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Standards and quality improvement for Health Services in response to Humanitarian Emergencies Proposals on how to achieve a common standard for health response to sudden disasters
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Bases for an Accreditation Process of Foreign Medical Teams
that participate in direct response to humanitarian emergencies
Towards a consensus in order to achieve a common standard
for Health Response to Sudden Onset Disasters
Extracted and translated from: Standards and quality improvement for Health Services
in response to Humanitarian Emergencies1
February, 2012
1 Calderón, M. Estébanez, P. Informe de Asistencia Técnica de la SEMHU a la OAH de AECID. Estandarización y mejora de la calidad
de la respuesta directa en salud a las emergencias humanitarias. Bases y fundamentos para un proceso de acreditación de equipos para la respuesta en salud a las emergencias. 2011.
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English version drafted and updated by: Mauricio Calderon Ortiz
The original Spanish version of this document was prepared by:
Mauricio Calderón Ortiz
and
Pilar Estébanez Estébanez
Members of the Spanish Society of Humanitarian Medicine (SEMHU2)
Table of Contents Page
Acronyms/Abbreviations 3
1.- Introduction 4
2.- Initial bases for a possible Accreditation Process 8
Elements in the service portfolio that can be normalized - base for a set of standards
16
Description of general aspects of Accreditation procedures 24
Global experience with accreditation processes of humanitarian actors 26
Existing standards and norms regarding formation, training and action of health response teams
36
Some aspects of the potential accreditation process 45
3.- Basic procedures of the Accreditation Process 47
General Illustration of the potential Accreditation Process 49
4.- Commentary on the utility of these processes 59
2 Sociedad Española de Medicina Humanitaria
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Acronyms/Abbreviations
AECID Agencia Española de Cooperación Internacional para el Desarrollo
ALNAP Active Network for Accountability and Performance in Humanitarian Action
AP Accreditation Process
ATLS Advanced Trauma Life Support
BUSF Bomberos Unidos Sin Fronteras
CICR Comité Internacional de la Cruz Roja
CMR Crude Mortality Rate
FFH Foreign Field Hospital
FICR Federación Internacional de la Cruz Roja
FMT Foreign Medical Team(s)
FMT-WG Foreign Medical Teams Working Group of the GHC-IASC
FST Foreign Surgical Team(s)
GHC Global Health Cluster
HA Humanitarian Action
HAC Health Action in Crisis
HAH Humanitarian Action in Health
HeRAMS Health Resource Availability Mapping System
HRT Health Response Team
HRTM(s) Health Response Team(s)/Module(s)
IASC Interagency Standing Committee
INSARAG International Search and Rescue Advisory Group
MDGs Millennium Development Goals
MISP Minimum Initial Service Package
MM Maternal Mortality
MoH Ministry of Health
NGO Non-Governmental Organization
ISEA Institute of Social and Ethical Accountability
UN United Nations
OAH Humanitarian Action Office of AECID
OCHA Office for the Coordination of Humanitarian Affairs
OSOCC On-Site Operations Coordination Centre, OCHA
PAHO Pan-American Health Organization
SAMUR Servicio de Asistencia Municipal de Urgencia y Rescate
SEMHU Sociedad Española de Medicina Humanitaria
SOD Sudden Onset Disaster
SUMMA Servicio de Urgencia Médica de Madrid
TA Technical Assistance
UN United Nations
UNDAC United Nations Disaster Assessment and Coordination
USAR Urban Search and Rescue
U5MR Mortality Rate of children under 5 years old
WADEM World Association Disaster and Emergency Medicine
WHO World Health Organization
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1.- Introduction
The Office of Humanitarian Action (OAH: “Oficina de Acción
Humanitaria”) of the Spanish Cooperation Agency (AECID) is currently
working towards the improvement of capacity, efficacy and
effectiveness of the Spanish humanitarian response in general, and in
particular of those actions representing the direct response in health
to humanitarian emergencies. With this in mind the OAH sought the
technical assistance of the Spanish Society of Humanitarian Medicine
(SEMHU: “Sociedad Española de Medicina Humanitaria”) for the
identification and documentation of basic principles for the adoption
of a comprehensive approach towards improvement of the planning
and delivery of health services, as part of AECID’s direct response to
humanitarian emergencies. The core objective for the technical
assistance (TA) mission being defined as: contributing to the
improvement of capacity and effectiveness of humanitarian actors
enabled and coordinated by the OAH, as the mainstay for quality of
their actions. The priority for this component of the TA is the
development of standards applicable to health response to sudden
onset disasters.
National and international public institutions and NGOs involved in
Humanitarian Action (HA), form action networks that respond to
emergency situations and share an interest to improve their
performance and their ability to learn from experience. Thus the
increasing importance given to the identification of best practices,
lessons learned and innovative approaches for response to
humanitarian crises, both of slow and sudden onset.
One of the policy objectives of the humanitarian sector throughout
the last decade has been to look for ways to improve quality and
accountability of humanitarian response3. With this in mind, and
within the context of a comprehensive understanding of quality of
Humanitarian Action, emerges the attempt to apply some of the tools
3 Buchanan-Smith, Margie. How the Sphere Project Came into Being: A Case Study of Policy-Making in the Humanitarian Aid Sector
and the Relative Influence of Research. July 2003. Overseas Development Institute. Lonon, July 2003. Available at:
http://www.odi.org.uk/resources/download/146.pdf
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and methods that have been successfully used in other sectors, such
as Certification and Accreditation Processes of Services and Organizations.
These processes respond to pre-established sets of quality and
performance standards. The OAH puts stock in the implicit
standardization of practice associated with these processes, as a key
tool for improvement of the quality of activities of those organizations
involved in humanitarian response operations.
As part of the technical assistance of SEMHU to the OAH, an
extensive bibliographic review of the current state of the art in
humanitarian response in health was conducted, as well as of
accreditation processes of humanitarian agents and organizations.
Also, a basic inventory was developed for the essential components of
health response to emergencies, including the required previous training
and formation for the teams/modules involved. An emphasis was
placed on identified existing standards and recognized best practices.
With these an initial recommendation was made for the following four
elements for each type of emergency response health team/module:
1. the portfolio of services
2. Technical means necessary
3. Human resources necessary
4. Curricula for required previous educational courses about
humanitarian action, healthcare during humanitarian
emergencies, and technical elements specific to those health
services deemed essential during humanitarian emergency
situations4.
On the basis of the previously mentioned work, this document
presents what can be considered essential elements for a potential
accreditation process of Health Response Teams/Modules (HRT/Ms)
that provide healthcare services during response operations to
humanitarian emergencies. In addition, the general functional
principles that would rule said accreditation process are presented.
Also, with a didactic aim, sample situations are described regarding
the application of an accreditation process to health teams/modules
that comply in varied degrees to the required standards.
4 Calderón Ortiz, M. y Estébanez Estébanez, P. Informe de Asistencia Técnica de la SEMHU a la OAH de AECI: Estandarización y
mejora de la calidad de la respuesta directa en salud a las emergencias humanitarias. 2010.
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Finally, some comments are put forward regarding possible results of
the adoption of proposed standards and the implementation of a
voluntary progressive accreditation process of humanitarian
teams/modules and the continuous improvement dynamic this
represents for source organizations of those teams/modules. The
latter with the corresponding potential for over-all improvement of
Spanish aid during humanitarian emergencies. At this point, as a
summary, it might be worthwhile to highlight the following from those
possible results:
o Improve efficacy and effectiveness of Spanish humanitarian
response, assuring its results and impact are more predictable.
o Achieve better coordination and complementarity between
organizations involved in Humanitarian Response, derived from
the integrated and coordinated formation of qualified health
teams.
o Availability of a clear roadmap so that humanitarian actors who
provide health response teams can implement a system of auto-
evaluation and continued improvement.
o Convenience for AECID, the OAH, and the donor community at
large, that there be organizations and groups following a formal
process of continuous improvement.
o Opportunities for regional administrations and municipalities to
allocate technical resources and form human resources to
constitute health response teams according to best practice
standards.
o Inclusion of all key humanitarian actors in the health sector, while
still respecting their individual mandates and program priorities.
During the bibliographic review, it was notable that while there are
several initiatives for general accreditation of humanitarian
organizations, with the exception of the INSARAG5 (International
Search and Rescue Advisory Group) experience for urban search and
rescue teams (USAR), there is little experience in the accreditation of teams
for humanitarian action on the field.
5 INSARAG, External Classification / Reclassification Guidelines. 2011, Edition.
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Currently there are humanitarian response organizations that have
Quality Management Systems certified under widely applied quality
management systems/models, such as the ISO 9001:2008 Norm or
the EFQM Model6. The scope of the ISO Norm can be taken to include
interventions in emergency situations and preventive health as well
as different types of education and training in healthcare. In the
documented experiences, the implementation of EFQM includes
“Customer results” as one of its criteria. The EFQM model is very
customer oriented, with Customers being defined by “the relation of
the various stakeholders to the primary process of the organization”.
Under this criterion the question is addressed in how far the
organization meets the expectations of the customers for
humanitarian aid7. Stakeholders - and thus “customers” - include the
affected populations, as well as the local health authorities and other
main stakeholders in the scenario of the humanitarian emergency.
However, to our knowledge, a specific procedure to include in this
normative systems either international humanitarian aid and/or the
delivery of healthcare services in response to humanitarian
emergency situations, has not been developed to date.
This underlines the importance of the process currently put forth by
the OAH; importance that has been confirmed by all the international
experts consulted. To our knowledge, this would one of the first
initiatives in the world in which the cooperation agency of one of the
principal donor countries adopts and integrates elements such as the
definition of standards and an accreditation process for the
improvement of quality of humanitarian action in health.
6 CONGDE. La calidad en las ONGD – Situación actual y retos. CONGDE, 2007 7 Griekspoor, A. From doing good to doing good things right. An analysis on the applicability of the EFQM model for Quality
Management to Humanitarian Organizations. Final paper as part of the Masters of Public Health Program of the Netherlands
School of Public Health. 2000.
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2.- Initial bases for a possible Accreditation Process
of Health Teams participating in direct response to
humanitarian emergencies
The Spanish Cooperation Agency and its Office for Humanitarian
Action have as one of their manifest objectives the support of an
effective humanitarian response to emergency situations, such as
those produced by both Slow- and Sudden-onset Disasters.
Over the last two decades8, humanitarian organizations have involved
themselves progressively in efforts to “do better”9, with a diverse
collection of initiatives to increase the quality of humanitarian
assistance, and among them the development and application of
standards for projects and organizations. These standards have been
proposed by both the humanitarian organizations themselves as well
as by external actors such as donors, agencies and governments,
reflecting an increased interest in the attainment of better quality,
impact, and accountability of humanitarian assistance. In other
words, initiatives towards the setting of Humanitarian Standards, and
of Certification & Accreditation arise from internal reflections/
experiences/practices, as well as from external challenges
/scrutiny/debates10.
To begin, it is essential to review working definitions for certain key
terms11, and to understand the differences among them:
Registration: a filing process of basic information into a register
or database. It does not confer any credential or recognition to
the entity registered.
8 Overseas Development Institute (ODI): Joint Evaluation of Emergency Assistance to Rwanda Study III Main Findings and
Recommendations. Relief and Rehabilitation Network Paper 16. Overseas Development Institute. 1996.
Overseas Development Institute (ODI): Joint Evaluation of Emergency Assistance to Rwanda, Study III: Humanitarian Aid and
Effects. ODI: London, UK. 1995. 9 Griekspoor, A. Enhancing the quality of humanitarian assistance: taking stock and future initiatives. Prehosp. Disaster Med.
2001 Oct-Dec;16(4):209-15. Available at: http://www.smartindicators.org/docs/quality_humanitarian_aid.pdf 10 Patel, S. Accreditation in the Humanitarian Sector: issues and updates. Lecture at: 27th ALNAP Meeting, Chennai, India. January
19, 2012. Available at: http://www.alnap.org/pool/files/day3-spatel.pdf 11
Based primarily (and supplemented) from: De Ville de Goyet, Claude. Working Groups Background Paper on Registration,
Certification and Coordination. PAHO/WHO Technical Consultation on International Medical Care Assistance in the Aftermath of
Sudden Onset Disasters, Cuba, 7-9 December 2010.
