Strategic health information

Over the past fifteen years, UNHCR has been strategically designing and implementing health information tools, including the Integrated Refugee Health Information System (iRHIS) and surveys, to ensure accurate information exists on refugees and the coverage and quality of health services they access. Reliable sources of health information are especially critical in contexts where refugees are not sufficiently captured in existing national systems. Ministries of health in refugee hosting countries increasingly recognize the importance of including refugees within national health plans and resource allocation, but to do so they need information. UNHCR’s refugee health information tools complement – not compete with - national health information systems.

How do UNHCR health information tools strategically improve refugee access to healthcare?

UNHCR’s health information tools increase refugee access to healthcare by addressing insufficiently available information on coverage and quality of healthcare. UNHCR maintains crosscutting tools to collect, store and monitor health, nutrition and water, sanitation and hygiene (WASH) data. The tools meet worldwide humanitarian standards, assist in data collection, collation and analysis, and are consistent across participating operations. As appropriate, governments and partners use the data to plan for and respond to refugee health needs.

In many operations, refugees play an integral role in the delivery of health services to other refugees. They are often frontline staff responsible for primary data collection and reporting. As refugees may not speak or write the same language as the host country, UNHCR’s health information tools used at the community level may be available in relevant refugee languages.

UNHCR’s strategic health information tools include:

The Integrated Refugee Health Information System (iRHIS)

Relaunched in 2020, the Integrated Refugee Health Information System (iRHIS) is an interactive digital system designed to collate and analyse a comprehensive set of health, nutrition, and WASH data that visualizes trends over time and generates a range of multisectoral reports. iRHIS provides country and global updates on standard indicators to inform programming and on comparative analysis with host communities across all subsections of public health. Frontline partner health staff in healthcare facilities use tablets or webform to collect data on some 4.7 million refugees from 159 sites in 19 countries. Data collected include births, deaths, notifiable disease surveillance, health conditions, and service coverage. Various stakeholders, including ministries of health, NGOs and other UN agencies, utilize the data and updates. Catering to operational realities, the system works both offline and online, with enhanced user-friendly data visualization and analytical functionality.

iRHIS has the capacity to monitor disease outbreaks to protect the community, prevent exposure and transmission, and reduce morbidity and mortality. The Outbreak Reporting Module of iRHIS helps public health practitioners track disease and transmission patterns and respond effectively. This module has been instrumental in tracking outbreaks of measles, cholera, and COVID-19.

Health Access and Utilization Surveys (HAUS)

Urban or non-camp settings present different challenges for surveillance and monitoring compared to traditional refugee camp settings. Reliable data on the health needs of non-camp refugees is relatively difficult to obtain compared to camp settings. Non-camp refugees often have greater freedom of movement and may consult a diverse range of service providers (e.g., government, private, NGO clinics). Out-of-camp refugees may also face many barriers in accessing health services, including economic, geographic, cultural, linguistic, and administrative. 

UNHCR’s HAUS monitors trends in how refugees outside of camps access and utilize health services over time. HAUS measures the health needs, health seeking behaviour, health expenditure, and access to key health services in a representative sample of the population.  HAUS can also pinpoint strengths and weaknesses accessing and successfully using appropriate health care services, particularly in an urban refugee population. Repeat surveys allow for monitoring trends in non-camp refugee access and utilization of health services, or how the impact of legislative, administrative or economic barriers change over time.

Standardized Expanded Nutrition Surveys (SENS)
UNHCR’s SENS measures levels of acute and chronic malnutrition and key health indicators in children, levels of anaemia in children and women, feeding practices of infants and young children, access to food assistance, access to safe drinking water, sanitation  and hygiene practices and access to and use of long-lasting, insecticide-treated mosquito nets at the household level. 

Since its inception, UNHCR and partners have conducted some 600 surveys with an average of 100 surveys per year. The results of these are not only used by UNHCR to prioritize nutrition interventions; they also contribute to food security, WASH, health, and other forms of assistance programming and are the foundation of UNHCR collaboration with WFP, UNICEF and FAO.

Surveys on Inclusion of Refugees in National Systems
The inclusion of refugees into national health systems is a fundamental priority. When scarce resources are concentrated in one system instead of diluted amongst several, the health of the community – both hosts and refugees – is more likely to be positively impacted. To track progress towards the goal of inclusion, UNHCR has designed a detailed country-level inclusion survey to assess the extent to which refugees are included in host country’s health policies, plans and systems. Conducted every two years, the survey provides detailed information on the extent of inclusion and integration of refugees in national system, tracks progress over time and identifies areas where inclusion could be strengthened.

Balanced Score Card (BSC)
Access to healthcare of sufficient quality is critical to achieving Sustainable Development Goal 3 (“Ensure healthy lives and promote wellbeing for all at all ages”). While the HAUS monitors how refugees access and use healthcare, UNHCR’s balanced score card assesses the quality of services provided to refugees in primary healthcare facilities. The balanced score card allocates scores to a health facility in the following domains: services provided; staffing and coverage; equipment and supplies; quality of care; patient satisfaction. The balanced score care identifies gaps in healthcare inputs and capacities so that UNHCR and partners can develop targeted recommendations and monitor improvements over time. Based on balanced scorecard results, UNHCR supports the development and provision of appropriate staff capacity building, resources, technical support and documented good practices. Balance score cards are conducted at least annually and more frequently in case of low scores where clinics are in need of improvement.

Maternal Death Audits
Maternal death audits are a systematic and structured process to understand the medical and social reasons that contributed to maternal death. Preventing maternal deaths is a priority for UNHCR’s health programmes. UNHCR advocates for maternal death audits to take place within 48 hours of the death. The audit results are analyzed at the country, regional and global level so that healthcare providers and policymakers can better understand the causes and contributing factors in order to take steps to improve healthcare services and systems.

Medical Referral Database (MRD)
Refugees with health needs that cannot be met at primary care level may be referred to secondary care often at hospital level. The medical referral database is a tool to track these refugees through the referral process to a hospital and back to the community. The system captures the reason for referral, the treatment provided, the outcome and costs. This tool supports the monitoring of the implementation of referral care programmes by partners. An online version of the database is under development in 2020 to be rolled out in 2021.

WASH Knowledge, Attitudes and Practices (KAP) Survey
The Water, Sanitation and Hygiene (WASH) Knowledge, Attitudes and Practices (KAP) reports on nine key household-level indicators on water collection and storage, drinking water hygiene, sanitation infrastructure and basic hygiene knowledge and behaviours. The resulting data is critical to inform design, monitoring and implementation of WASH programmes for refugees.