Part IV: The Role of the RBM Partnership
10. Humanitarian Crises
Up to 30% of malaria deaths in Africa occur in the wake of war, local violence or natural disasters. Malaria deaths often far exceed those that are directly caused by the emergency.[46]Guiding principles for malaria control in acute and chronic phase emergencies in Africa, Conclusions of WHO/ Roll Back Malaria
Consultation. Geneva, World Health Organization, 2004.
Furthermore, civil unrest has led to significant malaria resurgences in the past, for example in Afghanistan and Burundi.[47]Fatoumata Nafo-Traoré and David Nabarro. Breaking the cycle of malaria and death in emergencies: the way forward. Humanitarian Practice Network, 2008.
Click for source
To achieve the goals of the RBM Partnership, especially in the scale-up and sustained control stages, special efforts must be made to control malaria in humanitarian crises as these situations may quickly lead to a loss of the benefits achieved previously by the malaria control programs and a deterioration of malaria control in the affected country.
A humanitarian crisis is a situation which is triggered by either manmade disasters or natural disasters or even both. Most emergencies follow disasters of human cause and are described as situations that affect large civilian populations with war or civil strife, food shortages and population displacement, resulting in excess mortality and morbidity.[48]Malaria in Complex Emergencies: An inter-agency field handbook. Geneva, World Health Organization, 2005.
Click for source Humanitarian crises have an acute phase (immediate: 0 to 4 weeks; stabilization: 4 to 10 weeks) and a chronic phase (recovery: several months; settlement or repatriation: months or years). During the acute, immediate phase, the affected people are usually not accessible. Also, shifts between different phases for many years are common.
Today, the evidence suggests that natural disasters are becoming as common as manmade disasters and affect as many if not more people (e.g. tsunami, earth quake, large scale flooding, and famine). Humanitarian crises and other emergencies can undermine pre-existing malaria control measures and lead to a collapse of health services. If malaria was previously not endemic, the populations may have limited coverage with effective treatments and preventive measures. Displaced persons living in makeshift housing are vulnerable to malaria because they are more likely to be bitten by mosquitoes, are often ill with other infections and lack access to health care.
International responses to humanitarian crises follow highly coordinated processes. For example, when faced with a crisis, the Office for the Coordination of Humanitarian Affairs (OCHA) with guidance from the Inter-Agency Standing Committee (ISAC) coordinates the humanitarian activities of UN agencies and international NGOs.[49]See Health Action in Crisis webpage.
Click for source Humanitarian activities are grouped into 11 clusters, of which the ‘health cluster’ is currently led by WHO. International agencies involved in the health cluster are aware of the risks of malaria and are involved in distributing Interagency Emergency Health Kits. These kits are always supplied with the malaria modules and are designed to meet the initial primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate aftermath of a natural disaster or during an emergency.[50]The Interagency Emergency Health Kit 2006, An interagency handbook, Geneva, World Health Organization 2006.
Click for source For malaria, the basic malaria module includes artemether-lumefantrine, quinine sulfate and rapid diagnostic kits.
Furthermore, in humanitarian crises, the Communicable Diseases Working Group on Emergencies (CD-WGE) at WHO headquarters provides technical and operational assistance, including risk assessments, technical notes and country specific profiles. Technical notes provide up-to-date guidance on the major communicable disease threats to health professionals in UN agencies, nongovernmental organizations, donor agencies and local authorities working with populations affected by emergencies. The WHO-Global Malaria Program (GMP) contributes malaria-specific information to these technical notes.
Priorities
The Malaria in Emergencies Network (MEN) serves as a mechanism to provide effective and efficient response in malarious countries affected by humanitarian crises and other emergencies. Responses include evidence-based, malaria-specific guidelines and technical assistance to partners and agencies implementing humanitarian aid. MEN consists of more than 60 members from numerous organizations such as WHO, UNICEF, Merlin, the MENTOR Initiative, and Médecins Sans Frontières.
