HEALTH IN EMERGENCIES - WHOlistening, sharing experiences both formally and informally, and more through evaluations and lessons learnt workshops. One of the newer models of learning

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World HealthOrganization

HEALTH INEMERGENCIES

Issue No 16, April 2003

HEALTH INEMERGENCIES

LEARNING IN HUMANITARIAN ASSISTANCE 2CURRENT DEBATES

LEARNING IN THE FIELD

LEARNING FROM TEACHING

LEARNING THROUGH EVALUATION

EHA REGIONAL CONTACTS 16

When Médecins Sans Frontières (MSF) was awarded theNobel Peace Prize at the end of the last decade, its founderBernard Kouchner responded to the news of the prize bysaying that he ‘hoped the prize marks the recognition ofa new type of humanitarian work which fights injusticeand persecution’. The ‘new humanitarianism’, based ona rights based approach, argues that giving aid is morethan just about saving life - it is also about tackling theroot causes of conflict and delivering aid in a way that canultimately reduce violence and promote recovery,development and peace. Thus, for the modern emergencyhealth workers technical training by itself is not enough.they are also supposed to have a good understanding ofInternational Humanitarian Law and Protection, be able tocarry out context analysis and make linkages between shortterm relief and longer-term rehabilitation, recovery andpeace-building.

In practice however, it is doubtful that these links are beingmade, through aid in general, and more specifically throughemergency health interventions. The most recent analysisfrom the Active Learning Network for Accountability andPerformance in Humanitarian Action (ALNAP) evaluativereports data base reveals much short-term success inemergency health but a failure to link short-term objectiveswith any real lasting benefit. Evaluators found that inrecent emergency interventions, mortality and morbidityrates had been stabilised and infectious diseases had beenkept under control, often in conjunction with water andsanitation interventions. For example, health interventionsamongst flood affected populations in Mozambiqueprevented measles and cholera epidemics, meningitis andmalaria (ALNAP, 2002).

But short-term gain did not translate into longer-termcapacity building. For example, the Nyanza hospital inRwanda showed a very low attendance rate and wasunderstaffed. Even though the structure itself was of highquality and hence relatively stable, there was evidencethat investment had ignored contextual factors thatdictated the relevance of the project. These included priceof health services, transportation difficulties, distrust inthe quality of the staff, ethnic distrust in cases wherepatients came from one ethnic background and health careproviders from another.

In addition, a detailed analysis of ECHO health, nutritionand water/sanitation emergency interventions in SierraLeone found that the projects created better conditionsfor health staff but the issue of long term capacity of publicservices to sustain the required level of delivery remaineda very significant constraint (ALNAP 2003 forthcoming).

As one commentator put in ‘ can a relief operation beconsidered a success if, although the patient survives,the local emergency medical team that will treat thepatient’s next emergency remains marginalised orincapacitated?’

We are already aware of a number of ‘learning disabilities’- structural problems that impede both learning andpositive changes in the behaviour of relief workers andagencies. These include: high rates of staff turnover,excessive reporting demands, lack of reflective time in thefield, a general lack of training and training not linked toactive learning, a shortage of appropriately skilled andqualified personnel especially in the areas of managementand health and language skills.

ALNAP’s Annual Review 2002 summarised the problemthus: “For the performance of the sector to be dependenton a continuous supply of willing and able staff preparedto ‘give their all’ for a few years and then drop out towork in sectors that offer a more stable and secure lifestylecannot be sustainable. It is certainly not conducive tothe development of a strong learning culture”.

So, what can be done? Perhaps the first and mostfundamental step is for humanitarian organizations toprioritise developing the quality of their staff by offering

The New Humanitarianism: Challenges for Emergency Health Sectorto Improve Learning and Competencyby John Mitchell, Coordinator, ALNAP Secretariat

In This Issue

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HEALTH IN EMERGENCIES

WORLD HEALTH ORGANIZATION

LEARNING IN HUMANITARIAN ASSISTANCE

“Learning” in the humanitarian world is a relatively new,but already over-used term. It can mean anything fromsharing field experiences, monitoring and evaluatingprogrammes, lessons-learnt exercises or formal training.Most organizations operating in the humanitarian spherehave become self-declared “learning organizations” andmany are grappling with what this means in their day today activities.

The ultimate goal for “learning” is simple: to improvethe quality and effectiveness of humanitarian action. Butthe world of humanitarian action is complex, fast evolvingand still trying to define itself. It involves practical, hands-on work in changing and sometimes dangerous situations.It attracts a myriad of professionals from all sectors. Therules are still being written and at the same time, thedemands for accountability and professionalism are ever-increasing. As such, learning is treated with cold toleranceto boiling contempt.

The proliferation of natural disasters and complexemergencies over the last decade means that there is muchaccumulated experience that could and should be used toimprove humanitarian action. This knowledge andexperience needs to be identified, collected, analysed,packaged and transferred to an ever-increasing numberand diversity of humanitarian actors. Learning throughexperience can help demonstrate the essential link betweendevelopment and emergencies, serve as a strong advocacytool to draw attention to key issues and facilitate change.

In the humanitarian field, we learn from experts, we learnfrom each other and sometimes when we are astute enoughwe learn from the “beneficiaries”. We learn throughlistening, sharing experiences both formally and informally,and more through evaluations and lessons learntworkshops. One of the newer models of learning fromhumanitarian experience is a pilot Learning Support Officein Malawi which aims to facilitate learning from the fieldexperience and between the various actors in the field andprovide learning to other countries and regionsexperiencing similar situations.

The traditional role of learning has been with evaluatorsand researchers. But even solid evaluations and researchare often paid little or no attention and the learningsidentified are not applied. (Hence the cynicism linked to

Learning in the field: Aprofessional responsibility ofhumanitarian workers

“They need us only because they are still alive.......and as they are still alive they have something toteach us.”

longer-term contracts to tackle short-termism and byproviding more time and space for reflection and learning.A recent study on monitoring found that many reliefworkers complained of a crippling reporting burden,coupled with no ‘time to think’. The metaphor of a‘headless chicken’ may be unkind but we all recognise itnonetheless.

The message from the field is that that mangers andagencies must aim to create more ‘learning space’. Mostpeople learn best from concrete experience. But this isnot enough in itself. There needs to be time created forreflective observation (reflecting on the experience)abstract conceptualisation (forming theories andconclusions about the experience from the reflection) andactive experimentation (practising with the new theoriesbefore having a new experience).

Many agencies have already picked up on these ideasand efforts are underway to attempt to turn the rhetoric ofthe ‘learning organization’ into a reality. These includethe ICRC’s three layered approach to learning (inductiontraining, training for consolidation and training forspecialism) and UNHCR’s new staff development strategyoutlined in its learning policy and guidelines.

Other initiatives aim to create much needed space forreflection such as ‘after action reviews’, that areincreasingly being used to allow emergency personnel toreflect on their experiences. For example, World Visionused AAR’s in the recent Southern Africa crises to prioritisekey lessons that in turn informed their management andmonitoring systems.

Other agencies are finding that mentoring also can be anextremely useful source of knowledge transfer and thereis an increase in the number of training courses run byagencies such as RedR and Merlin, some of which are runin the regions to allow national staff to access training.Regular debriefings that occur the end of one assignmentand the beginning of another have always been important.There are also signs that web based training is beginningto have an impact.

