on GHC Core Functions)

GHC Review of evaluations country mission reports and ... · The objective of the document review was to provide the Global Health Cluster (GHC) with information on and analysis of

Documents