Primary health care and essential services

1Primary health care: organisation and Sphere benchmarks

Primary health care is the foundation of the response: curative consultations, integrated management of childhood illness (IMCI), antenatal and postnatal care, vaccination, nutritional screening, chronic diseases, referral to hospital. It relies on community health workers who detect cases, treat simple illnesses (malaria, diarrhoea, pneumonia) and monitor deaths.

Sphere planning benchmarks: about one primary health care facility per 10,000 people, one district hospital per 250,000 people, at least 22 skilled health workers (doctors, nurses, midwives) per 10,000 population, and a clinician who does not exceed 50 consultations per day. A utilisation rate of at least 1 new consultation per person per year indicates adequate access. Care is free at the point of service during the acute phase.

2The Minimum Initial Service Package for reproductive health (MISP)

The MISP defines the sexual and reproductive health services to be provided from the onset of a crisis, if possible within 48 hours. Its objectives according to the Inter-Agency Field Manual (IAWG, 2018):

• designate a lead organisation to coordinate reproductive health within the Health Cluster;
• prevent sexual violence and respond to survivors' needs: clinical management of rape, with HIV post-exposure prophylaxis within 72 hours and emergency contraception within 120 hours;
• prevent the transmission of HIV and other STIs (standard precautions, safe blood, condoms, continuity of antiretrovirals);
• prevent excess maternal and newborn morbidity and mortality: skilled birth attendance, basic (BEmONC) and comprehensive (CEmONC) emergency obstetric and newborn care, a 24/7 referral system, clean delivery kits for visibly pregnant women;
• prevent unintended pregnancies (contraception available);
• plan for comprehensive reproductive health services as soon as possible.

Safe abortion care, to the full extent of the law, is also among the priorities. The MISP is applied without waiting for a detailed assessment.

3Measles vaccination and routine immunisation

Measles kills on a massive scale in overcrowded camps, especially among malnourished children. The vaccination campaign is an absolute priority as soon as coverage is uncertain or below 90%:

• target: children aged 6 months to 15 years (at least 6 months to 5 years if resources are lacking), depending on the context and national policy;
• coverage target: 95%;
• vitamin A given at the same time to children aged 6 to 59 months;
• children vaccinated between 6 and 9 months receive a further dose at 9 months;
• monitored cold chain, injection safety, waste management.

Routine immunisation (Expanded Programme on Immunization) must resume as soon as possible: pentavalent, polio, pneumococcal, measles, etc. Coverage is checked through registers and surveys, not only through the number of doses administered.

4Mental health, psychosocial support and medicines

The IASC guidelines (2007) organise mental health and psychosocial support (MHPSS) into a four-layer pyramid: basic services and security delivered with dignity; community and family support; focused non-specialised support (psychological first aid, groups); specialised services. Mental disorders are common in conflict areas: WHO estimates that more than one person in five is affected. The mhGAP Humanitarian Intervention Guide enables non-specialist health workers to manage depression, psychosis, epilepsy or substance use, and psychological first aid can be taught to everyone.

For medicines, the Interagency Emergency Health Kit (IEHK 2017) makes it possible to start care without delay: the basic module (10 units) covers 1,000 people for 3 months for basic care, the supplementary module covers 10,000 people for 3 months at the level of qualified health workers, with separate modules (malaria, post-exposure prophylaxis). Kits are a start-up solution: you must quickly move on to consumption-based orders, with stock cards, inventories, the "first expired, first out" principle and alignment with the national essential medicines list.

5Opening and running a primary health care facility step by step

Opening a health post in an emergency is not just a matter of a tent and medicines. Facilities that work well have been designed from day one around four elements: a patient flow that protects staff and patients, staffing sized to actual demand, a clear service package and a minimum information system that makes it possible to manage the facility.

Step 1: deciding whether to open a facility (and where)

Before opening, check in HeRAMS and with the cluster whether an existing facility can be supported: additional staff, medicines, light rehabilitation. Opening a parallel facility next to a functioning public health centre weakens the system and creates exit problems. A new facility is opened when existing ones are destroyed, inaccessible (more than about an hour's walk, insecurity, discrimination) or overwhelmed beyond what reinforcement can absorb. The location is chosen with the community: within walking distance, safe for women and children, away from armed positions, with access to water.