The challenges to emergency health personnel laid downby the new humanitarianism are great. But as a culture oflearning begins to grow through these kinds of initiatives,there is every chance that those in the humanitarian sectorwill improve their understanding and competencies andwill provide a more effective and lasting service to themost vulnerable in future.

References: ALNAP Annual Review 2002 and forthcoming 2003-02-07 Georgina Brook. The Path to Professionalism: A Study ofthe Importance of Learning for the Humanitarian Worker.



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New Challenges for OrganizationalLearning

Development, relief and conflict transformationorganizations are recognizing that effective work requiresmore competencies than just technical ones. They arealso experimenting with new learning methods. But anysignificant improvement in organizational learning will bedependent on management changes.

New competencies: Historically agencies have emphasized‘technical’ knowledge and skill, complemented bymanagement administration skills (especially financialmanagement and planning, proposal and report writing).There is now greater appreciation of the need tounderstand the context in which one operates, not just interms of the institutional environment (with its policies,budgets and institutional dynamics), but also in itshistorical, socio-cultural and political dimensions.Additionally skill in relationship management is nowrecognized as a vital requirement for ‘good performance’.Hence the interest in ‘leadership’ and ‘leadership training’,a rather fuzzy label that can cover different ingredientsand that begs the question whether you can developpersonality traits through ‘training’.

New learning methods: Many staff of aid agencies stilltestify that most of their learning is ‘on-the-job’. This ishighly problematic: while there is undeniable value in‘experiential learning’, unguided ‘learning-by-doing’ inpractice amounts to much ‘trial-and-error’, reinventing ofthe wheel and repetition of by now-avoidable mistakes.The most common approach to agency-driven staffdevelopment, certainly in larger organizations, is throughtraining courses and workshops. While these have value,the new thinking is that organizations should create moreopportunities for team-based and team-driven learning.Some of the approaches being tried are: after-actionreviews, learning groups within an organization (in situamong field based teams but also across the organizationthrough Internet based exchange of ideas and

evaluations). Organizations that want to apply theselearnings are unable to transfer them to staff and partners.This gap can be filled by turning learnings fromevaluations and research into simple tools such asguidelines and handbooks. And training can help transferthis knowledge to the practitioner. These are all steps tolearning. They are interdependent and often uselesswithout the others.

Learning actually happens in some organizations, someof the time. The challenge is to make it part and parcel ofall humanitarian work. Improved humanitarian action mayresult.For more information please contact G. Gamhewage [email protected]

experiences), peer learning groups across organizations(e.g. programme managers from different agencies basedin the same location that trust and respect each otherenough to regularly meet around a certain topic orchallenge), and more effective use of reflective staffgatherings to review contextual, policy and programmaticissues rather than wait for the ‘big’ evaluation. Additionally,agencies are experimenting with developing and makingavailable self-study learning resources, often on CD-ROM.One element remains key in these mostly interactivestrategies: intellectual (and emotional) leadership to pushthe questions, draw out the insights and lessons andmanage the emotions.

New management approaches: Where time and budgetsare stressed, learning is often one of the first casualties.Organizational commitments are required to bring practicemore in line with the rhetorical importance attached tolearning. Thus organizations need to make a policycommitment to learning and write the responsibility tofoster learning in the job description of managers and holdthem accountable. Learning objectives are to be writteninto programme and project plans, with time and budgetaryresources allocated to learning. The organizational cultureshould not stress hierarchy for learning to thrive. Forlearning to thrive the organizational culture must not stresshierarchy. Learning also has to be built into the performanceappraisal process and staff that demonstrate learningresults need to be rewarded.For further information contact K. Van Brabant, Research Fellow,Disaster Studies, Wageningen University [email protected]

Learning Support OfficeUnder design for over two years, the international humanitarianlearning network, ALNAP, established a pilot Learning Supportoffice (LSO) in Malawi in October 2002. The LSO model aimedto explore how humanitarian action can be maximized throughreal-time, field based learning.

The Office provided a focus for sharing of information andexperiences between different humanitarian actors in the field,providing easy access to references, tools and guidelines andenabling lessons learnt to be compiled and shared withinMalawi and internationally. The LSO provided a physical andvirtual focal point for all humanitarian actors, national andinternational, involved in the Southern African crisis. The LSOhad a resource centre, electronic databases, web sites. Itconducted briefings, trainings and provided opportunities fordiscussion and mutual leaning throughout the crisis.

The LSO pilot experience is now being evaluated and if foundto be useful and transferable, may provide a model for fieldlearning in future emergencies. WHO has been involved in thedesign of the project and is currently serving on the SteeringCommittee for the pilot LSO.For more information see: www.alnap.org

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After having worked in different complex emergencies, itbecomes easy to recognise common features in both themanifestations of the emergencies and the ways reliefagencies respond to them. In fact, the most common causesof disease and death in a crisis have been long sinceidentified. The main ways health sectors react and adaptto a protracted crisis are also well known. Articles andbooks have pointed out the key interventions that needto be provided in order to reduce excess morbidity andmortality in emergencies1,2.

These considerations do not imply that one size fits all.Knowing the historical background, the actors and thecontextual factors of a crisis is critical for understandingits evolution and acting to mitigate its impact. Thus, oneneeds to go beyond the immediate causes of morbidityand mortality, and explore the underlying determinantsthat affect systems’ capacity to address health needs.

If some of the manifestations of the impact of emergenciesrepeat themselves, and the range of strategic andoperational options is limited, we can wonder why thesame mistakes are repeatedly made and the sameopportunities are constantly missed. It seems that “almostuniversal” lessons are frequently ignored by decision-makers and seldom acted upon by humanitarian workers.Minear3 identifies four impediments to learning: thetendency of humanitarian organisations to approach everycrisis as unique, their action-oriented nature, theirdefensiveness to criticism, and their lack of accountability.Cracknell4 looks at other factors, such as inertia, riskaverseness, rigid structures and organisational culture,which explain why knowledge originated from evaluationsdoes not always translate into action and improvement.We can also add the rapid turnover of staff, due to securityand hardship factors, that curbs documentation anddissemination efforts. Additionally, information systemsare the first victims in emergencies: the routine collectionof data collapses, communication is weakened, other mosturgent priorities compete with analysis and interpretationof information. Psychological factors also count: chroniccrises determine a general lack of confidence in afavourable outcome and short-sighted perspectives, whilemeaningful knowledge requires a sustained investmentin consolidating reliable information over time. The “riskof learning the wrong lessons and of inappropriate transferof lessons between contexts”5 can also be a deterrent tolearning and applying knowledge, mainly to newcomerswho are unfamiliar with the complex context.

The oral communications culture can also be a factor.Mobile phones, radios and other gadgets have replacedmore traditional written channels and humanitarian workers

Endnotes1 Médecins Sand Frontières, 19972 Waldman RJ, 20013 Minear L, 19984 Cracknell BS, 20015 Van Brabant K, 19976 Berg E, 2000

For further information and a complete list of references, pleasecontact S. Colombo at [email protected]

“we don’t learn lessons very well and the lessons we do learnare often the wrong lessons”

Roundtable on Humanitarian Action in Iraq, ISIM, 2003

often rely on these devices at the expense of morestructured methods of communication. The caricaturedimage of a typical field relief worker is that of someonewho is action-oriented, and as such, insensitive to localcontext, indifferent to the need for understanding andscarcely interested in scholar studies. The consequenceson the capacity of documenting and learning from othersare apparent.