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Certification: involves a technical evaluation in terms of
compliance with pre-established requirements or criteria. This
evaluation is normally done by a just/independent third party -
a “certification body”, who issues documentation to guarantee
that persons, products, procedures or services conform to the
procedures and activities required in said standard.
Licensure: a process by which a governmental authority grants
permission to an individual practitioner or an organization to
operate. “Licensure is a mandatory credentialing process
established by a government entity to protect public health and
safety. This as compared to certification, that may be defined
as a voluntary credentialing process—most often sponsored by
a nongovernmental or private-sector entity. If the license is
voluntary, it is not, strictly speaking, a license. Similarly, if the
certification is mandatory, it is really licensure” 12. In normal
situations, individual licensure is granted after
theoretical/practical examinations to demonstrate minimum
levels of competence and capability. Organizational licensure is
usually granted following an on-site inspection to determine if
minimum health and safety standards have been met. In
disaster situations, licensure is a de facto process with the
registration of the health humanitarian actor with the Ministry
of Health.
Accreditation: The official written recognition issued by a
designated agent that the accredited organization is capable of
executing required work, procedures or activities, and is
granted the power to perform those acts and duties.
For healthcare providers, accreditation entails “a formal process
by which a recognized body recognizes that a healthcare
organization meets applicable pre-determined and published
standards”. It represents a more advanced stage of
commitment and compliance with standards and best practices.
Accreditation can also be described as the technical process destined
to promote and assure the quality of a given service or product,
12
Balasa, Donald A. Certification and Licensure - Facts you should know 2009 . AAMA . Available at: http://www.aama-
ntl.org/resources/library/CMAandRMA.pdf - quoted by de Ville de Goyet, 2010
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through the application of self- and external evaluation
mechanisms13. Participants in this process are the members of the
organizations providing the products/services under scrutiny, as well
as external evaluators. All of them apply published and objective
criteria and procedures. The main objective of an Accreditation
Process is to assure, at the administrative, logistic and operational
levels, the QUALITY that is being offered. The AP should be
understood as a permanent system, applied in pre-established
cycles14. Sustained Quality is the byproduct of the continuous
improvement process, in which all components of the organization
participate actively for the provision of a service that satisfies the
needs of a community. This service must contemplate certain basic
criteria: it must be appropriate, sufficient, and opportune. Once these
basic criteria are met, a fourth and fifth key elements can be
considered: service efficiency and effectiveness. (please see section
entitled: “Description of general aspects of Accreditation procedures” of this
document).
In normal non-crisis situations, “An accreditation decision about a
specific health care organization is made following a periodic on-site
evaluation by a team of peer reviewers, typically conducted every two
to three years. Accreditation is often a voluntary process in which
organizations choose to participate, rather than one required by law
and regulation”. 15
For the matter at hand, of accreditation of health responders to
humanitarian emergency situations, the advantage of accreditation
would be to standardize, vet and endorse the certification process
done in many donor countries. International Accreditation may bear
more weight on the country being assisted and should facilitate entry
and licensure by the recipient ministry of health. WHO with the
support of OCHA should progressively encourage countries (local MoH
and Civil Protection) to primarily accept health facilities that are
licensed/certified/ accredited. This should not be a problem provided
that local authorities have trust in the accreditation process.
As already mentioned, accreditation involves an independent body
that monitors compliance with a set of standards or codes and
decides on accreditation accordingly. The independent body is
13
Ministerio de Educación, Estándares de acreditación Ley 24.521, República de Argentina. 14
Sarmiento, Juan Pablo. Acreditación. INSARAG, 2003.
15 Rooney, A., van Ostenberg, P. Licensure, Accreditation, and Certification: Approaches to Health Services Quality. USAID
Quality Assurance Project, 1999.
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normally an organization from the sector concerned that has been
mandated by that sector as the accreditation body. The accreditation
process can vary in its methodology and scope. Two models of
accreditation which may be relevant for the humanitarian sector can
be distinguished16:
In the first model, accreditation is formal and legalistic. It controls
whether organizations fulfill particular conditions regarding finance
and management. For instance, when applied to fund-raising
organizations, the accreditation system checks whether annual
reports are made available and whether institutional overheads
remain below a certain percentage of the budget. ECHO has
established such an accreditation mechanism for NGOs willing to
apply for funding with this organization17.
In the second model, accreditation is qualitative and value-based. It
is more comprehensive and combines self-evaluation with a peer-
review or an external visitation. This kind of accreditation allows for
both quality assurance and quality improvement by ensuring
compliance to standards while providing guidance, training, and
exchange of best practices among peers. There have been several
NGO initiatives that focus on accreditation or certification. For
example, in the USA almost 200 humanitarian organizations are
affiliated to InterAction18.
Accreditation is thus a label under which different membership
arrangements can be headed, varying in scope, level of control by
the accreditation institution and level of attention for qualitative
processes and learning. Variations pose different institutional
requirements and have different impact on quality and
accountability.
16
Hilhorst, Dorothea. Being Good at Doing Good? Review of Debates and Initiatives Concerning the Quality of Humanitarian
Assistance. Paper presented at the international working conference: “Enhancing the Quality of Humanitarian Assistance”.
Ministry of Foreign Affairs, Netherlands, 12 October 2001. 17
ECHO FPA WITH NGOs and International Organizations. ECHO 2003-2004-2008. Available at:
http://ec.europa.eu/echo/about/actors/archives_fpa2003_en.htm 18 This membership organization of private voluntary organizations requires its members to self-certify their adherence to “ethical
guidelines covering governance, financial reporting, fundraising, public relations, management practice, human resources and program services.”
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From very early on19, it was stated that while voluntary adoption and
implementation of the Code of Conduct and standards is clearly
preferable to edicts imposed on NGOs from outside, the Rwanda
experience indicated that it probably is not enough to rely on
voluntary adoption alone, and that some form of regulation or
enforcement is needed to ensure improvements in performance by
NGOs. In this regard, two options were formulated back in 1996: (i)
Self-managed regulation - Under this option, NGO networks could be
assisted in acquiring greater capacity to monitor member compliance
with the Code and standards. (ii) An international accreditation system -
Under this option, core criteria for accreditation would be developed
jointly by official agencies and NGOs. These criteria would need to be
adapted and supplemented for specific types of emergencies.
It is clear that although the second option is stronger than the first in
terms of enforcement, it raises a number of issues that would have to
be resolved, such as the selection of an entity to administer
accreditation, funding, reporting relationships, etc. Self-regulation
under the first option would be encouraged if donors and donor
governments agreed to restrict their funding and tax-free privileges
to agencies that have adopted the Code and standards. Similarly,
host-country governments could provide registration, work permits
and duty-free importation privileges only to those agencies that have
adopted the Code and standards. If implemented, these incentives
and disincentives would compensate for the weakness of the first
option. Of course, donors and governments would have to be
prepared to hold NGOs accountable to the Code and standards and
employ disincentives in the event of non-compliance.
There is no agreement on what the purpose of an accreditation/
certification system should be20. Is it to improve the quality and
impact of humanitarian response? Is it to strengthen the
accountability of NGOs, particularly with donors? Or is it to make sure
that only organizations that meet professional standards operate in
disaster response? The design of an accreditation/certification system
would largely depend on the answers to these questions. If the
primary purpose is to ensure the application of quality standards by
those certified, then self- and peer assessment are likely to play a
19 Overseas Development Institute (ODI): Joint Evaluation of Emergency Assistance to Rwanda Study III: Main Findings and
Recommendations. Relief and Rehabilitation Network Paper 16. ODI: London, UK. 1996. 20 Hofmann, Ch.A. NGO Certification: Time to bite the Bullet? Humanitarian Exchange Magazine, Issue 52, October, 2011. Available
at: http://www.odihpn.org/humanitarian-exchange-magazine/issue-52/ngo-certification-time-bite-bullet
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central role. If it is to exclude poorly performing organizations, a
more robust regulatory system needs to be in place. While these
different objectives are not mutually exclusive, the main driver for an
accreditation/certification system should be improving the quality of
humanitarian response. This would ultimately enhance the credibility
and professionalism of NGOs.
For our current analysis, whose priority is the development of
standards applicable to health response to sudden onset disasters, it
is important to understand that most of the currently available
standards and, in particular, the available key indicators for most of
the technical responses, have indeed derived largely from work in
acute emergency settings21, thus enhancing their appropriateness as
benchmarks for our purposes. A decade ago22, calls were already
made for the need for a system-wide approach to performance of
humanitarian response, as a means to improving accountability.
There is still today, however, much to be done in terms of
systematically documenting and analyzing healthcare on the field
during humanitarian emergency situations, and in particular
regarding certain key aspects of quality, such as developing a better
understanding on measures of effectiveness of humanitarian
assistance at large, and of healthcare response in particular.
Overall, increasing external accountability should be seen as an
additional opportunity for learning and improving, and hence to
contributing to more effective humanitarian assistance.
As stated above this document presents the concepts upon which an
accreditation process for Health Response Teams/Modules (HRT/Ms)
might be based. We propose to define and make real said
accreditation process following a scheme that reflects best existing
practices for certification and accreditation of services and
organizations.
21 Griekspoor A, Collins S: Raising standards in emergency relief: How useful are the “Sphere” minimum standards for
humanitarian assistance. BMJ, 2001. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121289/pdf/740.pdf 22 Emerging Issues and Future Needs in Humanitarian Assistance. Michael J. VanRooyen Available at:
http://www.jhsph.edu/bin/q/f/VanRooyen_2002-emerging_issues_and_future_needs.pdf
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The Accreditation Process (AP) would be directed towards those
organizations that participate in direct response operations in
collaboration with the OAH of AECID, during the “acute” phase of
humanitarian emergencies. More specifically, the proposed AP is
focused on the health response teams/modules (HRT/Ms) of those
organizations.
The proposed AP will serve as a roadmap so that humanitarian
organizations, as providers of health response teams, design and
implement a progressive system for recurrent self-evaluation and
continuous improvement, amenable of being followed by
Accreditation itself, and by the external recognition, through
progressive certification, of: (i) the compliance with standards; and
(ii) the quality of the organization’s HRT/Ms’ stand-by and operational
capacity. This on the basis of the resources, services, and
protocols/practices put forth prior to and during health response to
situations of humanitarian crisis.
The AP would also seek to improve the effectiveness of humanitarian
health response, assuring that its components are more predictable
as to their results and impacts, while at the same time achieving
better cooperation, coordination, and complementarity among the
HRT/Ms involved. This would represent added value relative to many
of the currently existing certification schemes world-wide, centered
on efficacy. In this manner the proposed AP follows the current global
efforts towards humanitarian reform, that intend to provide
comprehensive aid in an opportune and effective manner to the
largest possible number of beneficiaries, as well as measures of
protection and mitigation, all responding to identified real needs.
The proposed AP and its related standards will reflect the current
best international practice in health response to humanitarian
emergency situations.
Initially, accreditation could be eminently voluntary, but it would
serve as the entry path to public certification that the unit or group
(the HRT/M) submitted to an evaluation process meets the conditions
required to participate in humanitarian emergency response missions.
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Once the AP is consolidated and ratified, certification of compliance
with the AP could become mandatory prior to participation of
response missions organized by the OAH.
Additionally, other applications could be found for this AP, in matters
such as:
presentation of credentials to society at large
convenience for AECID, its OAH, and the donor community at
large, that there be organizations and groups following a formal
process of self-evaluation and accreditation
the priority that accredited/certified HRT/Ms might have for
inclusion and mobilization within missions organized by other
international agencies or groups (a.e.: WHO-HAC, OCHA, etc.)
in response to large scale emergencies.
