Bases for an Accreditation Process of Foreign Medical ...Mauricio Calderón Ortiz and Pilar Estébanez Estébanez Members of the Spanish Society of Humanitarian 2Medicine (SEMHU )

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.

http://www.smartindicators.org/docs/quality_humanitarian_aid.pdf

http://www.alnap.org/pool/files/day3-spatel.pdf


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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

http://www.aama-ntl.org/resources/library/CMAandRMA.pdf

http://www.aama-ntl.org/resources/library/CMAandRMA.pdf


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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.”

http://ec.europa.eu/echo/about/actors/archives_fpa2003_en.htm


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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

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

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121289/pdf/740.pdf

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

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

http://helid.digicollection.org/en/d/Jh0204e/8.3.html


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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


Página 21 de 59

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.


Página 23 de 59

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).


Página 24 de 59

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/

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

http://www.hapinternational.org/pool/files/2010-hap-standard-in-accountability.pdf

http://www.interaction.org/


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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


Página 29 de 59

• 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


Página 30 de 59

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.”

http://www.ccc-cambodia.org/

http://www.credibilityalliance.org/


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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.

http://www.pcp.org.pk/

http://www.peopleinaid.org/membership/directory.aspx


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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.

http://www.ncvo-vol.org.uk/


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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

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.

http://www.sphereproject.org/


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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/

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.


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



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



for).


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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


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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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.

Documents

Bases for an Accreditation Process of Foreign Medical ...Mauricio Calderón Ortiz and Pilar Estébanez Estébanez Members of the Spanish Society of Humanitarian 2Medicine (SEMHU )