Step 2: organising the patient flow

1. Reception and triage at the entrance: a nurse or trained worker identifies danger signs (lethargic child, convulsions, respiratory distress, severe dehydration, haemorrhage, woman in labour) and gives them priority. During an outbreak, triage includes screening suspected cases (acute watery diarrhoea, fever with rash) and directing them to an isolation area.
2. Registration: consultation register with age, sex, place of origin and diagnosis; a patient card kept by the patient.
3. Systematic nutrition screening of children aged 6 to 59 months by MUAC and checking for oedema.
4. Consultation: one station for children following IMCI, one adult station, one maternal health station (antenatal, postnatal, family planning) staffed by a midwife.
5. Treatment room and pharmacy: dressings, injections, dispensing of medicines with an explanation of the dosage.
6. Observation and referral: an observation area with a few beds for rehydration and stabilisation; a written referral procedure to the hospital, with an identified means of transport.

The flow must be one-way, with a handwashing point at the entrance and exit, and consultation spaces that preserve confidentiality. Women must be able to be examined by a female health worker if they so wish.

Step 3: sizing the staff

The calculation starts from the expected demand. In the acute phase, the utilisation rate is often 2 to 4 new consultations per person per year, because morbidity is high and care is free. The planning formula is as follows: consultations per day = population × annual utilisation rate ÷ number of opening days per year. The number of clinicians needed is this figure divided by 50, the maximum workload per clinician recommended by Sphere, plus 10 to 20% to cover absences and training.

The Sphere benchmark of 22 skilled health workers per 10,000 population applies to the whole system (doctors, nurses and midwives at all levels, including the hospital). It is used to measure the overall gap at district level, not to staff a single health post.

Step 4: defining the service package

The minimum package in the acute phase includes: management of common childhood illnesses (malaria, diarrhoea, pneumonia, malnutrition) and adult illnesses, antenatal and postnatal care and skilled birth attendance or referral, vaccination, clinical management of rape, continuity of treatment for non-communicable diseases (hypertension, diabetes, epilepsy, asthma), HIV and tuberculosis, first aid for injuries and psychological first aid. The package is aligned with the Ministry of Health's package where one exists and with the cluster's harmonised lists.

Step 5: the minimum information system

Mobile clinics: when and how

Mobile clinics are justified for populations that are dispersed, temporarily inaccessible or on the move. They are expensive, offer little continuity (follow-up of chronic diseases, deliveries, routine immunisation) and create dependency. A well-designed mobile clinic visits the same place on a fixed day and at a fixed time, at least once a week; it relies on community workers who provide follow-up between visits; and it has a plan for transition to a fixed facility as soon as conditions allow.

6The MISP in practice: the first 48 hours and quantified planning

The MISP is not a comprehensive reproductive health programme. It is a limited set of life-saving actions that must start immediately, without a prior assessment. The reproductive health coordinator designated within the cluster monitors its implementation using the IAWG MISP checklist.

The first 48 hours: who does what

Calculating needs for a given population

The IAWG MISP calculator uses a few demographic assumptions, which are replaced by local data as soon as they exist. For 10,000 people with a crude birth rate of 4% per year:

• Expected births: 10,000 × 0.04 ÷ 12, or about 33 per month.
• Obstetric complications: about 15% of births, i.e. 5 per month, who must have access to emergency obstetric care.
• Caesarean sections: between 5 and 15% of births, i.e. 2 to 5 per month; a rate below 5% signals insufficient access to comprehensive obstetric care.
• Pregnant women at any given time: about 3 to 4% of the population, i.e. 300 to 400.
• Women of reproductive age: about 25% of the population, i.e. 2,500, the basis for calculating contraception and hygiene product needs.

The Inter-Agency Reproductive Health Kits, coordinated by UNFPA, are organised in three levels: community and health post, health centre (basic emergency obstetric care), referral hospital (comprehensive emergency obstetric care). Each kit is sized for a given population and duration; refer to the current kits manual for selection and quantities.

Clinical management of rape: the time limits that matter

The health worker does not have to prove that rape occurred, demand that a complaint be filed or inform the police without the person's consent, except where there is a legal obligation, which must be explained clearly. They treat, document with consent and refer. Confidentiality and a survivor-centred approach are preconditions for access to care.