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Elements in the service portfolio that can be normalized -
base for a set of standards
The magnitude and dynamics of humanitarian emergencies vary
according to the type of event that causes them, since they produce
different impacts on the functional status of the affected society. A
given event can produce different types and magnitudes of damages
to the population, with variable numbers of deaths and injuries,
different patterns of diseases, as well as diverse kinds of damages to
both the human built environment and the natural environment in the
region affected by the disaster event.
The following table illustrates the diversity of short term effects
produced by different classes of natural disasters23, which in turn will
help define the types of services that should be included in the health
response:
Short-term effects of major disasters
Effect Type of Disaster
Earthquakes High winds
(without
flooding)
Tidal
waves/flash
floods
Slow-onset
floods
Landslides Volcanoes/
Lahars
Deaths –
Potential lethal
impact in absence of
preventive measures
Many Few Many Few Many Many
Severe injuries
requiring extensive
treatment
Many Moderate Few Few Few Few
Increased risk of
communicable
diseases
Potential risk following all major disasters -
(Probability rising with overcrowding and deteriorating sanitation)
Damage to health
facilities
Severe
(structure and
equipment)
Severe Severe but
localized
Severe
(equipment
only)
Severe but
localized
Severe
(structure
and
equipment)
Damage to water
systems
Severe Light Severe Light Severe but
localized
Severe
Food shortage Rare
(may occur due to economic and
logistic factors)
Common Common Rare Rare
Major population
movements
Rare
(may occur in heavily damaged
urban areas)
Common (generally limited)
23
PAHO. General Effects of Disasters on Health. Chapter 1 in: Natural Disasters: Protecting the Public’s Health. PAHO, 2000. Available at: http://helid.digicollection.org/en/d/Jh0204e/4.html
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Likewise, the timing in which certain types of health services are
required, with greater or lesser intensity, changes depending on the
type of disaster causing the humanitarian emergency. Accordingly the
needs and priorities change for: initial casualty management, disease
surveillance and control, environmental health (such as urgent supply
of water or the sanitation set-up for new population settlements – as
in refugee camps), or food distribution. This is illustrated in the
following graph, as time passes after an earthquake has occurred.
Variation over time of needs and priorities during the acute phase after an earthquake24
24
Modified from: Coordination of Disaster Response Activities and Assessment of Health Needs. Chapter 5 in: Natural Disasters:
Protecting the Public’s Health. PAHO, 2000. Available at: http://helid.digicollection.org/en/d/Jh0204e/8.3.html
Medical care of direct trauma
at pre-hospital and hospital settings
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Immediate Health Problems Related to the Type of Disaster25
Earthquakes Usually because of dwelling destruction, earthquakes may cause many deaths and injure large numbers of people. The toll depends mostly on three factors. 1. The first factor is housing type. Houses built of adobe, dry stone, or unreinforced masonry, even if
only a single story high, are highly unstable and their collapse causes many deaths and injuries. Lighter forms of construction, especially wood-frame, have proved much less dangerous. After the 1976 earthquake in Guatemala, for example, a survey showed that in one village with a population of 1,577, all of those killed (78) and severely injured had been in adobe buildings, whereas all residents of woodframe buildings survived. In the earthquake affecting the villages of Aiquile and Totora in Bolivia in 1998, 90% of deaths resulted from the collapse of adobe housing.
2. The second factor is the time of day at which the earthquake occurs. Night occurrence was particularly lethal in the earthquakes in Guatemala (1976) and Bolivia (1998), where most damage occurred in adobe houses. In urban areas with well-constructed housing but weak school or office structures, earthquakes occurring during the day result in higher death rates. This was the case in the 1997 earthquake that struck the towns of Cumaná and Cariaco, Venezuela. In Cumaná an office building collapsed, and in Cariaco two schools collapsed, accounting for most of the dead and injured.
3. The last factor is population density: the total number of deaths and injuries is likely to be much higher in densely populated areas.
There are large variations within disaster-affected areas. Mortality of up to 85% occasionally may occur close to the epicenter of the earthquake. The ratio of dead to injured decreases as the distance from the epicenter increases. Some age groups are more affected than others; fit adults are spared more than small children and the elderly, who are less able to protect themselves. However, 72% of the deaths resulting from collapsed buildings in the 1985 Mexico earthquake were among persons between the ages of 15 and 64. Secondary disasters may occur after earthquakes and increase the number of casualties requiring medical attention. Historically, the greatest risk is from fire, although in recent decades, post-earthquake fires causing mass casualties have been uncommon. However, in the aftermath of the earthquake that hit Kobe, Japan, in 1995, over 150 fires occurred. Some 500 deaths were attributed to fires, and approximately 6,900 structures were damaged. Fire-fighting efforts were hindered because streets were blocked by collapsed buildings and debris, and the water system was severely damaged. Regardless of the number of casualties, the broad pattern of injury is likely to be a mass of injured with minor cuts and bruises, a smaller group suffering from simple fractures, and a minority with serious multiple fractures or internal injuries requiring surgery and other intensive treatment. For example, after the 1985 earthquake in Mexico, 1,879 (14.9%) of the 12,605 patients treated by the emergency medical services (including certain routine cases) needed hospitalization, most of them for a 24-hour period. Most of the demand for health services occurs within the first 24 hours of an event. Injured persons may continue to show up at medical facilities only during the first three to five days, after which presentation patterns return almost to normal. Patients may appear in two waves, the first consisting of casualties from the immediate area around the medical facility and the second of referrals as humanitarian operations in more distant areas become organized. Destructive Winds Unless they are complicated by secondary disasters such as the floods or sea surges often associated with them, destructive winds cause relatively few deaths and injuries. Effective warning before such windstorms will limit morbidity and mortality, and most injuries will be relatively minor. Most of the public health consequences from hurricanes and tropical storms result from torrential rains and floods,
25
PAHO. Natural Disasters: Protecting the Public’s Health. PAHO. Washington, DC. 2000.
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rather than wind damage. The catastrophic death toll - an estimated 10,000 - in Central American countries after Hurricane Mitch in 1998 was primarily caused by flooding and mudslides. Flash Floods, Sea Surges, and Tsunamis These phenomena may cause many deaths, but leave relatively few severely injured in their wake. Deaths result mainly from drowning and are most common among the weakest members of the population. More than 50% of the deaths in Nicaragua following Hurricane Mitch in 1998 were due to flash floods and mudslides on the slopes of the Casitas Volcano. Volcanoes Volcanoes are found worldwide and significant numbers of people often live in close proximity to them. The fertile volcanic soil is good for agriculture and is attractive for the establishment of towns and villages. In addition, volcanoes have long periods of inactivity, and some generations have no experience with volcanic eruptions, thereby encouraging the population to feel some degree of security in spite of the danger in living close to a volcano. The difficulty in predicting a volcanic eruption compounds the situation. Volcanic eruptions affect the population and infrastructure in many ways. Immediate trauma injuries may be caused if there is contact with volcanic material. The super-heated ash, gases, rocks, and magma can cause bums severe enough to kill immediately. Falling rocks and boulders also can result in broken bones and other crush-type injuries. Breathing the gases and fumes can cause respiratory distress. Health facilities and other infrastructure can be destroyed in minutes if they lie in the path of pyroclastic flows and lahars (mudflows containing volcanic debris). Accumulated ash on roofs can greatly increase the risk of collapse. Contamination of the environment (e.g., water and food) with volcanic ash also can disrupt environmental health conditions; this effect is compounded when the population must be evacuated and housed in temporary shelters. If the eruptive phase is prolonged, as in the case on the Caribbean island of Montserrat where the Soufriere Hills volcano began erupting in July 1995 and continued for several years, other health effects, such as increased stress and anxiety in the remaining population, become important. Long-term inhalation of silica-rich ash also can result in pulmonary silicosis years later. One of the most devastating events to occur in Latin America was the November 1985 eruption of the Nevado del Ruiz volcano in Colombia. The heat and seismic forces melted a portion of the icecap on the volcano, resulting in an extensive lahar that buried the city of Armero, killing 23,000 people and injuring 1,224. Some 1,000 km2 of prime agricultural land at the base of the volcano were affected. Floods Slow-onset flooding causes limited immediate morbidity and mortality. A slight increase in deaths from venomous snakebites has been reported, but not fully substantiated. Traumatic injuries caused by flooding are few and require only limited medical attention. While flooding may not result in an increased frequency of disease, it does have the potential to spark communicable disease outbreaks because of the interruption of basic public health services and the overall deterioration of living conditions. This is of concern particularly when flooding is prolonged, as in the case of events caused by the El Niño phenomenon in 1997 and 1998. Landslides Landslides have become an increasingly common disaster in Latin America and the Caribbean; intense deforestation, soil erosion, and construction of human settlements in landslide-prone areas have resulted in catastrophic events in recent years. This has been the case in both urban and rural areas. Rain brought by Tropical Storm Bret triggered landslides in poor neighborhoods on the outskirts of Caracas, Venezuela, in August 1993. At least 100 people died, and 5,000 were left homeless. High death tolls occurred in the gold mining town of Llipi, Bolivia, in 1992, where a landslide buried the entire village, killing 49. Deforestation contributed significantly to the disaster, and mining tunnels collapsed. A similar disaster occurred in the gold mining region of Nambija, Ecuador, in 1993, claiming 140 lives. In general, this phenomenon causes high mortality, although injuries are few. If there are health structures (hospitals, health centers, water systems) in the path of the landslide, they can be severely damaged or destroyed.
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It is possible to clearly map the variation over time of
demand/utilization of specific types of services, as illustrated in the
following example of needs/use of hospital surgical resources for non-
trauma emergencies, trauma complications and elective surgery
before and following a sudden-impact disaster (SID)26 :
However, in spite of the previously mentioned variability, it is also
possible to identify elements common to any humanitarian
emergency situation. This allows us to propose an approach from
which to establish those healthcare services that are essential to
provide, even though their required timing, intensity and volume
might change depending on the type of disaster event.
This gives rise to the concept of components, “units”, or “modules”,
essential for any health response, and that it be valid to pre-define
the portfolio of services for each one of those modules; going on to
26
Modified from: von Schreeb, Johan, et al. Foreign Field Hospitals in the Recent Sudden-Onset Disasters in Iran, Haiti, Indonesia,
and Pakistan, Prehospital and Disaster Medicine Vol. 23,No. 2; 144-151. March–April 2008.
Hospital Resources
Service Demand/Utilization
Emergencies due to causes diferent to direct trauma
Elective Surgery
Direct Trauma
Sudden Impact Event (SID)Days after Sudden Impact Event
EXAMPLE: DEMAND FOR IN-HOSPITAL SURGICAL SERVICES
DEMAND FOR DIFFERENT SERVICES CHANGES OVER TIME
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define, also in modular fashion, for any given affected population (for
example a module or kit for each 10,000 or 30,000 inhabitants in the
zone affected by the emergency), the types and quantities of supplies
and technical elements, as well as the number and qualifications of
human resources required to guarantee effective access to the
necessary healthcare services.
This represents one of the fundamental concepts upon which to
build a coherent set of standards: essential uniform elements in
humanitarian healthcare response which can be normalized.
Health response normalized elements open the door to setting
definitions for the minimum standards for essential health response
services, and to establish an Accreditation Process as a tool for
quality improvement of the health component of humanitarian
response to emergency situations27. As mentioned above, this type
of process has to respond to a pre-defined set of quality and performance
standards, and will follow best existing practices for accreditation and
certification of organizations and services.