Priorities for scaling up. For 2010, the RBM Partnership will enhance the current mechanisms to support high-burden control countries in humanitarian crises. These mechanisms include the support by the Harmonization Working Group and support by the WHO-GMP. The RBM Partnership will also ensure a close link and active participation with the Malaria in Emergencies Network, which is facilitated by WHO.
A) Support countries in humanitarian crises. The Harmonization Working Group, WHO-GMP and the MEN as well as other partners supporting scale-up will provide support where it is possible, for example in countries that are experiencing prolonged humanitarian crises, such as Sudan, Chad and the Democratic Republic of the Congo. For example, the partners will help develop applications for funding from sources such as the Global Fund and will provide technical assistance to strengthen and develop malaria control programs.
B) Ensure a strong Malaria in Emergencies Network. WHO facilitates MEN, which is open to all major partners and implementing agencies. The network hosts regular telephone conferences and has an email listserv to share vital information. WHO will continue to support and encourage participation in this network. To strengthen the network, there will be a review of the list of current members and additions will be made as necessary. There should be regular consultations of experts, such as the participants in MEN, perhaps through biannual meetings and other forums. The RBM Partnership should advocate for the importance of these meetings to strengthen the global response and support in humanitarian crises and assist with raising the required resources.
C) Ensure exchange between RBM and MEN. The RBM Partnership will provide a close link and active participation with MEN. This may include recommending that the Harmonization Working Group continues to have a representative participate in MEN and key MEN members participate in select RBM meetings during the year, e.g. the HWG meeting. The RBM Partnership will also promote better visibility of MEN by providing a link on the website and by regularly posting upcoming and recent activities and developments together with the MEN facilitator.
D) Update the handbook on Malaria in Complex Emergencies. In 2005, WHO published a detailed inter-agency handbook: Malaria in Complex Emergencies. This handbook provides policy-makers, planners, field program managers and medical coordinators with practical guidance for designing and implementing measures to reduce malaria morbidity and mortality. MEN is currently facilitating the production of an updated handbook. The next edition should provide not just technical advice but solid “delivery strategies” that have been proven to work in emergencies and which are appropriate in different “humanitarian crisis” settings, e.g. developed to focus on both man-made and natural humanitarian crises.
E) Advocate for sufficient supplies for rapid response. The RBM Partnership will advocate that malaria modules continue to be included in international emergency health kits. The RBM Partnership will also advocate for the continued funding and availability of Interagency Emergency Health Kits.[51]Malaria in Complex Emergencies: An inter-agency field handbook. Geneva, World Health Organization, 2005.
Click for source The RBM Partnership, with guidance from MEN, will assess the recommendation to have a small stockpile of the kits, or potentially only the malaria modules, available for immediate delivery in a humanitarian crisis. Such a stockpile could be coordinated and logistically organized with the WHO-Health Action in Crises Operations Group and pre-positioned at the hubs in Dubai and Accra.
F) Advocate for resources in humanitarian crises. During the acute phase of humanitarian crises, there is often a need for technical assistance from a malaria expert for a short time period, such as three weeks. The RBM Partnership will advocate for the importance of such support to partner organizations.
During prolonged humanitarian crises, special funds support the development of malaria interventions to coordinate activities within the country. In addition, the funds help countries support a full-time person to redevelop their malaria control programs. These positions have the role of being international program officers supporting the coordination of the activities of the UN agencies, international and local NGOs. These positions also work closely with implementing partners (international and local NGOs) in ensuring that funds and evidence based tools are available to ensure health staff on the ground adequate technical capacity building and supervision to use tools effectively. Successful examples in the past have been in Afghanistan,[52]Kolaczinski J. Roll Back Malaria in the aftermath of complex emergencies: the example of Afghanistan. Tropical Medicine and International Health, 2005, Vol. 10.
Click for source Liberia, the Democratic Republic of Congo and Sudan (Southern Sudan).[53]Dr. José Nkuni, World Health Organization, personal communication, 2008.