Moving to comprehensive services

As soon as the situation stabilises, usually within three to six months, the reproductive health coordinator plans the integration of comprehensive services: quality antenatal care, family planning with a choice of long-acting methods, STI management, cervical cancer screening, and adolescent sexual and reproductive health. The MISP is not meant to last: a MISP still in place after a year signals a lack of planning.

7Microplanning a measles vaccination campaign

A successful mass vaccination campaign depends on microplanning: every sector, every team, every day and every dose is planned before day one. The method below follows WHO and UNICEF guidance for reactive campaigns in displacement settings.

Step 1: target population and objective

The age group is set with the Ministry of Health and the EPI technical working group: 6 months to 14 years in camps or high-density settings, at least 6 to 59 months if resources are lacking. The target population is the total population multiplied by the proportion in the age group, based on registration data where possible. The coverage objective is 95%; however, supplies are planned for 100% of the target.

Step 2: calculating supplies

Step 3: teams, duration and cold chain

A fixed-post team usually comprises two vaccinators, a recorder, a worker responsible for vitamin A and MUAC screening, and a social mobiliser or crowd controller. In high-density settings, such a team vaccinates around 250 to 400 children a day, depending on organisation and turnout. One supervisor is planned for every three to five teams. A campaign usually lasts five to seven days, followed by two days of mop-up for missed children.

Each team has a vaccine carrier or cold box with conditioned ice packs, a thermometer and a temperature recording sheet; vaccines are kept between 2 and 8 °C, and vaccine vial monitors (VVMs) are checked before each use. The central store must have enough freezing capacity for the ice packs, which is often the main logistical constraint.

Step 4: injection safety and waste management

No recapping, safety boxes closed when three-quarters full, daily collection, incineration or burial according to the approved plan. Surveillance of adverse events following immunisation (AEFI) is planned, with a notification form and a designated clinician.

Step 5: measuring coverage

Administrative coverage (doses administered ÷ target) is biased by errors in the population figure. It is supplemented by rapid convenience monitoring during the mop-up (house-to-house visits in randomly selected areas, verification by card or finger mark), then by a post-campaign coverage survey following WHO guidance. Administrative coverage above 100% indicates a wrong denominator or children coming from elsewhere, not success.

The campaign is also an opportunity to reach every child: vitamin A, malnutrition screening, deworming according to national policy, registration of unvaccinated children for routine catch-up. But each additional intervention slows the team down: it should be included only if it is built into the microplan.

8Medicines and supplies: from emergency kits to consumption-based quantification

The medicines supply chain is the most frequent cause of failure of a primary health care programme. Stock-outs drive patients away, overstocks expire, products of dubious quality put patients at risk and expose the organisation to donor sanctions.

Phase 1: starting with kits (first to third month)

Standard WHO kits make it possible to start providing care without prior quantification:

• Interagency Emergency Health Kit (IEHK 2017): 10 basic units (each for 1,000 people for 3 months, used by non-physician health workers) and one supplementary module (10,000 people for 3 months, for doctors and qualified nurses). Separate modules exist for malaria and post-exposure prophylaxis. The supplementary module contains controlled medicines (opioid analgesics, psychotropics) that require an import authorisation and a specific register.
• Non-communicable diseases kit (WHO NCD kit): for 10,000 people for 3 months, with medicine and equipment modules (hypertension, diabetes, asthma and COPD, epilepsy, mental health).
• Trauma and Emergency Surgery Kit (TESK), for facilities that treat the injured.
• WHO cholera kits and reproductive health kits, depending on the risks.

A kit contains quantities calculated on average morbidity: some products will run out in three weeks, others will remain unused. From day one, the pharmacy manager keeps stock cards for each product, which provide the consumption data needed for the next phase.

Phase 2: moving to quantification (from the second or third month)

The consumption-based method is the most reliable once two to three months of clean data are available. The ordering formula:

Quantity to order = average monthly consumption × (lead time in months + period covered by the order in months) + safety stock − (stock on hand + orders in the pipeline).

Average monthly consumption is adjusted for stock-out days (low consumption during a stock-out does not reflect demand) and for foreseeable changes in the population or season (malaria in the rainy season). Safety stock generally covers one to three months depending on the reliability of supply; it is higher under remote management or when roads are cut off for part of the year.

When consumption data are missing or distorted, the morbidity-based method is used: the number of expected episodes per diagnosis multiplied by the standard treatment in the national protocol. It is also used to check the consistency of the consumption-based method.