Both the lack of information and its opposite, overload,evident during emergencies, are hurdles to learning.Access to documentation produced elsewhere is oftenhindered by electronic connectivity limitations and at thesame time, the aid practitioner can be easily overwhelmedby too many documents that are impossible to absorb. Anincreasing number of evaluations of humanitarianassistance programme are being carried out, but this terrainis fraught with many methodological, ethical andoperational problems, and shortcomings in evaluationcannot be ruled out as additional obstacles.

Can we conclude that the inability of humanitarian agenciesto learn is a special case of the overall incapacity of aidorganisations, so well illustrated by Berg6? It would seemso, since some of the obstacles to learning identified byBerg for developmental agencies also apply tohumanitarian sectors: complexity, diversity and change incountry environments, evaluations’ deficiencies andinternal organisational factors.

Complex emergencies and post-conflict settings areturbulent contexts. Rapid changes, background noise andprimacy of action over other activities are commoncharacteristics of these environments. However, over thelast years, the body of knowledge on health in emergencieshas substantially grown, and its access has become easier.Studying lessons learned in other emergencies,documenting successes and failures, assessing howknowledge can be transferred and adapted to othercontexts are key activities in order to avoid the risk ofwrong decisions, counterproductive interventions and thewaste of precious resources.

Why is learning from past field experience so difficult in humanitarianassistance?



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Learning in the field: Minimum Standards for Successful TrainingIn order to have measurable impacts, it is vital that trainingis consistent, becomes institutionalised and converts intocapacity building. During the last two years, the EHAprogramme in WHO Nepal has gained considerableexperience in how to ensure training has measurableimpacts at the individual, agency and national levels.

Although the minimum standards suggested below aregeneric, they reflect the learnings from a mass casualtymanagement training programme in Nepal. The training isimplemented in collaborationwith the national disaster healthauthorities in the Epidemology& Disease Control Division ofthe Department of HealthServices, Ministry of Healthand the Disaster HealthWorking Group Secretariat.This is what we have learned:

I) Training must addressperceived needs. Medicaldoctors and health sectoremergency planners in Nepalfrequently express the urgencyof enhancing mass casualtymanagement because theyhave to respond to road traffic accidents and live with theever-present threat of a major earthquake. In response tothis, WHO and the national health authorities areimplementing a comprehensive mass casualty managementtraining focusing on stabilisation, triage and logistics.Almost one thousand health sector staff and firstresponders have been involved in the training.

II) Training must be contextualized. The computersoftware “Multi-User System for Training EmergencyResponse” (MUSTER) was field tested in WHO SEAROand WHO Nepal to ensure that users with limitedcomputer experience could adjust to the software withinone hour and that team work minimised the need forhardware knowledge. Moreover, the MUSTER producersdesigned a Nepal-specific earthquake scenario. Desk-topsimulations and mock drills were customized to reflectconditions in Nepal such as unreliable electricity supply.

III) Training modalities must be appealing. Interest andvisibility for the programmes was created by the innovativeinter-active computer software. Virtual earthquake and aircrash scenarios allowed the trainees to test theircollaboration and management skills on imaginary victimsequipped with realistic and dynamic injury profiles andthe programme was extended at the request of participantsto harness the full potential of the computer simulations.

The extension of virtual scenarios, debriefing of authoritiesduring the training took the shape of mock drills whereemergency responders were invited as guest performers.

IV) Training must be institutionalised. Coordination withthe Disaster Health Working Group Secretariat andcollaboration with the National Society for EarthquakeTechnology – Nepal, the Nepal Red Cross Society andKathmandu Medical College allowed an integration of thetraining into the national context. After the simulations,

trainees were requested to provideinput to the national emergencyplanning process based on theirown group identification ofproblems and solutions. Resourcepersons, trainers and managersfrom the OFDA / USAID PEERprogramme also took part in theprogramme and variations inapproach were discussed.

V) Follow-up initiatives should becompulsory. Due to the activeparticipation of the Disaster FocalPoint in the Ministry of Health, thetraining programme became anintegral part of the national health

sector emergency preparedness efforts. As a follow up,the Ministry of Health adopted a national template fortriage tags and almost 2000 tags are being distributed tohospitals throughout the country. Lastly, “MUSTERGuidelines on Computer-Based Mass CasualtyManagement Simulation Exercises” have been developedto allow other WHO offices in the South-East Asia Regionto replicate the programme.For further information please contact E. Kjaergaard [email protected]

Tools for learning: CD-ROM BasicSecurity in the field

The Minimum Operating Security Standards (MOSS),established by the UN Secretary General, stipulate that as ofJanuary 2003, all staff members must receive inductionbriefings and be certified as having received security trainingbefore being deployed to a high-risk duty station.

A CD ROM has been developed for this system-wide trainingand certification The CD-ROM, consists of six modules:Introduction, UN Security Management System, On themove, Where you work and live, Your health and welfare andYour personal safety. The CD course is designed to helpparticipants understand the basic security concepts andtechniques - to help ensure their safety, health and welfare.

Scene from MUSTER training in Katmandu, Nepal

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ICRC: Learning in emergenciesOver the last 20 years, there have been major efforts totrain health professionals in the management ofemergencies. At the beginning of the 1980s, thehumanitarian organizations started organizing courses fortheir personnel, and the ICRC set up a course entitledHELP (Health Emergencies in Large Populations), inconjunction with the WHO and the University of Geneva.The course is based on analysis of practical problemsencountered in the field and aims to improve participants’decision-making with regard to public health. The tangibleresults of the course have been impressive; it has spreadrapidly across the world, and is now being used in ninedifferent regions, with 1,600 participants to date. Moreimportantly, HELP shows how the concept of learning haschanged over the last 20 years.

We can identify three trends.

First, an increasing interest in humanitarian issues fromacademic institutions. At the start of the 1980s, there wassometimes a rather condescending attitude on their part,but they now recognise the professionalism of thehumanitarian agencies that are involved in health work.As a result, they are now analysing humanitarian issuesand promoting the application of operational research tohumanitarian situations.

Second, there has been a move from “staff training” to“the learning institution”. Humanitarian agencies – oftenat the instigation of academia – now realise that they needto train their personnel in line with an evidence-basedmodel, i.e. on the basis of a critical analysis of work in thefield and the results of operational research. Since thebeginning of the 1990s, these organizations havetherefore taken a more systematic approach to impactevaluation which, together with operational research, formsthe basis for operational policy. All this work has beenpublished and is available to the entire humanitariancommunity. Naturally, this material has influenced thecontent of training courses. The four elements in the first

diagram are the pillars on which organizations can formalizetheir learning processes. In turn, those learning processesprovide the framework for training their personnel.