The RBM Partnership will advocate for financial resources to facilitate the recruitment of short term staff.
G) Encourage operational research into best delivery approaches. Operational research for humanitarian crises is important to identify effective delivery mechanisms for all emergency situations. The RBM Partnership will also try to create a better understanding of how to support countries in the shift from the humanitarian crisis situation back to a normal, strong malaria control program.
Priorities for sustained control and elimination. As countries move into sustained control and elimination, the potential risks of re-emergence following humanitarian crises will be substantial, especially in areas with high natural transmission levels. Continued emphasis on country preparedness will be important to guard against failures of malaria control in humanitarian crisis situations of the future.
H) Continue advocacy. The RBM Partnership will advocate maintaining the awareness of malaria in humanitarian crises with international donors and with governments. This is particularly important when malaria control programs are successful and malaria is at low levels. Given the possibility that countries with successful malaria control can also be put at risk if their neighbors are experiencing displacement and migration, the RBM Partnership will advocate for funding and technical assistance on malaria control across entire regions. The goals will be to implement malaria interventions in emergency situations and also to maintain existing malaria control structures.
I) Planning for humanitarian crises. In addition, complimentary to a strong response mechanism once a humanitarian crisis occurs, it is fundamental that countries are prepared and have plans as well as emergency stocks in place to deal with a humanitarian crisis. For example, in anticipation of the humanitarian crisis in Iraq, partners increased malaria commodity stocks within the country to allow for continued malaria control when procurement or delivery of commodities is difficult or impossible. The RBM Partnership will continue to provide support to countries with guidance and best practices for how such preparation should look.
J) Encourage research to modify tools for humanitarian crises. The RBM Partnership will support research to identify innovative tools for prevention and cures that are suitable in humanitarian crisis and poorly prepared malaria epidemic situations. One example would be new formulation ACTs that significantly reduce the daily number of tablets to be taken.
Organizational Implications
The existing mechanisms should be reinforced and strengthened. The RBM Partnership will consider a dedicated liaison with the Malaria in Emergencies Network, to ensure alignment and to provide support where required.
In terms of costs, there is a need for an increase in resources towards mechanisms that are required to help in humanitarian crises. These include strengthening MEN, funding full-time staff in a few high priority countries to coordinate the activities within countries in prolonged humanitarian crises, funding the stock pile of interagency emergency health kits (IEHKs) and funding operational research into new approaches and tools. The RBM Partnership could provide support by advocating for these resource needs.
Table IV.11: Summary of Humanitarian Crises Activities
| Reference to priority | Major actions | Completed by | Coordinator (bold) / Sub-coordinatorsa |
| A | Coordinate implementation support to high-burden countries in humanitarian crises (e.g. DRC) | Ongoing | HWG, SRNs |
| D | Update Interagency Handbook on Complex Emergencies with major partners | 2010 | WHO-GMP (MEN) |
| E | Advocate for continued inclusion of malaria commodities for treatment and diagnostics in emergency health kits due to risks of malaria in humanitarian crises | 2010 | WHO-GMP (MEN) |
| F | Advocate to donors and international community for need of sustained financial support in drawn-out humanitarian crises | 2010 | MAWG |
| C | Collate and publish information on humanitarian crises on WHO-GMP website, as well as a link to this site from the RBM Partnership website | 2010 | WHO-GMP (MEN), RBM Secretariat |
| A, I, F, H | Provide technical assistance to countries in sustained control and elimination to incorporate detailed plans for malaria control in humanitarian emergency situations into their overall planning process | 2015 | WHO-GMP (MEN), HWG |
| G | Encourage operational research into new interventions for the management of malaria in humanitarian crises, e.g. blankets, insecticide-treated sheets, etc | 2015 | WHO-GMP (MEN) |
a) Main coordinating group / body in the RBM Partnership indicated in bold. Closely linked contributors within the RBM Partnership are also listed. RBM Partners are not listed explicitly as their involvement occurs through the Working Group.