Based on the review of key references about the state of the art of
practice (“benchmarking”), on the experience of SEMHU’s group of
experts and on the opinion of the international experts consulted, we
went on to identify the following components as essential for health
response during the acute phase of humanitarian emergencies, and thus as
operational packages or types of services for which standards and
criteria must be defined and included in an Accreditation Process of Health
Teams/Modules:
Logistic support of health services
Logistics of essential drugs and health supplies for emergency
situations
Epidemiologic surveillance and infectious disease control
Basic Healthcare - mobile advanced teams and fixed health
posts including:
- Emergency care on the field, triage, stabilization, referral
27
How the Sphere Project Came into Being: A Case Study of Policy-Making in the Humanitarian Aid Sector and the Relative
Influence of Research. Margie Buchanan-Smith July 2003. Margie Buchanan-Smith. Overseas Development Institute. Londres, julio
2003 http://www.odi.org.uk/resources/download/146.pdf
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- Immediate basic, essential curative, preventive and
community health care
- Maternal and Sexual/Reproductive Health services
- Child care services
- Mental Health and Psychosocial Support services at
primary care level
- Epidemiologic Surveillance Registry and Report
Services that support/complement National Hospital Capacity
- Surgical services – general/orthopaedics
- Mental Health and Psychosocial Support services at
specialty level
Health Information systems that are agile, robust and easy to
use, enabling the registration and systematic analysis of health
response to the emergency situation
For each one of these components, an initial recommendation was
made for the following four elements for each type of emergency
response health team/module: 1. the portfolio of services; 2. the
technical means necessary; and 3. the Human resources necessary;
and. These recommendations represent the technical requisites for
the integrated creation and action of qualified health response
teams/modules, and the basis for the compliance criteria to be used
during their Accreditation Process28.
In addition to the deployment of teams with special technical
qualifications, from the very beginning the need was identified to
normalize education and training curricula relative to humanitarian
action, healthcare during humanitarian emergencies, and training on
the technical elements specific to health services deemed essential
during humanitarian emergency situations.
This previous complementary education and training, was deemed
essential so that independently from their different clinical and
technical specialties, the activities of all individuals and organizations
involved are in accordance with humanitarian principles and
international humanitarian and disaster law, and have as a
cornerstone a common knowledge base about humanitarian action in
general and health response in particular. All this supported by
28
Calderón Ortiz, M. y Estébanez Estébanez, P. Informe de Asistencia Técnica de la SEMHU a la OAH de AECI: Estandarización y
mejora de la calidad de la respuesta directa en salud a las emergencias humanitarias. 2010.
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quality initiatives that reflect “best practices”, and are grounded on
compliance criteria that can be translated in a process of self-
evaluation, continuous learning, and accreditation for HRT/Ms (the
curricular proposals for the different modules can be consulted in:
Calderón Ortiz, M. and Estébanez Estébanez, P. Informe de Asistencia
Técnica de la SEMHU a la OAH de AECI: Estandarización y mejora de
la calidad de la respuesta directa en salud a las emergencias
humanitarias. 2010).
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Description of general aspects of Accreditation procedures
Accreditation is the technical process destined to promote and assure
the quality of a given service or product, through the application of
self- and external evaluation mechanisms29. Participants in this
process are the members of the organizations providing the
products/services under scrutiny, as well as external evaluators. All of
them apply published and objective criteria and procedures.
The main objective of an Accreditation Process is to assure, at the
administrative, logistic and operational levels, the QUALITY that is
being offered. The AP should be understood as a permanent system,
applied in pre-established cycles30.
Sustained Quality is the byproduct of the continuous improvement
process, in which all components of the organization participate
actively for the provision of a service that satisfies the needs of a
community. This service must contemplate certain basic criteria: it
must be appropriate, sufficient, and opportune. Once these basic
criteria are met, a fourth and fifth key elements can be considered:
service efficiency and effectiveness.
Accreditation requires a process with the following characteristics:
o Participation is often voluntary.
o Comprehensive – that is, it values the inputs, processes, and
results of the elements being evaluated, in our case HRT/Ms.
o It is objective, just and transparent.
o Internal, through self-evaluation mechanisms; and external via
peer and third party evaluation mechanisms.
o It is the product of collegiate work of people of recognized
competency in the matter, with expertise and capability in
evaluation procedures.
o It is temporal – this means that accreditation will have validity
for a limited pre-determined time. This implies the need for the
continuous search for quality, including continued education,
re-qualification and re-certification in key competencies and
abilities.
o It is trustworthy.
29
Ministerio de Educación, Estándares de acreditación Ley 24.521, República de Argentina. 30
Sarmiento, Juan Pablo. Acreditación. INSARAG, 2003.
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Accreditation is the culmination of an iterative process whose
objective is the continuous improvement of actions and programs in
the organizations involved. This process includes activities of:
registration - formal entry in a data base, that does not give any
special credential or recognition;
certification – after a technical evaluation of compliance with pre-
established criteria or requisites; and
accreditation – which represents a formal process through which it
is documented and verified that an organization, or a health
response team/module provided by an organization, complies with
applicable pre-established and published standards of good-
practice.
recognition of excellence - the AP also usually includes the possibility
to demonstrate that the activities of said HRT/M and the
technical/human/cognitive resources of the organization reflect
performance levels that can be considered samples of excellence,
reflecting sector/national/world class best-practices.
Re-accreditation – after a predefined period during which the
original accreditation decision is valid.
The extensive international experience with the application of
accreditation processes, as reflected in the review of available
bibliography, and complemented by the technical assistance team’s
own experience, permits the identification of the basic components of
any given AP. This type of process is always performed starting from
pre-established quality criteria and consists of five procedures,
successive in time, plus a discretionary review mechanism available
for when it is considered necessary. The following are the basic
components of any AP:
1. Registration and pledge to participate.
2. Self-assessment by the subject to be evaluated for accreditation.
3. External evaluation by peers and by a designated third party.
4. Accreditation decision.
5. Review mechanism of Accreditation decision.
6. Re-accreditation - after a predefined period during which the
original accreditation decision is valid.
These six components are considered universal and are commonly
applied in the education and health sectors. The AP proposed by this
technical assistance follows this general basic framework.
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Global experience with accreditation
processes of humanitarian actors
In the international humanitarian community, the mounting debate
regarding quality and accountability had its larger momentum after
the results of the Joint Evaluation of Emergency Assistance to the
humanitarian crisis of Rwanda in 1994 were published over the
following two years. This evaluation is considered to be one of the
landmarks that contributed to the demands for better performance
and accountability31. The report stated that up to 100,000 avoidable
deaths could be attributable to poor performance on the part of the
relief agencies, in good part due to their prevailing lack of standards
and weak systems of accountability.
This coincided with the appearance of initiatives such as the Code of
Conduct for the International Red Cross and Red Crescent Movement
and NGOs in Disaster Relief, drafted in Europe in 1994, and the
Providence Principles, drafted in the USA one year earlier32. These
were initial attempts to provide codification of the basic principles
that should guide agencies in a humanitarian emergency. Afterwards
many and varied initiatives have emerged in an attempt to improve
the quality of humanitarian action. In this varied landscape, quality is
also understood from different stand points: the satisfaction of the
affected people, the responsibility of agencies and donors,
transparency, accountability, participation of recipients, etc.33
Another one of the initiatives clearly traceable as responding to the
recommendations of the Rwanda Joint Evaluation Report is that of the
Humanitarian Accountability Partnership (HAP)34. Established in 2003,
HAP International is the humanitarian sector's first membership-
based self-regulatory body, and its work is based on the findings and
recommendations of the Humanitarian Accountability Project, an
inter-agency initiative set up in 2001 to identify, test and recommend
accountability mechanisms.
31
Joint Evaluation of Emergency Assistance to Rwanda, study III Humanitarian aid and effects, ODI, London, UK. 1995. 32 Minear, L. and Weiss, T. Humanitarian Action in Times of War. A Handbook for Practitioners. Boulder and London: Lynne
Rienner Publishers. 1993. 33
Urgoiti Aristegui, Ana. Las iniciativas de mejora de la calidad en el sector humanitario: tendencias del 2006. IECAH, dic. de 2007. 34
http://www.hapinternational.org/
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HAP-I members are committed to making their work more
accountable to their intended beneficiaries, following on from several
years of research and field trials conducted by HAP’s antecedents: the
Humanitarian Ombudsman Project (1999-2001) and the previously
mentioned Humanitarian Accountability Project (2001-2003). After
several years of consultation among its members, in 2007 HAP-I
published its “Standard in Humanitarian Accountability and Quality
Management”, and has produced an extensively updated 2nd edition
in 201035. New HAP members are required to submit an Accountability
Work plan mapping out how their organization will seek to implement
the HAP Accountability Principles, and HAP has developed a
certification system36 of compliance with its Standard.
Previously, there already existed other initiatives that attempted to
establish standards to improve humanitarian response quality.
Among them, in 1989, a coalition of NGOs in the USA formed
InterAction, which currently has almost 200 humanitarian affiliated
organizations. Its members have to certify compliance with the PVO
Standards. At the end of every calendar year, each InterAction
member is asked to review the Standards and re-certify compliance
(self-certification)37.
The rising interest in accountability has been accompanied by
increased interest by the humanitarian sector in addressing
accountability issues through self-regulation. Around the world, a
variety of self-regulatory programs have been created. These efforts
have involved the promulgation of standards by which member or
rated organizations are expected to govern themselves. Several
organizations have piloted certification mechanisms as a means to
increase the rigor with which self-regulatory standards are applied.
Certification involves an independent external review of an
organizations compliance with a given standard38. In several countries
government authorities recognize the determinations or
35
Available at: http://www.hapinternational.org/pool/files/2010-hap-standard-in-accountability.pdf 36 HAP Guide to Certification. November, 2011. 37
Formed in 1984, InterAction is based in Washington DC. InterAction’s Private Voluntary Organization (PVO) Standards, drafted
in 1991, help assure that its members are accountable in the vital areas of financial management, fundraising, governance and
programme performance. The standards were developed by the members themselves and are continually added to and
strengthened. The last revision is dated 2009. A standing committee governed by InterAction members helps oversee compliance.
http://www.interaction.org/ 38 Shea, C., Sitar S., NGO Accreditation and Certification: The Way Forward? An Evaluation of the Development Community’s
Experience. International Center for Not-for-Profit Law, Washington, D.C. 2005
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recommendations of a not-for-profit organization in decisions to
convey certain benefits.
In the year 2000, a group of agencies initiated the Quality Project39.
This project proposed a more holistic approach to quality, placing
interventions in a wider political context, and in relation to external
constraints and other humanitarian actors. It was based upon
responsibilities towards affected populations, responsibilities towards
other actors in the field, on technical and ethical guidance, the
relation with donors, and on a process in which these are analyzed.
The Quality Project evolved and in 2005 the “Quality COMPAS” was
presented as a quality assurance method specifically designed for the
quality management of humanitarian projects. The main innovation
proposed by the Quality COMPAS was a shift from quality control
(e.g. post evaluation and verification of compliance to standards) to
quality assurance (prevention by the management of critical points
during the project cycle). It is built around a unique comprehensive
quality reference system, called the Quality Rose. Affected
populations and their environment are at the heart of this quality
reference system. It is composed of twelve criteria that define the
quality of a humanitarian project, which take into account and go
beyond the OECD/DAC criteria. For example, it includes notions such
as ‘the project respects the population’, ‘the project is flexible’, ‘the
organization uses lessons learnt from experience’, etc.
Several models of certification mechanisms can be identified40:
• Self-certification is low cost, easy to administer for both the rated
and the rating organization, and is accessible to a wide range of
organizations. Because adherence to self-certification is almost solely
under the control of the rated organization, the effectiveness of this
mechanism depends in large part on the seriousness with which
individual organizations apply the program. Some organizations will
be rigorous in evaluating themselves, while others will simply sign
and submit their self-certification without significant evaluation.
.
39
Projet qualite projet pour l’amelioration de la qualite de l’action humanitaire. Groupe URD: July 2000. 40 Shea, C., Sitar S., NGO Accreditation and Certification: The Way Forward? An Evaluation of the Development Community’s
Experience. International Center for Not-for-Profit Law, Washington, D.C. 2005
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• Peer Review is one of the more rigorous evaluation methods. The
methodology is characterized by independence of the raters, technical
assistance in identifying and correcting organizational weaknesses,
and substantial responsibility on the part of rated organizations to
produce evidence of compliance with each standard. Because of its
cost and the high standard for compliance, it is a model that will be
out of reach for many organizations, such as those that are new,
small, undergoing transition, or otherwise unable to meet the costs
and burdens of participating in the program. On the other hand,
because of the rigorous standard and difficulty in compliance, the
certification, once obtained, is likely to be meaningful to donors, the
public, and others relying on the certification.