Third, we have witnessed the emergence of amultidisciplinary approach to health care in emergencies.Prevention is the backbone of public health, but whenprevention is stretched to its limits, such an approachbecomes vital. Furthermore, there is a need to considereconomic aspects, in order to establish a link betweenemergency action and the resumption of normal activities.In the case of rural populations, for instance, fooddistributions need to be linked to agricultural developmentprogrammes. During armed conflict, compliance withinternational humanitarian law protects health personneland systems against the effects of war, and is hence linkedto the maintenance of basic health conditions. It is alsoimportant that humanitarian agencies understand thechanging political and military situation during an armedconflict, so that they can analyse the effects on health ofsuch factors as embargoes and the indiscriminate use ofweapons. This presupposes a certain level of familiaritywith these topics.

The HELP II course (Health Ethics Law and Policies) is anattempt to adopt this multidisciplinary approach. There isa need to go further, offering master’s degrees in publichealth as it applies to humanitarian situations. Such acourse would enable health professionals to manage therelationships between public health and those areas ofthe six disciplines in the second diagram that are relevantto emergencies.

The common thread running through these three trends isan enhanced ability to learn, which will gradually raise thelevel of professionalism among humanitarian agencies andbring recognition lead to that professionalism beingrecognized.For further information please contact P. Perrin, Chief MedicalOfficer ICRC, at [email protected]

Master of Public Health for Emergencies

A Multidisciplinary Approach

Healthin

emergencies

Political sciences Warfare

Law

Economy

Sociology

Anthropology

Public health

TRAININGCOMMUNICATION

POLICYDEVELOPMENT

EVIDENCE BASEDAPPROACH

HealthInterventions

inEmergencies

Concept ofLearning

Institutions



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Training as a key component of“Exceptional Action” for health inEmergencies

· Specific skills, knowledge and attitudes essential foreffective Humanitarian Action

· Best public health practice, effective coordination,accountability, respect for human rights all requirecontinuing education and capacity building

· Attention must be paid to cross-sectoral training thatinvolves all humanitarian actors and partners

Human survival is the common aim of all humanitarianaction. The World Health Organization (WHO) believesthat key measures can save lives even in the direstcircumstances. Exceptional threats call for exceptionalaction and exceptional action demands continuouslearning.

As emergency after emergency continues to assault humanpopulations, training and capacity building to deal withemergencies becomes increasingly important. Theknowledge continuously accumulated through“humanitarian experience” needs to be analysed, packagedand transferred to the ever-increasing number anddiversity of humanitarian actors. Through experience onelearns about the essentialinteraction betweendevelopment processes andemergencies. Training canbe a strong advocacy tool tofacilitate change.

WHO defines a core set ofresponsibilities for healthactors that applies inany emergency: theseresponsibilities provide clearterms of predictability andaccountability, a precise listof what the Organization and its partners must be readyto deliver in crises and, therefore, a blueprint forpreparedness plans. Around these priorities, WHOpromotes institutional capacities and linkages in memberstates and partner agencies. Training is an essential partof the learning that is required for building capacities inmember countries and at regional and global levels toprovide support for effective management of emergencies.

Imparting and improving knowledge, skills and attitudesis only one aspect of training. Training presents a valuableand neutral opportunity for different humanitarian actorsto discuss differing views and practices on health inemergencies. It provides a forum to develop consensusfor commonality of practice and approach and strengthenpartnerships. Training brings together different actorsfrom different organizations. Increasingly “health training”for emergencies involves professionals from manydifferent sectors and is a tool for Coordination. Sometimes,training events can even bring together healthprofessionals from opposing sides of conflicts and providea forum for safe and constructive interaction such as inthe WHO Health as a Bridge for Peace Initiative.

Building core knowledge and skills related to emergencyand humanitarian action of WHO and its partners atHeadquarters, regional and country levels is a coreresponsibility of WHO/EHA. This is carried out incollaboration with regional and country offices andpartners. WHO benefits from its vast networks and globalreach and external training experts and consultants arebrought in as needed.

Training for different technical aspects of emergencypreparedness is carried out through many specializeddepartments of WHO. As the organizational focus for co-ordination of preparedness and response to emergencies,the Department of Emergency and Humanitarian Action

has approached training inthe following ways.

· We coordinate WHOand public health input intointernational trainings. WHO isa key resource for other UN andpartner agencies in the UnitedNations Disaster Assessmentand Coordination (UNDAC)training, the Emergency FieldCoordination Training (EFCT),United Nations DisasterManagement TrainingProgramme (UNDMTP), the

Consolidated Appeals Process (CAP) training and ICRC’sHealth Emergencies in large Populations (HELP).

· We use existing UN and partner agency trainings whereverpossible as a means to strengthen capacity of WHO staffand partners. WHO sponsors participants from MemberStates as well as country, regional and headquarter levelstaff to attend global or regional trainings on emergencies.

· We conduct selected trainings at global, regional andcountry levels. These include induction courses for keyfield staff and a limited number of partners, trainings onEvaluation of Humanitarian action and Health as a Bridgefor Peace.

· We develop new training for WHO and our partners.Recent and ongoing work is focused on ManagementPractice in Emergencies, Public Health Response toTerrorism, Health and Human Rights in Emergencies.

We maintain databases of training participants so thatthey can be drawn upon as resources by ourselves andothers. We share information on training and trainingmaterial on our web site: www.who.int/disasters.For further information please contact G. Gamhewege [email protected]

Learning as part of exceptional action for public health in emergencies

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Learning across the regions: LEADERS courseWHO/PAHO has just concluded its first ever English language training of the reputed LEADERS course on Disasters andDevelopment.

Nearly 30 disaster managers from the Caribbean joined five internal colleagues from Asia, Pacific and Africa as participantsat this landmark course in Jamaica which focused on disaster mitigation, preparedness and response. The course was aimedat mangers with responsibility for disaster vulnerability reduction from prevention, preparedness and response both ingovernmental and NGO sectors. The two week course offered a variety of instruments for problem-solving, designinginterventions, managing crises, and enhancing strategic planning, leadership and analytical skills.

PAHO is WHO‘s regional office in the Americas and has many years of experience conducting the course in Spanish LatinAmerica. WHO plans to help transfer PAHO’s vast expertise and experience in disasters to other regions by developing adaptedversions of this course to other regions, starting with Asia later this year.For more details contact G. Gamhewage at [email protected]

WHO’s Approach to learning: Amodel for emergencies?

Staff development plays a key role in how we perform asindividuals and an organization whether in our offices orin the field. It is interesting to see how organizationalpolicies apply in emergencies.

Three major learning goals currently drive the WHO staffdevelopment programme; these were agreed in early 2001and still apply in 2002-03. We give priority to the activitiesthat:

· Transition from training to learning and empower the learnerto take responsibility for their own development

· Help staff to become more productive and efficient incarrying out their day-to-day work

· Providing more equitable access and greater consistencyof content, across the organization, particularly for staffat the regional and country levels

As an organization, WHO provides an opportunity forstaff to define together with their teams, the knowledgeskills and competencies that will enable them to performbetter. Based on this analysis, WHO uses a variety ofmethods to facilitate competency building. Learning in

emergencies is a reflection of this approach. The diagramabove encapsulates three key messages that are requiredfor improved organizational learning. The table belowsummarizes our approach to staff development.