Quality and donor rules

Storage and rational use

• Dry, ventilated, locked store, protected from light, with pallets and temperature monitoring; cold chain at 2 to 8 °C for vaccines, oxytocin and some tests and insulins, with temperature readings twice a day.
• "First expired, first out" principle, monthly physical inventory, reconciliation between stock cards and consultation registers.
• Prescriptions according to standard protocols (for example MSF clinical and therapeutic guidelines or national protocols); quarterly audit of a sample of prescriptions: average number of medicines per prescription, proportion of antibiotics and injections. Antibiotics on more than half of prescriptions signal irrational prescribing.
• Loss control: inventory discrepancies above a few per cent are investigated, there is a procedure in case of theft or diversion, and the donor is informed in accordance with the contractual clauses.

9Worked example: planning essential services for the Bassoré site (25,000 people)

Fictional context: the Bassoré site has been hosting 25,000 displaced people for six weeks, in a rural area where the nearest public health centre, 4 kilometres away, already serves 12,000 residents. The initial analysis showed unknown measles coverage, worrying maternal mortality (three deaths in childbirth reported in one month) and chronic stock-outs at the public health centre. An NGO is mandated by the cluster to cover the site for six months.

1. Primary health care

Assumption: utilisation rate of 3 new consultations per person per year in the acute phase, facilities open 6 days a week (about 300 days a year). Expected consultations per day: 25,000 × 3 ÷ 300, or 250. Clinicians needed: 250 ÷ 50 = 5, plus 20%, i.e. 6 clinicians. The benchmark of one basic facility per 10,000 people leads to planning two health posts on the site (one in the north, one in the south), plus support to the public health centre for referral and deliveries.

2. Medicines for the first three months

• IEHK 2017: 3 kits (i.e. 30 basic units and 3 supplementary modules) to cover 25,000 people for 3 months, with a margin for the public health centre. The malaria module is ordered because the area is hyperendemic.
• NCD kit: 2 kits, as the population is young; to be readjusted after three months of data.
• Import authorisation for controlled medicines requested from the Ministry at the time of ordering.
• In month 3, consumption-based quantification. Example of amoxicillin dispersible 250 mg: consumption of 8,400 tablets in month 1 and 9,600 in month 2, i.e. an average of 9,000; lead time 3 months; period covered 3 months; safety stock 2 months (18,000); stock on hand 12,000. Quantity to order: 9,000 × (3 + 3) + 18,000 − 12,000 = 60,000 tablets.

3. MISP

Decisions: skilled birth attendance at the supported public health centre, which provides basic emergency obstetric care; written agreement with the district hospital (comprehensive care) located 35 kilometres away; an ambulance based on the site with a number reachable 24/7; clinical management of rape in both health posts and at the public health centre, announced by community volunteers and women's groups.

4. Measles vaccination campaign

Simulated result: 10,410 children vaccinated after the mop-up, i.e. administrative coverage of 97%. Rapid house-to-house monitoring in 10 randomly selected areas finds 93% of children vaccinated (verified by card or finger mark). The team adopts 93% as the most credible estimate, organises targeted catch-up in the two weakest sectors and integrates routine immunisation into both health posts from the following week.

5. Monitoring indicators presented to the donor

10Integrating mental health and non-communicable diseases into primary care

Deaths linked to non-communicable diseases (insulin-dependent diabetes, heart failure, asthma attacks, untreated epilepsy) and severe psychological distress are major causes of suffering and mortality in crises, especially in urban settings and in middle-income countries. Their management is part of primary health care, not just of specialised services.

Mental health and psychosocial support: organising services

1. Map existing services using the MHPSS working group's 4Ws tool (who is doing what, where and until when, at which level of the IASC intervention pyramid).
2. Train all staff in psychological first aid (guide by WHO and partners, 2011), in one to two days.
3. Train primary care clinicians in the mhGAP Humanitarian Intervention Guide (2015): moderate to severe depression, psychosis, epilepsy, substance use disorders, acute stress, grief, self-harm. Training lasts about three to five days, followed by regular clinical supervision by a specialist, without which skills erode quickly.
4. Ensure essential psychotropic medicines (an antidepressant, an antipsychotic, an antiepileptic, an anxiolytic for short-term use) are on the facility's list, with a follow-up procedure.
5. Organise referral to specialised services and protection services, and community support activities (groups, child-friendly spaces) with the other sectors.