• Evaluation by a ratings organization. In this type of program, the
rating organization functions much like a traditional “charity
watchdog” organization – it solicits information from the organization
being evaluated, and supplements this by evaluations done by
evaluators it has trained to complement the information provided;
these evaluations include information obtained from, for example,
beneficiaries of the organization’s services. The watch-dog
organization then produces a rating according to the standards, and
publishes its conclusion as to whether an organization has met the
standards, as well as a report detailing its findings, for public
consumption. These programs depend heavily on the credibility of
the rating agency. The rating organization often, allows organizations
who meet the standards to display a recognition logo – such as the
“National Charity Seal”.
Accreditation by an accreditation agency: in which an audit is
performed by an authorized accreditation agency, provides perhaps
the most significant assurance that an organization meets certain
standards of quality in its delivery of services. It is without question
one of the most expensive types of mechanisms to implement, both
for the rating and the rated organization. Its use is as a result
probably best confined to those circumstances in which the
protection of the beneficiaries is paramount, such as is the situation
in the context of health response to humanitarian emergencies.
Awards. National/International awards - such as the Malcolm
Baldrige National Quality Award in the USA41 – have substantial
41 The Baldrige National Quality Award is presented yearly by the President of the United States to businesses – manufacturing
and service, education and health care organizations. Since 2006, non-profit and government organizations are also eligible for the
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prestige associated with them, with high public visibility that draws
substantial attention to the program and to the standards it sets.
Thus, while the number of organizations that have won the Baldrige
award is small, thousands request and attempt to apply its principles,
and a number of foreign countries replicate the program. This
mechanism, however, is, like accreditation, one of the most costly to
implement and out of reach for many organizations.
In the global scenario, other organizations and initiatives in which an
Accreditation Process of humanitarian actors has been established
and documented, including elements of self-assessment and
evaluation by third parties of compliance, include:
The Philippines Council for NGO Certification – PCNC: established
in 1998 approves NGOs to qualify for tax deductible charity
donations. It requires demonstration of compliance with minimum
criteria of financial management and account rendering. In the
1998-2010 period nearly 900 organizations have been certified.
The Palestinian Coalition for Accountability and Integrity- AMAN)
completed its pilot phase in 2007 with the “Nahaza Project”, and
has conferred “good governance certificates” to several national
NGOs.
The Charities Evaluation Service – CES, in the U.K. has its own
accreditation process called the “PQASSO QualityMark”.
The Cooperation Committee for Cambodia – CCC, has produced
the Code of Ethical Principles and Minimum Standards for NGOs in
Cambodia, which includes a certification process of compliance,
that has been applied to 114 international and Cambodian NGOs
(http://www.ccc-cambodia.org).
The Credibility Alliance, in India that introduced in 2007 a
certification to “Minimum Norms” and “Desirable Norms”, that has
been applied to date to 25 voluntary organizations
(http://www.credibilityalliance.org/).
The Pakistan Centre for Philanthropy – PCP, which, on the basis of
the Philippine PCNC, established in 2003 the PCP Seal of Good
National Quality Award.
To receive the Award, organizations must be “outstanding in seven areas: leadership, strategic planning, customer and market focus, information and analysis, human resources focus, process management, and business results.”
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Practice, that to date has awarded certification to 31 organizations
(http://www.pcp.org.pk/).
The organization People in Aid, that developed its People in Aid
Code of Good Practice42 , which has 182 members, of whom, to
date, 13 have verified compliance to the Code via external audit,
while 14 more are in the process of compliance verification.
(http://www.peopleinaid.org/membership/directory.aspx).
The International Search and Rescue Advisory Group (INSARAG)
accreditation initiative, for first response search and rescue
teams, endorsed in UN GA Resolution 57/150 of 16 December
2002 on “Strengthening the Effectiveness and Coordination of
International USAR Assistance”, as the principal reference for the
coordination of international Urban Search and Rescue (USAR)
response. The INSARAG Guidelines, developed and practiced by
emergency responders from around the world, serve to guide
international USAR teams and disaster-affected countries during
international USAR response operations. OCHA supports this
initiative.
The INSARAG community acknowledges the importance of
providing rapid professional USAR support during disasters which
result in structural collapse. In an effort to achieve this objective,
the INSARAG community has developed a voluntary, independent,
peer review process, the INSARAG External Classification (IEC).
The IEC has been unanimously endorsed by the INSARAG
Steering Group (ISG). To ensure that a USAR team’s international
response capability remains current and continues to subscribe to
the INSARAG methodology, the ISG has also endorsed the
INSARAG External Reclassification (IER) process. Taken together
these two processes form the INSARAG Classification System43.
In the United Kingdom, volunteer agencies from the National
Council for Voluntary Organizations organized the Quality
Standards Task Group in 1997, in response to the Deakin
Commission on the future of the voluntary sector which stated
that voluntary organizations needed to engage with quality
standards. The QSTG was set up as a 5 year project to act as a
catalyst to help voluntary and community organizations engage in
quality improvement. It aimed to provide independent, informed
42
The People in Aid Code of Good Practice in the Management and Support of Aid Personnel. People in Aid, 2003. 43
INSARAG External Classification / Reclassification Guidelines. 2011, Edition.
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and impartial advice on quality issues. In 1998 QSTG proposed a
set of quality principles which all VCOs are encouraged to adopt. A
quality voluntary organization: i) strives for continuous
improvement in all it does; ii) uses recognized standards as a
means to continuous improvement and not as an end; iii) agrees
requirements with stakeholders and endeavours to meet or
exceed these first time and every time; iv) promotes equality of
opportunity through its internal and external conduct; v) is
accountable to stakeholders; and vi) adds value to its end users
and beneficiaries44. More than 8,300 organizations are members
of the NCVO.
It is conceivable that over the next several years national
humanitarian aid programs and the institutions responsible for these
programs, require that international NGOs participate in the national
accreditation and certification schemes in order to be able to operate
in those countries; as is the case now in Cambodia, for example.
There is concern regarding to what degree those national
accreditation processes will recognize international accreditation
initiatives such as HAP, and there have been calls for the
establishment of a framework, or an institution, at international level
to facilitate the communication and development of accreditation
standards for NGOs, which would become, in a sense, an
“international association of accrediting organisms” 45.
However, to date and to our knowledge, no initiative has been
implemented to establish universal guides and standards for health
teams that respond to humanitarian emergencies, although, notably,
there have been recommendations for the use of field hospitals in
post-disaster settings (PAHO 2003).
Two close references
Among available examples of experiences with accreditation
processes in the humanitarian sector, we find two that are worthwhile
mentioning briefly. One is that of the European Community
Humanitarian Office (ECHO), and the other is that of AECID itself. We
review them although we are aware that the two processes are
44
NCVO: Quality for the voluntary sector. (http://www.ncvo-vol.org.uk/) 45
Borton, John. Overview of Humanitarian Accountability. HAP, marzo de 2009.
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indeed designed for very different purposes to those of contributing
to quality improvement of short missions during response to
humanitarian emergencies.
The process established by ECHO is the one associated with
the Framework Partnership Agreement (FPA) between ECHO
and humanitarian organizations46. This process has been in
force since 1992, and in essence it determines the aptitude an
organization (whether it is an NGO or an international
organization with a humanitarian calling, such as the ICRC or
the IFRC) to establish contracts by which ECHO finances
humanitarian action on the field. The FPA is the instrument
that sets the principles of partnership, defines the respective
roles, rights and obligations of partners and contains the legal
provisions applicable. It is understood as “a mechanism to
optimize the implementation and results of humanitarian
operations financed by ECHO”.
Throughout its existence, the FPA has undergone three major
revisions, responding not only to new EC general regulations,
but also to lessons learned, and to periodic consultation with
implementing partners, reflecting a spirit open to continuous
improvement and organizational learning. New partner
selection is based on well-defined eligibility and suitability
criteria, some imposed by the current regulatory framework of
the Commission, others arising from the need for introducing
higher quality standards.
To determine a humanitarian organization’s suitability for
ECHO partnership, the FAP includes documentation and
analysis of the following factors:
1. Administrative and financial management capacities;
2. Technical and logistical capacity;
3. Experience in the field of humanitarian aid;
4. Results of previous Operations carried out by the
organization concerned, and in particular those financed
by the Community;
5. Readiness to take part in co-ordination system set up for
humanitarian operations;
46
ECHO FPA WITH NGOs and International Organizations. ECHO 2003-2004-2008. Available at:
http://ec.europa.eu/echo/partners/humanitarian_aid/archives_fpa2003_en.htm
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6. Ability and readiness to work with humanitarian actors
and communities in third countries;
7. The organization’s impartiality in the implementation of
humanitarian aid;
8. Its previous experience in third countries.
The following minimum eligibility requirements are compulsorily
verified:
1. Act of legal registration with the national authorities and
copy of the statute/bylaws of the organization;
2. List of members of the board and organization chart, with
reference to the number of permanent full time
employees, accompanied by a sworn declaration certifying
that the organization does not fall within any pre-defined
exclusion causes
3. Annual activity reports of the last two years proving a
minimum three years of operational experience in
humanitarian aid;
4. Certified audited financial statements for the last two
financial years and indication of repartition per sector of
activities showing that at least 10% of total annual
budget is devoted to humanitarian aid Operations;
5. Subscription of a voluntary code of conduct or charter
stating the adhesion to the principles of impartiality,
independence and neutrality in the delivery of
humanitarian aid.
Organizations applying to the FAP undergo a pre-screening
procedure, respond to a screening and capacity survey and
submit a complete set of documents in support of their
declarations.
ECHO performs verification of eligibility and suitability criteria
by the following means:
- analysis of the information provided by the applicant,
with the possibility to request additional documentation;
- request of confirmation of the information provided by the
applicant and complementary information by the Member
State’s national authorities;
- verification missions by Commission representatives on
the premises of the organization.
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AECID has instituted the “Process of evaluation of NGOs
qualified as specialized entities”47, that includes criteria divided
in three blocks, as follows:
- Analysis Block 1 - compliance with pre-qualification
criteria: from the Statute of the humanitarian worker
(“Estatuto del Cooperante”) and financial status of the
organization. This block includes mandatory criteria for
the initial qualification process.
- Analysis Block 2 – Implemented improvements and good
management practices: quantitative and qualitative
evaluations from the Self-Assessment Manual (“Manual
de Autoevaluación”) performed when the organization is
presented for initial qualification and for re-qualification.
It deals with quality and management improvements
over the previous three years.
- Analysis Bock 3 – Implementation and Follow-up of
Performance Agreements: includes criteria according to
the Cooperation Agreement Follow-up Norms
(“normativa de seguimiento de los Convenios de
Cooperación”).
This process has been structured by AECID to validate
the organizations’ capacity to fulfill successfully large
scale programs over an extended period of time (several
years), and this explains why financial management
capacity is given special importance, since most of these
entail large amounts of funding to implement multiple
projects included in any given program.
These two processes (ECHO and AECID) assign paramount
importance to cost-accounting capability and financial stability,
which, although significant might not necessarily be among the main
imperatives OAH will demand for participation in short missions in
response to humanitarian emergencies.
47
Proceso de calificación de ONGDs calificadas como entidades especializadas – “Resolución de 22 de abril de 2009 de la
presidencia de la AECID por la que se establece el procedimiento para la obtención de la calificación por las ONGDs y para su
revisión y revocación”.
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Existing standards and norms regarding
formation, training and action of health response teams
1.- The Sphere Project
Among the global initiatives to set standards for NGOs engaged in
humanitarian work, although to date it has not been involved with a
certification process, it is worth highlighting The Sphere Project 48, since
“this initiative illustrates the potential for international NGOs and
donors to collaborate on standard setting for the benefit of their
constituents” (Shea 2005).