Some examples, across the organization of the way thatwe learn:· Learning through experience sharing: EHA Induction brief

· Formal technical training: CDS training in Lyon

· Learning through joint planning: Common CountryStrategy process through CCO

· Learning research: Reproductive Health and Research

· Learning by doing: Security field training

· Learning by listening: WHO technical briefings

· Individual learning: Security briefing CD Rom

· Active learning: Simulation exercises in Leaders, MUSTER

This is not an exhaustive list and many technicaldepartments have, and are developing new and innovativeways of learning.For further information please contact H. Robinson [email protected]

Now Toward

LEARNING Build technical Build capacity toOBJECTIVES skills - how to deliver results

CONTENT Skills, one More integratedFOCUS -by-one managerial skills

linked to technicalteam etc.

LEARNER Individual Work teams;FOCUS staff/client teams

LEARNING Classrooms, ILT Blended learning;METHODS peer learning

action learning,e-learning

VALUE Nice if I have time; Improvingreward outcomes; integral

part of our work

S truc tu ra l/C utu ra l

Ind iv idua ls , Un its

, Leve ls

and Org

anizatio

ns

Learning For Im p rovedPerform a n c e :

A M o d e l for W H O

Improved Shar ing o f Knowledgeand Informat ion

Indi

vidu

al

Improved Synerg ies,Partnerships and Col laborat ion

Creat ing an Enabl ingEnv i ronment



9

The notion of learning is an essential aspect of thedevelopment of a professional community. Such acommunity cannot exist without a system which enablesthe creation of a capital of competencies and whichprovides opportunities for the sustainable developmentof that capital. In more basic terms, this means promotingactivities based on the principle of sharing experience,either between actual members of the community, orbetween current members and future aspirants.

Bioforce, a training organization for aid workers based inLyon, France, has, for 20 years, been committed to thisapproach. In a ‘professional community’ where there is anabsence of centralisation of competencies and recognitionof standards, where learning tends to be agency-linked asopposed to a cross-the-board community vision, there isan obvious need for a more fundamental approach tocompetency building through the provision of trainingschemes based on community learning.

Bioforce’s approach is based on the principle that we needto learn from the successes and failures of the past. It isalso based on the conviction that, the international aidsector needs new professional members in order tocontinue developing. In practical terms this involves anumber of foundation training schemes which produceover 100 new members each year, from over 15 countriesto help the aid community develop its skills. At presentthere are 4 such programmes :

· Logistician for International Aid· Administrator for International Aid

· Project Management for International Aid· Water & Sanitation Technician for International Aid

· Humanitarian Programme Manager (to be launched in 2004)

These programmes are all designed and implementedaccording to a common set of procedures :

Target situation analysis. Extensive research is carriedout to identify the precise needs of the communityconcerning the various ‘professions’. This results in adetailed, non-agency specific, ‘job-description’ for alogistician, administrator etc. based on the community’sexperience and evolving needs. It produces the necessarydata for the determination of course objectives andcontents fully adapted to the reality of the field.

Trainers from the community. The training is providedessentially by present or past members of the communityin order to ensure the ‘capitalisation’ of experience.

The participants. In order to be selected for theprogrammes, the participants have to prove theircommitment to the objectives of the aid community anddemonstrate basic skills and experience in the field of theirfuture work.


Learning in the ‘humanitarian community’: the example of BioforceAccreditation. Most of the programmes lead to an officialdiploma, providing a system of recognition of professionalcompetence.

Follow-up. These new members of the aid community who,go on to work with agencies all around the world, areprovided with various forms of support to help them intheir ‘first steps’.

The organization also offers other programmes aimed atresponding to the ever-growing needs of the community,for example :

· The provision of in-service training for aid professionalsto promote on-going competency building.

· Programmes aimed at promoting professional developmentwithin the community.

Conclusion Of course, Bioforce’s activity represents onlya small contribution to the enormous learning needs ofthe aid community. The question is whether there shouldnot be a greater effort to promote learning in theinternational aid community through the development ofmore foundation training programmes or perhaps eventhrough the creation of recognised community-specificvocational training bodies with shared recognition ofstandards for the required competencies. If we believethat the aid community should be professional then suchan evolution would seem essential.For further information please contact Director Rory DownhamBioforce Development Institut, 44, boulevard Lénine, 69200Vénissieux, France

New Directions for LearningNew learning models have been evolving over the past decadeor so to improve emergency and humanitarian actionincluding:

Distance Learning

Many organizations are turning more and more to distancelearning. UNHCR with its decentralized structure hasdeveloped a successful programme for its staff throughoutthe world. The teaching/learning focuses on four areas:Management, Protection, Resource management andOperations.For further information: www.unhcr.org

“Just-in-Time” learning

The Just-in-Time learning model provides made-to-measuretraining for personnel prior to field deployment inemergencies. The “trainee” does a quick survey on a checklistof 15 key areas and decides which modules to select for pre-departure training. WFP plans to test this new model oflearningFor further information,: www.wfp.org

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Until fairly recently, evaluations of humanitarian assistanceprogrammes were relatively rare. However, with the increasein funding for humanitarian action, gradually the numberof evaluations did increase. In particular it was the system-wide evaluation of the humanitarian response to the crisisin Rwanda1, which resulted in more attention for evaluationof humanitarian action. The study sparked work on moreappropriate methodologies for this kind of evaluation,including complex issues such as protection andbeneficiary participation. By expressing concerns aboutthe quality of the humanitarian response, it also led tofurther initiatives such as the creation of ALNAP (ActiveLearning Network for Accountability and Performance inHumanitarian Action), the formulation of the Sphereminimum standards and the Humanitarian AccountabilityProject2.

The gradual increase in the number and sophistication ofhumanitarian evaluations implies a demand for evaluatorswith relevant skills in evaluation and health programmingin the humanitarian context. Since a combination of theseskills is still relatively rare, a short course entitled the“Evaluation of Health Programmes in ComplexEmergencies” was developed three years ago at theLondon School of Hygiene and Tropical Medicine. Thecourse offers instruction in practical evaluation tools, aswell as highlighting some of the unresolved challenges ofhumanitarian assistance evaluation. By increasing thenumber of people available to perform health sectorevaluations, it is hoped that at least one bottleneck toincreased learning capacity within the humanitarian systemwill be reduced.

One of the main challenges to evaluation remains theattribution of health activities to health gains in the targetpopulation. Because health impacts, even under stableconditions, are notoriously difficult to measure, mosthealth project evaluations rely on process and outputindicators. Attribution of health impact to a specific projectis almost never attempted. Since most health activitiesare helpful and most projects fulfil at least some of theirstated objectives, many project evaluations end on arelatively positive note.

As evaluations tend to focus on a single project or a singledonor, a number of key questions usually remain for agiven geographic area. These include: what is the overallcoverage of the health response, is the mix of implementedactivities by different agencies appropriate and targetedcorrectly, and what is the available evidence-base uponwhich to measure health gains. The Sphere standards forhealth are not very helpful in this respect and definitelynot applicable to chronic complex emergencies.

Learning from Teaching: a Courseon Evaluation of Humanitarian Action

A key lesson learned from teaching the short course is thesubstantive lack of sector-wide evaluations of the healthsector in specific complex emergency settings. It is hopedthat this kind of evaluation will be commissioned moreoften. Undoubtedly, such studies will have to overcome anumber of methodological problems. But it is expectedthat sector-wide evaluations will give more insight to thevalue of investments in health during complex emergencies.