The MHPSS Minimum Service Package published by the IASC and its partners (2022) describes the priority activities to be funded and implemented in each sector; donors and clusters use it as a framework for identifying gaps.

Non-communicable diseases: continuity first

• Rapidly identify patients on life-sustaining treatment (insulin, anticonvulsants, antihypertensives, dialysis) through community volunteers and registration.
• Ensure continuity of treatment with the NCD kit and simplified protocols, for example those of the WHO HEARTS technical package for hypertension.
• Plan the cold chain for insulin, and glucometers with test strips.
• Dispense one month's treatment when the patient is stable, to reduce travel.
• Plan referral for severe cases (dialysis, cancers) with the cluster, bearing in mind that services will be limited.

A simple and useful indicator: the proportion of registered hypertensive or diabetic patients who received their treatment in the past month. It measures continuity, which is the primary objective in an emergency, far better than the number of consultations.

11Common mistakes, contextual variations, interview questions and references

Common mistakes

What donors and evaluators look at

• Consistency between the service package and the identified causes of mortality.
• Compliance with national protocols and the national essential medicines list, and quality assurance in procurement.
• Quality indicators, not just volume: workload per clinician, protocol adherence, prescription audits, satisfaction and complaints mechanisms.
• Integration of the MISP and MHPSS, increasingly checked by donors and by inter-agency evaluations.
• A credible exit or transition strategy from the design stage.
• For audits: traceability of medicines, from purchase order to dispensing to the patient.

Variations by context

Interview questions and elements of a strong answer

1. "How many clinicians would you plan for a population of 20,000 people?" An explicit assumption on the utilisation rate, calculation of consultations per day, ratio of 50 consultations per clinician, margin for absences, distinction from the system benchmark of 22 health workers per 10,000, and adjustment based on actual data after a few weeks.
2. "What are the MISP priorities in the first 48 hours?" Designated coordinator, kit orders, identification of emergency obstetric care facilities, 24/7 referral, clinical management of rape with its time limits (72 hours, 120 hours), HIV prevention, contraception, clean delivery kits, without waiting for an assessment.
3. "Your campaign's administrative coverage is 112%. What do you conclude?" Underestimated denominator or children from elsewhere; verification through rapid monitoring and a post-campaign survey; revision of the denominator for other programmes.
4. "How do you move from kits to regular orders?" Stock cards from the start, average consumption adjusted for stock-outs, ordering formula, safety stock adapted to lead time, quality assurance and donor rules.
5. "How do you integrate mental health into a primary care programme?" IASC pyramid, psychological first aid for all, mhGAP for clinicians with supervision, essential psychotropic medicines, referral, coordination with the MHPSS working group.
6. "A donor asks you to open a clinic in an area where the public health centre is performing poorly. What do you propose?" Support to the public health centre (staff, medicines, supervision) rather than a parallel facility, with conditions and indicators, and an argument based on sustainability and on the cluster's guidance.

Key references

• Sphere Association, The Sphere Handbook, 2018 edition, Health chapter (health systems, communicable diseases, child health, sexual and reproductive health, mental health, non-communicable diseases).
• Inter-Agency Working Group on Reproductive Health in Crises (IAWG), Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings, 2018, and the MISP checklist.
• UNFPA, Inter-Agency Reproductive Health Kits for Use in Humanitarian Settings manual, current edition.
• WHO, Interagency Emergency Health Kit 2017 and Non-Communicable Diseases Kit.
• WHO, guidance on planning and implementing measles vaccination campaigns and on rapid convenience monitoring of coverage.
• WHO, Guidelines for Medicine Donations (2010) and Model Quality Assurance System for Procurement Agencies.
• IASC, Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007) and MHPSS Minimum Service Package.
• WHO and UNHCR, mhGAP Humanitarian Intervention Guide (2015); WHO and partners, Psychological First Aid: Guide for Field Workers (2011).
• Médecins Sans Frontières, Clinical Guidelines: Diagnosis and Treatment Manual and Essential Drugs: Practical Guidelines.
• WHO and UNICEF, guidance on Integrated Management of Childhood Illness (IMCI) and integrated community case management (iCCM).