The Sphere project was launched in 1997 by a group of humanitarian
NGOs and the Red Cross and Red Crescent movement. Sphere is
“based on two core beliefs: first, that all possible steps should be
taken to alleviate human suffering arising out of calamity and conflict,
and second, that those affected by disaster have a right to life with
dignity and therefore a right to assistance.” The project provides a
handbook that includes Minimum Standards and indicators that are
intended to “inform different aspects of humanitarian action, from
initial assessment through to coordination and advocacy.” The
handbook also includes standards and indicators in four technical
areas relevant to humanitarian work. One of the notable attributes of
the Sphere project was the collaborative and participatory nature in
which the handbook and other Sphere programs were developed –
according to Sphere, representatives of over 300 organizations from
60 countries participated in some aspect of the project.
Sphere Standards regarding Health Systems
Regarding Health Systems49, Sphere standards are organized
according to the WHO health system framework, consisting of six
building blocks: leadership, human resources, drugs and medical
supplies, health financing, health information management and
service delivery. These health system building blocks are the
functions that are required to deliver essential health services.
Sphere states that health interventions during disaster response
should be designed and implemented in a way that contributes to
48 http://www.sphereproject.org/ 49 The Sphere Project. The Sphere Handbook. Humanitarian Charter and Minimum Standards in Humanitarian Response. Practical
Action Publishing, Belmont Press Ltd, Northampton, United Kingdom, 2011.
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strengthening health systems. The new Standards (2011) include
criteria for:
Health service delivery: People must have equal access to
effective, safe and quality health services that are standardized
and follow accepted protocols and guidelines. Health services are
provided at the appropriate level of the health system. Levels
include household and community, clinic or health post, health
center and hospital (see guidance note 1). Health facilities are
categorized by level of care according to their size and the services
provided. The number and location of health facilities required can
vary from context to context.
Health systems must also develop a process for continuity of care,
achieved by establishing an effective referral system, especially for
life-saving interventions. The referral system should function 24
hours a day, seven days a week.
Standardized case management protocols should be adapted or
established for the most common diseases, taking account of
national standards and guidelines. This should include a
standardized system of triage at all health facilities to ensure those
with emergency signs receive immediate treatment.
Also, health education and promotion activities should be
conducted at community and health facility levels. An active
programme of community health promotion should be initiated in
consultation with local health authorities and community
representatives, ensuring a balanced representation of women and
men. The programme should provide information on the major
health problems, health risks, the availability and location of
health services and behaviours that protect and promote good
health, and address and discourage harmful practices.
Health Service Delivery Standards also include criteria for:
o safe and rational use of blood supply and blood products
o laboratory services
o avoidance of the establishment of alternative or parallel
health services, including mobile clinics and field hospitals
(see guidance notes 7–8).
o design of health services in a manner that ensures patients’
rights to privacy, confidentiality and informed consent
o appropriate waste management procedures, safety measures
and infection control methods in health.
o disposal of dead bodies in a manner that is dignified,
culturally appropriate and based on good public health.
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The treatment in the 2011 Sphere Standards of several key topics for Health
Response Teams/Modules deserves detailed review:
Regarding the utilization rate of health services: “there is no minimum defined
threshold for the use of health services, as this will vary from context to context.
Among stable rural and dispersed populations, utilization rates should be at least 1
new consultation/person/year. Among disaster-affected populations, an average of
2–4 new consultations/person/year may be expected and >1 new
consultations/person/year among rural and dispersed populations. If the rate is
lower than expected, it may indicate inadequate access to health services. If the
rate is higher, it may suggest over-utilization due to a specific public health
problem or under-estimation of the target population. In analyzing utilization rates,
consideration should ideally also be given to utilization by sex, age, ethnic origin
and disability.”
Key indicators are defined, associated to the minimum adequate number of health facilities required to meet the essential health needs of all the disaster-affected population:
- one basic health unit/10,000 population (basic health units are primary healthcare facilities where general health services are offered) - one health centre/50,000 people - one district or rural hospital/250,000 people - more than 10 inpatient and maternity beds/10,000 people Mobile clinics: “During some disasters, it may be necessary to operate mobile
clinics in order to meet the needs of isolated or mobile populations who have
limited access to healthcare. Mobile clinics have also been proven crucial in
increasing access to treatment in outbreaks where a large number of cases are
expected, such as malaria outbreaks. Mobile clinics should be introduced only after
consultation with the lead agency for the health sector and with local authorities.”
Field hospitals: “Occasionally, field hospitals may be the only way to provide
healthcare when existing hospitals are severely damaged or destroyed. However, it
is usually more effective to provide resources to existing hospitals so that they can
start working again or cope with the extra load. It may be appropriate to deploy a
field hospital for the immediate care of traumatic injuries (first 48 hours),
secondary care of traumatic injuries and routine surgical and obstetrical
emergencies (days 3–15) or as a temporary facility to substitute for a damaged
local hospital until it is reconstructed. Because field hospitals are highly visible,
there is often substantial political pressure from donor governments to deploy
them. However, it is important to make the decision to deploy field hospitals based
solely on need and value added”.
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Health System Standards are also defined for:
Human resources: Health services should be provided by trained
and competent health workforces who have an adequate mix of
knowledge and skills to meet the health needs of the
population.
Drugs and medical supplies: People should have access to a
consistent supply of essential medicines and consumables.
Health financing: People should have access to free primary
healthcare services for the duration of the disaster.
Health information management: The design and delivery of
health services should be guided by the collection, analysis,
interpretation and utilization of relevant public health data.
Leadership and coordination: People should have access to health
services that are coordinated across agencies and sectors to
achieve maximum impact.
Sphere Standards regarding Essential health services Essential health services are preventive and curative health services that
are appropriate to address the health needs of populations affected
by disasters. They include interventions that are most effective in
preventing and reducing excess morbidity and mortality from
communicable and non-communicable diseases, the consequences of
conflict and mass casualty events. During disasters, death rates can
be extremely high and identification of the major causes of morbidity
and mortality is important for the design of appropriate essential
health services. The essential health service standards are
categorized under six sections: control of communicable diseases;
child health; sexual and reproductive health; injury; mental health;
and non-communicable diseases. They include:
Prioritized health services: People should have access to health
services that are prioritized to address the main causes of
excess mortality and morbidity.
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Control of communicable diseases - Communicable disease
prevention: People should have access to information and
services that are designed to prevent the communicable
diseases that contribute most significantly to excess morbidity
and mortality.
Control of communicable diseases - Communicable disease diagnosis
and case management: People should have access to effective
diagnosis and treatment for those infectious diseases that
contribute most significantly to preventable excess morbidity
and mortality.
Control of communicable diseases - Outbreak detection and
response: Outbreaks are prepared for, detected, investigated
and controlled in a timely and effective manner.
Child health - Prevention of vaccine-preventable diseases: Children
aged 6 months to 15 years should have immunity against
measles and access to routine Expanded Programme on
Immunization (EPI) services once the situation is stabilized.
Child health - Management of newborn and childhood illness:
Children have access to priority health services that are
designed to address the major causes of newborn and
childhood morbidity and mortality.
Sexual and reproductive health - Reproductive health:
People should have access to the priority reproductive health
services of the Minimum Initial Service Package (MISP) at the
onset of an emergency and comprehensive Reproductive Health
as the situation stabilizes.
Sexual and reproductive health - HIV and AIDS: People should have
access to the minimum set of HIV prevention, treatment, care
and support services during disasters.
Injury - Injury care: People should have access to effective injury
care during disasters to prevent avoidable morbidity, mortality
and disability. Injury is usually the major cause of excess
mortality and morbidity following acute-onset natural disasters
such as earthquakes. Many acute-onset natural disasters are
mass casualty events, meaning more people are made patients
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than the locally available resources can manage using routine
procedures. Injury due to physical violence is also associated
with complex emergencies. During armed conflict for example,
most trauma-related deaths occur in insecure regions away
from health facilities and therefore cannot usually be prevented
by medical care.
Mental health: People should have access to health services that
prevent or reduce mental health problems and associated
impaired functioning. Mental health and psychosocial problems
occur in all humanitarian settings. The horrors, losses,
uncertainties and numerous other stressors associated with
conflict and other disasters place people at increased risk of
diverse social, behavioural, psychological and psychiatric
problems. Mental health and psychosocial support involves
multi-sectoral supports requiring coordinated implementation
e.g. through a cross-cluster or cross-sectoral working group.
Non-communicable diseases: People should have access to
essential therapies to reduce morbidity and mortality due to
acute complications or exacerbation of their chronic health
condition. Population ageing and increase in life expectancy
have shifted disease profiles from infectious to non-
communicable diseases (NCDs) in many countries including
low- and middle-income countries. As a result, NCDs are
growing in importance as a major public health issue in disaster
settings. Increases in health problems due to the exacerbation
of existing chronic health conditions have become a common
feature of many disasters.
On the subject of human resources selection and training, Sphere Core
Standard 6, relative to Aid worker performance, states that
Humanitarian agencies shall provide appropriate management,
supervisory and psychosocial support, enabling aid workers to have
the knowledge, skills, behaviour and attitudes to plan and implement
an effective humanitarian response with humanity and respect.
Managers are to be provided with adequate leadership training,
familiarity with key policies and the resources to manage effectively.
Organizations must recruit teams with a balance of women and men,
ethnicity, age and social background so that the team’s diversity is
appropriate to the local culture and context. Aid workers (staff,
volunteers and consultants, both national and international) must be
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provided adequate and timely inductions, briefings, clear reporting
lines and updated job descriptions to enable them to understand their
responsibilities, work objectives, organizational values, key policies
and local context. Also security and evacuation guidelines and health
and safety policies must be established and used to brief aid workers
before they start work. In its Health systems standard 2, relative to
Human resources, Sphere defines the need for health services to be
provided by trained and competent health workforces who have an
adequate mix of knowledge and skills to meet the health needs of the
population.
Training programs: should be standardized and prioritized according to
key health needs and competence gaps.
Training and supervision of staff: Health workers should have the proper
training, skills and supervisory support for their level of responsibility.
Agencies have an obligation to train and supervise staff to ensure
that their knowledge is up-to-date. Training and supervision will be
high priorities especially where staff has not received continuing
education or where new protocols are introduced. As far as possible,
training programs should be standardized and prioritized according to
key health needs and competence gaps identified through
supervision. Records should be maintained of who has been trained in
what by whom, when and where. These should be shared with the
human resources section of the local health authorities.
Staffing levels: review of staffing levels and capacity is defined as a
key component of the baseline health assessment, and response
organizations should address imbalances in the number of staff, their
mix of skills and gender and/ or ethnic ratios where possible. The
health workforce includes a wide range of health workers including
medical doctors, nurses, midwives, clinical officers or physician
assistants, lab technicians, pharmacists, community health workers,
etc., as well as management and support staff. There is no consensus
about an optimal level of health workers for a population and this can
vary from context to context. However, there is correlation between
the availability of health workers and coverage of health
interventions. For example, the presence of just one female health
worker or one representative of a marginalized ethnic group on a
staff may significantly increase the access of women or people from
minority groups to health services. Imbalance in staffing must be
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addressed through the redeployment and/or recruitment of health
workers to areas where there are critical gaps in relation to health
needs.
With the previous considerations in mind, Sphere defines the
following types of staffing indicators:
•• - There are at least 22 qualified health workers (medical doctors, nurses and midwifes)/10,000 population - at least one medical doctor/50,000 population - at least one qualified nurse/10,000 population - at least one midwife/10,000 population.
- at least one Community Health Worker (CHW)/1,000 population - at least one supervisor/10 home visitors and one senior supervisor at Community level.
- clinicians are not required to consult more than 50 patients a day consistently. If this threshold is regularly exceeded, additional clinical staff are recruited.
Other organizations that have defined and published minimum
requisites and/or guides for their own teams include Physicians
Without Borders, the NGO International Medical Corps and also the
organization called Medical Teams International.
2.- Physicians Without Borders (MSF)
The NGO Physicians without Borders, created in 1971, has developed
minimum requisite criteria and guidelines for health professionals,
logistics personnel and administrative staff. This organization
considers it is desirable for candidates to make part of response
teams to have previous experience living or working in diverse
cultural settings, and it offers introduction courses to humanitarian
work for the new volunteers, who are then placed on a waiting list,
ready to be called for field deployment.