Endnotes1 JEEAR (1996) The International Response to Conflict and Genocide: Lessons from the Rwanda Experience Vols. 1–4 (Copenhagen: The Steering Committee of the Joint Evaluation of Emergency Assistance to Rwanda)2 Griekspoor A, Sondorp E: Enhancing the quality of humanitarian assistance: Taking stock and future initiatives. Prehospital Disaster Medicine 2001:16(4):209–215.

For further information please contact E. Sondorp, Senior LecturerLondon School of Hygiene and Tropical Medicine [email protected]

International Diploma inHumanitarian AssistanceThe International Diploma in Humanitarian Assistance(IDHA) provides an operational and academic intensivetraining for those who participate in humanitarian crises,particularly during armed conflicts and disasters.The IDHA is a multidisciplinary program created tosimulate a humanitarian crisis for students from a varietyof backgrounds and experience.The overall course objectives include:1. To provide volunteers and professionals from a wide

variety of backgrounds with a comprehensive insightinto the needs with refugees and internally displacedpeople in acute and chronic settings and equip themwith the awareness, understanding and skills that areessential for effective service in a humanitarian crisis.

2. To enable humanitarian workers to function effectively,both as individuals and members of a team, in acute andchronic situations of conflict and disaster.

3. To promote cooperation and dialogue betweeninternational, governmental or non-governmental agenciesinvolved in humanitarian action (assistance andprotection).

4. To evaluate interventions and identify examples of goodpractice.

5. To examine ways in which humanitarian crisis may beanticipated and prevented.

For further information: http://www.idha.ch/

EHA’s web site provides information on what is happening inemergency situations (health situation reports, epidemiological

surveillance, needs assessments, etc.) and what to do about it (technical guidance).

http://www.who.int/disasters



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Aligning resources for success involves a well-plannedapproach to achieve a sense of mission in any situation.On the other hand, performance management needs toget to the heart of the organization to make sure it reflectsand supports the culture, strategy and style of theenvironment in which it is working. This performancemanagement in the Kosovo humanitarian emergency wasessential for determining the problems to be addressed,acknowledging reasons for WHO intervention andidentifying solutions to improve the emergency situation.The performance tools communicated what was expected,how the teams would deliver results and what results wererequired by the Government and Ministry for Health aspart of the Kosovo recovery plan. This mapping, managing,measuring of the WHO Kosovo programme was reviewedthrough an open evaluation workshop attended by theWHO country team. The participants recorded anddisseminated the successes and learning from the three-year programmes and this article reflects the findings ofthe workshop.

Taking the Pulse

Performance management starts by “Taking the Pulse” ofany organization. The Internal Evaluation of WHOResponse in Kosovo (June - December 1999) took stockof the WHO role in the Kosovo. Both the workshop andthe initial report gave a balanced assessment with usefulrecommendations to improve performance. The summariesgave direction for future intervention and investment. Theinternal evaluation report identified the competenciesneeded to provide leadership to continue and improve theprocess.

Plotting the course

The report was used to prioritise objectives and defineleadership and performance management roles includingcreating tools to measure and manage programmeperformance, assisting the Ministry of Health and otherpartners to achieve their potential and developing a highperformance team.

WHO is obliged to prove knowledge transfer

The assessment of the emergency humanitarian assistanceintervention was completed during the team workshop.The purpose was to assess through discussion, reflectionand documentation if the programme performance duringthe emergency period made a difference. WHO providedcapacity building through programmes of technicalassistance and standard setting at governance, institutionand municipal health facilities, providing the support andexpertise for the public health agenda and building the

Learning in the field: Kosovo Emergency Humanitarian Interventionprogramme workshop

competency of the Kosovo health workforce. The purposewas to ensure a record of sustainable learning to assistand inform the team and other WHO internal and externalstakeholders. The local staff team led the discussions,distilled, provided feedback and documented the resultsof the event.

Documenting experience to direct change

A range of performance tools were used to document andreflect programme performance. This included a problemtree analysis, problem tree priority setting for action,process activity analysis, identification of outcomesuccesses and lessons learned. The workshop alsoprovided a safe and open environment to record and assessthe strengths, weakness, opportunity and potential threatsto the programme investment if not sustained as part ofthe Kosovo health system recovery process.

Learning from practice

Performance management is an effective evidence basefor longer-term vision and subsequent funding by creatingan early climate of trust to empower, manage and problem-solve. This requires learning lessons from the team’sperformance and developing team skills to challenge andchange current situations. The team and its partners areinvolved in the design of the intervention programme byidentifying the necessary tools and discussing howperformance management tools can focus on the decisionslinked to agreed outcomes. This demonstrates that thetransition from emergency to longer-term sustainabilityrequires the repositioning of performance management sothat it becomes a vital and integral component of the wayWHO assesses its contribution to a country health caresystem.

Unless the measurement of invention becomes standardpractice how can field programmes be judged assuccessful?For further information please contact Sue Woodward AssistantChief Executive (Performance Management and Modernisation),Mid Yorkshire Hospitals NHS Trust UK, former WHO Head ofMission Kosovo at [email protected]

The “stainless steel” law states that the better designed theoutcome evaluation, the less effective the intervention seems.Rossi also proposed an “iron” law of evaluation, which statesthat the expected value of any impact assessment of any largescale social programme is zero

Rossi P. The iron law of evaluation and other metallic rules.Research in Social Problems and Public Policy 1987; 4: 3-20

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Evaluation - Why Bother?Evaluation is often thought of – and carried out - as asystematic and objective event, done by ‘an expert’ at theend of a project or programme, designed to show thatgoals were accomplished, improvements made, moneyspent wisely. There may not even be a sense of ownershipof an evaluation by those involved in implementing aprogramme or project.

A broader way of conceptualising and using evaluation isas an on-going process which forms part of every decisionwhen it is made, and as its implementation progresses. Todo this, evaluation has to be at the centre of problemsolving, decision making processes, and used in aniterative way. Using evaluation this way means that itbegins as soon as the ideas for a programme begin: it isused by all those involved in or by the initiative, to guideplanning and implementation of work, as well as to assesswhat has been accomplished. In this way, evaluation canshow what has been achieved, but in addition, can helpindividuals and organizations learn from experience todo things better.

The evaluation family

Monitoring, audit and evaluation are all part of the ‘family’of evaluation in that they are linked but not the same.

The word ‘monitor comes from the Latin ‘monitum’ whichmeans ‘to show or warn’. This is exactly what monitoringshould do: it is a system to measure indicators periodicallyto show whether a programme is operating as it shouldand indicate where action should be taken if necessary.Tasks, performance and outputs can all be monitored.

Monitoring has become increasingly important in the lastfew years, as it offers a route to Results BasedManagement (RBM). The emphasis on RBM is onparticipation in setting the indicators and articulating whatresults are expected. RBM is increasingly being used bydonors to encourage participation in developingcountries. The much-used blueprint approach to aidfocuses on measuring compliance, inputs and activitiesand is primarily about management control. In contrast,RBM focuses on outputs, performance, strategic

objectives rather than activities and on using the datafrom monitoring for management improvement.

If monitoring is a truly participative process – so that whatis to be monitored is agreed by all involved, and there isflexibility for performance to be adjusted with ‘no blame’in response to monitoring, then it can be empowering andallow all to learn from what is happening.

Audit derives from the Latin verb ‘audire’ meaning ‘tohear’. More recently it has been associated with checkingof financial accounts, but the word has crept intomanagement as a way of checking that an organization isdoing what it should and relates activities to spending.

How to learn from evaluation

While audit and evaluation are related, they have keydifferences which are helpful in thinking about what canbe learned from each of these processes.

It is almost impossible not to learn from open enquiryevaluation – but there are certain prerequisites for this tohappen. The first is that the evaluation has to be built into each step of the process of programme development,and include all of those involved. From the formulation ofthe problem to be tackled, to the construction of aprogramme of interventions and its implementation,through to deciding what has to be evaluated – all ofthese stages have to be developed through a series ofiterations based on evaluations.

Using evaluation this way is clearly time consuming anddemands a different approach to understanding problemsand their contexts, which includes the perspectives of allof those affected by the issue. Using evaluation in thisway is similar to the techniques of action research, whereresearchers and the subjects of research are united as acommon system of interest, and both can contribute to allaspects of research. The main critiques of action researchare that it is unscientific, and indeed there is a sense inwhich this is true. Nevertheless, action research and itsmethods are a foundation for development based on realityfrom many perspectives.

To learn from evaluation, there must be an organizationalculture which allows admission that things can be

improved, without asense that evaluationis a search for theguilty. This is one wayin which learningorganizations arecreated. Learningorganizations arecharacterized by beingoriented to the future– looking ahead;

Open enquiry evaluation Audit review• Inquiry – to seek• Starts with the questions:How are we doing? Is this activity working?In what ways? What do we think of it?• Asks problem-posing and solving

questions:How could we improve things?

• Explores what is happening in order togenerate new theory from practice andexperience

• Requires intuitive thinking, questioning,observation, imagination and creativity

• Audit- to check• Starts with the questions:Have we set out to do what we wanted to do?Are we meeting our objectives?• Asks questions to narrow down to correct

answers:What are we doing that we shouldn’t bedoing? What should we be doing?• Examines practice from the perspective

of already developed objectives – knowncriteria

• Requires systematic orderly observantorganized and analytical mind.



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Resources, further readingThe Stanford Learning Organization Web (SLOW) is aninformal network of Stanford researchers, staff, and studentsalong with colleagues and friends from the corporate worldinterested in the nature and development of learningorganizations.

http://www.stanford.edu/group/SLOW/

The Society for Organizational Learning , is a learningcommunity created to connect corporations and organizations,researchers and consultants to generate knowledge about andcapacity for fundamental innovation and change by engagingin collaborative action inquiry projects.

http://www.solonline.org/

The American Evaluation Association is an internationalprofessional association of evaluators devoted to theapplication and exploration of program evaluation, personnelevaluation, technology, and many other forms of evaluation.Evaluation involves assessing the strengths and weaknesses ofprograms, policies, personnel, products, and organizations toimprove their effectiveness.

http://www.eval.org

Evaluation and humanitarianassistance: relevance to and role forWHOEvaluations can only be used properly when establishedwithin a wider range of managerial tools andresponsibilities. It requires clarity about the intentions andmandate of the organisation.

Over the last decade, evaluation has become a well-established process in humanitarian aid agencies foraccountability purposes and as tool to improveperformance. The Active Learning Network onAccountability and Performance in humanitarian actionhas provided a productive platform to discuss and developthe methodologies and processes for evaluation. It alsoplaced evaluation in a wider spectrum of tools that agencieshave at their disposal to learn, and improve internalmanagement and overall performance. Useful as these toolsmay be, they are not the only factor on which decisionsare based or changes instigated.

Despite all that is available, the application of the know-how related to evaluation for humanitarian action remainsa challenge for most organisations, especiallyorganisations like WHO where emergencies can be seenas only a small part of the organisational mandate. WHOintroduced results based management some years ago,and continues to work on using this effectively at alldifferent levels. Also, a new department for planning,monitoring and evaluation has been created and theCountry Focus Initiative is focusing on strengtheningWHO’s country offices.

The use of evaluations of humanitarian assistance forWHO has to be seen within these broader organisationaldevelopments. Efforts are made to integrate evaluation ofWHO’s role in emergency countries in the organisationalguidelines for planning monitoring and evaluation,particularly those that apply at country level. This willensure that WHO staff sees evaluations as part of theirnormal range of responsibilities.

While linking to organisational developments is one way

transparent; open to stakeholder participation; andacknowledge that they are learning to do new thingsthrough what they have done – they make use oforganizational history.

Evaluation can be a powerful tool for development, oforganizations and with countries, provided it is open, allowsparticipation and is part of a flexible and responsiveframework for change.For further information please contact B. Stillwell [email protected] or H. Mercer at [email protected]

to improve the effective use of evaluations, evaluationsare also coordinated more often with important donors.The process of joint evaluations improves thecommunication, trust and understanding between WHOand the donors involved.

Evaluations are not only an instrument to improve onWHO’s own performance in emergencies, they can also beof service to abroad range of stakeholders when they openup to cover the entire health sector. When looking at WHO’sfunctions, it is clear that health sector evaluations canbecome a valuable support to all of these functions:

1. Analysing and synthesising the best available informationabout health issues;

2. Helping to prioritise how best to use scarce resources forhealth, and to establish optimal strategies;

3. Offering up-to-date technical guidance on healthinterventions,

4. Coordinating the efforts of government, NGO andinternational agencies in the health field, and trackingprogress and quality of the response.

There are currently plans to initiate such evaluations thathave the potential to bring together various actors involvedin the health programs, national and international.

To conclude, WHO needs to explore and make use of theentire spectrum of evaluation and learning processes.When doing evaluations, we have to make use ofopportunities offered by internal organisational changes,as well as from working more closely with our partners.For further information please contact A. Griekspoor [email protected]

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From October 24 through November 12, the U.S.Department of State’s Bureau of Population, Refugees,and Migration (PRM) for the first time participated in acomprehensive evaluation of WHO humanitarianoperations in the North Caucasus. The evaluation resultedin a 48-page report posted to WHO’s website in the publicdomain: http://www.who.int/disasters/repo/8676.pdf.

PRM’s role in the external evaluation represents animportant first step towards establishing more systematicevaluation mechanisms for such operations involvingdonors. PRM felt the evaluation was a success and apositive move towards greater transparency andaccountability, as demonstrated by WHO’s commitmentto making the evaluation report public, despite some initialhesitation. We hope this evaluation will pave the way fora standard multi-agency review process, involving multipledonors, which could become routine in the future.

The evaluation team specifically felt that WHO was opento suggested improvements of its operations as well aspraise for its excellent staff in the field, and that thisopenness is essential to eventual program success. Theteam made the following recommendations to WHO: 1)WHO needs to develop a longer-term vision; 2) WHOshould adopt a greater role in formulating goals andpriorities for all actors involved in the health sector ofhumanitarian programs; 3) WHO should strengthen itsefforts to reach displaced populations in Chechnya; and4) WHO should work to mitigate the limitations imposedby security restrictions to improve service to hard-to-serveareas. Most importantly, the team recommended greaterdecentralization of the management process, with morefinancial and programmatic decision-making conductedat the field level to better serve beneficiaries and avoidcostly delays.