MSF has developed guidelines on different topics, among them the
following: Essential Medicines 2010, Clinical Guidelines 2010,
Tuberculosis 2010, Obstetrics in Remote Settings 2008, Rapid
Assessment of Health Status of Displaced or Refugee Populations
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1997. Also in internal documents such as “Influx of Wounded Pocket
Guide” and another called “Mass Casualty”, MSF establishes
definitions for health service procedures and delivery goals for its
health teams, as well as for the responsibilities of the different types
of personnel in each team.
3.- International Medical Corps
This NGO was established in 1984. It has the objective of delivering
health services on the field within the first 48 hours after a decision
for deployment. As minimum requisites, they look for “highly
trained” personnel to be included in their roster that, in addition,
must be willing and able to deploy within a period of 48 hours for
periods of 2-8 weeks. However, they don’t have specific guidelines
established for their teams.
4.- Medical Teams International
This organization sets up multidisciplinary response teams – including
physicians, general and specialty nurses, psychosocial professionals,
paramedics and technical staff. They have established minimum
requisites for personnel certification and licensure, interviews prior to
inclusion in the roster, previous experience in humanitarian work in
the field, medical certificate of physical aptitude, updated traveling
documentation, complete immunization, as well as a prior
commitment for service on the field for at least 4 weeks, with priority
given to personnel that can travel on short notice and has ability with
the local language in the site of deployment. They do not have
defined/documented Service Guidelines for their teams.
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Some aspects of the potential Accreditation Process
of Teams that participate in Health Response missions organized by
the OAH during humanitarian emergencies.
It is advisable that the Accreditation Process (AP) is set up with a
structure that follows the universal parameters of service provider
accreditation, widely used in the health and education sectors
throughout the last several decades.
These Accreditation Processes typically include the following phases:
Acceptance and adoption of proposed standards
Training and education in essential curricula
Progressive registration and documentation of experience
Self-assessment
Evaluation by Peers
External evaluation by third parties
Certification and periodic re-certification
The AP that is established for experts and organizations that provide
teams for health response to humanitarian emergencies should be
based on the compliance with a set of standards and with the
systematic application of training/learning, evaluation and
certification elements to be adopted and recommended by the OAH
as essential50.
This process must include a continuous improvement and periodic
self-assessment system, to be followed by accreditation and external
recognition. Accreditation is usually an eminently voluntary process
that provides as a main advantage the public certification and
recognition that the organization being subject to the AP meets the
required conditions to participate with quality in emergency response
missions 51. Beyond this, other applications and uses can be found for
the AP mechanism, in issues such as presentation of credentials
Additionally, other applications could be found for this AP, in matters
such as: presentation of credentials to society at large; convenience
for AECID, its OAH, and the donor community at large, that there be
organizations and groups following a formal process of self-evaluation
50
A good description of the components, timing, and mechanisms of an Accreditation Process can be found in: CCQI. The ECTAS
Accreditation Process. College Centre for Quality Improvement. London, Dec. 2007. 51
ACCSC. The Accreditation Process - http://www.accsc.org/Content/Accreditation/TheAccreditationProcess/
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and accreditation; as well as the priority that accredited/certified
HRT/Ms might have for inclusion and mobilization within missions
organized/coordinated by other international agencies or groups
(a.e.: WHO-HAC, OCHA, etc.) in response to large scale emergencies.
During response operations on the field, humanitarian organizations
always depend on one another for fulfillment of their general
objectives, and depend on other actors for provision of critical
resources (funding, equipment and supplies, kits, medicines, etc.). In
addition there is horizontal inter-dependence for the provision of
complementary services without which effectiveness of their own
actions would be hindered (for example, an intervention in nutrition
that is not accompanied by adequate shelter, water and sanitation,
and healthcare).
Until recently, efforts to improve accountability in the humanitarian
sector were focused on development of internal reporting systems
within organizations. As a growing number of organizations has
improved systems for rendering of results, the need for improvement
of reporting systems between organizations has arisen, particularly
for international NGOs, financing agencies and other donors. This
makes the present time a very opportune moment for the OAH of
AECID to consider the definition, adoption and recommendation of
standards and of an Accreditation Process for participants in
humanitarian response missions.
Independent from the specific characteristics defined for the new
accreditation process, an intense effort will be needed towards
promotion/sensitization and education of the NGOs, regarding the AP itself,
as well as its methods and tools, as has been necessary over the years for the
extended application by organizations such as AECID and ECHO of their
procedures to credential partners and providers.
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3.- Basic procedures of the Accreditation Process
To begin, it is necessary to make certain comments regarding three
fundamental aspects of the AP, as it would be applied by the OAH:
1. Who are the actors subject to the AP? Or, put another way, who
the accredited parties are.
2. What is the purpose of the AP?
3. What key problem(s) does the application of the AP intend to solve?
Regarding whom the accredited actors are, throughout this analysis
it has been considered that accreditation would be granted to
humanitarian organizations capable of providing essential health
services in response to the priority needs and risks identified with the
study of the population affected by the emergency situation. It is
important to mention that characteristically the teams/modules that
provide health services on the field are not autonomous groups, but
that they always exist as the product of the strategy and planning of
a formally established humanitarian organization or public institution
that accumulates a baggage of relevant experience.
The OAH has presented as one of its options the organization and
deployment of its own health response modular teams, composed
from a roster of selected experts. To this end, the OAH will have to
define what treatment would be given within the context of the AP to
experts that the Office might call upon individually, to participate in
specialized groups (surgery, mental health) to cover specific gaps in
essential services. It has to be understood and declared that these
experts and the groups they make part of, the “modular teams” that
would be coordinated directly by the OAH, would have to comply fully
with the accreditation criteria and/or which of those criteria must be
fulfilled as a minimum (for example, completion of essential
education in humanitarian action, healthcare in humanitarian
settings, and specific training on the applications of their individual
specialties on the field in emergency conditions).
Regarding the purpose of the AP, the OAH must define if the
objectives of the AP include its consideration for the establishment of
contracts and financing of projects to be implemented by given
organizations (these organizations would perceive the AP as a mean –
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more or less explicit/implicit – to certify their general competency in
humanitarian action, and thus as a possibility to “hook up” and
formalize their relationship with the OAH), and/or if the AP’s purpose
is only to validate the participation of organizations and their HRT/Ms
in humanitarian response operations.
Regarding What key problem(s) does the application of the AP
intend to solve, upon analysis of health response operations during
sudden onset disasters over the years, the lack of coordination of
organizations and teams that participate in health response has been
repeatedly identified as one of the most important obstacles for
quality. This problem has also been confirmed upon review of Spanish
response operations. Being this a critical problem, it also has to be
recognized as an area presenting enormous opportunities for quality
improvement. Because of this, it will be fundamental for the OAH to
include in its new Accreditation Process elements that require and
enable joint coordinated action of humanitarian actors within the
general framework of health sector response to the priority needs and
risks of the affected population, according to sector coordination
mechanisms developed as part of global humanitarian reform.
In opinion of the consultants for this AT, it must be considered
that one of the work fronts of the OAH towards quality
improvement must be the search of complementarity and
coordination of humanitarian response actors, always as a function
of identified priority needs of the affected population, and striving
to fill the gaps in services essential to respond to those needs.
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General Illustration of the potential Accreditation Process
To illustrate the potential AP, we briefly develop a concrete example
detailing specific possible scenarios, in regards to compliance with
sample verifiable criteria. We also present a possible classification for
accreditation levels or types, according to varying degrees of
compliance with established criteria. This example summarizes the
opinion of the consultants, informed by their own experience and the
bibliographic review, as well as the semi-structured interviews of
national and international stakeholders52.
The example is based on an implicit model or specific type of AP,
which is relatively simple (when compared with APs typical of some
sectors), but we believe represents a good starting point, upon which
to build on later, as time goes by and the AP is consolidated,
incorporating additional elements, and incrementally constructing a
wider framework for quality improvement of Spanish humanitarian
response, leaded and enabled by the OAH.
This illustration exercise aims to present in a clear and concise
manner some of the basic elements of the AP, including its methods
and tools:
i. The characteristics of activities required prior to the AP, or “pre-
accreditation”;
ii. The elements that can be accredited by humanitarian and other
participating organizations;
iii. The minimum requirements for compliance with the standard
for each element to be accredited;
iv. The levels of accreditation decision;
v. The period of accreditation validity, and thus the time allowed
for cycles of correction of identified deficiencies and for re-
accreditation;
vi. The specific recommendations for continuous improvement with
a view to progressive accreditation/re-accreditation, and the
types/modalities of technical assistance that the OAH and/or its
designated agents, would provide to humanitarian organizations
and public institutions in order to overcome identified
deficiencies.
52 For details regarding the interview process, please see: Calderón, M. Estébanez, P. Informe de Asistencia Técnica de la SEMHU a la
OAH de AECID. Estandarización y mejora de la calidad de la respuesta directa en salud a las emergencias humanitarias. Bases y fundamentos para un proceso de acreditación de equipos para la respuesta en salud a las emergencias. 2011.
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vii. Finally, some possible scenarios of application of the AP to
different types of organizations that might represent “typical
clients” of the accreditation procedures are briefly described.
i.- About activities required prior to the AP -
“pre-accreditation” and self-assessment:
(Example)53
To be invited to participate in the AP, humanitarian organizations
must fulfill a prior procedure, responding to a data questionnaire for
verification of experiences and capacities, and presenting a
standardized set of documents that support the declared expertise
and capacity. These will accompany a formal application document
presented to the designated Accreditation entity.
A self-assessment tool will be available in electronic form (on-line via
web) to all the organizations interested in the AP, so that they can
assess their degree of compliance with the defined Standards and
their associated criteria. The self-assessment will be recommended
prior to application to the AP, but obviously will be available at any
time that an organization might want to verify compliance (samples
of the self-assessment tool screens can be found attached to this
document).
The candidate organization must complete the application and pre-
accreditation procedure within a pre-determined limited timeframe
that is notified to the applicant in advance.
Not presenting the application and pre-accreditation documentation in
correct and due form, with veridical documentation and within the time
allotted for this purpose might (should) result in the candidate
organization being discarded from the selection process for a period
that can vary between 1 and 2 years.
The OAH and/or its designated agents will proceed with the
verification of both the eligibility and suitability criteria by any of the
following means:
- analysis of the information provided by the applicant, with the
possibility to request additional documentation;
53 Some of the following texts are based on the procedure descriptions in: ECHO. Framework Partnership Agreement with
Humanitarian Organizations. Ver. 041221. ECHO, 2004.
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- request of confirmation of the information provided by the
applicant and request of complementary information to national
authorities and to representative sector organizations in the
country were the candidate has its headquarters (be this in
Spain – like surely will be in most cases – or in another country
if, for example, the scope of AP is extended to key sector allies
in priority countries for Spanish Cooperation);
- Through verification missions/visits to the premises of the
organization, and when possible to specific sites of action on
the field, by representatives officially designated for this
purpose. The candidate will cooperate with the full and correct
completion of all verification procedures.
- The candidate organization will give the necessary authorization
for access to its information and its people, in order to complete
the previous procedures, including reports of technical and
financial results of specific projects included in the
documentation that supports the application for participation in
the AP.
Once they are defined, the general conditions for the
Accreditation Process and the application procedure must describe
in detail the specific provisions for each of the previously
mentioned steps.
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ii.- About the elements that can be accredited by organizations:
(Example) – The elements that can be accredited by organizations
participating in the AP include:
Accreditation Element 1: Experience / participation –
participation in missions directly providing health response
services in humanitarian emergency situations.
Accreditation Element 2: Services– provision of specific packages
of essential services during humanitarian health response
missions.
Accreditation Element 3: Specialized Teams/Modules– formally
established specialized Teams/Modules – with pre-defined
packages of all resources essential for work on the field for a
given period of time and a relatively stable nucleus of available
key professionals – for the provision of specific packages of
essential services during participation in humanitarian health
response missions. (This element will be applicable
independently for each specific type of service package and
Team/Module the organization wants to obtain accreditation
for).