Lessons Identified: The evaluation team’s findings andrecommendations were conveyed to decision-makers atall levels within WHO, through the 48-page report, as wellas briefings by the evaluation team in Copenhagen andGeneva. Follow-up plans have been put in place toimplement key recommendations, demonstrating therelative success of this process. As a donor, the U.S.Government welcomed the opportunity to participate inthe evaluation process to determine the cost-effectivenessof the WHO programs it helps support. In an effort toimprove the evaluation process, we encouragestandardizing evaluations between donor agencies andinternational humanitarian groups. With greater buy-infrom donors into the evaluation process, they may be moreinclined to take action to ensure that the recommendationsthat come out of such evaluations are actuallyimplemented. When engaged, committed donors who

participate in evaluations can also help improve thetransparency of operations and program accountability.We recommend making routine multi-agency evaluationsa regular part of the relationship between donors andrecipients. Of course, such efforts require financialresources that could be directed to other competing needs.Even so, effective monitoring and evaluation remain anessential component of “good donorship.”C. Santos, U.S. Department of State, Bureau of Population,Refugees, and Migration (PRM)

Evaluation as an Essential Component to “Good Donorship”

Evaluating in the ConsolidatedAppeal Process: Case Study -Democratic Republic of Congo

As part of a doctoral thesis, an independent study wasconducted between July 2001 and February 2002. The aimof this study was, through system analysis, to study theprocess of preparing health projects within the UnitedNations Consolidated Appeal Process (CAP). Theresulting information can be used to develop guidelinestowards improving this process. The Democratic Republicof Congo (DRC) was used as a case study.

WHO has become increasingly involved in responding todisasters and in coordination with the other UN agenciesand NGOs. The CAP was established in order to facilitatea coordinated response to a country in need, avoidingduplication of programs, and promoting cost effectiveness,efficient relief and recovery strategies.. Activities aredivided into different sectors: health and nutrition; foodsecurity; water and sanitation; education; andcoordination.

By studying the process of preparing health projectproposals within the CAP the following questions were ofinterest: What are strong steps within the Appealpreparation process? What are weak steps within thepreparation process? What are unnecessary or mistake-prone steps? How can this process be strengthened andimproved?

For the analysis, use was made of system analysis andquality assurance tools to graphically display the datacollected. These can be useful to tackle managementproblems, the existence of such were confirmed by thisstudy. The cause and effect analysis used describes thedissatisfaction with the CAP, and generates andcategorizes the ideas about causes of problems within theCAP preparation process. The recommendations are basedon lessons learned, feasibility and efficacy of theinterventions.



15

Conflict, disasters and infectiousdiseases: An emerging researchportfolio

There is a growing body of knowledge on technicalaspects of humanitarian responses in complexemergencies. However, there is lack of research regardingoptions for health service delivery and policyimplementation in societies suffering from protracted armedconflict and/or natural disasters. Particularly, there hasbeen limited research, at least from within the public healthfield, on how individuals, communities and health systemscope with adversity.

Exploring the interface of the TDR diseases with armedconflict and other forms of disasters in today’s uncertainworld is an area that has been taken up by the SteeringCommittee for Strategic Social, Economic and BehaviouralResearch (SEB) of WHO’s Special Programme for Researchand Training in Tropical Diseases (TDR).

Recognising the research gap, and as an initial step to afuture research portfolio, an international conferenceentitled “Surviving crisis: How systems and communitiescope with instability, insecurity and infection” was heldin April 2002. The conference brought together twenty-five social scientists, epidemiologists and health systemsresearchers and served as an occasion to clarify conceptsassociated with collective violence particularly crisis,resilience and vulnerability1.

The TDR Programme is currently funding an exploratorymulti-country study entitled “Resilience of community andhealth systems under conflict for responding to infectiousdisease” being carried out in the Democratic Republic ofCongo, South Sudan, Uganda, the Philippines and SriLanka. It is anticipated that this multi-country study willgenerate insights and hypotheses for research in othersettings that may have similar experiences of collectiveviolence.

The conference and the multi-country study are beingseen as the beginning of a more challenging and ongoingexploration of the interface of TDR diseases with conflictand other crises in today’s uncertain world. Conflictresearch highlighting issues in relation to inequalities ofaccess and globalization effects is encouraged in a recentlyissued call for grant applications2.Endnotes1 Please consult http://www.who.int/tdr/publications/tdrnews/

news68/conflict.htm for the upcoming conference proceedings2 Please consult the call for grant application at

http://www.who.int/tdr/grants/grants/seb.htm

For further information please consult TDR’s website athttp://www.who.int/tdr/topics/social-research/default.htm orcontact J. Sommerfeld at [email protected]


Active Learning Network on Accountability andParticipation in humanitarian action (ODI)http://www.alnap.org

OECD. DAC Working Party on Evaluation (1999).Guidance for Evaluating Humanitarian Assistance inComplex Emergencies.http://www.oecd.org//dac/Evaluation/pdf/human_en.pdf

ECHO. European Commission Humanitarian AidOffice http://europa.eu.int/comm/echo/evaluation/index_en.htm

The Sphere Projecthttp://www.sphereproject.org

United Nations High Commissioner for Refugees,evaluation and policy analysis unit http://www.unhcr.org

Monitoring and Evaluation News (MandE)http://www.mande.co.uk

Evaluation Resources: Web Sites

The major weakness delineated is that the process is fartoo complex with too many steps that lack ownership. Theprocess needs to be streamlined and simplified, byeliminating some of the steps that are not followed orrepeated unnecessary, into a structured approachmatching actual practice. WHO should play a key role inhealth information reporting in the country and shareinformation with all humanitarian actors. By taking a leadrole through information sharing the effectiveness of thehealth coordination can be increased. The workload ofpreparing the CAP needs to be spread more evenlythroughout the year, through regular health coordinationmeetings, during which the joint strategy and activitiesare discussed. The CAP process becomes less of stressfulevent and more a regular activity that can be controlled.Joint analysis of the health problems as well as jointplanning with the other health agencies will promoteownership of the process, which is crucial for success.Standards for data collection developed at HQ andRegional level should be shared with the countries forfield testing and use. Standard of the shelf projectproposals jointly prepared with the technical departmentsshould be distributed to the countries. Memos ofUnderstanding, prepared at HQ and Regional level can beused as a negotiation tool when coordination issues andlack of participation arise among the agencies.For further information please contact I. Pluut at [email protected]

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CONTACTS

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Regional Office for the EasternMediterranean (EMRO)Coordination, ResourceMobilization and Emergency Relief(CMR)WHO Post OfficeAbdul Razzak Al Sanhouri Street,(opposite Children's Library)Nasr CityCairo 11371EgyptPhone: (202) 670 25 35Fax: (202) 670 24 92/94email: [email protected]

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© World Health Organization, 2003

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Health in Emergencies is a newsletter of the Department of Emergency and Humanitarian Action ofthe World Health Organization (WHO). This newsletter is not a formal publication of WHO.

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Correspondence and inquiries for subscription should be addressed to:The EditorThe Department of Emergency and Humanitarian Action World Health Organization20 Avenue Appia1211 Geneva, SwitzerlandPhone: (41 22 ) 791 4037Fax: (41 22) 791 4844email: [email protected]

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HEALTH IN EMERGENCIES - WHOlistening, sharing experiences both formally and informally, and more through evaluations and lessons learnt workshops. One of the newer models of learning