Accreditation Element 4: Specialized Personnel- The
organization has an identifiable roster of key personnel to form
the specialized Team, including both health and technical
support professionals, according to planned service types and
activity volumes - they don’t need to be employees, but a
constant collaboration relationship with the organization can be
demonstrated for a minimum required time. (This element will
be applicable independently for each specific type of service
package and Team/Module the organization wants to obtain
accreditation for).
Accreditation Element 5: Education & Training – The
organization provides specific formal education & training
activities for the specialized professional and technical
personnel of the Teams/Modules, in subjects such as the
following: Humanitarian action. Humanitarian health response.
Joint work with the established mechanisms of coordination of
the health sector response, in particular for (i) contribution to
the joint diagnosis of health status of the affected population;
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(ii) joint assessment of priority health needs and risks; and (iii)
joint assessment and response to gaps in availability and/or
access to essential health services. Also, field logistics for
essential services and supplies to provide specified service
packages, and for self-sufficiency of Teams/Modules. Utilization
of essential drugs and supplies, and use of specialized
technologies in humanitarian response settings, Security of
Health Response Teams/Modules, etc.
iii.- About the minimum requirements for compliance
with the standard for each element to be accredited:
(Example) – Minimum requirements for compliance with the pre-
established standards for each element to be accredited include:
Requirements for Accreditation Element 1:
Experience/participation – participation in missions directly
providing health response services in humanitarian emergency
situations:
- Minimum Requirement 1.1 (example): participation in at least 2
missions a year during the previous 3-5 years.
Requirements for Accreditation Element 2:
Services – provision of specific packages of essential services during
humanitarian health response missions.
- Minimum Requirement 2.1 (example): provision of specific
packages of essential services in at least 2 missions a year
during the previous 3-5 years. (This requirement is applicable
independently for each specific type of service package and
Team/Module the organization wants to obtain accreditation
for).
- Minimum Requirement 2.2 (example): Healthcare protocols/guides
defined, documented, published and formally adopted as
benchmarks for practice during provision on the field of specific
packages of essential services. (This requirement is applicable
independently for each specific type of service package and
Team/Module the organization wants to obtain accreditation
for).
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Requirements for Accreditation Element 3:
Specialized Teams/Modules – formally established specialized
Teams/Modules for the provision of specific packages of essential
services during participation in humanitarian health response
missions. (This requirement is applicable independently for each
specific type of service package and Team/Module the organization
wants to obtain accreditation for).
- Minimum Requirement 3.1 (example): Specialized Teams/Modules
formally constituted and completed schedule of required
activities for preparation prior to deployment on short notice,
such as:
- Supply kits defined & purchased/pre-purchased
- Pre-flight and flight logistics plans reviewed and updated
- Periodic workshops for review of specialized practice
standards
- Roster commitment agreements updated periodically
- Periodic dummy run exercises of field deployment
Requirements for Accreditation Element 4:
Specialized Personnel - The organization has an identifiable roster
of key personnel to form the specialized Team, according to planned
service types and activity volumes, with a demonstrable constant
collaboration relationship with the organization for a required time.
(This requirement is applicable independently for each specific type of
service package and Team/Module the organization wants to obtain
accreditation for).
- Minimum Requirement 4.1 (example): Participation of identified
health and technical support professionals in provision of the
specialized package of essential services in at least 2 missions
a year during the previous 3-5 years.
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Requirements for Accreditation Element 5:
Education & Training – The organization provides specific formal
education & training activities for the specialized professional and
technical personnel of Health Response Teams/Modules (all
requirements regarding Element 5 are applicable independently for
each specific type of service package and Team/Module the
organization wants to obtain accreditation for).
- Minimum Requirement 5.1 (example): The organization has defined
training and education curricula, and these have been regularly
offered during the previous 3-5 years.
- Minimum Requirement 5.2 (example): A minimum of 80% of the
identified health and technical support professionals have
received/updated all required curricula during the previous 2
years.
- Minimum Requirement 5.3 (example): 100% of the identified
health and technical support professionals responsible for
coordination/management of Health Response Teams/Modules
have received/updated all required curricula relative to
coordination/management during the previous 2 years.
- Minimum Requirement 5.4 (example): The educational and training
activities cover the key subjects identified as essential
components of the required knowledge-base, for the
appropriate pre-deployment preparation of the Health
Response Teams/Modules, covering subjects such as:
Humanitarian action. Humanitarian health response. Joint work
with the established mechanisms of coordination of the health
sector response, in particular for (i) contribution to the joint
diagnosis of health status of the affected population; (ii) joint
assessment of priority health needs and risks; and (iii) joint
assessment and response to gaps in availability and/or access
to essential health services. Also, field logistics for essential
services and supplies to provide specified service packages,
and for self-sufficiency of Teams/Modules. Utilization of
essential drugs and supplies, and use of specialized
technologies in humanitarian response settings, Security of
Health Response Teams/Modules, etc.
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(iv) and (v).- About The levels of accreditation decision, the period
of accreditation validity, and the time allowed for cycles of
correction of identified deficiencies and for re-accreditation:
(Example) – Accreditation levels are established according to de
degree of compliance with the set of requirements, once the
evaluation visits verify the minimum required level of compliance with
standards is satisfied. Each Accreditation level is associated with pre-
determined validity periods. These periods define the allotted time for
deficiency correction cycles as well as Re-Accreditation. The levels of
Accreditation decision/award are:
Level 1 Accreditation (full accreditation with recognition of excellence)
Compliance with 100% of accreditation requirements – Accreditation
awarded for a period of 3-5 years (to be decided). Status as a
preferential partner for health response missions including the
specific specialty area(s) accredited. Re-Accreditation Agreement set
for the end of the award period.
Level 2 Accreditation (accreditation of sufficiency) Compliance with
80% of accreditation requirements – Accreditation awarded for a
period of 2 years. Status as an optional or 2nd line partner for health
response missions including the specific specialty area(s) accredited.
Agreement with moratorium for the correction of deficiencies over 2
years and participation in Re-Accreditation at the end of the award
period.
Level 3 Accreditation (conditional accreditation) Compliance with
50% of accreditation requirements – Accreditation awarded for a
period of 1 year. Status as an optional or 2nd line partner for health
response missions. Must operate on the field under the
accompaniment and direction of another organization fully accredited
in the same specific specialty area(s). Agreement with moratorium
for the correction of deficiencies over 1 year and participation in Re-
Accreditation at the end of the award period.
Accreditation Denial – Compliance with less than 50% of
accreditation requirements – Offer of accompaniment by the OAH
and/or its designated agents in a process of organizational learning
and continuous quality improvement that permits the organization to
present itself again for the Accreditation Process, after an
improvement cycle lasting a minimum of 1 year.
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vi.- About the specific recommendations for continuous
improvement with a view to progressive accreditation/re-
accreditation, and the types/modalities of technical
assistance that the OAH and/or its designated agents would
provide to humanitarian organizations and public
institutions in order to overcome identified deficiencies.
These items are pending development after consultation with
the OAH. This issue is of particular importance from the
perspective of highlighting and validating the role of the OAH as
leader and catalyst of quality improvement of Spanish
humanitarian response.
These examples have been developed in the knowledge that there
are still many questions to be answered regarding multiple aspects
of the proposed AP. Even more so, with the understanding that the
appropriate parties to define many of these issues are both the OAH
and the AP’s stakeholders (humanitarian organizations and public
institutions that provide HRT/Ms). This depending on the criteria
selected for certain key aspects, such as: if Accreditation is going to
be linked with policy elements that imply it is really mandatory (be
this explicit or implicit); the periods allotted for the different
Accreditation levels, as well as for the deficiency correction cycles
and for Re-Accreditation; or if the objectives of the Accreditation
Process include its inclusion in the factors taken in consideration for
the establishment of contracts and financing of projects to be
implemented by given organizations (these organizations would
perceive the AP as a mean – more or less explicit/implicit – to
certify their general competency in humanitarian action, and thus as
a possibility to “hook up” and formalize their relationship with the
OAH), and/or if the AP’s purpose is only to validate the capacity and
quality for participation of organizations and their HRT/Ms in
humanitarian response operations.
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vii. - Brief description of some possible scenarios of application of
the AP to different types of organizations that might
represent “typical clients” of the accreditation procedures.
This aims to illustrate in a general manner how the Accreditation standards and
their associated requirements could be applied. The following scenarios depict
possible frequent situations, defined by the particular characteristics of
organizations that participate in the AP.
Scenario 1: Organization that complies fully (100%) with accreditation requirements.
Type of organization: a large international NGO. The organization receives
Level 1 Accreditation for a period of 3-5 years. During that period it enjoys
status as a preferential partner for health response missions including the specific
specialty area(s) accredited. In coordination with the OAH, it may establish
agreements with other organizations that have been given conditional accreditation,
to accompany them in health response missions, and assist them in their quality
improvement journey. Re-Accreditation Agreement is set for the end of the award
period.
Scenario 2: Organization that complies with 80% of accreditation requirements.
Type of organization: a consolidated NGO that complies with technical requirements
for health services in the chosen specialty area(s), but complies only partially with
the requirements for education and training in humanitarian issues and does not
have any demonstrable capacity/experience in epidemiologic surveillance nor in the
use of tolls for joint assessment of priority health needs and risks of the affected
population. The organization receives Level 2 Accreditation for a period of 2
years. During that period it has status as an optional or 2nd line partner for health
response missions including the specific specialty area(s) accredited. Agreement
with moratorium for the correction of deficiencies over 2 years and participation in
Re-Accreditation at the end of the award period.
Scenario 3: Organization that complies with 50% of accreditation requirements.
Type of organization: a small NGO that does not comply fully with technical
requirements for health services in the chosen specialty area(s) - it wants to be
accredited in surgical services in support of national hospital capacity, but does not
have in its roster surgeons with the required education/training/experience in
surgical humanitarian response; or it wants to deliver basic ambulatory health
services but does not have a working procurement/distribution process for essential
drugs and medical supplies. Neither does it comply with the requirements for
education and training in general humanitarian issues.
Many European Civil Protection Standard Health Team/Modules, organized by either
regional or municipal authorities, might fit in this typology, at least during their
initial formative and consolidation periods.
The organization receives Level 3 - Conditional Accreditation, for a period of
1 year. It must operate on the field under the accompaniment and direction of
another organization fully accredited in the same specific specialty area(s).
Agreement for participation in Re-Accreditation at the end of the 1 year award
period, with moratorium for the correction of deficiencies during that time.
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4.- Commentary on the utility of the proposed AP
The following would be some of the results that could be expected upon
adoption and extended application by Spanish organizations of the
standards for essential components of health humanitarian response; being
these accompanied by self-assessment and continuous improvement
initiatives, as well as by participation in an Accreditation Process with its
self-, peer-, and external reviewer-evaluation procedures:
o Improved efficacy and effectiveness of Spanish humanitarian response,
assuring its results and impact are more predictable.
o Contribution to overall improvement of Spanish Humanitarian
Assistance, in accordance with AECID`s and OAH’s mandates, as well as
with the current global humanitarian reform initiatives.
o Better coordination and complementarity between organizations involved
in Humanitarian Response, derived from the integrated and coordinated
formation and action of qualified health teams.
o Availability of a clear roadmap so that humanitarian actors who provide
health response teams can implement a system of auto-evaluation and
continued improvement.
o Convenience for AECID, the OAH, and the donor community at large,
that there be organizations and groups following a formal process of
continuous improvement.
o Opportunities for regional administrations and municipalities to allocate
technical resources and form human resources to constitute health
response teams according to best practice standards and civil protection
mandates.
o Inclusion of all key humanitarian actors in the health sector, while still
respecting their individual mandates and program priorities.
o presentation of credentials to society at large
o convenience for AECID, its OAH, and the donor community at large, that
there be organizations and groups following a formal process of self-
evaluation and accreditation
o the priority that accredited/certified HRT/Ms might have for inclusion and
mobilization within missions organized by other international agencies or
groups (a.e.: WHO-HAC, OCHA, etc.) in response to large scale
emergencies.